Objective: To compare the opinions of teachers in private and public schools about school nurses.
Methods: This descriptive study was conducted at 10 randomly selected private and public schools in Izmir in western Turkey during April-May 2016, and comprised teachers who consented to participate. A questionnaire was used to collect the data about socio-demographic information of the subjects (six questions), problems frequently encountered in school and the teachers\\\' opinions about school health nurses (seven questions). Two open-ended questions on the roles of school nurses and the most important health education topics were asked. SPSS 22 was used to analyse data.
Results: Of the 720 subjects, 517(72%) were females and 203(18%) were men. There were 360(50%) teachers from private schools and an equal number were from the public schools. The mean ages of the teachers from the private and public schools were 36.22±8.69 and 43.12±7.78 years, respectively. Besides, 337(93.6%) teachers of the private schools and 338(93.9%) teachers of the public school believed that school nurses were needed, while 19(5.3%) private school teachers and 162(45%) public school teachers said they had "no idea" about the roles of the school nurse. The most important role of the school nurse was promoting good health habits according to the public school teachers and health education according to the private school teachers.
Conclusion: Half of the public school teachers said they had no idea about the role of a school nurse.
Keywords: School nurse, Teacher, Opinion, Public school, Private school. (JPMA 68: 753; 2018)
After families, schools are the most important institutions that provide the opportunity for children to fulfil their roles as healthy citizens.1 Because of this, schools need trained specialists that will work to protect and improve the health of their pupils.2 The National Association of School Nurses3defines school nursing as "a specialised practice of professional nursing that advances the wellbeing, academic success, and lifelong achievement of schoolchildren".Nurses need to be present in the school setting so that they can contribute to increasing the health and academic achievement of students as well as to their physical, mental and social development in the long term.4,5 When they are present in schools, nurses work together with school personnel towards the common goal of attaining students\\\' healthy growth and development.3,6,7At the same time, as one study8 has stated in its Humanistic Nursing Theory, communication between nurses and teachers is vitally important. Communication between teachers and the school nurse helps the nurse serve as a guide in the care of children with special needs such as children with chronic diseases like asthma and epilepsy or impairments of sight, hearing and other deficiencies.6,9Teachers have an impact on improving the wellbeing, health and behaviour of the students because of their frequent and direct communication with them.10MThe literature reveals studies of the various roles of school nurses, including in the areas of immunisation,11 management of mental health issues,12 acute and chronic health issues,9,13 advocating health promotion,14 environmental safety5 and injuries at school,15 as researcher,3 leader,16 liaising with the community4,6 and as an educator.14,17It is important that administrators, teachers and parents understand the roles of the school nurse.5,15 It is asserted in the literature that nurses\\\' roles are misinterpreted and that nurses experience difficulties in their cooperation with administrators and teachers.18 A study15 stated that administrators fail to understand some of the roles of school nurses. These misunderstood roles encompass the direct care nurses provide to students, checking students with chronic diseases, creating individual healthcare plans and acting as an intermediary to ensure those children and their families have access to healthcare services.The institution of school nursing appeared for the first time in Turkey in 1949 at the meeting of the National Education Council. The appointment of nurses to schools was accepted in the Primary School Bill that was passed in 1961. This law, however, never came into force due to budget shortages.19 School health services in Turkey are conducted jointly by the Ministry of National Education and the Ministry of Health as part of a School Health Cooperation Protocol.20 School health is an issue that is of interest to all children, from nursery school to high school. In the 2015-2016 academic year, Turkey had an enrolment of 11 million students, including pre-school, primary and secondary schools, and this figures represents 14% of the population.21 Today, school health nurses are employed in the private schools. However, the practice of employing school nurses is not widespread in the public schools. 19Various studies have been conducted to evaluate the perception of parents, administrators and teachers about the roles of school nurses. It is this perception that influences the coordinating role of the nurse and the nurse\\\'s participation in school health activities.1,5,6,13,18 There is very limited number of studies examining opinions expressed about the roles of school nurses in Turkey.22-24 The paucity of studies in this area is striking despite the importance of cooperation between teachers and nurses in terms of ensuring good health and school attendance among students. The current study was planned to compare the opinions of teachers in private and public schools about school nurses.
Subjects and Methods
This descriptive study was conducted at randomly selected 5 private and 5 public schools in Izmir in western Turkey during April-May 2016, and comprised teachers who consented to participate. Permission was obtained from the Ege University School of Nursing Ethical Committee and the participating schools. Verbal consent of the participating teachers was also obtained after they were informed about the nature of the study. Data was collected using a questionnaire prepared in the light of literature.5,6,13,23 It comprised three sections, having a total of 15 items. The first section comprised socio-demographic information about the teachers\\\' age, gender, education, civil status, parenthood, and the duration of their professional lives (six questions). The second section contained statements on problems frequently encountered in school and the teachers\\\' opinions about school health nurses (seven questions). To determine the opinions of the teachers, they were asked about whether or not there was a nurse in their school, and whether they preferred to have a school nurse, the reasons they preferred to have a school nurse, the benefits of having a school health nurse, whether they sought the services of a school nurse and if so, what kind of services they benefited from. The third section contained two open-ended questions on the roles of school nurses and the most important health education topics.The questionnaire was submitted to a panel of three experts from the Nursing Faculty in Izmir to determine content validity. Necessary revisions were accordingly made. Pilot study was carried out on 10 teachers in order to confirm the applicability, simplicity of the questionnaire and to assess the time needed to complete/fill out the questionnaires.SPSS 22 was used to analyse data. Numbers, percentages and means along with standard deviation were calculated. The teachers\\\' responses to the open-ended questions were analysed for themes and associations. P<0.05 was considered statistically significant.
Initially 850 teachers were approached with the questionnaire. There were 394(46%) teachers in the private schools and 456(54%) in public schools. After leaving out those who did not volunteer to participate or turned in incomplete questionnaires, the final study sample stood at 720(85%). It had 360(50%) subjects from private schools and an equal number were from the public schools. Of the total, 517(72%) were females and 203(18%) were males. The mean ages of the participating teachers at the private and public schools were 36.22±8.69 and 43.12±7.78 years, respectively (Table-1).
There were 6 school nurses; 5(83%) in the private schools and 1(17%) in a public school. Falls and accidents were reported as the most commonly experienced health issue by both private schools 252(70%) and public schools 299(83%). Expressing opinion about school nurses 337(93.6%) teachers of the private schools and 338(93.9%) teachers of the public school believed that school nurses were needed (Table-2).
A look into the reasons why the teachers thought a school nurse was needed showed that 201(55.8%) private and 170(47.2%) public school teachers stated first-aid. Nine (2.5%) private school teachers and 16(4.4%) public school teachers said that having a nurse in a school setting was "not an advantage." Besides, 254(70.6%) private school teachers and 210(58.3%) teachers of the public school stated that having a school nurse was an advantage in terms of providing first-aid in emergencies. Moreover, 146(40.6%) private school teachers and 84(23.3%) public school teachers offered their perception of an advantage as "providing health education to students and promoting good health habits." Another 104(28.9%) of the private school teachers and 34(9.4%) of the public school teachers had obtained school health services. Discussing benefits of education, 201(55.8%) private school teachers stated that they had benefited from health education-counselling, 10(9.6%) from back-to-school checks, 1(2.9%) from body mass screening and 20(19.2%) from all of the services. In comparison, 15(44.1%) public school teachers stated that they had benefited from health education-counselling, 1(2.9%) from back-to-school checks, and 74(20.6%) from all of the services.In response to the open-ended questions, the private school teachers stated that the issues school nurses should address in health education are hygiene 129(35.8%), healthy eating 125(34.7%), preventing infections 122(33.9%), smoking 82(22.8%), and mental health 19(5.3%). Public school teachers stated that the issues school nurses should address in health education should be hygiene 114(35.7%), healthy eating 117(32.5%), preventing infections 99(27.5%), smoking 74(20.6%), mental health 15(4.2%). Besides, 194(53.9%) private school teachers and 224(62.2%) public school teachers expressed their desire to have school nurses offer health education.
The private school teachers cited three primary roles of school nurses as "Providing health education for students" 165(45.8%), "Promoting good health habits" 133(36.9%) and "Evaluating students with behavioural problems" 5(14.2%). Of the private school teachers, 19(5.3%) and 162(45.0%) of the public school teachers said they had "no idea" about the roles of the school nurse (Figure-).
The school nurse is a key participant in the school\\\'s health team.3 School nurses have the capability of immediately intervening in the event of health issues commonly experienced in the school environment. In this study, it was reported by both private school and public school teachers that falls and accidents were the most commonly experienced health issue. Findings are similar with Greek study5 which asserted that teachers believe that a school nurse is needed in terms of possible accidents. School health services are services that medical, teaching and other professionals provide in or out of school to improve the health and well-being of children and in some cases the whole families.2 In Turkey, there is no legal requirement for public schools to employ nurses.20 parallel to this, the lack of nurses in public schools was shown in this study. The remarkably higher rate of school nurse employment in the private schools is due to the greater resources available to the private schools. The health trends adopted at the private schools must be transferred to the state schools as well. In one study 5 it was reported that teachers in schools equipped with school nurses felt 41 times more secure than teachers working at schools that did not employ school nurses. The present study indicated that almost all private school and public school teachers felt that school nurses were needed at the schools. Another study 2 3 conducted in Turkey revealed that 92.7% of teachers felt the need for school nurses. A Greek study 5 reported that 90.3% of teachers expressed the need for the employment of a school nurse. In the present study, the reasons teachers offered as to why school nurses were needed were similar in both groups, with first aid, health education, health screening, advising parents and teachers on health topics, preventing infectious diseases and immunization being mentioned. Another study6 reported that more than 80.0% of teachers working at different schools that employed school nurses on a full-time basis reported on the positive contribution of the school nurse in emergency medical situations.6 In one study,15 administrators stated the roles of the school nurses as providing emergency care for ill and injured children and being responsible for managing immunisation and keeping health records. The present study revealed that teachers thought school nurses necessary for similar reasons. In the present study, the presence of a nurse in the school setting was seen as an advantage by almost all of the teachers at both private and public schools. The leading reason given for wanting a school nurse to be employed was their contribution in emergency situations according to the private school teachers while public school teachers rather pointed to providing health education for students and promoting good health habits. The impact of social determinants of health is felt in the school setting and is well known to school nurses.25 The school nurse plays an important role in identifying the services that would improve care and education outcomes for children who are unable to access regular medical care.4,6 In one study,5 59.2% of the teachers reported that having a nurse at school was an advantage in terms of accident prevention and ensuring a safe environment. In another Turkish study,23 91.9% of the participating teachers thought a school nurse would contribute to the students\\\' wellbeing and 72.1% believed it would enhance academic achievement. The results of the present study were consistent with the findings in the literature. Although the reasons submitted by the private and public school teachers differed, it was seen that having a school nurse was perceived as an advantage. Again in the present study, the teachers\\\' rate of making use of available health services in both groups was low. In private and public schools, the primary benefit that school health services provided to the teachers was identified as health education-counselling. It was found that back-to-school checks and body mass screening services were inadequate. In one study,13 it was observed that teachers\\\' self-control progress was greater when nurses made more classroom visits or when they provided teachers with more counselling services. In addition, when nurses included physical education teachers and guidance counsellors in their care plans, teachers were perceived to be more successful in achieving improvement in students\\\' self-management. Nurses who included the physical education teacher and the guidance counsellor in the care plan were perceived by teachers as being more successful in improving the child\\\'s self-management.13 Communication between teachers and school nurses and the awareness of teachers about school health services is effective in achieving general wellbeing and improving health behaviour. 10 In the present study, the rate of benefiting from school health services was low among both the private and the public school teachers. The study queried the teachers\\\' opinions about health education. In both groups of teachers, more than half were in favour of having health education on the topics of hygiene, healthy eating, preventing infections, smoking and mental health. Similarly, one study 14 found that hand hygiene, tooth decay and oral health, sexual health, smoking, mental health, obesity and healthy eating were topics that were considered as a priority in health education. The current study explored the opinions of private and public school teachers about the roles of school nurses through open-ended questions. The private school teachers stated the roles of school nurses as providing health education for students, promoting good health habits, evaluating students with behavioural problems and evaluating the environment. The public school teachers indicated the same roles but percentages were lower than in the private schools. Furthermore, although almost all of the private school teachers had knowledge of the roles of the school nurse, almost half of the public school teachers responded with no idea, in effect leaving the question unanswered. In another Turkish study,23 teachers expressed the duties of the school nurse as first aid applications (95.7%), health applications such as checking blood pressure, temperature, etc. (92.7%), and health education (87.4%). In a study5 carried out in Greece with educators, the fundamental role of the nurse was expressed by 63.9% of participants as administering first aid. In one study,7 school principals listed the three primary roles of school nurses as following up on chronically ill students (83%), providing first aid (81.8%), and referrals of students with health problems (78%). There are several limitations of the current study. The research was conducted at 10 primary schools within Izmir. It is not therefore generalisable to the whole of Turkey. Furthermore, the fact that the opinions of the teachers about school nurses are self-reported statements is another limitation of the study. The absence of school nurses in public schools due to financial constraints was another limitation of the study. Additionally, in the sample worked with, most of the teachers constituted females and the opinions of very few male teachers could be obtained. It is believed that collecting the opinions of a greater number of male teachers would be useful. The opinions of the teachers are limited to the questions asked on the questionnaire. The role of school nurses in Turkey has been defined in nursing regulations. However, there is no legal requirement for schools to employ nurses. It might be suggested that policies need to be formulated, and financing allocated to make possible the employment of full-time nurses at schools as a fundamental requirement of school health programmes, and that nursing schools and associations should conduct lobbying activities toward this aim.
Although all private school teachers identified the roles of a school nurse, close to half of the public school teachers said they had no idea. Falls and accidents were found to be the most frequently encountered health problem experienced at schools by both groups of teachers.
Acknowledgements: We are grateful to nursing students Deniz Gencel and Ebru Akbas for their help in data collection.
Disclaimer: The study was presented as an oral presentation in Celal Bayar University Graduate School of Health Sciences, 2nd International Graduate Education Congress, held from May 12 to 14, 2017 in Manisa, Turkey.
Conflict of Interest: None.
Source of Funding: None.
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