Abstract
School nurses are leaders every day, sometimes with ambivalence and sometimes fully embracing the leadership role. The authors were participants and trainers in the successful School Nurse Leadership Program of the Healthy Schools Campaign. The article describes five principles of effective school nurse leadership to help school nurses discover the leaders within themselves: passion, knowledge, advocacy, relationships, and communication. School nurses are encouraged to set leadership goals. Participants in a session at the NASN 2011 annual conference described a variety of 6-month goals including “Invite myself to the administrative meetings at least one time per quarter; present on a topic for at least 5 minutes.” Setting simple yet attainable goals is the first step to recognizing leadership in oneself.
Keywords
The professional school nurse is defined as the leader in the school community to oversee school health policies and programs (National Association of School Nurses, 2011). Many nurses embrace this leadership role; however, some nurses have to look a bit deeper to recognize and discover the leader within them. Opportunities for leadership may be sought after or arrive serendipitously at the school health office door. School nurses must be prepared to use leadership skills to become positive change agents in their communities.
Discovering the leader within oneself involves assessing one’s passion, motivation, knowledge, communication skills, and current role in leadership. The 2011 NASN conference provided the opportunity for school nurses to recognize and further hone their leadership skills and natural leadership capabilities. This article has been developed from a NASN conference presentation, “Discover the Leader Within Yourself.”
The School Nurse Leadership Program
Trainers, staff, and graduates of the School Nurse Leadership Program (SNLP) of the Healthy Schools Campaign (www.healthyschoolscampaign.org/schoolnurse) developed the Discover the Leader Within Yourself session.
The SNLP empowers school nurses to take leadership roles in developing policies and programs for the health of students and adults in school communities. Individual programs have focused on nutrition, indoor air quality, physical activity, and the prevention of asthma and obesity in schools. One hundred twenty-five school nurses in Illinois have completed the SNLP between 2006 and 2011.
Leadership Traits and Qualities
Leadership includes what leaders do and say as well as how they make others feel and react. Leading by consensus, the judgment arrived at by most of those concerned (Consensus, n.d.) is vastly different than leading by dictate, an authoritative rule, prescription, or injunction (Dictate, n.d.). At the conference presentation, school nurses were asked whom they admired and why those leaders were admirable. Words used to describe leaders included risk-taker, passionate, motivator, provider of inspiration, good listener, able to see all view points in the group, respectful of others, decisive, innovative, disciplined, flexible, and adaptable. Some of these traits may seem mutually exclusive, but all have a role in the development of leadership. Being able to listen to all suggestions and think outside the box may inspire but will not create meaningful change without the ability to delegate, plan, and implement the steps needed to reach those changes. Each nurse brings a different skill set and preferred style and can learn to strategically use these skills to lead others in achieving the goal that all see as beneficial.
Some [traits used to describe leaders] may seem mutually exclusive, but all have a role in the development of leadership.
Leadership has many definitions and there are many different ways to cultivate one’s leadership skills. After five years of implementing the SNLP, the authors believe school nurse leadership includes passion, knowledge, advocacy, relationships, and communication.
Leadership in School Nursing
The field of nursing has excellent examples of leadership: famous nurse leaders such as Florence Nightingale, with her ability to use data to drive improved practice; Clara Barton, who used any and all resources at her disposal to deliver a service that others needed; and Lillian Wald, who used data and a pilot project to demonstrate the impact of nursing interventions on the health and education of school children in New York over 100 years ago. A more recent school nurse leader is Mary Pappas, school nurse in New York, who identified and triaged the first cluster of H1N1 victims in her high school in April 2009. Subsequently, she has used that recognition to speak out as an advocate for school nurses across the country (Pappas, 2011). These and other nurse leaders are studied in the SNLP as a model for leadership.
School nurses exhibit leadership on a daily basis in many ways, including autonomous management of a school health program; research and development of health policies; education and training of various school personnel; advice to administration concerning the health and safety of the school population; and service as a health and wellness resource to the school, community, staff, students, and parents (American Academy of Pediatrics, Council on School Health, 2008). In the area of wellness, for example, school nurses motivate and organize students and parents into walking school buses, plan after-school walking clubs, and advocate for healthier school food and more time for physical education. School nurses conduct illness and injury surveillance to identify risk management and prevention strategies, and they identify indoor air quality issues. School nurses bring health promotion strategies to school communities.
Often, school nurses need to move outside their own ranks to influence and advocate for changes in the larger system and community so that they can lead within their schools. Each person the school nurse meets should be seen as a potential ally in advocating for the improvement in the health of his or her students. This may involve stretching the nurse’s imagination to see how even apparent dissenters may be able to help achieve goals. That is the essence of leadership.
Passion
History shows that some leaders step forward because of their passion to see that students’ health needs are met or that injustices are mediated. Sometimes, nurses discover the leader within themselves when a leadership vacuum develops and nurses feel the need to push themselves to step up and advocate for student health. School nurses completing the SNLP became leaders by developing physical activity programs for students and staff; conducting school walk-throughs to identify indoor air quality issues; and presenting to school boards, parent organizations, and staff. Most nurses are familiar with Maslow’s Hierarchy of Needs, and all school nurses know some students who are not having their most basic physiological needs met.
History shows that some leaders step forward because of their passion to see that students’ health needs are met or that injustices are mediated.
For example, one of the authors is passionate about dental care service. Dental care is often expensive, time consuming, and difficult to access; therefore, preventive care, and often restorative care, is not completed. As a school nurse, she was able to contract with her local health department to have dental personnel come to the school to provide examinations, cleanings, and sealants for low-income students. The nurse became a leader not only by having a passion but also by actualizing the service. Roadblocks included access to space within the school, justifying students’ time away from academics, and difficulty in communication with non-English-speaking families to receive consent. She worked to turn this passion into reality by building relationships with teachers who were willing to hold their classes in another area of the school for a day, advocating for the importance of this service by providing documentation on the connection of basic dental care to a student’s readiness to learn, and partnering with English language learner (ELL) teachers to provide communication and build trust with families.
Knowledge
Leaders are respected for their knowledge. Leaders demonstrate that needs and solutions are based on evidence and not anecdotes. School nurses need to keep current with research on clinical and public health practice and constantly communicate that knowledge to school stakeholders with language that is adapted to specific audiences. Knowledge is a powerful leadership tool that allows the school nurse to advocate for policies and procedures that are based on scientific facts where the outcomes can be identified based on the evidence. Many publicly available websites such as PubMed are great resources for school nurses.
Leaders are respected for their knowledge. Leaders demonstrate that needs and solutions are based on evidence and not anecdotes.
Advocacy
Leadership means working within existing rules, working outside of the rules, or creating new rules that work to bring nursing practice up to contemporary evidence-based standards. SNLP participants advocated successfully for improved nutrition standards, bus idling policies, remediation of mold in classrooms, and additional time for physical education classes. School nurses need to identify those with decision-making authority and those who influence decision makers, and then they must use persuasion and evidence to convince these individuals of the need for new policies and programming to support student health. Advocacy is always accomplished with partners. It is critical for school nurses to invite other stakeholders, including school principals, teachers, and school staff, into the advocacy process and to acknowledge the contribution of partners (Editorial, 2007).
Leadership means working within existing rules, working outside of the rules, or creating new rules that work to bring nursing practice up to contemporary evidence-based standards.
An example of this is a well thought-out campaign to change the way a district deals with the issue of pediculosis. Does the nurse continue to follow district policies that contradict current evidence or use her influence and leadership to change the policy and practice? Using leadership to change practice may allow the nurse to reallocate precious time to needed health education rather than a practice that does not benefit students.
Advocacy can be a long, slow process that can be measured by small wins along the way. Anticipate challenges, start with easy wins, and celebrate successes.
Relationships
Health promotion requires partnerships to ensure that children receive health messages from many messengers. School nurses should engage community members and other stakeholders in assessing problems and creating solutions. It is critical to solicit feedback from other health advocates, even those with opposing viewpoints. School nurses use their passion for health and learning to engage, energize, and empower others and help partners to feel valued and appreciated. Appreciation is a valuable tool in the school nurse leader’s skill set.
School nurses also benefit from acquiring meeting facilitation skills. Leaders engage all members of task forces and committees and allow everyone to speak and contribute and assume responsibility for tasks. Leaders help others by modeling fairness and good listening. Leadership skills include crafting a tight agenda with times for discussion of each topic, asking all members to speak and not allowing one member to dominate the discussion, personally asking members to take leadership for at least one task, and regularly thanking and celebrating volunteers and successes.
School nurses use their passion for health and learning to engage, energize, and empower others and help partners to feel valued and appreciated.
A critical relationship for the school nurse is with administrators. As part of the SNLP, nurses build this relationship by scheduling a meeting, sharing a current résumé so administrators see their credentials; offering help in developing health policies and procedures; and offering solutions to health issues and problems (Bergren, 2011). While it can be difficult to establish and maintain relationships with administrators as nurses are stretched among several schools, this relationship building is important to work improving student health.
Communication
School nurses often serve as the conduit of information to the school community on student health issues. Nurses must communicate about evidence to school stakeholders through e-mails, newsletters, presentations, and the web.
Knowledge and evidence do not always change positions that involve emotions or a commitment to maintain current practice. In order to communicate effectively, nurses must keep in mind their audiences’ emotions and beliefs as well as the relevant evidence. An example is head lice policy in many districts. Administration, staff, and parents may sometimes be so emotionally involved that they are unable or unwilling to respond to evidence. The school nurse’s leadership abilities to understand and use communication and interactive skills to facilitate change can be a challenge yet an exciting opportunity to step up and practice new or existing skills.
School nurses’ knowledge and analytical thinking can be difficult to translate into the sound bites that have become the standard of much communication today. School nurses need to practice crafting succinct, meaningful sound bites to describe health issues or even the field of school nursing—and they need to repeat these messages consistently.
Communication skills include both verbal and nonverbal communication. With this in mind, school nurses need to think about how they communicate with nonverbal messages and how they can look and act like leaders. This can include professional attire or including professional credentials in introductions, on nametags, on the health office door, and in all written communications.
School nurses need to practice crafting succinct, meaningful sound bites to describe health issues or even the field of school nursing—and they need to repeat these messages consistently.
The ability to advocate and share passion through writing is also important. School nurses need to utilize electronic communication as an important vehicle for reaching families and the community. Using social media and blogs can help make health issues more visible and raise awareness of student health needs and the connection between health and learning.
School nurse leaders must carefully craft messages for social media, newsletters, websites, letters to the editor, and blogs to be clear and include evidence and persuasive language (Brandt, 2002). School nurses should work with district communication staff to create clear writing that is not open to misinterpretation.
Leadership Ambivalence
Leadership often brings increased responsibility and accountability. Nursing has a history of being a subservient occupation. As the science of nursing has developed, nurses find themselves in leadership roles and need to develop the ability to take responsibility and accountability for decisions. This may create emotional stress, especially when school nurses are in situations where they do not make policy and the policy is not in the best interest of students or may not be in alignment with current evidence. The ability of the school nurse to advocate can assist in overcoming this ambivalence.
Based on anecdotal evidence and the NASN School Nurse Ratio Ruler, school nurses are trying to meet more needs with less time and resources. In this atmosphere, there is little time to take on extra leadership roles, yet it is also a critical time for school nurses to reflect on their practice and school policies and procedures that affect student health as well as their own role as a nurse leader.
Setting Leadership Goals
At the NASN presentation, participants were asked to set a leadership goal to be accomplished within 6 months. Some of the goals included the following: “Invite myself to the administrative meetings at least one time per quarter; present on a topic for at least 5 minutes.” “Update District Health Services website and create template for individual school websites.” “Increase my participation in local politics to advocate for women’s and children’s rights.” “Enlist support of staff to comply with wellness policy: specifically focus on creating a timeline and policies for use of food as rewards and classroom celebrations.” “Complete my PhD program with school nursing leadership as my possible dissertation topic.”
It is important to set goals and then assess the process and outcome of the accomplishment of these goals. How did serving as a leader make me feel? Did I shy away from a leadership opportunity when it was presented? If so, why? How have my leadership experiences influenced me as a school nurse? Was I motivated to pursue continued development of my knowledge or my leadership skills? Changes in practice and continued growth often depend on reflection concerning past experiences as these reflections influence decision making in the future.
When setting goals, nurses can ask, What do you want to do to discover the leader within yourself? Do you need to identify a change that you want to champion and develop a plan for intervention? What partners can you work with to make policy or practice changes that improve the health of children? Leaders set goals for themselves as well as for those they lead and are accountable for progress toward those goals.
We enter nursing because we have a passion—a passion to care for, provide for, and help people realize their full potential. We spend a significant amount of time learning our craft. Our undergraduate course work is rigorous and many of us obtain additional degrees and certifications. The idea of leadership is taking this passion and knowledge to make a difference. Often, nurses are the only people in the school environment with focused knowledge on health and wellness. Nurses need to identify people to partner with to effect change. There are allies in schools—school board members, parents, respected teachers and administrators—who can be part of the nurse’s team. Nurses can communicate their leadership activities by attending committee meetings, presenting to the school board, and visiting with the parent teacher associations. The work nurses do and the difference they can make is too important to let this opportunity pass by. Start small. Nurses can choose one way to make a difference and set goals. We can’t wait to hear about it! ■
School Nurse Champions a Walking Path
One of the authors became aware of the National Walk to School Day and thought it was a great idea; however, all of her students were bused to school because they live in a semi-rural area. Instead, she found another way to increase physical activity in her students. She collaborated with the school district and building PTA to build a walking path on school grounds to be used before, during, and after school. The parents added fitness equipment after seeking the guidance of the physical education teachers. The path is used throughout the day including during PE class and recess.
This school nurse noted that the school down the road had the opposite problem. All of the students lived within walking distance yet many were driven to school by parents. In an attempt to shift this pattern, the nurse met with parents to discover barriers to walking and then established a Walking School Bus program led by parent volunteers.
Footnotes
Acknowledgements
We’d like to thank Donna Fishman and Mark Bishop of Healthy Schools Campaign, Chicago, for their support of school nursing issues and leadership training for school nurses.