physical, mental, and social well-being of each recipient” does make a weighty commitment. A more realistic interpretation might be offered: “The highest level of physical, mental, and social functioning of which each recipient is capable.” The schools in concert with other agencies in the community, state, and region can achieve this outcome. This necessary communication, coordination, and liaison was one of the major conference focuses. The important message to be gained from the very comprehensive end product suggested is that many of the respondents are sensitive to the development of the whole child-the physical, cognitive, affective, and social child-as the concern of those involved in school health efforts. The Delphi process provided the groundwork for a very stimulating concept-the design and development of a conference based solely on potential participant input. It served as an effective planning tool. The definitional elements and priority issues contributed by the multidisciplinary participants were the source materials for the design of panel sessions, special interest group sessions, and conference resources.
BIBLIOGRAPHY Fincher J: Thinking all together. Hum Behav 5:17-23, 1976 Hencley S, Yates J: Futurism in Education: Methodologies. McCutchan Publ, 1974. Huckfeldt VE, Judd RC: Methods for Large-Scale Delphi Studies.
Western Interstate Commission for Higher Education, Boulder, Colo, 1975. Judd RC: Delphi decision methods in higher education administration, unpublished. University of Toledo, Ohio. Linstone H, Turoff M: The Delphi Method: Techniques and Applications. Reading, Mass, Addison-Wesley Pub1 Co, 1975. Pill J: The delphi method: Substance, context, a critique and an annotated bibliography. Technical memorandum No. 183, May 1970. Operations Research Dept, School of Management, Case Western Reserve University, Cleveland. Sandow SA: Education Policy Formulation: Planning With the Focus Delphi and the Cross-Matrix, RR-9. US Department of Health, Education, and Welfare, Office of Education, Educational Policy Research Center, Feb 1972. Scott RF, Simmons DB: Programmer productivity and the delphi technique. Dotamation pp 71-73. May 1974. Synder M: Benefits and disbenefits of forecasting: Techniques in planning a curriculum for future health care, unpublished. University of Minnesota, Minneapolis, 1977. Toffler A (ed): Learning for Tomorrow: The Role of the Future in Education. New York, Random House, 1974.
Eileen A . Crowley, MA, is Research Fellow, Public Health Nursing, School of Public Health, University of Minnesota, Minneapolis, MN 55455 (corresponding author). Judith L . Johnson, RN, MPH, formerly Research Assistant, Maternal and Child Health Program, School of Public Health, University of Minnesota, is currently Cancer Education Coordinator, North Memorial Medical Center, Minneapolis, MN 55422.
Bridging the Communication Gap Between Health Professionals and Educators Judith B. Igoe, RN, MS “Communication is not a secondary or derived aspect of organization-a ‘helper’ of the other and more basic functions. Rather, it is the essence of organized activity and is the basic process out of which all other functions derive. ” How effectivelyare educators and health professionals communicating with each other? From personal interviews, reviewing the literature, and directly observing many interactions between educators and ‘Davis K, et al: Human Relations and Organizational Behavior, p 215.
SEPTEMBER 1977
health professionals in an effort to understand better the roles, relationships, expectations and ensuing communication patterns that exist between the two groups, I have found there are serious communication difficulties. The following anecdotes illustrate a number of factors that appear to contribute to this situation. Incident One: Last summer Jane X, age 10, underwent open heart surgery at a university hospital and returned to school in the fall with a note from her mother stating that the child was to be excused from all gym activity because of her heart condition. Jane’s THE JOURNAL OF SCHOOL HEALTH
405
teacher, fearful that the child might suffer from any type of physical activity, decided to keep the child inside during recess periods as well. By chance the school nurse heard Jane’s teacher discussing the child’s health during a coffee break and volunteered to contact Jane’s mother to clarify the situation. In discussion with the school nurse, Jane’s mother admitted she was confused about the doctor’s instructions and that she was hesitant to disturb the doctor (because of the busy clinic atmosphere) before their next appointment, which was three months away. With the mother’s permission, the school nurse tried to contact the physician. Four telephone calls and two days later, the nurse reached the physician. Unfortunately, without Jane’s record, the physician was unable to provide any information and, because of the hectic clinic schedule, the doctor hurriedly asked the school nurse for details about the case. The school nurse, having had no previous information from the hospital, experienced a tinge of annoyance and curtly replied, “Don’t ask me. We never get any information from you people.” The physician, who was rushed, suggested the nurse call back after he’d had a chance to review the record. Totally frustrated, the nurse delayed calling back for several days and then discovered a new physician had been assigned to Jane’s case! Finally, a public health nurse who was the clinic coordinator interceded and assisted the school in obtaining the necessary information, which was that Jane’s restrictions involved only the most rigorous of physical activity. In the meantime, however, the school nurse, prevented from immediately getting the information promised to the teacher, made several derogatory remarks in the coffee room with regard to the efficiency of hospitals in general. Comment: Traditionally, health services and education have been provided in completely separate environments with virtually no formalized and efficient system for mutually exchanging available information. However, as we begin to realize the mutuality of influence that exists between health and school performance, the need for closer relationships and increased and improved communication between health professionals and educators becomes evident. Development of functionally organized communication networks between schools and health agencies is not only a complex but also a costly process. Some of the factors that must be taken into account in the establishment of such a system are: 1. The communication network must be continuously in operation if closer relationships between health professionals and educators are to emerge. This is not the situation today in most communities. Instead, efforts at communication between the two groups are frequently episodic and usually initiated only when a problem arises that requires exchange of information. A 406
THE JOURNAL OF SCHOOL HEALTH
crises-oriented communication network is frequently inefficient because provisions for such elements of successful communication as timing, proper flow of messages, mutual agreement, understanding and clarity have not been made. Some schools have attempted to establish such a network and to develop closer relationships with health professionals in the community through the creation of community boards that include educators and those health professionals from whom the children in that school district most frequently seek health care. Such boards must meet regularly to be effective. What is needed today is a model plan for the development of an effective and functional communication network between educators and health professionals designed to be applicable to the needs of numerous communities. 2. Because of the numbers of people involved, development and organization of an ongoing linkage system between educators and all health professionals in a community become almost an impossible task, unless the feedback circuits are so designed as to place certain responsibility on the parents and children. Specifically, health professionals and educators must directly involve the child and his parents in the entire communication network. Parents and children, if they are considered by educators and health professionals to be actual members of the health and educational team, should be oriented to assume responsibility for the transfer of information from clinic to school and vice versa, either directly or indirectly, by motivating the professionals involved to talk with one another. A formal process of orientation for children and their parents will be necessary if they are to serve as facilitators of information exchange. It is, of course, expected that parents and children will participate in making the necessary decisions with regard to the release of information for exchange between educators and health professionals. 3. To be effective, the communication network must include individuals who are capable of identifying the implications of a health problem to the educator and the importance of the child’s functioning in school to the health professional. In a recent chart review involving the records of 300 school-age children seen at a pediatric clinic, 98% of the care plans failed to include any recommendations for contacting the school, although 60% of the cases were judged to have school-related implications. On the other hand, health professionals in the clinic had little or no information from the school at the time the child was evaluated (less than 10% of the cases). To alleviate this situation to some degree, this particular clinic designated a nurse with school experience to review records of children before their clinic appointment, to contact schools as SEPTEMBER 1977
indicated, and to make appropriate school-related notations in the record. This arrangement has increased the frequency with which health professionals are considering the school in health care planning. Although budgetary constraints may make it impossible for many clinics to add a school coordinator to their staffs, the feasibility of orienting parents and children to assume some responsibility for conveying school information to health professionals may be a viable alternative in many instances. 4. As seen in the case example involving Jane, the child with the heart ailment, the foremost cause of disturbed communication is frustration. The school nurse, unable to obtain quickly the desired information, became frustrated, and provided negative information about hospitals to the teachers, who, in turn, began to behave differently. Specifically, the frequency of negative remarks about health care agencies increased. In all likelihood, their understanding and perceptions of health facilities were influenced by the information they received. This example serves as an additional rationale for the need to establish an effective communication network through which gratification, the most important criterion of successful communication, can occur, and the chances of transmittal of negative information, which shapes behavior incorrectly, can be diminished. Incident Two: Studies of the role of the school nurse as perceived by the nurses themselves and school personnel generally indicate a discrepancy between the perceptions of the two groups and a failure to assign similar priorities to certain tasks attributed to the school nurse role. Ineffective communication between educators and school nurses is to blame. The following statements illustrate this point and the resulting ambiguity regarding the role of school nurses. “All they want me to d o is put on bandages.” (school nurse) “The role and functions of school nurses are poorly understood by both the nurses themselves and by those with whom they work.” (school nurse and teachers) “What is really needed is a school nurse who can make sound judgments in health matters.” (school administrator) “Lack of communication with teachers, special services personnel, and school administrators is an everpresent problem.” (school nurse) “Is our school health program necessary?” (parents and school board members) Comment: Difficulties in communication within an organization are more often than not mere symptoms of underlying difficulties in relationships between the parties involved. The confusion that persists regarding the role of the school nurse and the importance of the school health program verifies the need for further SEPTEMBER 1977
development and improvement of the health professional-educator relationship locally as well as at a national level. Ironically, these efforts to achieve close collaboration may come too late if we do not act promptly. With the present interest in Washington, for example, in separating the Department of Health, Education, and Welfare, the opportunity for interface of health and education on a national level may be obliterated. There are several significant contributing forces that have prolonged the dilemma in the health professionaleducator relationship: I . Historically, school health programs and school nurses have been identified as having secondary importance to the successful functioning of a school. Educators are not to blame for this interpretation of the relationship that should exist between the school and the health program. A quick review of numerous school health texts (generally written by health professionals) reveals a unanimous effort to define, or to imply at least, that the health program within a school setting, although worthwhile, is of secondary importance to the more primary goal, education. Several leaders in school health, as well as medical sociologists, have speculated that this age-old philosophy of school health originated at a time when it was important to protect the interests of private medicine, which in the past has generally monopolized the enterprise of health service delivery. Whatever the reasons for giving school health programs subsidiary importance in school, as long as this particular thinking persists, those involved in school health will forever struggle in vain to achieve truly collaborative relationships with their educational colleagues. Philosophically, there is nothing now in the theory of school health to support the concept of equitable relationships between health professionals and educators. Health, however, can no longer be given secondary consideration in schools. (1) Communities are now turning to schools for more than the customary educational activities. In some areas of the country, schools are viewed as community centers offering a wide range of new services, including health care. (2) Society through the health consumer movement has begun to demand greater availability and accessibility to health care facilities. The school has been designated as a logical site for the delivery of health services to children in need. (3) The importance of the relationship between health and school performance has become increasingly evident in recent years. Recognition of this phenomenon justifies the need to emphasize health as a primary component of any school system. (4) Current efforts to mainstream children with physical and mental handicaps into regular classrooms have further heightened an awareness of the importance of health to learning. THE JOURNAL OF SCHOOL HEALTH
407
Clarification of the significance of health in school settiilgs is an issue that must first be discussed and about which a harmonious decision must be reached among health professionals before attempts to involve the educators begin. Presently there is no agreement among health professionals on the salience of school health. Some health providers believe that health must take a low profile within school settings. Other health professionals insist the school should be a site for primary health care delivery, which would, of course, place health in a much more prestigious position within schools than presently exists. 2. Another problem to be resolved in promoting more effective relationships and communication between health professionals and educators involves the relationship between those health professionals who work in school health and their colleagues in the traditional health agencies within the community (eg, physicians’ offices, hospital outpatient departments, public health clinics). Unfortunately, a mutual support system between these groups is missing, as evidenced by the jokes frequently made in health agencies about the competence of school nurses and, conversely, the disparaging remarks school health personnel often make regarding the quality of care available in the community. Therefore, we as health professionals must unite in our thinking and dealings with one another if the goal of improved working relationships with educators is to be ,achieved. 3. Disparate perceptions of the role of school nurses and school health programs, another communication disturbance between educators and health professionals, are largely influenced by the fact that the two groups do not share the same role expectations for the school nurse. For school administrators there is a general expectation that the nurses’ first priority will be to care for the injured and ill, thereby safeguarding the school from potential legal encounters. The nurse, on the other hand, skilled and interested in health promotion activities (nutrition, exercise, health education), often is more inclined to assign a higher priority to health teaching and counseling than first aid. Amelioration of the situation requires mutual understanding, some compromise, and eventually joint agreement. School nurses may seriously jeopardize their credibility when they flatly refuse to recognize that the educators’ expectation for first aid services is predicated upon an actual need to ensure the safety of the children while at school. Conflicting expectations between school nurses and educators with regard to the role of the school nurse is also closely related to nursing’s inability to articulate to others what it is they do outside hospitals and the merits of these activities. The following parody may express the problem some school nurses are having: “I know 408
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you believe you understand what you think I said, but I am not sure you realize that what you heard is not what I meant.” School nurses also must work rapidly to establish evidence of the importance of health maintenance and preventive health care and education because the American public (including educators) apparently assigns virtually no value to these activities. Answers must be found for the questions: “Does an annual health checkup reduce health care costs and days lost from school and why?’’ “Is poor health related to school failure?” “Does health education actually improve a child’s health and school performance? How?” 4. Finally, the observation that health professionals (and more specifically school nurses) and educators possess different communication styles may further contribute to the problem of misunderstanding about the school nurses’ role and school health program and negatively influence their importance in the minds of educators. Generally, educators learn to communicate in a manner conducive to maintaining an authoritarian role and to keep control of and order in group settings. One education text, for example, emphasizes the need to avoid confusion or the appearance of helplessness. Nurses, on the other hand, especially in health maintenance situations, have been trained to promote participation on the part of the child in his own health care. To achieve this goal, the nurse frequently communicates in a give-and-take manner with little effort to maintain a position of authority or control, The extent to which educators view this type of communication as indicative of helplessness on the part of the nurse is not documented. However, in numerous interviews with educators and school nurses, one group frequently identifies the other group as “too easy with the students” and the other, “too strict.” Certainly such perceptions influence the nature of relationships between the two groups and need further examination. When communication is ineffective, one needs to look initially at the nature of the relationships that exist among the individuals involved. In the instance of the health professional-educator relationship, a number of circumstances have seriously inhibited collaboration. To alleviate the situation, health professionals within and outside schools must strengthen their allegiance to one another; the importance of school health programs must be recognized; clarity with regard to the role of the school nurse is necessary; and an increased awareness of the discrepancies in expectations that exist between health professionals and educators must be acknowledged and resolved. Incident Three: Mrs. GNmpS takes her son Jack to see Dr. Fixit. Jack is nine and is experiencing learning SEPTEMBER 1977
difficulties. The school has recently requested that the parents consent to an acadmeic evaluation and the possibility of special educational assistance in the future has been mentioned. Mrs. Grumps, convinced that the school has never liked her son, immediately contacts Dr. Fixit, who has known and cared for the child since birth. While Mrs. Grumps intermittently sobs and angrily blames the school for hurting her son, Dr. Fixit kindly listens and assures the mother not be worry. “I’ll take care of everything,” the physician says in a comforting, fatherly tone. Later, having completed a physical examination and laboratory tests showing Jack to be normal, Dr. Fixit calls the school and demands that they “leave the boy alone“ because “he’s well enough to learn.” Although the school attempts to explain the reasons for their concern about Jack to the doctor, Dr. Fixit interprets the conversation to mean that someone is questioning his authority and becomes even more adamant that they “leave this boy alone.” The conversation is ended. The school no longer pursues the chance of an academic evaluation, and Jack’s school performance continues to decline. Six months later Mrs. Grumps takes Jack to see the doctor again. Unfortunately, Jack has begun to experience headaches regularly, which are mysteriously present only on school days. Incident Four: Dr. Y walks into the examining room to greet Billy and his mother. Billy’s mother immediately hands Dr. Y a referral from the school that concludes: “Child needs an EEG.” Dr. Y utters a hostile “1’11 bet!” and makes a mental note that schools are getting out of hand.
Comment: Disturbances in communication occur when individuals act contrary to the general expectations. Incidents Three and Four are common occurrences in which one profession presumes to tell another profession what to do. Generally, it is not expected that physicians will dictate the approaches necessary for a learning problem, nor is it generally customary for an educator or other school personnel to decide for a physician which medical tests are warranted for a particular child. While the communication problems that ensue from such encounters may be obvious, because of the frequency with which such situations arise, this communication pattern requires attention. Perhaps such incidents occur as a result of the misunderstanding that presently exists between educators and health professionals with respect to one another’s role or perhaps an element of hostility within both
SEPTEMBER 1977
groups hinged to previous negative experiences with one another. In any event, we cannot deny that in both incidents lack of appreciation for one another’s unique talents exists, and in every case, unfortunately, the one who loses is the child. Might we all be better off in our efforts to improve communication with one another if we set aside our own professional interests and petty jealousies and focused our attention on the children who are so much in need?
Summary This paper described a number of situations and issues presently impeding communication efforts between educators and health professionals. The following approaches toward improved collaboration with one another were proposed: 1. A formal ongoing communication network between schools and health agencies should be developed in which the parent and the child assume some responsibility. 2. Relationships between educators and health professionals must improve before communication problems will be resolved. 3. Health professionals within and outside schools must strengthen their support for one another. 4. School health must attain a position of greater importance if equable relationships and collaborative communication are to develop between educators and health professionals. 5 . Communication will improve when the child’s welfare becomes the shared central goal for all our relationships with one another.
BIBLIOGRAPHY Davis K, Scott W: Human Relations and Organizational Behavior: Readings and Comments. New York, McGraw-Hill, 1%9. Hawkins N: Is there a school nurse role? Am J Nun Oct 1972. Horton P: Sociology and the Health Sciences. New York. McGrawHill, 1%5. Ruesch J: Disturbed Communication. New York. WW Norton & Co Inc, 1957. Stephens J: The Psychology of Classroom Learning. New York, Hold, Rinehart and Winston Inc. 1965.
Judith B. Igoe, RN, MS,is Associate Professor, School Nurse Practitioner Program, School of Nursing, University of Colorado Medical Center, 4200 East Ninth A venue, Container #C287, Denver, CO 80262.
THE JOURNAL
OF SCHOOL HEALTH
409
BIBLIOGRAPHY Fincher J: Thinking all together. Hum Behav 5:17-23, 1976 Hencley S, Yates J: Futurism in Education: Methodologies. McCutchan Publ, 1974. Huckfeldt VE, Judd RC: Methods for Large-Scale Delphi Studies.
Western Interstate Commission for Higher Education, Boulder, Colo, 1975. Judd RC: Delphi decision methods in higher education administration, unpublished. University of Toledo, Ohio. Linstone H, Turoff M: The Delphi Method: Techniques and Applications. Reading, Mass, Addison-Wesley Pub1 Co, 1975. Pill J: The delphi method: Substance, context, a critique and an annotated bibliography. Technical memorandum No. 183, May 1970. Operations Research Dept, School of Management, Case Western Reserve University, Cleveland. Sandow SA: Education Policy Formulation: Planning With the Focus Delphi and the Cross-Matrix, RR-9. US Department of Health, Education, and Welfare, Office of Education, Educational Policy Research Center, Feb 1972. Scott RF, Simmons DB: Programmer productivity and the delphi technique. Dotamation pp 71-73. May 1974. Synder M: Benefits and disbenefits of forecasting: Techniques in planning a curriculum for future health care, unpublished. University of Minnesota, Minneapolis, 1977. Toffler A (ed): Learning for Tomorrow: The Role of the Future in Education. New York, Random House, 1974.
Eileen A . Crowley, MA, is Research Fellow, Public Health Nursing, School of Public Health, University of Minnesota, Minneapolis, MN 55455 (corresponding author). Judith L . Johnson, RN, MPH, formerly Research Assistant, Maternal and Child Health Program, School of Public Health, University of Minnesota, is currently Cancer Education Coordinator, North Memorial Medical Center, Minneapolis, MN 55422.
Bridging the Communication Gap Between Health Professionals and Educators Judith B. Igoe, RN, MS “Communication is not a secondary or derived aspect of organization-a ‘helper’ of the other and more basic functions. Rather, it is the essence of organized activity and is the basic process out of which all other functions derive. ” How effectivelyare educators and health professionals communicating with each other? From personal interviews, reviewing the literature, and directly observing many interactions between educators and ‘Davis K, et al: Human Relations and Organizational Behavior, p 215.
SEPTEMBER 1977
health professionals in an effort to understand better the roles, relationships, expectations and ensuing communication patterns that exist between the two groups, I have found there are serious communication difficulties. The following anecdotes illustrate a number of factors that appear to contribute to this situation. Incident One: Last summer Jane X, age 10, underwent open heart surgery at a university hospital and returned to school in the fall with a note from her mother stating that the child was to be excused from all gym activity because of her heart condition. Jane’s THE JOURNAL OF SCHOOL HEALTH
405
teacher, fearful that the child might suffer from any type of physical activity, decided to keep the child inside during recess periods as well. By chance the school nurse heard Jane’s teacher discussing the child’s health during a coffee break and volunteered to contact Jane’s mother to clarify the situation. In discussion with the school nurse, Jane’s mother admitted she was confused about the doctor’s instructions and that she was hesitant to disturb the doctor (because of the busy clinic atmosphere) before their next appointment, which was three months away. With the mother’s permission, the school nurse tried to contact the physician. Four telephone calls and two days later, the nurse reached the physician. Unfortunately, without Jane’s record, the physician was unable to provide any information and, because of the hectic clinic schedule, the doctor hurriedly asked the school nurse for details about the case. The school nurse, having had no previous information from the hospital, experienced a tinge of annoyance and curtly replied, “Don’t ask me. We never get any information from you people.” The physician, who was rushed, suggested the nurse call back after he’d had a chance to review the record. Totally frustrated, the nurse delayed calling back for several days and then discovered a new physician had been assigned to Jane’s case! Finally, a public health nurse who was the clinic coordinator interceded and assisted the school in obtaining the necessary information, which was that Jane’s restrictions involved only the most rigorous of physical activity. In the meantime, however, the school nurse, prevented from immediately getting the information promised to the teacher, made several derogatory remarks in the coffee room with regard to the efficiency of hospitals in general. Comment: Traditionally, health services and education have been provided in completely separate environments with virtually no formalized and efficient system for mutually exchanging available information. However, as we begin to realize the mutuality of influence that exists between health and school performance, the need for closer relationships and increased and improved communication between health professionals and educators becomes evident. Development of functionally organized communication networks between schools and health agencies is not only a complex but also a costly process. Some of the factors that must be taken into account in the establishment of such a system are: 1. The communication network must be continuously in operation if closer relationships between health professionals and educators are to emerge. This is not the situation today in most communities. Instead, efforts at communication between the two groups are frequently episodic and usually initiated only when a problem arises that requires exchange of information. A 406
THE JOURNAL OF SCHOOL HEALTH
crises-oriented communication network is frequently inefficient because provisions for such elements of successful communication as timing, proper flow of messages, mutual agreement, understanding and clarity have not been made. Some schools have attempted to establish such a network and to develop closer relationships with health professionals in the community through the creation of community boards that include educators and those health professionals from whom the children in that school district most frequently seek health care. Such boards must meet regularly to be effective. What is needed today is a model plan for the development of an effective and functional communication network between educators and health professionals designed to be applicable to the needs of numerous communities. 2. Because of the numbers of people involved, development and organization of an ongoing linkage system between educators and all health professionals in a community become almost an impossible task, unless the feedback circuits are so designed as to place certain responsibility on the parents and children. Specifically, health professionals and educators must directly involve the child and his parents in the entire communication network. Parents and children, if they are considered by educators and health professionals to be actual members of the health and educational team, should be oriented to assume responsibility for the transfer of information from clinic to school and vice versa, either directly or indirectly, by motivating the professionals involved to talk with one another. A formal process of orientation for children and their parents will be necessary if they are to serve as facilitators of information exchange. It is, of course, expected that parents and children will participate in making the necessary decisions with regard to the release of information for exchange between educators and health professionals. 3. To be effective, the communication network must include individuals who are capable of identifying the implications of a health problem to the educator and the importance of the child’s functioning in school to the health professional. In a recent chart review involving the records of 300 school-age children seen at a pediatric clinic, 98% of the care plans failed to include any recommendations for contacting the school, although 60% of the cases were judged to have school-related implications. On the other hand, health professionals in the clinic had little or no information from the school at the time the child was evaluated (less than 10% of the cases). To alleviate this situation to some degree, this particular clinic designated a nurse with school experience to review records of children before their clinic appointment, to contact schools as SEPTEMBER 1977
indicated, and to make appropriate school-related notations in the record. This arrangement has increased the frequency with which health professionals are considering the school in health care planning. Although budgetary constraints may make it impossible for many clinics to add a school coordinator to their staffs, the feasibility of orienting parents and children to assume some responsibility for conveying school information to health professionals may be a viable alternative in many instances. 4. As seen in the case example involving Jane, the child with the heart ailment, the foremost cause of disturbed communication is frustration. The school nurse, unable to obtain quickly the desired information, became frustrated, and provided negative information about hospitals to the teachers, who, in turn, began to behave differently. Specifically, the frequency of negative remarks about health care agencies increased. In all likelihood, their understanding and perceptions of health facilities were influenced by the information they received. This example serves as an additional rationale for the need to establish an effective communication network through which gratification, the most important criterion of successful communication, can occur, and the chances of transmittal of negative information, which shapes behavior incorrectly, can be diminished. Incident Two: Studies of the role of the school nurse as perceived by the nurses themselves and school personnel generally indicate a discrepancy between the perceptions of the two groups and a failure to assign similar priorities to certain tasks attributed to the school nurse role. Ineffective communication between educators and school nurses is to blame. The following statements illustrate this point and the resulting ambiguity regarding the role of school nurses. “All they want me to d o is put on bandages.” (school nurse) “The role and functions of school nurses are poorly understood by both the nurses themselves and by those with whom they work.” (school nurse and teachers) “What is really needed is a school nurse who can make sound judgments in health matters.” (school administrator) “Lack of communication with teachers, special services personnel, and school administrators is an everpresent problem.” (school nurse) “Is our school health program necessary?” (parents and school board members) Comment: Difficulties in communication within an organization are more often than not mere symptoms of underlying difficulties in relationships between the parties involved. The confusion that persists regarding the role of the school nurse and the importance of the school health program verifies the need for further SEPTEMBER 1977
development and improvement of the health professional-educator relationship locally as well as at a national level. Ironically, these efforts to achieve close collaboration may come too late if we do not act promptly. With the present interest in Washington, for example, in separating the Department of Health, Education, and Welfare, the opportunity for interface of health and education on a national level may be obliterated. There are several significant contributing forces that have prolonged the dilemma in the health professionaleducator relationship: I . Historically, school health programs and school nurses have been identified as having secondary importance to the successful functioning of a school. Educators are not to blame for this interpretation of the relationship that should exist between the school and the health program. A quick review of numerous school health texts (generally written by health professionals) reveals a unanimous effort to define, or to imply at least, that the health program within a school setting, although worthwhile, is of secondary importance to the more primary goal, education. Several leaders in school health, as well as medical sociologists, have speculated that this age-old philosophy of school health originated at a time when it was important to protect the interests of private medicine, which in the past has generally monopolized the enterprise of health service delivery. Whatever the reasons for giving school health programs subsidiary importance in school, as long as this particular thinking persists, those involved in school health will forever struggle in vain to achieve truly collaborative relationships with their educational colleagues. Philosophically, there is nothing now in the theory of school health to support the concept of equitable relationships between health professionals and educators. Health, however, can no longer be given secondary consideration in schools. (1) Communities are now turning to schools for more than the customary educational activities. In some areas of the country, schools are viewed as community centers offering a wide range of new services, including health care. (2) Society through the health consumer movement has begun to demand greater availability and accessibility to health care facilities. The school has been designated as a logical site for the delivery of health services to children in need. (3) The importance of the relationship between health and school performance has become increasingly evident in recent years. Recognition of this phenomenon justifies the need to emphasize health as a primary component of any school system. (4) Current efforts to mainstream children with physical and mental handicaps into regular classrooms have further heightened an awareness of the importance of health to learning. THE JOURNAL OF SCHOOL HEALTH
407
Clarification of the significance of health in school settiilgs is an issue that must first be discussed and about which a harmonious decision must be reached among health professionals before attempts to involve the educators begin. Presently there is no agreement among health professionals on the salience of school health. Some health providers believe that health must take a low profile within school settings. Other health professionals insist the school should be a site for primary health care delivery, which would, of course, place health in a much more prestigious position within schools than presently exists. 2. Another problem to be resolved in promoting more effective relationships and communication between health professionals and educators involves the relationship between those health professionals who work in school health and their colleagues in the traditional health agencies within the community (eg, physicians’ offices, hospital outpatient departments, public health clinics). Unfortunately, a mutual support system between these groups is missing, as evidenced by the jokes frequently made in health agencies about the competence of school nurses and, conversely, the disparaging remarks school health personnel often make regarding the quality of care available in the community. Therefore, we as health professionals must unite in our thinking and dealings with one another if the goal of improved working relationships with educators is to be ,achieved. 3. Disparate perceptions of the role of school nurses and school health programs, another communication disturbance between educators and health professionals, are largely influenced by the fact that the two groups do not share the same role expectations for the school nurse. For school administrators there is a general expectation that the nurses’ first priority will be to care for the injured and ill, thereby safeguarding the school from potential legal encounters. The nurse, on the other hand, skilled and interested in health promotion activities (nutrition, exercise, health education), often is more inclined to assign a higher priority to health teaching and counseling than first aid. Amelioration of the situation requires mutual understanding, some compromise, and eventually joint agreement. School nurses may seriously jeopardize their credibility when they flatly refuse to recognize that the educators’ expectation for first aid services is predicated upon an actual need to ensure the safety of the children while at school. Conflicting expectations between school nurses and educators with regard to the role of the school nurse is also closely related to nursing’s inability to articulate to others what it is they do outside hospitals and the merits of these activities. The following parody may express the problem some school nurses are having: “I know 408
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you believe you understand what you think I said, but I am not sure you realize that what you heard is not what I meant.” School nurses also must work rapidly to establish evidence of the importance of health maintenance and preventive health care and education because the American public (including educators) apparently assigns virtually no value to these activities. Answers must be found for the questions: “Does an annual health checkup reduce health care costs and days lost from school and why?’’ “Is poor health related to school failure?” “Does health education actually improve a child’s health and school performance? How?” 4. Finally, the observation that health professionals (and more specifically school nurses) and educators possess different communication styles may further contribute to the problem of misunderstanding about the school nurses’ role and school health program and negatively influence their importance in the minds of educators. Generally, educators learn to communicate in a manner conducive to maintaining an authoritarian role and to keep control of and order in group settings. One education text, for example, emphasizes the need to avoid confusion or the appearance of helplessness. Nurses, on the other hand, especially in health maintenance situations, have been trained to promote participation on the part of the child in his own health care. To achieve this goal, the nurse frequently communicates in a give-and-take manner with little effort to maintain a position of authority or control, The extent to which educators view this type of communication as indicative of helplessness on the part of the nurse is not documented. However, in numerous interviews with educators and school nurses, one group frequently identifies the other group as “too easy with the students” and the other, “too strict.” Certainly such perceptions influence the nature of relationships between the two groups and need further examination. When communication is ineffective, one needs to look initially at the nature of the relationships that exist among the individuals involved. In the instance of the health professional-educator relationship, a number of circumstances have seriously inhibited collaboration. To alleviate the situation, health professionals within and outside schools must strengthen their allegiance to one another; the importance of school health programs must be recognized; clarity with regard to the role of the school nurse is necessary; and an increased awareness of the discrepancies in expectations that exist between health professionals and educators must be acknowledged and resolved. Incident Three: Mrs. GNmpS takes her son Jack to see Dr. Fixit. Jack is nine and is experiencing learning SEPTEMBER 1977
difficulties. The school has recently requested that the parents consent to an acadmeic evaluation and the possibility of special educational assistance in the future has been mentioned. Mrs. Grumps, convinced that the school has never liked her son, immediately contacts Dr. Fixit, who has known and cared for the child since birth. While Mrs. Grumps intermittently sobs and angrily blames the school for hurting her son, Dr. Fixit kindly listens and assures the mother not be worry. “I’ll take care of everything,” the physician says in a comforting, fatherly tone. Later, having completed a physical examination and laboratory tests showing Jack to be normal, Dr. Fixit calls the school and demands that they “leave the boy alone“ because “he’s well enough to learn.” Although the school attempts to explain the reasons for their concern about Jack to the doctor, Dr. Fixit interprets the conversation to mean that someone is questioning his authority and becomes even more adamant that they “leave this boy alone.” The conversation is ended. The school no longer pursues the chance of an academic evaluation, and Jack’s school performance continues to decline. Six months later Mrs. Grumps takes Jack to see the doctor again. Unfortunately, Jack has begun to experience headaches regularly, which are mysteriously present only on school days. Incident Four: Dr. Y walks into the examining room to greet Billy and his mother. Billy’s mother immediately hands Dr. Y a referral from the school that concludes: “Child needs an EEG.” Dr. Y utters a hostile “1’11 bet!” and makes a mental note that schools are getting out of hand.
Comment: Disturbances in communication occur when individuals act contrary to the general expectations. Incidents Three and Four are common occurrences in which one profession presumes to tell another profession what to do. Generally, it is not expected that physicians will dictate the approaches necessary for a learning problem, nor is it generally customary for an educator or other school personnel to decide for a physician which medical tests are warranted for a particular child. While the communication problems that ensue from such encounters may be obvious, because of the frequency with which such situations arise, this communication pattern requires attention. Perhaps such incidents occur as a result of the misunderstanding that presently exists between educators and health professionals with respect to one another’s role or perhaps an element of hostility within both
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groups hinged to previous negative experiences with one another. In any event, we cannot deny that in both incidents lack of appreciation for one another’s unique talents exists, and in every case, unfortunately, the one who loses is the child. Might we all be better off in our efforts to improve communication with one another if we set aside our own professional interests and petty jealousies and focused our attention on the children who are so much in need?
Summary This paper described a number of situations and issues presently impeding communication efforts between educators and health professionals. The following approaches toward improved collaboration with one another were proposed: 1. A formal ongoing communication network between schools and health agencies should be developed in which the parent and the child assume some responsibility. 2. Relationships between educators and health professionals must improve before communication problems will be resolved. 3. Health professionals within and outside schools must strengthen their support for one another. 4. School health must attain a position of greater importance if equable relationships and collaborative communication are to develop between educators and health professionals. 5 . Communication will improve when the child’s welfare becomes the shared central goal for all our relationships with one another.
BIBLIOGRAPHY Davis K, Scott W: Human Relations and Organizational Behavior: Readings and Comments. New York, McGraw-Hill, 1%9. Hawkins N: Is there a school nurse role? Am J Nun Oct 1972. Horton P: Sociology and the Health Sciences. New York. McGrawHill, 1%5. Ruesch J: Disturbed Communication. New York. WW Norton & Co Inc, 1957. Stephens J: The Psychology of Classroom Learning. New York, Hold, Rinehart and Winston Inc. 1965.
Judith B. Igoe, RN, MS,is Associate Professor, School Nurse Practitioner Program, School of Nursing, University of Colorado Medical Center, 4200 East Ninth A venue, Container #C287, Denver, CO 80262.
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