Visits by Elementary School Children - to the School Nurse

Charlotte Stephenson

ABSTRACT Various factors seem to influence health seeking and illness behavior in

childhood. among which are early socialization, modeling behavior in adults, the labeling of illness and psychological distress. The characteristics of a group of elementary school children who visited the nurse’s office were observed and descriptive data were obtained on 551 students during a six-month period. Correlation analysis of the data was made. The conclusion of the study supported the following ideas: 1) health seeking and illness behavior was a learned process; 2) there was no differences noted in the frequency of visitation by boys or girls; and 3) recurrent health problems contributed to the frequency of visitation. The role of the school nurse in assessing potential physical and or psychological problems was affirmed.

The school nurse’s role provides an opportunity for a variety of interactions within the school population. Receiving and assessing children who have a problem can be challenging because the children come to the nurse’s office for a variety of reasons. Some children are very articulate in expressing their needs while others are not. At times the stated problem may not be the real problem. Therefore, the nurse has to discern the needs of the children and act accordingly.

PURPOSE This study’s purpose was to observe the character-

istics of a group of elementary school children who visited the school nurse’s office in an attempt to answer the following research questions:

1. What types of visits are made to the school nurse? ;

2. Does grade (age), academic achievement, and/or gender contribute to frequency of visitation?;

3. Does the families’ socioeconomic status influence the children’s frequency of visitation?; and

4. Does the presence of a recurrent health problem contribute to frequency of visitation?

To obtain descriptive information and investigate possible relationships, all visits to the elementary school nurse’s office were systematically recorded over a six- month period and reviewed for correlation and fre- quency of visits.

LITERATURE The study of individual and group behavior in a

social environment has been the focus of social psychol- ogy in the literature. According to Campbell,’ the roots

of adult general social orientations are often ascribed to childhood, and views on health and illness may also stem from the early years. The child health orientation may involve several factors including role models, parental goals and values. After the early years of child- hood, extra familial influences, such as peer and school environment, seem to contribute to the socialization process.2

Kasl and Cobb) have attempted to describe the three types of behavior as health, illness and sick role. Health behavior has been defined as action on the part of an apparently healthy person to stay well. illness behavior involved action by a person who feels ill to define the state of his health and seek a remedy. Sick role behavior involved activities by those who consider themselves ill to get well. All of these definitions apply to the school situation, but the focus seems to be more on illness.

The most marked experience of cultural learning and socialization occurs during the child’s early develop- ment and continues throughout life. Social learning theorists‘ propose that the manner in which ideas and ideals are communicated and enforced, the ways in which rewards and punishments are allocated and the fashion in which annoyances and support are expressed all play an important part in the development of per- sonality traits. Thus, the family plays an important role in the child’s day-to-day psychosocial functioning and long-range social development.

illness behavior is part of the socialization process. it is shaped over time depending on the occurrence of the illness, learning and social experiences of the child and environmental factors. Mechanic6 states that the definition of the ill state involves three parts: bodily sen- sations, or feeling different; social stress, which heightens attention on inner feelings and an attempt by the person to define or describe what they are feeling.

Role theorists maintain that learning traditional roles and modeling of illness behavior by adults account for illness behavior in children.‘ That is, when children are ill they model behavior that has been observed in adults who are ill. As the child grows older, there is a shift in expectations that parents and others have for the child’s behavior. The child is expected to act “like a big boy or girl” with behavior involving more and more

594 JOSH December1983,Vol.53,No. 10

self-discipline. Also as the child grows older, the youth is better able to acquire and use information about self and the social wor1d.l It is assumed that as the child matures, the youth will increasingly adopt adult per- spectives and share with adults similar concepts leading to appropriate role functioning.’

The labeling of diseases or illness as a problem is another factor that is learned. Generally a group of people, family, friends, neighbors or a common society must label a condition as a disease or disability before it can be considered a health problem to that group. Often the more frequently a disease occurs, the more likely it will be considered normal rather than ill health for that population group.

Psychological distress also contributes to the sociali- zation process. Kaplan and KaplanLo suggested that if a person’s psychological defenses are inadequate to de- crease an excited or anxious state of emotional tension, then a variety of psychosomatic diseases may be pro- duced in susceptible individuals. Children who com- plain frequently of stomachaches and headaches are possibly experiencing psychological stress. Complain- ers, according to Mechanic,L1 learn to use symptoms as means of coping with psychological problems and these illness behaviors tend to be reinforced by parents, teachers and health personnel. Thus somatic complaints can serve as a source of social reinforcement.” When used infrequently, somatic complaints gain concern and sympathy from others, and/or an opportunity to avoid a stressful situation.

Children respond to frustration by developing physi- cal illness symptoms. Contributing to the frustration may be family conflicts in which the child is acting out a family problem. I 3 A child’s behavior or physical illness may be an attempt at problem solving.

In the early 195Os, Talcott ParsonsL4 published his thoughts on the sick role in our society. Although his ideas have been debated over the years, two relate to the present study. First, he felt the expectation of the sick person was to be exempt from normal social role responsibility. Second, the person was to be exempt from the responsibility of being sick. Does this apply to children? Is this part of the health seeking behavior? Do children expect an exemption from normal activity and expectations if they are “sick?”

Utilization of health services also relate to this study. According to Rosenstock,IJ those who use preventive health services seem to be younger or middle age people, female, better educated and with a higher income. Those who delay utilizing health services seem to be the older population group, lower socioeconomic status and, in some studies, males. Utilization of services seems to have a demographic variation.

Age seems to be one of the mentioned variable in

health and illness behavior. In a study by Palmer and Lewis1* of elementary school children, they found that the higher the grade the more the children were able to interpret bodily cues in making decisions about how they felt. The younger children seemed to exhibit Piaget’s syncretic thinking in relationship to illness. They may attribute “catching a cold” to going outdoors without a jacket. Older children knew more about germs and had more realistic thinking in relation to ill- ness. As part of the maturation process, younger chil- dren seemed to mention vague feelings when ill while older children become more specific in expression.

According to Mechanic,‘ most data on health service utilization by children indicate few sex differences. This is probably because mothers usually make the decision about utilization for both boys and girls. In a study of fourth grade children, no sex differences were reported in willingness to tell others when they were not feeling well. However with increasing age, girls were willing to report not feeling well, but boys were less willing. Socialization patterns may contribute to the encourage- ment of boys to become more stoical.

Learning may influence the tendency of males, as compared to females, to take more risks, to seek medi- cal care less readily and to be less expressive about illness. I ’ Accident rates among males is higher than females presumably due to genetical differences, behav- ior patterns and vocational choices.”

Sex differences have been reported with respect to increased morbidity and mortality among males as com- pared to females from birth. According to Carter” girls seem to be more mature than boys from birth through- out childhood, as measured by bone age. Male vulner- ability to infection may be linked to the presence of the immune mechanism on the x chromosome which contri- butes to immune weakness from birth in males. How- ever, the reported rate for acute conditions seem to be higher in adult females than males. Females may be more willing to report these physical ailments.’@ Also, women generally seem to have more knowledge about health matters than men,” and seem more willing to care for themselves when feeling il1.l8

Utilization of health services has also been linked to socioeconomic variables. According to Campbell’ indices of socioeconomic status seem to be an objective indication of variations in life styles, orientation toward the social world, attitudes and values. It seems reason- able that chronic situational barriers like poverty, lack of transportation, family problems and negative experi- ences with health agencies, may make some groups pessimistic and provide low motivation to utilize these services.” Children reared in these environments may adapt the same attitudes and behaviors as adults.

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HYPOTHETICAL FORMULATION Because certain variables were known or suspected

to be of significance in accounting for visits to the nurse’s office, the following research hypothetical state- ments were formulated to be tested:

1) Children on free lunch program will visit the nurse’s office more frequently than children not on free lunch program.

2) Children who do not have a private physician will visit the nurse’s office more frequently than those who have a private physician.

3) Children in grades three-five will visit the nurse’s office more frequently than those children in grades

4) Children in the lower levels within each grade will visit the nurse’s office more frequently than those in the upper level in each grade.

5) There will be no difference in the frequency of visitations between boys and girls to the nurse’s office.

6. Children who have a history of recurrent health problems will visit the nurse’s office more frequently than children who have no history of recurrent health problems.

7) There will be no difference in distribution of health problems between boys and girls.

K-2.

METHODOLOGY Setting

The study was conducted in an independent school district in the suburbs of Houston, Texas, during a six- month period. The community was predominately white, middle and upper lower, socioeconomic class, with the minorities being Hispanic and Black (3%). One elementary school with 551 students from kindergarten through fifth grade (ages 5-1 1) was used for the study.

The school had a school nurse and an aide to staff the school. The school nurse was responsible for two schools in close proximity to each other. The school nurse alternated days between the two schools, but was available by phone for consultation and/or emergencies.

Data Collection Data for the study came from three sources. The

first source was a flow sheet on which each visit to the nurses’s office during the six months was recorded. The flow sheet included identification of the child, time of visit, teacher, grade, stated problem and disposition.

Assessment and interventions by the school nurse were directed at the presenting problem. In case of an accident, assessment and intervention related to the cause of the accident and presenting symptoms. Parents

or guardians were notified of all accidents that could have potential complications. For those problems that were not accident related, objective assessment included vital sign measurement, otoscopic and/or opthalmo- scopic examination and other measures of physical parameters. Subjective assessment included teacher ob- servation and notes as well as questions related to rest patterns and nutrition that might give clues to actual problem. Parents were notified of obvious problems like temperature over 99.6 or possible communicable disease.

From the information obtained, the types of visits were classified into trauma or accidents at school, non- referred, which included any problem other than trauma in which the child was sent home or to a physi- cian. Frequencies were collected on each type of visit and total number of visits per child. These categories were first used by Van Arsdell’O in his study of ele- mentary school children’s visitation to a school nurse and served as a guideline for classification in this study although other means of classification could have been possible.

The second source of information was the data com- puter sheets of the total population of the elementary school. The information collected from these sheets was grade and grade level of each child, sex of each child and a list of students on the free lunch program. Partici- pation in the free lunch program denoted a documenta- tion of family income and an estimation of socio- economic level.

The health record was used as the third source of in- formation. Each child’s record was current with an assessment and evaluation by the school nurse and pertinent information supplied by the parent or guard- ian. All student’s records were reviewed for a listing of a private physician and the presence of recurrent health problems.

Analysis The date from visits, computer sheets and health

records were tabulated and subjected to frequency dis- tribution and multivariance analysis technique. Mann- Whitney U, with a level of significance of 0.05, was used to compare total visits by children on free lunch, with a private physician, by sex and with recurrent health problem. Pearson correlation coefficient was used to compare grade, grade level and total visits. Chi Square was used to compare recurrent health problems by sex.

PRESENTATION AND ANALYSIS During the six months, 28% of the school popula-

tion (N= 154) did not visit the nurse’s office. Of the

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72% who visited (N=397), the total number of visits were 1,402. The distribution varied from one visit to 20 visits per child, with the mean being 2.5 visits per child.

More than 31% of the visits occurred each week on Monday, with Thursday and Friday having lesser per- centages, 13% and 16%, respectively. The time for the visits varied. Visits for trauma seemed to cluster early in the morning and around noon. These are times of decreased supervision by teachers and during recess time. Trauma cases accounted for approximately 29% (N=406) of the total visits to the nurse’s office (Table 1).

Nonreferred problems accounted for 56% (N = 785) of the total visits to the nurse’s office (Table 1). For these visits, the child has a systematic assessment. If fever was not present (99.6) and no acute problem identified, the child was generally returned to the class- room. Occasionally, for headaches or stomachaches, the child was allowed to rest for a few minutes in the office. A list was tabulated for the nonreferred problems to show the distribution of the visits (Table 2). Stomachaches and headaches, as distinct entities, oc- curred in 35% (N = 275 out of N = 785) of the nonrefer- red visits. Both of these problems vary in intensity and can be related to a variety of problems.

Visits that were referred accounted for 15% (N=210) of the total visits (Table 1). Frequency of visitation for referred problems varied from zero to seven, with the mean of 0.37 per child. Table 3

Table 1 Distribution of Total Visits to the Nurse’s Office Distribution of Total Visits to the Nurse’s Office

Non-Ref erred

56%

Referred

~ ~ ~ ~

Table 2 Frequency Distribution of Nonreferred Problems

hpblW m t a g e s

--- StOMchache 20

mscellanecus(Ex. splmters, blisters) 16

Headache 15

NauseaJ-tmg 10

Earache 10

sore throat Wlthaut fm 6

HeadacheaIdstaMdrache 6

Uose tmw tcothazhe 5

Rash/ zllsect bites 2

D U Z L D e S S 2

cau3hmg 1

sore feet/ ankles 1

Mseblet-d 0.4

cherheated 0.3

0 . 3

100.0

Dmtlonal upset -

represents the frequency distribution of problems for which a child was referred. The most frequently occur- ring problem was fever (temperature over 99.6 orally). In referring a child, the parent/guardian was called and the child was sent home or to a physician. In suspected communicable diseases, the child was excluded from school with a requirement that a release be obtained from a physician prior to returning to school. For other problems, a release may not be required although a sug- gestion might be made to see a physician.

RESULTS In the study, 15% of the population (N = 81) were on

the free lunch program. Participation in this program denoted a certain level of family income. Although it was assumed that children on the free lunch program would visit the nurse’s office more frequently than the population not on the free lunch program, the study did not show any significant relationship (p =0.26).

In the population studied, 18% (N = 101) of the chil- dren did not have a private physician. The second hypothesis was that children who did not have a private physician would visit the nurse’s office more frequently. However the data did not show a significant correlation between visiting and not having a physician (p =0.58).

Six grades were represented in the study, kinder- garten to fifth. The numerical distribution in each grade did not vary more than 10 students. The study did show

~ ~ ~~

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that the higher the grade the greater the frequency of visitation (p = O.OO), which supported the third hypothesis.

Grade level within each grade was correlated with frequency of visitation. Each grade had at least three levels, the lower for students achieving below grade level at the beginning of the school year, the middle for stu- dents at grade level and the higher for students above grade level. Placement within these levels was docu- mented by achievement testing and academic achieve- ment and did not change during the study. Approxi- mately 77% (N=424) of the school population was at grade level or above, with approximately 23% (N = 127) below grade level. It was assumed that children in the lower grade levels would visit the nurse more frequently than the rest of the population. However, the data did not support this to a significant degree (p=0.063).

The study population was comprised of 57% males (N=318) and 43% females (N=232). Sex was corre- lated with frequency of visitation. The statistics sup- ported the hypothesis that there would be no difference in visitation between sexes (p =0.57).

Twenty-six percent (N = 143) of the student popula- tion had a recurrent health problem. Table 4 lists the problems that were recurrent in this particular popula- tion. As anticipated in the study, students with recurrent health problems did visit the nurse's office more fre- quently than those who did not report recurrent health problems (p = 0.40). In considering recurrent health problems by sex, 31% of the boys, and 20% of the girls had recurrent health problems, with a level of signifi- cance of p=0.0014. This seemed to support the final hypothesis.

DISCUSSION One of the findings was that children who were on

free lunch did not visit the nurse's office more frequent- ly than the rest of the population. Part of the result could have been the small percentage of students in the population (15%) whose parents chose to participate in the program. In other studies, use of health services among adults was correlated with socioeconomic status, in that the lower the socioeconomic status, the less visitation occurred.2

The data did not show a significant correlation be- tween frequency of visitation and not having a physician. Two factors could have influenced this result. First, more than 82% of the school population had a private physician. Second, a factor that could not be controlled was utilization of the physician by those who said they had one. Utilization of physician services by the family would have probably given more accurate information, but the data was not available.

The study did show that the higher the grade the greater the frequency of visits. This seemed to support the idea of health-seeking behavior being a learned pro- cess. Perhaps older children seem to know how to use the sytem to meet their own needs, while those who are younger lack this knowledge." Palmer and Lewist6 found that the higher the grade, the greater the children's ability to differentiate the ill and injured state, and to communicate this difference.

In correlating sex with frequency of visitation, there was no significant difference between the sexes. Van ArsdellZo also found no difference between the number of visits made by boys or girls in the elementary years. Perhaps health-seeking behavior and/or illness behavior

-

Table 3 Frequency Distribution of Referred Problems

hoblen

-- Fever (no other anplajnt)

HeadachewithFRner

S i m u x b d ~ w i t h Few

V a n i t i n g ( w i t h or w i t h a t fwer)

anwJhing with fever

Possible Connrnicable disease

sarethrmt with fwer

Farack w i t h fever

D i a n h e a

Dizziness (rut releaved by rest%)

profuse rnsebleed

rresuency -----

29

18

15

12

6

6

6

4

2

1

1 iooa

Table 4 Frequency Distribution of Rcearrent Health Problems

598 JOSH December 1983, Vol. 53, No. 10

being expressed openly by boys begins to change in the adolescent years.

As expected in the study, students with recurrent health problems did visit the nurse’s office more fre- quently than those who did not report recurrent health problems. One interesting feature was the distributions of the recurrent health problems among the sexes, with more males than females having recurrent health prob- lems. Carter” reported increased morbidity in boys during the prenatal and childhood periods. However, females in the general population seem to have greater morbidity in health statistics.’* This may relate to reporting and seeking health interventions, rather than actual occurrence of morbidity.

Although the psychological variable was not specifi- cally isolated in this study, it would be interesting to note the rationale for visiting the nurse, particularly among the nonreferred group. It could be speculated that psychological factors, such as anxiety, fear of fail- ure and stress in the classroom would make a contribu- tion to the visitation. These would be difficult to docu- ment in children because their intellectual capacity has not reached full maturity and communication skills are not fully developed. Yet the climate created in the class- room certainly influences the child’s perception of him- self and others.

Kasl and Cobb’ commented that it is possible that psychological distress generates symptoms from which a person would want relief even though the person may not seek a physician. It is not known what proportion of individuals who come to the nurse’s office seek psycho- logical help. However, physical symptoms may cause psychological distress and psychological distress may cause physical symptoms. Other factors that can con- tribute to the child’s feelings include level of self- esteem, guilt, sadness and family difficulties.

CONCLUSION Although the findings from this study cannot be

generalized to another population group, they do show a trend in one selected population. The trend is for boys and girls alike to visit the nurse with the frequency increasing with the age group, Children from families of lower income did not necessarily visit the nurse more frequently than those from the general population. The presence of a recurrent health problem does affect the visitation to the nurse’s office and contribute to health seeking behavior.

Campbell’ stated that the childhood years provide a social apprenticeship in which the child learns the be- havioral context and standards for significant roles in society. If health seeking behavior or illness behavior is a learned behavior, which it seems to be, what contribu-

tion does the school environment make to the behavior patterning?

The school nurse is in a unique position to assess potential physical and psychological problems in the school child. Knowing the behavior patterns of a par- ticular population group in which service is rendered is one step in defining particular problem areas. From this assessment, the focus of attention can be directed and evaluations made. Nursing becomes a channel to meet a child’s need for physical and/or psychological attention.

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2. Inkels A: Society, social structure and the child, in Clausen JA (ed): SociPluation and Society. Boston. Little & Brown, 1968.

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behavior. J Sch Health 46(7):401-402, September 1976. 17. Carter CO: Sex differences in the distribution of physical illness

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Charlotte Stephenson, RN, MS, is an Assistant Pro fa- sor, in the School of Nursing at Northeast Louisiana Univemity, Monroe, LA 71209.

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