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Nursing and Health Sciences (2013), 15, 353–359
Research Article
Sustaining secondary school nursing practice in Australia: A qualitative study Diana Guzys, BPubHlth, GradDip Ed, GradDip AdolHlth & Welf, MN, RN, Amanda Kenny, BN, MN, PhD, Post Grad Dip Mid, Grad Cert, Higher Ed, RN, RM and Melanie Bish, BN(hons), BCN, MN, RN La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
Abstract
This interpretive descriptive, qualitative study explored secondary school nurses’ perceptions of factors that impact on their role and their views on how their role can be best supported. Nine secondary school nurses from four Department of Human Services regions in Victoria, Australia, participated in semistructured, in-depth interviews. Purposive sampling was used, with participants required to have a minimum of 2 years’ experience as secondary school nurses. Data were thematically analyzed, revealing a complex and challenging role. The findings identified key factors necessary to support quality practice. All stakeholders need a shared understanding of the purpose and principles underpinning the secondary school nurse role and the nurse’s professional obligations. Knowledge and experience are required that recognize the breadth and depth necessary for secondary school nurses to work effectively within their scope of practice. The adoption of a model of critical companionship is recommended to provide facilitated reflection on practice as a support mechanism for the role.
Key words
critical companionship, interpretive description, quality practice, role clarity, secondary school nurse, school nursing.
INTRODUCTION Healthcare reform reflects recognition by governments and policy makers that a greater emphasis on primary healthcare, preventative health, and health promotion are an economic and social requirement (Department of Health, 2011; Duckett & Willcox, 2011). Nursing is at the forefront of healthcare delivery, and the increasing emphasis on primary health care indicates the need for further evolution and expansion of community nursing practice. Secondary school nursing is an important community health nursing role that focuses on the health of young people and their families, within a specific school community (Keller & Ryberg, 2004; St John, 2007). School nurses are employed in a number of countries, including Australia, New Zealand (NZ), the UK, USA, and parts of Europe, with the role varying between and within countries (Merrel et al., 2007; Buckley et al., 2009; Smith & Firmin, 2009; Haddad et al., 2010; Reutersward & Lagerstrom, 2010). School nurses engage in a diverse range of activities, responding to local need, regulation, and
Correspondence address: Diana Guzys, Nursing & Midwifery, La Trobe Rural Health School, La Trobe University, PO Box 169, Bendigo, Vic 3552, Australia. Email:
[email protected] Received 19 July 2012; revision received 10 December 2012; accepted 30 December 2012.
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organizational directives (Downie et al., 2002; Barnes et al., 2004a; Buckley et al., 2009; Smith & Firmin, 2009; Haddad et al., 2010; Sendall et al., 2011). Some school nurses provide primary care services, such as screening, monitoring chronic conditions, and clinical care for subacute minor conditions and first aid (Downie et al., 2002; Buckley et al., 2009; Mitchell & Ellis, 2011), while others focus on healthpromotion activities (Barnes et al., 2004a; Department of Human Services, 2006b; St John, 2007; Buckley et al., 2009; Reutersward & Lagerstrom, 2010). The breadth of activities in which school nurses are frequently involved is indicative of the complexity of the role, necessitating a broad knowledge and skill set.
Literature review Limited published research relating to school nursing in Australia was revealed during the literature search. The search strategy involved several electronic databases, including Ovid, Informit, CINAHL, Medline, Google Scholar, and Google. The search terms were “school nurse”, “secondary school nurse”, “school nursing”, and “nursing in schools”, solely, as well as in conjunction, with Australia. Focused searches were made seeking relevant references not identified using database searches, but referred to in the literature obtained. The parameters for the literature search were limited to relevant references from 1995 onwards. doi: 10.1111/nhs.12039
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Secondary school nursing in Australia In Australia, secondary school nurses are important in the provision of primary health care, with their primary role and function to reduce negative health outcomes and risktaking behavior of students (Department of Human Services, 2006b). This is addressed through a range of healthpromotion activities, including involvement in curriculum development, participating in classes, and community networks (Barnes et al., 2004a; KPMG, 2009). Primary health care is delivered through individual student support, health counseling, and referrals (Barnes et al., 2004a; KPMG, 2009). Most frequently, these activities relate to sexual health, substance use, and mental health (Barnes et al., 2004a; KPMG, 2009).
Key challenges of the school nursing role Poor understanding of the school nurse’s role (Newell et al., 2003; Rice et al., 2005; Merrel et al., 2007; Buckley et al., 2009; Smith & Firmin, 2009), and a lack of understanding of professional responsibilities and legal requirements of nursing professionals (Newell et al., 2003; Rice et al., 2005; Broussard, 2007; Smith & Firmin, 2009; Sendall et al., 2011), are the most commonly identified challenges discussed in school nursing literature internationally. Role strain, described in terms of emotional fatigue and burnout, has been identified as a symptom of professional isolation (Downie et al., 2002; Barnes et al., 2004a; Buckley et al., 2009), and a factor that impacts on school nurses’ effectiveness of practice (KPMG, 2009). This is commonly associated with difficulty in referring students to appropriate healthcare services, particularly in rural and remote areas (Barnes et al., 2004b; KPMG, 2009; Buckley et al., 2009). Difficulties in referring students to community agencies were identified as an issue for 45.5% of secondary school nurses in Victoria, Australia (KPMG, 2009). The nurses indicated that this issue was usually due to community agencies being unable to provide the service required, or having excessive waiting lists for the required service (KPMG, 2009). Difficulties in accessing appropriate community agencies were most apparent in rural areas (KPMG, 2009). Barnes et al. (2004b) noted that Australian school nurses in rural and remote areas acknowledge that while they are not always the most appropriate healthcare provider, they feel obligated to provide support to students beyond their recognized scope of practice, when the most appropriate health service is absent or unavailable. A greater blurring of professional boundaries is frequently experienced in rural practice (Mills et al., 2010). Lack of clinical oversight experienced by some nurses in NZ secondary schools was found to be associated with professional isolation (Buckley et al., 2009). A formal system of debriefing, or clinical supervision, was suggested as a support strategy to overcome professional isolation of secondary school nurses in Queensland, Australia (Barnes et al., 2004a). Engaging in regular meetings with other nurses undertaking secondary school nursing roles and supervision and support provided externally to the school were factors that supported © 2013 Wiley Publishing Asia Pty Ltd.
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the most effective and motivated approach to secondary school nursing in NZ (Kool et al., 2008).
Aim In this study, we aimed to explore Victorian secondary school nurses’ perceptions of the factors that impact on their role, and to identify their views on how their role can be best supported.
METHODS Study design This qualitative study used an interpretive, descriptive approach informed by the interpretive/constructivist paradigm (Ponterotto, 2005; Haverkamp & Young, 2007). Interpretive descriptive research has been explained as a small-scale qualitative examination of subjective perceptions of phenomena to inform clinical understanding (Thorne et al., 2004). This method is well established within nursing when the research question relates to understanding nurses’ experiences and perceptions (Calvin et al., 2009; Vervoort et al., 2010).
Participants Our purposive sampling criteria required participants to have a minimum of 2 years’ experience as secondary school nurses in either a full-time or part-time capacity. An emailed invitation to participate was sent to all secondary school nurses in Victoria, providing them with detailed information regarding the research for them to make informed decisions regarding participation (Liamputtong & Ezzy, 2005). Nine secondary school nurses, who met the inclusion criteria, from four of the eight Department of Human Services (DHS) regions participated.
Ethical considerations Ethics approval was sought and obtained from La Trobe University Faculty of Health Science Human Ethics Committee and the Ethics Committee of the then DHS (now Department of Health), Victoria, Australia. Consideration for maintaining the anonymity of participants was implemented during each stage of the study, and pseudonyms were used for reporting.
Data collection Data were collected through 1–1.5 h semistructured, in-depth interviews that were digitally recorded and transcribed verbatim.
Data analysis Using a thematic network approach, identified patterns of data were grouped under organizing themes to explain the common concept represented throughout the analysis
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caused them to question their professional boundaries. Nevertheless, while blurring of professional boundaries caused some concern, the resultant flexibility and opportunities to exercise autonomy in practice were valued: It’s good that perhaps those boundaries aren’t so defined, because it allows us the flexibility to make our own judgment about where we need to go with things. (Amy)
More than ticking boxes
Figure 1.
Thematic network of global and organizing themes.
(Attride-Stirling, 2001). When no further logical blending of data groups seemed appropriate, all of the organizing themes from the data were clustered under a global theme, which is a metaphor integrating all of the organizing themes (Attride-Stirling, 2001). The thematic network is illustrated in Figure 1.
RESULTS The global theme was identified as sustaining quality practice. This reflects the six organizing themes: respecting our work, one size does not fit all, more than ticking boxes, having the right tools for the job, with or without a safety net, and coaching from the sidelines. The themes describe a complex and challenging nursing role, and the supports needed for school nurses to deliver high-quality care.
Respecting our work The theme “respecting our work” centered on recognizing the uniqueness and complexity of the secondary school nurse role, the need for role clarity, and the need for professional activities to be understood and supported. The lack of a shared understanding of the secondary school nursing role within the practice environment was recognized as having a substantial impact on the nurse’s ability to practice: I don’t find the health promotion working . . . with grumpy teachers . . . getting the programs into the school . . . feeling like I’m stepping on other peoples toes . . . all that work . . . politics . . . navigating through resistant teachers.(Donna)
One size does not fit all Responding to the individual needs of each school, and the presence or absence of other service providers within the communities, are acknowledged in the theme “one size does not fit all”. Most of the nurses had experienced issues that
A number of organizational mechanisms that provide support for practice, such as team and cluster meetings, professional development opportunities, the provision of appropriate resources, and operational supervision are acknowledged in the theme “more than ticking boxes”. However, some nurses expressed mistrust and negativity when management identified what the secondary school nurses considered operational supervision, as clinical supervision: Operational supervision probably is fine by management, and for sure, then checking that you’re doing your job is fine, because, you know, let’s face it, we should be doing the job that we’re meant to be doing, and that’s okay. (Caitlyn) Further concern was expressed by the nurses, who perceived the need to recruit secondary school nurses to meet organizational targets often resulted in lack of due consideration of nurses’ educational background and previous experience as part of the recruitment process.
Having the right tool for the job A range of factors contributed to the theme “having the right tool for the job”. These included the knowledge and skills of the secondary school nurse, resource availability, peer support, and appropriate time to deliver the service required. Practice informed by evolving professional knowledge was recognized as a significant component of quality practice. Participants expressed a common belief that professional practice decisions needed to be based on the best evidence available: Also the evidence for what you know is best practice and rationales for what you’re doing, and how. (Bella) Regional and geographic differences were emphasized when discussing resource availability. Nurses in metropolitan areas were perceived to be better resourced, and more able to refer students on to other organizations for support with ongoing issues, highlighting a sense of inequity, which was identified by nurses based in remote communities: We do notice how the nurses that work out of the larger centers seem to have resources at their fingertips and access to resources that we don’t. We’re always making do out in the country. A bit of hay band and barbed wire – it’s amazing what you can do. (Amy) © 2013 Wiley Publishing Asia Pty Ltd.
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With or without the safety net Feeling obligated to provide clients with the care they required, despite this sometimes being beyond the nurses’ recognized experience and professional comfort zone, is acknowledged through the theme “with or without the safety net”. Activities undertaken frequently reflected the availability or lack of other service providers, such as counselors, psychologists, drug and alcohol workers, and reproductive health services. Despite autonomy in practice being highly valued by the secondary school nurses, this was tempered by concern about whether the decisions made were professionally sound: We are out here alone. Most of the time, those decisions are left up to us and to work with, and so you do the best you can. (Cath) Most commonly, such concern was addressed through reliance on informal peer support. Other secondary school nurses were universally acknowledged as a significant source of professional guidance: I feel if there had been interactions with the students and I need support, say if there’s been suicidal idealization, pregnancy issues, morning after pill, and things like that, I find that there isn’t very much support I can gain within the schools . . . and it is more sharing with other school nurses; to know what their practices are, and it’s more reassurance, I suppose, in what you are doing is right and correct. (Claire)
Coaching from the sidelines The theme of “coaching from the sidelines” describes the concept that professional support is a requirement for delivering quality nursing practice. To successfully remain in their positions, the nurses had developed personal strategies to deal with the sense of stress that resulted from the complexities of the secondary school nurse role and issues they commonly had to deal with. Reflection on practice was one strategy used to mitigate professional stress: Some nurses are very clinical in their school nursing roles, but then, still even so, you still need to talk about, “I did this and that”, and “how could I have done it better?” or “what was good about it, and how do I feel about it?”. (Anna) Despite reflexivity and the use of informal peer support to assist with reflection on practice, some secondary school nurses required a more formal arrangement of support. Most of the secondary school nurses who participated in this study nominated clinical supervision as a mechanism they believed would facilitate critical reflection on practice, thereby ensuring professional quality.
DISCUSSION A flexible and responsive environment is required to sustain quality nursing practice. Four focus areas that positively © 2013 Wiley Publishing Asia Pty Ltd.
Figure 2. Factors that positively influence and best support the secondary school nurse role.
influence and best support the secondary school nurse role were identified: an expert knowledge base, a focus on collaboration, role expectations, and effective organization. The schematic framework representing this is presented diagrammatically in Figure 2.
An expert knowledge base Internationally, there is no consistently-recognized qualification or required level of professional experience identified to undertake the role of a school nurse. Postgraduate qualifications in a range of areas have been identified as required by secondary school nursing, including adolescent health and development, adolescent mental health, family planning and sexual health, psychosocial health, primary health care, and health promotion (Barnes et al., 2004a, Department of Human Services, 2006a; Buckley et al., 2009; KPMG, 2009). Keller and Ryberg (2004) argued that school nurses require a master degree level of education; others advocate that this is a nurse practitioner role (Kool et al., 2008). In Australia, nurse practitioners are prepared at master degree level and have a clearly identified and credentialed extended scope of practice (Mills et al., 2010).The nurse practitioner role has been described as independent autonomous practice incorporating a high level of clinical leadership (Cant et al., 2011). Nurse practitioner roles have been recognized as a way to assist rural and remote health services to fill a practice gap and better meet the needs of their communities (Mills et al., 2010; Cant et al., 2011). Requiring secondary school nurses to be adolescent health nurse practitioners acknowledges the demands of the role, and would enable nurses to work within a fully-recognized scope of practice.
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A focus on collaboration
Effective organization
The integration of nurses into the school fabric appears to be influenced by the model of secondary school nursing practice. Kool et al. (2008) found that nurses, whose role was predominantly to engage in the provision of first aid, lacked motivation, were isolated from school management, and did not function as part of the health team. The majority of nurses in our study described a positive working relationship with staff who had a student welfare role. Most school staff who undertook these roles appeared to have an understanding of the school nurse’s primary healthcare role. Commonly, members of the student welfare team were seen as a support for school nursing practice, and were consulted as necessary when making decisions regarding student issues. Yet not all teaching and administrative staff in schools had a similar understanding of the professional activities and responsibilities of the contemporary secondary school nurse. Having clear goals and processes has been identified as fostering inter-professional teamwork in community care, while conflict arises when there is a lack of understanding of each other’s roles and tasks (Xyrichis & Lowton, 2008). The student’s right to privacy, and the obligation of the nurse to provide confidentiality, are prime examples of a common area of misunderstanding in secondary school nursing practice. The Review of the Victorian Secondary School Nursing Program in Australia stated that school staff felt they had a right to know what was happening in the student’s life, and were unsure as to what should be done when the nurse was unavailable (KPMG, 2009). In response, that report recommended involving the regional manager with such information and the development of guidelines involving schools and community stakeholders as to how to manage students when the nurse was not at the school (KPMG, 2009). The consideration or implementation of such a recommendation demonstrates a lack of understanding of the ethical and professional conduct of nurses. Secondary school nurses with a limited presence in a school are acutely aware of the implications of this, and are ethically responsible for negotiating an alternative support with the student for them to access when they are not available.
Most of the secondary school nurses who participated in this study nominated clinical supervision as a mechanism to support and maintain their practice, described in terms of facilitated critical reflection on practice. One Australian study identified regional managers as providing clinical supervision for secondary school nurses (KPMG, 2009). In this study, several nurses expressed concern that regional managers identified what the secondary school nurses considered operational supervision, as clinical supervision. Many of the nurses identified a sense of discomfort in relation to professional supervision by management. Concerns relating to managers providing clinical supervision have been highlighted by others in regards to a range of nursing roles, particularly associating this with monitoring and surveillance (Walsh et al., 2003; Butterworth et al., 2008).The general view of the nurses in this study was that the most ideal arrangement would be for the facilitator to be employed within the same organization as the secondary school nurses, with similar, if not greater, authority as the regional school nursing program manager, and not answerable to their line manager. The term “clinical supervision” is not commonly used in Australia, except within mental health nursing, and recognition of the place of clinical supervision for Australian nurses has been a slow process (Cummins, 2009). Confusion and disagreement about the definition of clinical supervision as it relates to nursing appears endemic, leading to the suggestion that the concept of clinical supervision is a practice with no name and should possibly be called something else (Kilcullen, 2007). Despite the variety of definitions and models of clinical supervision, its purpose is to provide a process that enables professionals to reflect on their practice, with the aim of improving clinical practice, and thereby improve client care and outcomes (Winstanley & White, 2003; Cummins, 2009). Rather than using the confusing label of clinical supervision, the term “critical companionship” could be considered a suitable alternate, as it encapsulates what the nurses in this study described. Critical companionship has been described as a mechanism that is supportive, focused on developing evidenced-based, person-centered care, practitioner effectiveness, and expertise (Manley & Garbett, 2000; Titchen, 2003).
Role expectations
Limitations
Role strain has frequently been attributed to a lack of understanding of school nurses’ legal and professional responsibilities by school authorities and parents (Barnes et al., 2004a; Buckley et al., 2009; Sendall, 2009; Smith & Firmin, 2009). The perception of a lack of role clarity persists primarily due to a fundamental misunderstanding of the meaning of the concepts used to describe the role, rather than a failure to clearly define the role. Congruent with the findings of this study, Sendall (2009) noted that it was not that the secondary school nurse role was poorly marketed, but rather, those in the school environment were struggling to understand theoretical principles underpinning the activities undertaken in performing the role.
This study has limitations related to setting, sample, and approach. Participants were recruited from only four of the eight DHS regions in one state of Australia, and the small sample size might not be reflective of the broader school nursing workforce. However, data saturation was evident within the first seven interviews, with no new information generated in the final interviews. Using focus groups, rather than individual interviews, might have resulted in richer data from group interaction, but individual interviews did allow detailed and personal responses. While qualitative studies have limitations related to credibility, dependability, and confirmability (Lincoln & Guba, 1985), the research was strengthened by participant review of transcripts for © 2013 Wiley Publishing Asia Pty Ltd.
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accuracy, use of participant quotes in reporting, all authors’ involvement in the analysis, and independent review of the study by other researchers, who confirmed the appropriateness of the developed thematic networks.
Recommendations Nurses should have appropriate education and experience to meet the expected requirements of the secondary school nursing role. A suitable postgraduate course, which incorporates health promotion, adolescent health and adolescent mental health, primary health care, family planning, and sexual health qualifications, is required. Ideally, this course would be offered via distance education mode to maximize participation, irrespective of geographic location. A focused educational campaign within school communities is required to promote the value of health promotion and primary healthcare activities related to student health outcomes, and understanding of these concepts. Meeting regularly with other secondary school nurses should be encouraged to facilitate the distribution of information and to reduce professional isolation. However, professional support through facilitated reflection on practice should be available to secondary school nurses with someone with sufficient knowledge to act as a critical companion, and who does not have organizational management responsibilities. Use of the term “clinical supervision” should be avoided.
Conclusion and implications for practice The findings from this study might be transferable, and could assist in informing support strategies to facilitate secondary school nursing in Australia and internationally. Further research is needed to determine if the schematic framework for sustaining quality practice, developed during this study, is applicable to other community nursing roles or other areas of nursing practice. In this study, we identified the complex and challenging nature of school nursing, and portrayed the essential nexus of autonomous practice, problem solving, and independent decision-making based on appropriate knowledge, and within a recognized scope of practice. Key findings indicate that Victorian secondary school nurses perceive the environment in which they work influences the effectiveness and quality of their practice. They suggested that quality practice was supported when the complexity and expertise required for the role was duly recognized, nurses had the appropriate knowledge to undertake the role, as well as a suitable mechanism for facilitated reflection on practice. Critical companionship has been suggested as a model of facilitated critical reflection on practice that could address these concerns. Secondary school nursing has developed in recognition of the positive role nurses can have in reaching and working with young people. The health concerns targeted by secondary school nurses are multifaceted and diverse, reflecting the life issues and multiple areas of decision-making faced by young people. If there is a commitment to primary health care and preventative health as a means of promoting good health and addressing health inequities, then it is crucial to © 2013 Wiley Publishing Asia Pty Ltd.
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provide an effective, accessible, and flexible service to young people. Failure to support secondary school nurses in this vital role, through the provision of a practice environment that enables quality practice, is myopic, socially irresponsible, and suggests a lack of commitment to the healthcare reform agenda.
CONTRIBUTIONS Study Design: DG. Data Collection and Analysis: DG, AK, MB. Manuscript Writing: DG, AK, MB.
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