The Effectiveness of School Nurse Practitioners: A Review of the Literature

Laura Driscoll Goodwin

In a recent article in The Journal of School Health. Brink, Dale, Williamson and Nader described the results of a study comparing the activities of pediatric nurse practi- tioners (PNPs) and regular school nurses in school settings.’ The article is certainly thought provoking. To what extent are school nurse practitioners (or pediatric nurse practitioners who work in schools) different from regular school nurses? And, if differences between the two types of nurse are not very large, what institutional or other factors might account for the lack of more significant differences?

The Brink et al. article served as a stimulus for the following summary and discussion of available data that pertains to the effectiveness of school nurse practitioners (especially in terms of differences between SNPs and regular school nurses), and to possible impediments to full use of the expanded role in schools. Cumulative informa- tion demonstrates that nurse practitioners in schools d o perform different activities than regular school nurses and strongly suggests that such activities help increase and improve school health services. Two other considerations also emerge: 1) there are several important institutional factors that are at least perceived impediments to maximum use of the new role; and 2) further research is needed on the real relationships between institutional factors and nurse practitioner effectiveness.

In reviewing the findings from other studies, it is helpful to differentiate among three types of variables that could be investigated: structure, process and outcome ~ a r i a b l e s . ~ J . ~ Structure variables include those institutional factors that “set the stage” for delivery of health care in schools, eg, administrative and financial support, pupil-to-nurse ratios, job requirements, responsibilities and restrictions, facilities and support personnel and physician involvement and support. Process variables describe the activities of nurses and relevant other personnel in providing health care to school children, eg, assessment skills, management plans and referral and follow-up activities. Outcome variables are the end results of activities performed and services provided; included would be such factors as the health status of children served, results of referrals and parental satisfaction with services provided. How a particular variable is categorized can be partly a function of the purpose of the study and how the variable is measured. For example, “physician involvement” might clearly be a structure variable in one study, but a process variable in

another. Nevertheless, the categorization scheme provides a useful way of generally summarizing the findings from a number of studies and pointing out the areas of study that are in greatest need in terms of future research.

Most of the studies conducted thus far on nurse practitioners in schools have focused on process variables - that is, what activities SNPs and regular school nurses engage in and the proportions of time spent in various activities. Hilmar and McAtee used pupil contact forms to collect data on types of health service provided to students by SNPs and regular school nurses. They found several important differences: 1) SNPs developed more specific and focused management plans than did the regular school nurses; 2) SNPs excluded about one-half as many students from school and referred one-half as many students for further evaluation, care or consultation; and 3) SNPs provided clearer advice to parents of excluded children.’

In a separate study, McAtee used direct observation to examine daily activities of SNPs and regular school nurses. She found that, compared to the regular school nurses, SNPs spent more time with patients, performed more thorough and extensive health assessments, spent less time in clerical and administrative tasks, had more contacts and consultations with parents and with school and other health personnel and performed throat cultures, tuberculin tests, urinalyses and developmental tests more frequently.6

Lewis et al. also conducted a comparative study in which SNPs and regular school nurses completed encounter forms and critical incident reports during a one-month period. Their findings showed that SNPs emphasized disease detection, reduction of disability and improvement in communication between teachers, families and other health providers more so than the regular school nurses.’

Several other studies dealt with effectiveness of school nurse practitioners in terms of process variables. In a descriptive study conducted in Pennsylvania, SNPs found health problems in 46% of the tenth graders examined; and 75% of those problems had never been previously diag- nosed.’ Henzell examined the assessment skills of nurse practitioners working in schools in Australia and found that the NPs performed pre-school and school entry health appraisals as effectively as school physician^.^ Nader et al. studied the changes that occurred in one high school after the nurse completed P N P training, a full-time health aide was added and clinic management forms were introduced. They discovered that the P N P identified twice as many

NOVEMBER 1981 THE JOURNAL OF SCHOOL HEALTH 623

problems requiring referral after her PNP training as management plans; time devoted to individual students: compared to previously, that her written problem identifi- cation increased in specificity and that her phone contacts with physicians increased in frequency.’O Goodwin used a self-report technique to investigate differences between a much larger number of both SNPs and regular school nurses. Findings showed that SNPs spent more time with each child seen in the clinic than did regular school nurses and were seeing more children because of learning problems, physical handicaps, behavior problems and psychosocial/learning problems. Further, SNPs spent proportionately less time in screening and clerical work and more time in physical assessment and management. There were no significant differences in referral rates, but SNPs sent significantly fewer children home because of illness or injury.“

Outcome variables have been almost ignored, due in part to the greater difficulties involved in adequately measuring outcome variables. However, a few attempts at outcome measurement have been made. In the study conducted by Hilman and McAtee, parents of excluded children were contacted with a follow-up phone call; and it was found that the parents of children seen by SNPs were more likely to have agreed with and followed the SNPs’ advice than parents of children seen by regular school nurses.’ Although Lewis et a1 found no differences between SNPs and regular school nurses in their referral rates, they did find that SNPs indicated positive outcomes of the referrals on the critical incident reports more frequently than did regular school nurses.’ Similarly, Nader et al found that a greater percentage of the nurse’s referrals resulted in care received by the children after the PNP training than before.lD

When variables dealing with the NPs’ own feelings of satisfaction and competence are classified as outcome vari- ables, two other findings are relevant: Henzell’s finding that both the NPs and the school physicians reported greater job satisfaction following the introduction of NPs into school settings9 and Goodwin’s finding that SNPs’ self-rated competency levels were higher than regular school nurses for a wide range of both traditional and expanded role activities.”

Structure variables have been studied even less frequently than outcome varibles. Especially lacking are studies on the relationships between the process or outcome variables and important institutional factors that logically could affect the activities of nurse practitioners and the outcomes of those activities. Goodwin did find that the presence or absence of health aides was not an influential factor in most of the differences found between SNPs and regular school nurses. When asked how satisfied they were with their new role, however, those SNPs with aides were more likely to report satisfaction than those without aides. I n that same study, the SNPs’ most frequently cited impediments t o full role functioning were all structure variables: lack of school

I administration support for the role; lack of time, facilities and budget to fully implement the role; excessive clerical work demands; large pupil-to-nurse ratios; lack of aides; and unclear differentiation of roles within the school system.”

When considered cumulatively, the data indicate nurse practitioners in schools are different from regular school nurses in terms of several important process variables, including: emphasis on, and specificity of, assessment and

prob1;m identification skills; attention to children with special physical, behavioral or learning needs; and number of contacts with parents, school personnel and other health professionals. Findings from two studies showed that SNPs exclude fewer children from school because of illness or injury. The findings on referral rates have been mixed, with one study showing fewer referrals for SNPs, two showing no differences between SNPs and regular school nurses in referral rates, and one showing an increase in referrals following NP training as compared to previously. As a variable, “referral rate” presents some methodological concerns since it is actually the accuracy of the decision to refer and the outcomes of the referrals that are the important considerations. The findings from three studies did suggest that SNPs’ referrals and exclusions resulted in more positive outcomes than those of regular school nurses.

Although the process variable data support the belief that nurse practitioners in schools are making valuable contributions t o the effectiveness of the school health serv- ices offered, there remains the unanswered question about effects of institutional factors on nurse practitioner effectiveness. The SNPs themselves perceive a large number of institutional impediments to full role functioning. The extent to which the impediments are real, however, is largely unknown and needs to be investigated. In doing such research, answers to related questions about the type and extent of association between institutional factors and relevant process and outcome variables will begin t o emerge also. Data of that type would greatly enhance our under- standing of the effectiveness of nurse practitioners in various types of school settings. Until such data are available, however, the evidence to date is more encouraging than not - suggesting that nurse practitioners in schools d o increase and improve health services.

I . Brink SG, Dale S , Williamson MC, et al: Nurses and nurse practitioners in schools. J Sch Health 51(1):7-10, 1981.

2. Bloch D: Evaluation of nursing care in terms of process and outcome: Issues in research and quality assurance. Nurs Research ’

3. Brook RH, Williams KN, Avery AD: Quality assurance today and tomorrow: Forecast for the future. Annuals In/ Medicine 85:809-817, 1976.

4. Prescott P. Driscoll LA: Nurse practitioner effectiveness: A review of physician-nurse practitioner comparison studies. Eva/ and Health Prof 2 3 7 - 4 1 8 , 1971.

5 . Hilmar NA, McAtee PA: The school nurse practitioner and her practice: A study of traditional and expanded health care responsibilities for nurses in elementary schools. J Sch Heulth 43(7):43 1-441, 1973.

6. McAtee PA: Nurse practitioners in our public schools?: An assessment of their expanded role as compared with school nurses. Clin Pediarr 13360-362, 1974.

7. Lewis CE, Lorimar A, Lindeman C, et al: An evaluation of the impact of school nurse practitioners. J Sch Health

8 . Pennsylvania Nurses’ Association: Lower Doriphin School District leads the way into the use of school nurse practitioners for improving health care in the public schools. Pennsyl Nurse 33:7-8, 1978.

9. Henzell JM: The expanded role of the school health nurse in pediatric screening. Austr Pediatr J 13:44-48, 1977.

10. Nader PR, Conrad J, Williamson M, et al: The high school nurse practitioner. J Sch HeaNh 48(3):157-159, 1978.

1 1 . Goodwin LD: School nurse practitioners versus “regular” school nurses: How different are thev? In oress. 1981.

24:256-263, 1975.

44(6):331-335, 1974.

Laura Driscoll Goodwin, PhD, Associate Professor and Program Evaluafor, School Health Programs (School Nurse Practitioner Program and School Nurse Achievement Program), University of Colorado School of Nursing, 4200 E. Ninth A venue, Denver, CO 80262.

624 THE JOURNAL OF SCHOOL HEALTH NOVEMBER 1981