Abstract
This study examined school nurses’ communication with community physicians and its relationship to school nurse satisfaction with school health services. A stratified random sample of school nurses in Pennsylvania (N = 615) were surveyed about communication effectiveness with community physicians, satisfaction with school health services for students, perception of leadership, and students’ health care needs. Additional information from national/state education data on student poverty, nurse-to-student ratio, and rural/urban location was included. Findings indicate that having a leadership role in influencing school health policy is related to school nurses’ communication with community physicians and satisfaction with school health services. Effective communication with physicians was found to be a salient issue influencing satisfaction with school health services, suggesting the importance of stressing communication as well as leadership skills in school nurse education.
Keywords
School nurses play a pivotal role in the provision of child health care (Guttu, Keehner Engelke, & Swanson, 2004). As the health professionals most consistently involved in meeting children’s health needs in the school setting, school nurses have an implicit role in effectively communicating with physicians to coordinate the provision of high-quality care (DeBell, 2006; Schainker, O’Brien, Fox, & Bauchner, 2005). In particular, communication between physicians and school nurses is instrumental in facilitating disease management and care for students (Hillemeier, Gusic, & Bai, 2006). Furthermore, many parents expect that school nurses are able to effectively communicate with community physicians to provide satisfactory levels of service for their children (Cramer & Iverson, 1999). Although researchers have studied communication between nurses and physicians in clinical settings (Manojlovich, 2005; Narasimhan, Eisen, Mahoney, Acerra, & Rosen, 2006), few have examined school nurse communication with community physicians and how this communication influences school nurses’ satisfaction with health services for students. This study examines perceptions of communication effectiveness with physicians among Pennsylvania school nurses and whether effective communication is associated with satisfaction with school health services.
LITERATURE REVIEW
Effective communication is considered necessary for nurses to deliver appropriate care to patients. In inpatient settings, communication is a method for conveying patient information and details among health care providers, as well as gaining and distributing patient information to others (Ito & Lambert, 2002). Research on nurse and physician communication in clinical settings finds that communication with physicians has an important influence on patient outcomes, such as length of stay (Narasimhan et al., 2006), as well as job satisfaction rates among nurses (Manojlovich, 2005). For example, a study of 500 hospital nurses found that 60% of the variance in job satisfaction was predicted by their satisfaction with physician communication (Manojlovich, 2005). As a part of evaluating nurses’ job satisfaction, studies include the task requirements to be performed (Manojlovich, 2005). For the job satisfaction of school nurses, this can mean satisfaction with school health services being provided to students. School health services are an integral part of the overall duties that school nurses are asked to perform (DeBell, 2006) and are potentially influenced by physician communication.
“Research on nurse and physician communication in clinical settings finds that communication with physicians has an important influence on patient outcomes, such as length of stay, as well as job satisfaction rates among nurses.”
Little research has focused on the communication effectiveness between physicians and school nurses and its impact on satisfaction with the school health services provided to students. School nurses provide a variety of services, including health screening, physician referrals and follow-up, administration of prescribed medications, first aid and emergency care, provision of health education for students, and the education of teachers and staff on health requirements for students with special needs (Cramer & Iverson, 1999). School nurses engage in many communication interactions as they provide school health services; however, the most salient communication may be with community physicians in developing and managing health care plans for students. School nurses need to coordinate with physicians to develop health care plans for children—especially, those that have special health needs, such as asthma (Hillemeier, Gusic, et al., 2006). Poor communication with physicians can lead to a decrease in the ability to provide care for students, and it can consequently contribute to school nurses’ experiencing poor satisfaction with the health services being given to students.
When examining the type of communication between physicians and school nurses, research suggests that school nurse–physician communication may be primarily written rather than oral. For instance, a 2006 survey of 314 Pennsylvania state-certified school nurses found that 95% of school nurses require a health provider’s written order before administering prescribed medication and that 95% of these health providers are physicians (Ficca & Welk, 2006). Furthermore, an analysis of the Boston Public Schools 2001–2002 Health Services database revealed that of the more than 93 full-time nurses employed, 1.1% of the nurses’ verbal communication was with community agencies or health care providers and 4.1% of their encounters were with existing primary care providers (Schainker et al., 2005). It appears that communication is needed between school nurses and physicians and that sometimes this communication is minimal. Work is thus needed to understand more about school nurse and physician communication, as well as how this can contribute to satisfaction with school health services being provided to students.
INFLUENCES ON SCHOOL NURSE COMMUNICATION
Several individual and school factors influence a school nurse’s communication effectiveness. One of the more critical factors is leadership. Specifically, leadership perception is relevant to understanding the role of school nurses and their ability to perform their duties (Stock, Larter, Kieckehefer, Thronson, & Maire, 2002), including their communication with physicians. School nurses operate in team environments and are sometimes relied on to lead unlicensed personnel in providing services to students (DeBell, 2006). Training sessions such as the North Carolina Leadership Institute focus on building leadership skills among school nurse managers and enhancing their abilities to negotiate, manage, and communicate with staff and physicians (Guttu, 2007). Consequently, perception of leadership may contribute to school nurses’ confidence in their capabilities and in turn influence their communication with physicians about maintaining student health care. In addition, perceiving oneself in a leadership role may contribute to greater satisfaction with the school health care being provided because of the ability to be a part of the decision-making process concerning such provision of care.
“Perception of leadership may contribute to school nurses’ confidence in their capabilities and in turn influence their communication with physicians about maintaining student health care.”
Moreover, variables such as age and experience at the school may also have an impact on communication with physicians. These variables have been seen to influence nurse–physician communication overall (Manojlovich, 2005). It is possible that more experience with the school system and students overall provides an advantage of being able to communicate well with physicians on student needs because of the background knowledge available.
The geographical environment can also influence a school nurse’s communication effectiveness with physicians and overall satisfaction with school health services. For example, schools nurses often provide services for several schools that are miles apart (Gamm, Castillo, & Williams, 2004). In Pennsylvania, there is only 1 pediatrician for every 3,636 children in rural areas, compared to 1 pediatrician per 1,303 in the state as a whole (Hillemeier, Davis, & Smith, 2006). Furthermore, the poverty level of the school district and the size of the school are contextual factors that can influence the funds and resources available to school nurses for provision of health care services. For example, in Pennsylvania, rural schools have lower per-pupil expenditures than do urban schools (Hillemeier, Gusic, et al., 2006). A survey of Kansas school health resources indicated that the lack of appropriate resources and the economic well-being of the school environment threatened school nurse positions and that nurses feared losing their jobs because of economic constraints (Tetuan & Akagi, 2004). Research also suggests that the nurse-to-student ratio can affect student health outcomes, with schools having higher ratios showing higher percentages of children with health problems (Guttu et al., 2004). For example, schools with more favorable (i.e., lower) ratios have been found to provide more counseling services and follow-up care to students (Guttu et al., 2004). It is possible that the nurse-to-student ratio influences a school nurse’s ability to communicate with physicians. With higher nurse-to-student ratios and with school nurses caring for students across separate school districts, the amount of time that they have to speak or write to a physician about a student’s care may be limited and consequently compromised.
Given the critical role of school nurses and the role of communicating with physicians as a part of providing services for students with chronic conditions, it is important to understand how school nurses perceive their communication effectiveness with physicians. It is possible that school nurses perceive a need to communicate better with physicians and that perceived communication effectiveness with physicians influences school nurses’ satisfaction with the school health services provided. Using 2005 data from a survey of Pennsylvania school nurses, the following research questions were posited:
How effective do school nurses perceive their communication to be with community physicians? What factors are associated with greater perceived communication effectiveness with community physicians? Is perceived communication effectiveness with community physicians associated with school nurse satisfaction with school health services for students?
METHOD
Participants
This study examines responses from the 615 Pennsylvania public school nurses who participated in a larger study assessing school nurse, principal, and parent perceptions of school health services (Hillemeier, Davis, et al., 2006). A random sample of 997 Pennsylvania public schools, stratified to include one elementary and one secondary school building within each of the 500 active school districts, were recruited to participate in the study.
Procedure
A survey packet was mailed to each school building in the sample, addressed to the attention of the school nurse, using contact information from the Pennsylvania Department of Education. A cover letter to the school nurse explained the study and invited the nurse to complete the questionnaire. A $2 incentive and prepaid return envelope was included with the questionnaire. A total of 615 surveys were returned, resulting in a 62% response rate. In about 90% of the schools, there was only one nurse per building. Instructions stated that if there was more than one nurse present, the questionnaire could be completed by any of the nurses. To boost the response rate, reminder cards were mailed to those who did not respond within 3 weeks. The study was reviewed and approved by The Pennsylvania State University.
Survey Instrument
Via open-and closed-ended measures, the survey assessed the content and effectiveness of school nurse services across a range of dimensions of care. This report includes responses to the closed-ended items. Questions asked participants to report on the following: grades housed in the school (“Please indicate all the grades housed in this school”); perception of important duties as a school nurse (“What do you feel are the four most important duties you have as a school nurse?”); number of children enrolled in the school and specific health care needs of these children (“How many children in this school currently have each of the following health care needs?” e.g., allergies, diabetes, cancer); estimates of nursing services provided, including how many students in the school routinely receive at least one medication during school hours, which procedures are performed within the school setting, percentage of students receiving health screening tests annually, and whether health education instruction on various health topics (e.g., personal hygiene, first aid) is delivered one-on-one or via small group instruction; any parental permission and emergency care requirements; perceptions of leadership, satisfaction, and effectiveness of school health services and areas for improvement in health services; and demographic information. The entire questionnaire was four pages long.
Dependent Variables
Communication effectiveness with physicians. The first two research questions focused on perceived effectiveness of school nurse communication with physicians and factors associated with communication effectiveness. School nurses responded to the following question: “In your opinion, how effective are the following nursing services in meeting health needs in this school?” A total of 12 nursing services were listed, including health screening, medication administration, and therapeutic procedures (e.g., IV care, oxygen therapy). The outcome variable for this study was the response to the nursing service referred to as communication with community physicians. Respondents answered along a scale of very effective to not effective, not offered in this school, and unsure.
Satisfaction with health services for students. The third research question considered the relationship between perceived effectiveness of communication with physicians and school nurse satisfaction with the health services provided in the school. Participants were asked to evaluate their level of satisfaction with the amount of nursing service that the school is currently able to provide for 12 nursing services (e.g., health screening, medication administration, therapeutic procedures). The outcome variable was constructed with responses to the level of satisfaction with the service referred to as amount of health care for students in their school, ranging from very satisfied to very dissatisfied and unsure.
Independent Variables
Leadership. One of the questions that school nurses responded to involved their perception of leadership. The questionnaire stated, “Please indicate the level to which you agree or disagree with the following statement: Nurses in this school serve in a leadership role in developing school policies and programs.” School nurses could respond to the statement along a range of strongly agree to strongly disagree. They could also answer unsure.
School size. Responses to an open-ended question assessed school size (“In total, how many children are enrolled at this school?”). School nurses reported a range of 4 to 1,950 students enrolled in their school. For this study, schools with more than 537 students were considered large.
Poverty. To quantify poverty level among students in the sampled schools, data from the Pennsylvania Department of Education (2007) was used regarding the percentage of students eligible for free and reduced-price lunch in each school. According to the department, students qualify for a free lunch if they come from families with incomes at or below 130% of the poverty level, from families receiving Temporary Assistance for Needy Families, or from families receiving food stamp benefits; children in families whose income is between 130% and 185% of the poverty level are eligible for reduced-price lunches.
Type of school. School nurses reported the grades housed in the school, ranging from pre-K to 12th grade. A school was classified as elementary if the highest grade at that school was less than or equal to 6th grade. All other schools were considered secondary schools.
School nurse age. School nurses were asked to report their age. The ages of the school nurses in the sample ranged from 24 to 69 years, with a median age of 49 years.
Nurse-to-student ratio. The number of students per certified school nurse was calculated from data provided by the Pennsylvania Division of School Health. The Pennsylvania Joint State Government Commission requires a nurse-to-student ratio of 1 to 1,500 (Hillemeier, Davis, et al., 2006). The median for this sample was 1:1,008.
Health care burden. To understand the intensity of health care services provided to students, school nurses answered a question asking how many students receive any health care for a number of health conditions. Nurses could answer that a child had more than one condition. The following conditions—which potentially require significant nursing involvement in care, such as medication administration and symptom monitoring—were included in the present analyses: attention-deficit/hyperactivity disorder and attention-deficit disorder, arthritis, asthma, cancer, cardiac conditions, cerebral palsy, diabetes, and seizure disorder. The total number of children receiving health care services for each condition was divided by the total number of children enrolled in the school, and the resulting percentages were summed to create an overall measure of health care burden at the school.
Rural/urban. Urban school districts were defined as having more than 274 people per square mile (Center for Rural Pennsylvania, 2007). All schools were coded as being either rural or urban based on this definition.
Data Analysis
Data analysis included descriptive statistics of the participant demographics and the frequency distributions for the study variables. Logistic regression models were estimated to answer the research questions and evaluate whether the independent variables of interest are associated with the outcomes of communication effectiveness with physicians and satisfaction with school health services. A p value of <.05 was used to identify statistically significant effects. All analyses were performed using the SAS 9.1.
RESULTS
School nurses in the sample reported working an average of 23.0 years (SD = 8.9) as a school nurse and spending an estimated 9.8 years (SD = 7.2) at their current school. Table 1 provides descriptive demographic information for schools in the study sample. The majority of schools had an enrollment size of between 300 and 699 students, and in more than one fifth of schools, there was a high level of economic disadvantage, with 40% or more of the students qualifying for free or reduced-price lunch. Schools in the sample were almost evenly split between rural and urban location.
Addressing the first research question concerning perceived effectiveness of communication with community physicians among school nurses, univariate analyses revealed that 76% of school nurses reported very effective or effective communication with physicians. It was also the case that 15% of the school nurses surveyed reported being dissatisfied or very dissatisfied with school health services in their schools. To answer the second research question, multiple logistic regression analysis was used to understand which of the independent variables are associated with perceived communication effectiveness with community physicians (Table 2).
Results show that perceived leadership is significantly associated with perceived communication effectiveness with community physicians (p < .001). The odds ratio of 2.05 shown for this association indicates that school nurses who perceived themselves as having more of a leadership role were over twice as likely to report effective communication with community physicians when compared to school nurses who perceived having less of a leadership role. School nurses in urban locations were somewhat less likely (p = .07) to perceive that they had effective communication with community physicians, as indicated by an odds ratio less than 1.00. Other variables in the model—including school size, proportion of students eligible for free or reduced-price lunch, school nurse age, nurse-to-student ratio, and health care burden—were not statistically significant.
Multiple logistic regression analysis was also used to answer the third research question, whether perceived communication effectiveness with physicians is associated with satisfaction of school health services (Table 3). The odds ratio of 1.75 associated with the variable communication with community physicians indicates that school nurses who reported having greater effective communication with physicians are 75% more likely to be very satisfied or satisfied with health care for students in the school when compared to school nurses who reported poor effective communication with physicians (p < .001). In addition, school nurses reporting more perceived leadership were more than twice as likely to express satisfaction with school health services provided, compared to school nurses who reported having low perceived leadership (odds ratio = 2.15, p = .05). Finally, the odds ratio of less than 1.00 indicates that school nurses who work in economically disadvantaged schools (i.e., greater proportion of students eligible for free or reduced-price lunches) are significantly less likely to be satisfied with school health services for students when compared to school nurses who are working in more economically advantaged schools (p = .001). Other variables in the model were not significantly associated with satisfaction with school health services.
DISCUSSION
The purpose of this study was to explore school nurses’ perceptions regarding the effectiveness of their communication with community physicians, to identify factors that influence this perception, and to understand what factors are associated with satisfaction with school health services. Multivariate analyses showed that whereas a majority of nurses reported effective or very effective communication with community physicians, a sizable proportion (24%) viewed their communication as being relatively ineffective. In addition, 15% reported being dissatisfied or very dissatisfied with school health services for students in their schools.
The study results indicate that having a leadership role, including having greater autonomy in developing school health policies and programs, has important positive implications for school nursing practice, as well as for the health of children in their care. Greater school nurse leadership appears to facilitate higher levels of effective communication with community physicians and, ultimately, better health care services to students. Given the many responsibilities of school nurses and the array of health services they provide, it is not surprising that leadership skills are emphasized (Guttu, 2007). These leadership skills can influence not only communication with physicians but also the degree to which school nurses become involved in policy development and community issues. Leadership appears to be a skill that should continue to be cultivated and emphasized in continuing education seminars for school nurses. It is possible that the creation of additional opportunities to exercise leadership behaviors in schools may contribute to more effective communication with physicians.
“Whereas a majority of nurses reported effective or very effective communication with community physicians, a sizable proportion viewed their communication as being relatively ineffective.”
An additional factor influencing effective communication with physicians is the location of the school district. With many rural school nurses coordinating health services across as many as three to five buildings (Ficca & Welk, 2006), it is reasonable that nurses in rural settings, when compared to those in urban settings, may (by necessity) be more likely to cultivate effective communication with physicians. Although statistically significant to only a marginal degree, results here mirror previous research on school nurse communication related to asthma management in Pennsylvania public schools, which found that urban school nurses were more likely to report having poor or very poor physician communication when compared to nurses in rural communities (Hillemeier, Gusic, et al., 2006). It is also possible that rural school nurses have a greater need to effectively communicate with community physicians, because there are fewer health resources available within schools themselves. In addition, in the smaller communities where rural school nurses practice, they may be more likely to be personally acquainted with the community physicians with whom they interact about student health needs. Education to improve communication between school nurses and physicians should be tailored to the setting of the school.
In understanding school nurses’ satisfaction with health services for students, greater satisfaction was associated with more effective communication with community physicians. Similar to findings in clinical settings, these results highlight the synergy needed between community physicians and school nurses in providing satisfactory care for students. School nurses’ reports suggest that working with community physicians is an integral part of their job, and communicating well with community physicians is an important factor influencing their personal satisfaction of health services for students. Future research investigating ways to improve satisfaction among school nurses should incorporate strategies to build or maintain communication activities with community physicians. Given these findings, communication skills are also warranted in school nurse training seminars, given that more training of these professionals has been recommended (Institute of Medicine, 2003).
Another important factor influencing satisfaction with school health services is the economic well-being of students in the school. In more economically disadvantaged schools, the lack of resources available for health and support services could be responsible for lower satisfaction levels. Prior research suggests that worries about monetary support and available resources have contributed toward concerns over school nurses’ job security (Tetuan & Akagi, 2004). It is also likely that school nurses in less economically advantaged settings are consistently faced with relatively greater health needs and resource constraints that limit their abilities to meet those needs.
No significant associations were found between the age of the school nurses and either their perceptions of effective communication with physicians or their satisfaction with school health services. It is interesting to note, however, that approximately 70% of school nurses in the sample were 45 years old or older and that 20% were 55 or older. This suggests that there will be large numbers of school nurses reaching retirement age in the near future, which has important implications given current and projected shortages of registered nurses.
Limitations
This study has several limitations that should be considered. The data are cross-sectional; so, causal direction cannot be inferred between the measured variables and effective communication with community physicians and satisfaction with health services for students. It is also possible that unmeasured characteristics of the school nurses themselves and their practice settings may have influenced the outcomes of interest. Potentially relevant information about the training, expectations, and previous professional experiences of the nurses in the study was not available for inclusion in the analyses, nor were any health-related policies and programs in the school district and community settings where they practice. The data come from a sample of school nurses in one state; therefore, caution should be used in generalizing to other populations.
Implications for School Nursing Practice
The purpose of this study was to understand whether school nurses find communication with community physicians to be effective and how this communication influences school nurse satisfaction of services provided to students. Although there has been some research on nurse–physician communication, little has been written about school nurse–physician communication. Findings from this study indicate that although a majority of school nurses surveyed perceive their communication with community physicians to be effective, fully one fourth of the respondents regard their physician communication as being relatively ineffective. This is an important area for improvement, especially when considering that effective communication with physicians is shown to be an important predictor of nurses’ overall satisfaction with the health services delivered in their schools. Communication with physicians can be facilitated through written care plans, more so in instances where children have chronic conditions such as asthma. School nurses should routinely inform parents about the possibility that written parental permission is needed to aid communication about their children’s care.
More broadly, school nurses should work to maintain open channels of communication with physicians in their communities. These efforts can be made possible by increasing school nurse staffing levels, thereby freeing up additional time for school nurses to perform care coordination activities. Additional school nurse staffing would also allow for more participation in school health policy development and leadership activities. More involvement in a leadership capacity is important; as evidenced by nurses in the present study, those who perceived themselves in a leadership role experienced more effective communication with physicians and reported greater satisfaction with the health services in their schools. These findings suggest that development of leadership skills should be given high priority in school nurse education programs and continuing education activities.
Footnotes