1. ON THE FRONT LINE IN CHILDREN’S HEALTH CARE: CASELOADS, SCOPE OF PRACTICE, AND SATISFACTION WITH CARE AMONG RURAL AND URBAN SCHOOL NURSES IN PENNSYLVANIA Marianne M. Hillemeier, PhD, MPH and Lisa A. Davis, MHA Department of Health Policy and Administration The Pennsylvania State University Research Objectives 1.To evaluate the scope of nursing services provided in rural and urban public schools in Pennsylvania 2.To assess perceived satisfaction and effectiveness of school nursing services among school nurses, principals, and parents 3. To assess perceptions of need among school nurses, principals, and parents Acknowledgement: This research was funded in part by the Center for Rural Pennsylvania Methods A stratified random sample of school nurses (n=615; response rate=61.7%) representing each of Pennsylvania’s 500 active school districts was surveyed about current school nursing services including perceived satisfaction and effectiveness of current level of service and perceived needs. Two additional surveys, one for school principals and one for a parent (usually president of the school PTO/PTA) were included in each mailing. There were 431 surveys returned from school principals (response rate=43.2%); the response rate for parent surveys was 34.8% (n=347). Additional information about school nurse:student ratios and school district characteristics was obtained from the PA Division of School Health. Results  The areas perceived by nurses as most in need of improvement were budget levels for nursing services, nurse staffing levels, training, and communication with physicians and parents  Principals were the least likely to express the need for improvement in any of the dimensions assessed  Parents were most likely to mention the budget for nursing services and more supplies as needed improvements.  School nurse caseloads contain a sizable proportion of children with special needs; the most prevalent problems were asthma, allergies, weight disorder, and ADHD.  Specialized procedures were often provided including blood sugar testing, nebulizer treatments, insulin pump management, and urinary catheterization. Similar types and numbers of treatments were provided in rural and urban schools.  Over 70% of all secondary school nurses provided education and counseling on pregnancy and STD prevention and substance use, however education and counseling on other important issues including nutrition, injury prevention, and aspects of mental health were less often provided. Conclusions  The health care needs of school children are increasingly diverse and complex, and school nurses are called upon to perform many skill-intensive procedures  Nurses were least satisfied with the level of health education currently provided for students and staff  Professional nursing organizations and Healthy People 2010 recommend that school nurse:student ratios not exceed 1:750; in Pennsylvania where the ratio averages 1:1012 study findings suggest that a lower ratio would result in greater satisfaction with school nursing services  Nurse:student ratios were lower in rural districts  Students in rural districts were more likely to be economically disadvantaged Table 1. Summary Nurse Staffing and School District Characteristics, 2004-200 Indicator All PA Districts Rural Districts Urban Districts Staffing Mean number pupils per certified school nurse10129361084 Mean number pupils per nursing/health support staff556539572 Mean number certified school nurses per district4.12.45.7 School District Characteristics Mean student body size4,0502,2035,781 Mean teacher:pupil ratio1:15.41:15.21:15.7 Mean number school buildings per district10.75.315.7 School District Demographics Average total population size per district24,51413,60834,786 Median family income$48,937$42,662$54,848 Average Proportion of families in poverty9.4%10.6%8.3% Correlation between median family income and mean number of pupils per certified school nurse0.310.330.21 Data source: PA Division of School Health. Median family income and proportion of families in poverty are from the 2000 US Census Table 2. Health Conditions Among Rural and Urban PA Secondary School Children Rural Schools (n=124)Urban Schools (n=110) Mean Number Students per School w/Condition Overall Proportion of Students w/Condition Mean Number Students per School w/Condition Overall Proportion of Students w/Condition Asthma608.7%8810.5% Allergies334.7% 536.2% Weight464.9%605.4% ADHD344.9% 414.8% Depression172.3%212.3% Migraines141.9%161.8% Orthopedic101.3%111.3% Cardiac91.3%111.3% Develop Delay111.3%80.9% Vision101.4%70.8% Neurological70.9%111.1% Table 3. Proportion of Rural and Urban Pennsylvania Schools Providing Specialized Nursing Care Procedures, 2004-5 Elementary Schools Rural Schools (n=185) Urban Schools (n=196) Proportion of Schools Providing This Care P Nebulizer Treatments71.4%78.6%0.10 Blood Sugar Testing67.0%67.4%0.95 Insulin Injection51.4%43.9%0.14 Insulin Pump Management35.1%17.9%<0.01 Catheterization15.1%12.8%0.50 Gastrostomy Feedings10.3%8.7%0.53 Oxygen Therapy6.0%5.6%0.89 Ostomy Care4.3%4.1%0.91 Suctioning2.2%4.6%0.19 Tracheostomy Care2.2%3.1%0.58 Intravenous Therapy1.6%2.0%0.76 Nasogastric Feedings1.1%0.5%0.53 Secondary Schools Rural Schools (n=124) Urban Schools (n=110) Proportion of Schools Providing This Care P Blood Sugar Testing87.9%91.8%0.32 Insulin Injection70.2%69.1%0.86 Insulin Pump Management68.6%60.9%0.22 Nebulizer Treatments60.5%57.3%0.62 Catheterization16.9%18.2%0.80 Gastrostomy Feedings8.1%10.0%0.61 Oxygen Therapy3.2%13.6%0.005 Ostomy Care4.0%7.3%0.29 Suctioning4.0%3.6%0.87 Tracheostomy Care0.8%1.8%0.50 Intravenous Therapy1.6%0.9%0.63 Over 80% of school nurses reported being “very satisfied” or “satisfied” with selected aspects of services provided; they were least satisfied with health education for students and staff, the level of communication with physicians, and the school environment. Three-quarters or more of school nurses rated all nursing services assessed as “very effective” or “effective” Both school principals and parents tended to report high levels of satisfaction with school nurse services and to perceive them as effective Lower school nurse:student ratios were positively associated with greater perceived satisfaction with nursing services provided among school nurses (r=.08, p=.05)