What clinical, professional or educational issues do expert non- government school nurses in Western Australia perceive as a priority for research investigation?

Anita Moyes*

RN, PhD

Edith Cowan University, WA, Australia Email A.Moyes@ecu.edu.au

Elizabeth Rankin

RN. RM. Grad.Cert Nurs
South Australian School Nurses Association, SA, Australia

Chelsey Williams

B.Sc (Nursing), Grad.Dip Mental Health Edith Cowan University, WA, Australia

*Corresponding author

Abstract

Background

School nurses provide health care to children and young people in the school setting. Little has been published about school nursing in Western Australia, highlighting a pressing need to establish a comprehensive list of research priorities to address the knowledge gap.

Methods

This study employed a four step Nominal Group Technique to explore school nursing priorities from the perspective of expert school nurses working in non-government schools in Western Australia. Five nurses with more than 60 years of school nursing experience collectively generated more than 60 research ideas using this approach, subsequently grouping these into key areas through facilitated discussion and group consensus.

Findings

Priority research issues were strongly inter-related and primarily reflected school-level professional concerns which impact school nursing practice. The findings highlighted that nurses want greater opportunity to practice to their full scope, be acknowledged for school nursing work, to have improved professional identity as a school nurse and to be positioned as a leader in student health and well-being.

Conclusion

Expert school nurses want to understand how school leaders perceive the role and contributions of the school nurse. This insight is crucial in improving the visibility of school nursing work and may contribute to addressing the professional issues identified in the study.

Keywords: school nursing, Australia, research priorities, nominal group technique, scope of practice

For referencing: Moyes A, Rankin E and Williams C. What clinical, professional or educational issues do expert non-government school nurses in Western Australia perceive as a priority for research investigation? Journal of Children and Young People’s Health 2024;5(1):5-11

DOI https://doi.org/10.33235/jcyph.5.1.5-11
Submitted 14 October 2023, Accepted 11 December 2023

Background

School nurses provide care to children and young people attending school. While school nursing has a long history in Western Australia,¹ there is a paucity of research exploring

this work. A review of the literature identified only four peer-reviewed studies specific to school nursing in Western Australia. The earliest described the growing complexity of the role²; a second considered the resources needed for effective practice.³ Moyes explored the history of school nursing,1 while the most recent publication explored school nurses’ work in mental health.⁴ These published works do not identify what school nurses themselves consider to be important priorities for their practice. If school nurses are to benefit from future research in the field of school nursing, a study exploring what nurses identify as research priorities is a crucial first step.

There are 815 government and 315 non-government schools in Western Australia.⁵ School nurses work in both school systems, but there is little publicly available data about school nursing work in either system. According to the Department of Health, government school nurses undertake a role aligned to the social model of health with emphasis on health promotion, early intervention, and safeguarding.⁶ As visitors on the school site they report to a clinical nurse manager located off-site from the school. They do not routinely respond to student injury or illness, are not responsible for routine health care planning and do not typically administer medication.⁶ Responsibility for these activities rests with the school.⁷

In contrast, non-government school nurses are employed directly by the school where they are based and are line- managed by a member of the school staff.⁸ They undertake health care planning and provide routine medical support for diagnosed health conditions, as well as triage, assessment and intervention with acute illness, injury, medical emergencies, and general health concerns. Some may also attend to the ongoing health needs of boarding school students.⁸

Given the diversity of school nurse practice in Western Australia, the researchers elected to focus on non- government school nurses. The purpose of this study was to identify what nurses employed in non-government schools in Western Australia identify as key research priority areas for their practice. The research question was: What clinical, professional or educational issues do non-government school nurses in Western Australia perceive as a priority for research investigation?

Methodology

Design

The study employed Nominal Group Technique, as described by Van de Ven and Delbecq.⁹

Method

A highly structured and transparent method,¹⁰ Nominal Group Technique combines elements of an individual survey and a focus group.¹¹ The method is useful for generating a diverse range of ideas, while also aiming to achieve agreement among a group of experts or stakeholders. It has been used in a wide range of health-related studies.^12-14

The technique involves a four-step process with an expert group during a single face-to-face meeting. The approach is ‘nominal’ because the individual views of each participant are equally weighted, minimising the influence of dominant individuals.¹⁵ Four clearly defined sequential steps generate a group consensus while also limiting the risk of influential group dynamics or the generation of ‘group think’.¹¹

The nominal group technique is illustrated in Figure 1. Step one involves the silent generation of ideas at the individual level. In step two, participants select one idea from their list and share it with group members. This process is repeated in ‘round robin’ fashion until all participants have shared all of their ideas. During this time participants are also permitted to continue generating new ideas. In step three, participants discuss the ideas put forward with the goal of clarification. Ideas can be amalgamated, excluded, or altered, but only if group members agree. In step four each participant selects the five ideas they believe to be the most important. Each participant weight these with the most important idea being given the most weight. Finally, the facilitator aggregates the weighted individual findings to generate an aggregate list of most important to least important ideas.

Institutional Review Board approval

The study received Ethics approval from Edith Cowan University Human Research Ethics Committee (2022-03657- MOYES).

Population, sampling and recruitment

The study was conducted in collaboration with the Western Australian School Nurses Association (WASNA), a professional association for school nurses. Most registered nurses employed in non-government schools are members of the association. The study co-investigators are unaffiliated with the association while the principal investigator is the association’s research officer. All members of the research team are female registered nurses with school nursing experience.

The sample was purposive and drawn from the association membership. The criteria for inclusion was a minimum of five years of experience as a school nurse in a non-government school in Western Australia and current employment in that context. This group are referred to here as expert school nurses. The association has approximately 70 members, half of whom met the inclusion criteria. The rationale for selecting an expert group was to capture the views of established school nurses, rather than nurses transitioning to school nursing practice. Nurses employed as a school nurse for less than five years, those employed as enrolled nurses and registered nurses employed in government schools were excluded from the study.

An invitation to participate was extended to the association members in the form of an email from the President. The participant information sheet and consent form were also provided. Interested individuals contacted the principal investigator directly to express interest. The principal investigator confirmed eligibility according to the inclusion criteria and ensured that participants had received the information sheet. Written consent to participate was collected ahead of the meeting. Eight individuals provided a signed consent form, representing 22.8% of the eligible membership. One was not able to attend the meeting due to a scheduling conflict. Two others were unable to attend on the day due to illness. Five participants therefore participated in the study. There are no accepted guidelines for participant numbers in a nominal group meeting, however the original authors suggest five to nine.¹⁶ All the participants were female. Collectively they had worked in 17 schools, had more than 62 years of experience in school nursing, and they all currently worked in both high and low socioeconomic areas.

Data collection and analysis

Data was collected during a single face-to-face meeting in May 2023. The facilitator provided a brief overview of the four steps that would be undertaken (see Figure 1). Participants were instructed to consider the following question: What clinical, professional or educational issues do school nurses in Western Australia perceive as a priority for research investigation? The facilitator gave non-specific examples of clinical, professional, or educational issues participants might perceive to be important. An example of the wording for clinical suggestions was: “How can school nurses support students who present with…?” There were no limitations to the type or number of ideas participants could raise.

In step one of the nominal group meeting, participants were given twenty minutes to reflect silently on the question. In this step, participants wrote as many ideas as they could think of onto individual sticky notes.

In step two, participants read out one idea from their sticky notes and handed this to the facilitator to display. The participant seated to their left then did the same in an iterative manner. When each participant in the group had put forward one sticky note the process was repeated, until all participants had put forward all their sticky notes. During this step participants were not permitted to discuss or debate the ideas, however participants were permitted to write new sticky notes while step two was ongoing. Step two concluded when the participants had no further sticky notes to put forward. During steps one and two participants identified approximately 58 ideas.

In step three the facilitator read out each sticky note. During the facilitated discussion participants were encouraged to question and clarify the content. Where ideas were clarified, this was noted by the facilitator on the relevant sticky note. The group determined that each idea was unique and elected not to amalgamate or exclude any of the ideas. The group also noted that many of the ideas could be grouped around four core issues and primarily reflected school-level professional concerns. The sticky notes were re-arranged to reflect these core ideas until a consensus was reached. Further discussion prompted participants to propose a label that reflected the meaning of the four core groups of ideas. The four labels were noted by the facilitator on a sticky note and placed with the relevant group of ideas. The inclusion of the four new labels increased the overall number of sticky notes from 58 to 62. This concluded step three.

Finally, in step four each individual participant selected five ideas which they believed to be the highest priority, assigning five points to the most important idea and one point to the least important idea. All but one participant selected a core group of ideas. The aggregate scores were then tallied by the facilitator during the meeting and shared with the group. This concluded the nominal group meeting.

Data management and storage

All sticky note data, including clarification notes made by the facilitator, were transcribed within 48 hours of the meeting. The sticky notes remained in the possession of the principal investigator until they could be stored in line with university policy for the safe storage of physical data. The digital data will be stored for seven years on centrally provisioned university storage through Microsoft SharePoint in line with the university research data management storage policy.

Findings

In this study participants were asked to identify clinical, professional, or educational issues that school nurses in Western Australia perceive as a priority for research investigation. Participants identified 62 ideas during the nominal group technique meeting and prioritised nine groups of ideas at the aggregate level. The findings are shown in Table 1.

Overarching research idea	Name for the group of ideas	Points awarded	Aggregate points:	Overarching research idea aggregate points:
Perception of school nursing contributions	Not feeling valued: Ask the principal what the school nurse brings to the school.	Participant 1 = 4 points Participant 2 = 5 points Participant 5 = 3 points	12	22
	Workload pressure: Investigate the lack of time for clinical care.	Participant 2 = 2 points Participant 4 = 3 points	5
	Invisible workload: Explore the lack of administration time for effective school nurse practice.	Participant 3 = 2 points Participant 4 = 2 points Participant 5 = 1 points	5
Perceptions of the school nurse role	What is the perception of the school nurse role from the perspectives of the school leadership group?	Participant 1 = 2 points Participant 3 = 4 points Participant 4 = 5 points	11	19
Perceptions of the school nurse role	Excluded and marginalised: Explore the lack of collaboration and consultation.	Participant 2 = 4 points Participant 4 = 4 points	8	19
School motivations for employing a school nurse	Why do schools have a school nurse?	Participant 1 = 5 points Participant 3 = 3 points	8	10
School motivations for employing a school nurse	Explore school-level service boundaries. What should school nurses provide?	Participant 2 = 1 point Participant 3 = 1 point	2	10
Fitting into the school organisational structure	Where does the school nurse fit into the school?	Participant 1 = 3 points Participant 3 = 5 point	8	9
Fitting into the school organisational structure	Explore the difficulties with non-nurse line management.	Participant 4 = 1 point	1	9

Table 1. Individual and aggregate points awarded.

Research ideas predominantly related to professional issues, with very few describing educational or clinical concerns. Given the degree of interrelatedness the findings are reported here in a narrative form incorporating the ideas. The nine groups were categorised into four topics: Perception of school nursing contributions; Perceptions of the school nurse role; School motivations for employing a school nurse; and Fitting into the school organisational structure.

Perception of school nursing contributions

The first priority issue was Perception of school nursing contributions. As one participant put it, “What do you think I do?” This topic included three groups of ideas:

1. Not feeling valued: Ask the principal what the school nurse brings to the school

2. Workload pressure: Investigate the lack of time for clinical care

3. Invisible workload: Explore the lack of administration time for effective school nurse practice.

A feeling of being unacknowledged and undervalued was expressed in various ways. Participants indicated that nursing interventions that facilitated school metrics, such as student attendance and educational outcomes were rarely recognised. There was a perceived mismatch between nursing responsibilities and the remuneration offered, a lack of attention to the physical space and location provided for school nursing services and poor support for nursing professional development.

A related issue was workload pressure. Participants were concerned there was a lack of time for clinical care, and a high volume of unacknowledged administrative work and follow-up. The time required to plan care for health issues such as diabetes, epilepsy, asthma, and anaphylaxis was often significant, but largely invisible. Administrative tasks such as data entry, following up with parents regarding medical action plans, out-of-date adrenalin autoinjectors, missing medical certificates, lost vaccination consent forms, and related paperwork took up a significant amount of time. Engagement in these tasks was even more invisible if parents or service providers did not initially respond to requests for information, an outcome that was not unusual. One participant was officially provided with four hours per week for administrative tasks, a time allocation the group deemed to be entirely insufficient.

Participants reported that time spent caring for students with complex social needs was also undervalued, for example in cases of boarding school students from remote Aboriginal communities or from overseas. Some of these students did not speak English as a first language, and some came from regions where there were limited health services. Out-of-area students often presented with homesickness and difficulties transitioning to an unfamiliar culture and school environment, while others had health issues, such as chronic otitis media or a sexually transmitted infection. Obtaining accurate information about the health services students had received previously could be difficult. Some boarding school students were also scholarship recipients with limited financial means. This combination of factors could make the task of referring students for required health services substantially more complex.

Another source of feeling undervalued was when participants were provided with a physical space that was unsuitable or inadequate to work effectively. Space was so limited in some schools that one participant described using their office as a treatment room. This was an issue not only for the nurses themselves, but also for the quality of clinical care that could be provided. Confidentiality could be difficult to maintain when there were so many students in a small space. Poor visibility within the space could compromise the welfare of students as well as the safety of nursing staff. Some participants described the physical location of the health centre within the school as being very isolated and expressed a need to have adequate staff available to provide support in the event of a medical emergency. Co-location with other well-being staff would also aid consultation and collaboration. Isolated school health centres were a source of concern from a nurse-safety perspective, as it was not uncommon for participants to find themselves working alone in the school health centre until the early evening. Darkness during the winter months and the proximity of the school health centre to the external boundaries of the school added to their safety concerns.

Adequate remuneration and support for professional development may have helped to overcome a lack of acknowledgement and sense of being valued, but participants felt there was considerable room for improvement on these points. Participants described a high prevalence of unpaid overtime and were often unable to take scheduled meal breaks due to urgent clinical demands. Some participants were also required to be on call to the boarding school staff over the weekend, a task for which they felt poorly remunerated. Participants were frustrated that schools were hesitant to fund or release school nurses to engage in professional development, particularly when schools were often cognisant of this need for teachers. They felt the school leadership group did not understand the professional responsibilities and regulatory obligations school nurses have, nor the need for nurses to adhere to nursing standards of practice.

Perceptions of the school nurse role

The second priority issue Perceptions of the school nurse role included two groups of ideas: 1. What is the perception of the school nurse role from the perspectives of the school leadership group? and 2. Excluded and marginalised: Explore the lack of collaboration and consultation.

In contrast to the first priority where participants explained they felt undervalued and unacknowledged for their work, this topic related to feeling they were not able to practice to their full scope. Participants were concerned the school leadership group did not understand the professional scope, responsibilities or educational background registered nurses brought to the school nurse role. They reported being viewed as the recipients of health directives from education staff rather than experts on student health.

Participants were frustrated when they were not invited to collaborate or consult on student health issues and sometimes felt excluded. There could be an absence of school nursing involvement in the process of enrolling new students, even when the student had high health needs or high-risk circumstances that required resource-intensive management. This limited the ability to plan for the nursing resources needed to manage the student’s health issue and was cited as a missed opportunity to acquire information about students’ health needs directly from parents.

Participants also felt marginalised in student health promotion activities. They were not invited to collaborate on student wellbeing initiatives, such as promoting good sleep, nor were they included in addressing health concerns, such as vaping. Similar issues were raised about mental health. Schools often perceived student mental health concerns to be the domain of the school psychologist, but anxious students were often sent to them when the psychologist was unavailable. Despite this being a common practice, participants were not typically appraised of the student’s school-based management plan. They felt frustrated at this exclusion and noted this was a lost opportunity to respond to the students’ health needs in a coordinated manner.

Overall, participants reflected that the perception of the school nurse role was limited compared to other positions — such as teachers — who were more commonly recognised for their contributions to pastoral care, student leadership, and student wellbeing. In contrast to teachers, school nurses did not have a defined career pathway in the school context and could not hope to progress in their career in the same way teachers did.

School motivations for employing a school nurse

The third priority issue was School motivations for employing a school nurse. This priority issue included two groups of ideas: 1. Why do schools have a school nurse? and 2. Explore school-level service boundaries. What should school nurses provide?

In this key priority area participants sought to understand what the school community expected from a school nursing service. Participants explained that the boundaries or limitations of the school nursing service were poorly defined. Both schools and parents appeared to have expectations of school nurses that participants did not perceive as a good use of limited nursing resources.

A major concern for participants was the amount of work they were engaged in that could more effectively have been undertaken by other school staff. In many instances students had been sent to the school nurse for very minor ailments that could have been managed by teachers: “the tiniest papercut” as one participant described it. First aid kits were typically located all over the school and school staff were aware of this, but the issue persisted. Some junior teachers were reluctant even to supervise the application of a Band-Aid in case this was not the right course of action. Participants wanted teachers to encourage students with basic self- care strategies and guidance on managing minor health issues independently. They explained this promoted student resilience, development of self-care skills, and confidence in their own abilities. This approach would also permit a more optimal use of school nursing time.

A parallel issue was that some parents viewed the school nursing service as a school-based entitlement when they were unavailable to manage their child’s health issues. Participants noted that parents often had high expectations in line with being a fee-paying customer. This could create additional pressures for school nurses, as parents could have heightened expectations regarding the level of service and individual attention that could be provided to their child. Participants emphasised a need to clearly define the scope of the school nursing service and the corresponding responsibilities of parents. They noted instances where parents would send their child to the school nurse for assessment of an acute health issue — such as a weekend ankle sprain — expecting immediate solutions or referrals. Participants worried that parents did not recognise a need for ongoing care and follow-up that could only be managed by the parent themselves. These challenges underscored the importance of setting realistic expectations with parents, ensuring they understood the role and limitations of the school nursing service and their own responsibilities in the health of their child.

Fitting into the school organisational structure

The last priority issue Fitting into the school organisational structure included two groups of ideas: 1. Where does the school nurse fit into the school? and 2. Explore the difficulties with non-nurse line management.

A considerable source of frustration was the experience of being line managed by a non-nurse, especially one who had little health literacy. Participants variously described reporting to line managers, such as the school bursar, the deputy principal, or the head of the boarding school. Participants complained that their direct line manager was not always interested in understanding the school nursing perspective. This could make communication difficult, impeded nursing decision-making and posed challenges in managing clinical work. Some participants had attempted to address the issue by advocating for a change in line management to better position the school nursing role, but with little success.

Participants also emphasised the importance of establishing a flow of information that promoted a holistic approach to student health while also respecting confidentiality and limiting sharing of information on a need-to-know basis. These two apparently conflicting perspectives reflected the desire for a team approach rather than a siloed approach to student health care and reflected a lack of clarity about nurses’ place in the school organisational structure.

Discussion

This study is the first to examine what expert non-government school nurses in Western Australia identify as key research priorities for their own practice. The main priority issues were strongly inter-related and primarily reflected school-level professional concerns which impact school nursing practice.

The key finding was that school nurses want to understand how school leaders perceive their contributions and role as school nurses. This insight is crucial in addressing broader professional issues that were also raised in the study. These include improving the ability of school nurses to practice to their full scope, acknowledgement of school nursing work, promoting school nursing professional identity, and positioning the school nurse as a key consultant for student health and well-being in the school organisational structure.

At an international level, these findings are not new,^17-20 but further comparisons are limited by the diversity of health and education systems in which these studies were conducted. Whether other Australian states and territories experience similar issues is also unclear. Australian school nursing practice is highly heterogenous²¹ and literature very limited.

In the Western Australian context, only one other paper investigating the work of non-government school nurses has been published³. McCluskey³ focused on the needs of the school as a community rather than the needs of school nurses themselves and therefore involved a broader range of stakeholders, such as students, parents and teachers. McCluskey’s participants noted similar issues to those described in the current study, including a lack of nursing time and high workloads, unsuitable physical spaces to work in, limited support for professional development and professional isolation.3 Feeling undervalued and being limited in one’s scope of practice can impact the wellbeing of nurses and contribute to attrition.²² It is therefore important to note that the broader stakeholder group in McCluskey’s study did value school nursing work.³

An unexpected finding was the exclusive focus on professional issues. This is notable given there was no limit to the number of ideas participants could put forward. Moreover, a range of non-specific clinical, educational, and professional examples were provided during the orientation to the meeting. This finding implies that expert school nurses feel proficient with their clinical practice. One explanation for the predominance of professional issues is that these may only emerge as school nurses become more experienced and clinically competent in their roles. Experienced nurses may also be more likely to have resolved problems they are able to influence, leaving only those issues that are less amenable to their own unilateral efforts.

Future school nursing research in Western Australian should explore several related issues. The first is to investigate perceptions of the non-government school nurse role from the perspective of the school leadership group, as identified by participants in the current study. The second is to explore the priorities school nurses at all levels of experience identify as important to their practice. The finding that expert non- government school nurses had few clinical or educational priorities is noteworthy. It raises many questions about the professional journey to becoming an expert school nurse and should be explored further.

Lastly, while service evaluation may be a low priority for school nurses owing to the workload demands already identified, researchers should examine means to alleviate this burden by designing and testing appropriate metrics for school nursing work. While some of these are necessarily of importance to school nurses themselves, employing metrics that are meaningful to the school leadership group will improve the visibility of school nursing contributions.

Limitations

The study has a number of limitations. The sample size was small and limited to non-government school nurses. Participants were highly experienced and the findings may therefore not be representative of less experienced school nurses. Participants were all based in urban areas of Western Australia, and the findings may therefore not be representative of the view of regional school nurses.

Nominal group technique also has limitations for this research question. The method is highly reliant on having a group of adequate size meeting in a synchronous manner. Unexpected participant absence should be anticipated and planned for. Participants also require clarity in relation to the question posed at the outset of step one. Pilot testing the question is highly recommended as a question that is imprecise may generate ideas that are inconsistent with the purpose of the study. Finally, to aid fidelity in applying the method facilitators should be experienced in the management of groups and group dynamics.

Conclusion

This study investigated the research priorities expert school nurses in non-government schools in Western Australia have for their practice. The findings highlighted that nurses want to be acknowledged by the school leadership for school nursing work, want improved professional identity as a school nurse, have greater opportunity to practise to their full scope and be positioned as a leader in student health and well-being.

Conflict of interest

The authors declare no conflicts of interest.

Funding

The authors received no funding for this study.

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