ORIGINAL ARTICLE
Rural-Urban Disparities in School Nursing: Implications for Continuing Education and Rural School Health Mary M. Ramos, MD, MPH;1 Lynne Fullerton, PhD;2 Robert Sapien, MD;2 Cynthia Greenberg, RN, BSN, MSN;3 & Judith Bauer-Creegan, MSN, RN4 1 Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico 2 Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico 3 New Mexico Department of Health, Albuquerque, New Mexico 4 Gadsden Independent School District, Anthony, New Mexico
Abstract The authors have no conflicts of interest to disclose. Funding support was obtained from the University of New Mexico Clinical and Translational Science Center, #1UL1RR031977. We thank the 2009 School Nurse Survey Workgroup for their assistance in creating the survey instrument used in this study. For further information, contact: Mary M. Ramos, MD, MPH, Department of Pediatrics, University of New Mexico School of Medicine, 625 Silver Ave. SW, Suite 324, Albuquerque, NM 87102; e-mail: [email protected]. doi: 10.1111/jrh.12058
Purpose: Little is known about the professional and educational challenges experienced by rural school nurses. We conducted this study to describe disparities between the urban and rural professional school nurse workforce in New Mexico and to identify how best to meet the continuing education needs of New Mexico’s rural school nurse workforce. Methods: We analyzed state data from a 2009 New Mexico Department of Health school nurse workforce survey (71.7% response rate). We included all survey respondents who indicated working as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311). Findings: Rural school nurses were twice as likely as metropolitan nurses to provide clinical services to multiple school campuses (67.3% compared to 30.1%, P < .0001). They were less likely to hold a nursing degree at the baccalaureate level or higher (62.7% compared to 82.3%, P = .0002). Rural school nurses were less likely than metropolitan nurses to have received recent continuing education on anaphylaxis (P < .0001), asthma (P = .027), body mass index (BMI)/healthy weight (P = .0002), diabetes (P < .0001), lesbian, gay, bisexual and transgender (LGBT) health (P = .0004), and suicide risk identification and prevention (P = .015). Online courses and telehealth were identified by rural school nurses as among the preferred means for receiving continuing education. Conclusions: Our findings support the provision of online courses and telehealth content to address urban-rural disparities in school nursing education and support rural school health. Key words health disparities, health services research, nursing, rural health, school health.
School nurses and school health services are vital parts of the pediatric health care infrastructure in the United States.1-4 There are over 70,000 school nurses providing care to children and adolescents in US public schools.5 School nurses are professionals who provide direct care for students and school staff with chronic diseases or acute injury or illness; provide emergent care for stu-
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 265–274
dents with life-threatening behavioral or physical illness; provide leadership and guidance on school health policy and practice and emergency preparedness; provide health screenings and referrals; promote health and a healthy and safe school environment; and serve as liaison between school personnel, family, health care professionals, and community.1
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Rural-Urban Disparities in School Nursing
School nursing has become more complex over the past several decades as student needs have increased and the scope of practice of school nursing has expanded.6 Data from the 2001 National Survey of Children’s Health indicate that the proportion of school-aged children 617 years old with a special health care need (SHCN) was less than 20%.7 In the 2011/2012 National Survey of Children’s Health, however, almost a quarter of schoolaged children 6-17 years old had a SHCN, a significant increase.8 These children with SHCNs include those with long-term physical, emotional, or development disorders that often require prescription medications and ongoing nursing care while at school.9 In addition, schools are now the primary providers of mental health services for many children and adolescents in the United States who cannot access mental health care elsewhere.10-12 One in every 5 youth before the age of 19 in the United States meets criteria for a mental health disorder with severe impairment.13,14 Most adolescents with mental health disorders do not receive mental health care in the community because of a shortage of outpatient adolescent services.11,15 Thus, schoolbased programs and services are increasingly relied on to improve access to mental health services for youth.10,12 School nurses, working as members of school behavioral health teams, provide screenings and emergency management for behavioral health problems.10 A 2009 workforce survey in New Mexico found that 40% of school nurses working in secondary schools had provided emergency management for youth suicidal behavior in the prior school year (NM Department of Health, unpublished data). With the passage of the 2010 Patient Protection and Affordable Care Act (ACA), there are mandated changes to health care delivery in the United States in an effort to reduce costs and increase access and quality of care.16 The ACA mandates a modernization of public health systems to increase access to quality clinical preventive services. Although the focus largely has been on costly adult health care, there is an increasing interest in the role of pediatric and school nurses in providing preventive care and care coordination.6,17 Promoting healthy behaviors and providing care management to avoid hospitalization of children with SHCNs is a major component of the school nurse role.1 Yet, little is known about the depth of adequate preparation of school nurses for this increasingly complex scope of work.18-22 Even less is known about the professional and educational challenges experienced by rural school nurses. Published research on school nursing practice and education has focused primarily on urban settings23-26 with notable exceptions.27-29 Meeting the educational needs of rural health care professionals has
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Ramos et al.
been described as difficult. Barriers that have been noted include geographic isolation, lack of financial resources, lack of regional educators, and inability to take time away from patient care responsibilities.30-34 We conducted this study to (1) describe disparities between the urban and rural professional school nurse workforce in New Mexico, and (2) identify how best to meet the continuing education (CE) needs of New Mexico’s rural school nurse workforce. Findings from this study were used to garner support for CE opportunities for school nurses in New Mexico.
Methods Subjects The New Mexico Department of Health (NMDOH) Office of School and Adolescent Health conducted a statewide school nurse workforce survey in April 2009. School nurses in New Mexico are professionals who must obtain additional licensure with the NM Public Education Department. School nurses (N = 502) working in public schools, kindergarten through 12th grade, who were listed in the 2008-2009 NMDOH school nurse directory were surveyed. The directory included nurses working in public, charter, and alternative schools, but it did not include nurses in private or parochial schools. E-mail addresses and mailing addresses were included in the directory.
Instrument Subject matter experts in school nursing, nursing education, public health, emergency medicine, and pediatrics created the survey instrument to better understand the needs of the school nurse workforce in New Mexico. The survey was cognitively tested by 8 school nurses to ensure content validity prior to administration statewide. Specifically, the survey was used to identify challenges faced by school nurses working in public schools and the CE content areas most needed. Specific survey domains included: demographics, professional characteristics such as educational level and years of experience, recent CE and preferred means of receiving CE.
Procedure The survey was conducted anonymously. A unique identifier was assigned to each school nurse in the directory to identify respondents and nonrespondents. In April 2009, a notice about the upcoming survey was e-mailed to all school nurses in the directory. One week later, the paper survey was mailed to all New Mexico public school nurses
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 265–274
Ramos et al.
in the directory. School nurses were asked to complete the survey in one of several ways. Respondents could return the completed paper survey via mail, using a provided postage-paid return envelope; they could fax the completed paper survey; or they could access the survey online using a web link that was included with information accompanying the mailed survey. A $5 gift card to an online bookstore was included in the mailing as an incentive. A reminder notice was e-mailed to nonresponders 2 and 3 weeks after the survey was mailed. The e-mailed reminder notice included a web link to the survey and the survey instrument as an electronic attachment. Completed surveys were received from April 2009 to May 2009.
Data Set Of the 502 nurses listed in the state school nurse directory, 360 responded (71.7% response rate). The 360 respondents included 111 whose surveys were completed online and 249 who completed paper surveys. The paper survey answers were transferred into an electronic database and combined with responses to the online survey. Metropolitan counties were defined per US Census definitions.35 Respondents who reported working in metropolitan counties were considered metropolitan or urban; all others were defined as rural. No differences were observed in response rates between metropolitan and rural school nurses.
Analytic Sample For the present study, we included all respondents to the workforce survey who worked as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311).
Data Analysis The data collected were cross-sectional, and they were analyzed using chi-square tests and Fisher’s exact tests. Statistical analysis was conducted using Stata, version 11.0 (StataCorp LP, College Station, Texas, USA).
Results Demographics and Characteristics of Sample New Mexico school nurse respondents were predominantly white (88.0%) and female (96.4%). A minority of school nurses, 19.7%, self-identified as Hispanic. Almost two-thirds, 62.3%, were at least 50 years old. Among respondents, 200 (64.3%) worked in metropolitan counties
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 265–274
Rural-Urban Disparities in School Nursing
and 111 (35.7%) worked in rural counties. No significant differences in demographic characteristics (ie, race, ethnicity, gender, age) were found between school nurses working in metropolitan and rural counties. Compared with school nurses from metropolitan counties, school nurses working in rural counties were less likely to have a baccalaureate degree or higher in nursing and less likely to be nationally certified as a school nurse (Table 1). Rural school nurses were twice as likely as metropolitan school nurses to work at multiple school campuses and were more likely to work in both elementary and secondary school settings (Table 1).
Children With Special Health Care Needs A majority of school nurses in both metropolitan and rural areas reported having at least one student in their school(s) with each of the following special health care needs: diabetes, asthma, history of anaphylaxis, and seizure disorder (Table 1). School nurses in rural areas were more likely to report having at least one pregnant student at their school(s); school nurses in metropolitan areas were more likely to report having at least one student with asthma, anaphylaxis history, and seizure disorder in their school(s) (Table 1).
Continuing Education Compared with nurses from metropolitan areas, rural school nurses were less likely to report having received CE within the previous 5 years on a number of physical health topics including anaphylaxis, asthma, body mass index (BMI) measurement/healthy weight, and diabetes (Table 2). Additionally, rural school nurses, in comparison with metropolitan school nurses, were less likely to report having had Helping Administer to the Needs of the Student with Diabetes in School (HANDS) training within the previous 5 years (33.9%, compared with 81.3%, respectively, P value < .0001). HANDS training is a full-day live continuing educational session on school-based diabetes management that was developed by the National Association of School Nurses.36 Finally, rural school nurses, compared with metropolitan school nurses, were less likely to have had CE within the previous 5 years on 2 behavioral health topics: suicide risk identification and prevention, and lesbian, gay, bisexual, and transgender (LGBT) health (Table 2). School district on-site, classroom-based in-services were the preferred means for both rural and metropolitan school nurses to receive CE (Table 3). Online courses accessed at home were the second most popular means of receiving education for both rural and metropolitan school nurses (Table 3). Teleconferencing was named a
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Ramos et al.
Table 1 Selected Characteristics of School Nurses—New Mexico, 2009
Nursing educational level No Bachelor degree in nursing Bachelor or higher in nursing National certified school nurse certificate Years worked as school nurse ≤5 years >5 years Serve more than one school campus School settings Elementary only Secondary only (6th to 12th) Elementary and secondary) Children with special needs in at least 1 school they serve Anaphylaxis history Asthma Bladder catheterization Diabetes Infants or toddlers Mechanical ventilation Parenteral feeds (ie, gastric tube) Pregnant student Requiring supplemental oxygen Seizure disorder Tracheostomy
Metropolitan (N = 200)
Rural (N = 111)
34/192 (17.7%) 158/192 (82.3%) 46/190 (24.2%)
41/110 (37.3%) 69/110 (62.7%) 5/102 (4.9%)
79/193 (40.9%) 114/193 (59.1%) 58/193 (30.1%)
37/111 (33.3%) 74/111 (66.7%) 74/110 (67.3%)
97/196 (49.5%) 62/196 (31.6%) 37/196 (18.9%)
39/110 (35.4%) 26/110 (23.6%) 45/110 (40.9%)
165/200 (82.5%) 193/200 (96.5%) 40/200 (20.0%) 136/200 (68.0%) 45/200 (22.5%) 10/200 (5.0%) 61/200 (30.5%) 51/200 (25.5%) 23/200 (11.5%) 171/200 (85.5%) 30/200 (15.0%)
78/111 (70.3%) 99/111 (89.2%) 14/111 (12.6%) 76/111 (68.5%) 20/111 (18.0%) 2/111 (1.8%) 24/111 (21.6%) 42/111 (37.8%) 18/111 (16.2%) 84/111 (75.7%) 3/111 (2.7%)
P valuea .0003
Rural-Urban Disparities in School Nursing: Implications for Continuing Education and Rural School Health Mary M. Ramos, MD, MPH;1 Lynne Fullerton, PhD;2 Robert Sapien, MD;2 Cynthia Greenberg, RN, BSN, MSN;3 & Judith Bauer-Creegan, MSN, RN4 1 Department of Pediatrics, University of New Mexico, Albuquerque, New Mexico 2 Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico 3 New Mexico Department of Health, Albuquerque, New Mexico 4 Gadsden Independent School District, Anthony, New Mexico
Abstract The authors have no conflicts of interest to disclose. Funding support was obtained from the University of New Mexico Clinical and Translational Science Center, #1UL1RR031977. We thank the 2009 School Nurse Survey Workgroup for their assistance in creating the survey instrument used in this study. For further information, contact: Mary M. Ramos, MD, MPH, Department of Pediatrics, University of New Mexico School of Medicine, 625 Silver Ave. SW, Suite 324, Albuquerque, NM 87102; e-mail: [email protected]. doi: 10.1111/jrh.12058
Purpose: Little is known about the professional and educational challenges experienced by rural school nurses. We conducted this study to describe disparities between the urban and rural professional school nurse workforce in New Mexico and to identify how best to meet the continuing education needs of New Mexico’s rural school nurse workforce. Methods: We analyzed state data from a 2009 New Mexico Department of Health school nurse workforce survey (71.7% response rate). We included all survey respondents who indicated working as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311). Findings: Rural school nurses were twice as likely as metropolitan nurses to provide clinical services to multiple school campuses (67.3% compared to 30.1%, P < .0001). They were less likely to hold a nursing degree at the baccalaureate level or higher (62.7% compared to 82.3%, P = .0002). Rural school nurses were less likely than metropolitan nurses to have received recent continuing education on anaphylaxis (P < .0001), asthma (P = .027), body mass index (BMI)/healthy weight (P = .0002), diabetes (P < .0001), lesbian, gay, bisexual and transgender (LGBT) health (P = .0004), and suicide risk identification and prevention (P = .015). Online courses and telehealth were identified by rural school nurses as among the preferred means for receiving continuing education. Conclusions: Our findings support the provision of online courses and telehealth content to address urban-rural disparities in school nursing education and support rural school health. Key words health disparities, health services research, nursing, rural health, school health.
School nurses and school health services are vital parts of the pediatric health care infrastructure in the United States.1-4 There are over 70,000 school nurses providing care to children and adolescents in US public schools.5 School nurses are professionals who provide direct care for students and school staff with chronic diseases or acute injury or illness; provide emergent care for stu-
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 265–274
dents with life-threatening behavioral or physical illness; provide leadership and guidance on school health policy and practice and emergency preparedness; provide health screenings and referrals; promote health and a healthy and safe school environment; and serve as liaison between school personnel, family, health care professionals, and community.1
265
Rural-Urban Disparities in School Nursing
School nursing has become more complex over the past several decades as student needs have increased and the scope of practice of school nursing has expanded.6 Data from the 2001 National Survey of Children’s Health indicate that the proportion of school-aged children 617 years old with a special health care need (SHCN) was less than 20%.7 In the 2011/2012 National Survey of Children’s Health, however, almost a quarter of schoolaged children 6-17 years old had a SHCN, a significant increase.8 These children with SHCNs include those with long-term physical, emotional, or development disorders that often require prescription medications and ongoing nursing care while at school.9 In addition, schools are now the primary providers of mental health services for many children and adolescents in the United States who cannot access mental health care elsewhere.10-12 One in every 5 youth before the age of 19 in the United States meets criteria for a mental health disorder with severe impairment.13,14 Most adolescents with mental health disorders do not receive mental health care in the community because of a shortage of outpatient adolescent services.11,15 Thus, schoolbased programs and services are increasingly relied on to improve access to mental health services for youth.10,12 School nurses, working as members of school behavioral health teams, provide screenings and emergency management for behavioral health problems.10 A 2009 workforce survey in New Mexico found that 40% of school nurses working in secondary schools had provided emergency management for youth suicidal behavior in the prior school year (NM Department of Health, unpublished data). With the passage of the 2010 Patient Protection and Affordable Care Act (ACA), there are mandated changes to health care delivery in the United States in an effort to reduce costs and increase access and quality of care.16 The ACA mandates a modernization of public health systems to increase access to quality clinical preventive services. Although the focus largely has been on costly adult health care, there is an increasing interest in the role of pediatric and school nurses in providing preventive care and care coordination.6,17 Promoting healthy behaviors and providing care management to avoid hospitalization of children with SHCNs is a major component of the school nurse role.1 Yet, little is known about the depth of adequate preparation of school nurses for this increasingly complex scope of work.18-22 Even less is known about the professional and educational challenges experienced by rural school nurses. Published research on school nursing practice and education has focused primarily on urban settings23-26 with notable exceptions.27-29 Meeting the educational needs of rural health care professionals has
266
Ramos et al.
been described as difficult. Barriers that have been noted include geographic isolation, lack of financial resources, lack of regional educators, and inability to take time away from patient care responsibilities.30-34 We conducted this study to (1) describe disparities between the urban and rural professional school nurse workforce in New Mexico, and (2) identify how best to meet the continuing education (CE) needs of New Mexico’s rural school nurse workforce. Findings from this study were used to garner support for CE opportunities for school nurses in New Mexico.
Methods Subjects The New Mexico Department of Health (NMDOH) Office of School and Adolescent Health conducted a statewide school nurse workforce survey in April 2009. School nurses in New Mexico are professionals who must obtain additional licensure with the NM Public Education Department. School nurses (N = 502) working in public schools, kindergarten through 12th grade, who were listed in the 2008-2009 NMDOH school nurse directory were surveyed. The directory included nurses working in public, charter, and alternative schools, but it did not include nurses in private or parochial schools. E-mail addresses and mailing addresses were included in the directory.
Instrument Subject matter experts in school nursing, nursing education, public health, emergency medicine, and pediatrics created the survey instrument to better understand the needs of the school nurse workforce in New Mexico. The survey was cognitively tested by 8 school nurses to ensure content validity prior to administration statewide. Specifically, the survey was used to identify challenges faced by school nurses working in public schools and the CE content areas most needed. Specific survey domains included: demographics, professional characteristics such as educational level and years of experience, recent CE and preferred means of receiving CE.
Procedure The survey was conducted anonymously. A unique identifier was assigned to each school nurse in the directory to identify respondents and nonrespondents. In April 2009, a notice about the upcoming survey was e-mailed to all school nurses in the directory. One week later, the paper survey was mailed to all New Mexico public school nurses
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 265–274
Ramos et al.
in the directory. School nurses were asked to complete the survey in one of several ways. Respondents could return the completed paper survey via mail, using a provided postage-paid return envelope; they could fax the completed paper survey; or they could access the survey online using a web link that was included with information accompanying the mailed survey. A $5 gift card to an online bookstore was included in the mailing as an incentive. A reminder notice was e-mailed to nonresponders 2 and 3 weeks after the survey was mailed. The e-mailed reminder notice included a web link to the survey and the survey instrument as an electronic attachment. Completed surveys were received from April 2009 to May 2009.
Data Set Of the 502 nurses listed in the state school nurse directory, 360 responded (71.7% response rate). The 360 respondents included 111 whose surveys were completed online and 249 who completed paper surveys. The paper survey answers were transferred into an electronic database and combined with responses to the online survey. Metropolitan counties were defined per US Census definitions.35 Respondents who reported working in metropolitan counties were considered metropolitan or urban; all others were defined as rural. No differences were observed in response rates between metropolitan and rural school nurses.
Analytic Sample For the present study, we included all respondents to the workforce survey who worked as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311).
Data Analysis The data collected were cross-sectional, and they were analyzed using chi-square tests and Fisher’s exact tests. Statistical analysis was conducted using Stata, version 11.0 (StataCorp LP, College Station, Texas, USA).
Results Demographics and Characteristics of Sample New Mexico school nurse respondents were predominantly white (88.0%) and female (96.4%). A minority of school nurses, 19.7%, self-identified as Hispanic. Almost two-thirds, 62.3%, were at least 50 years old. Among respondents, 200 (64.3%) worked in metropolitan counties
c 2014 National Rural Health Association The Journal of Rural Health 30 (2014) 265–274
Rural-Urban Disparities in School Nursing
and 111 (35.7%) worked in rural counties. No significant differences in demographic characteristics (ie, race, ethnicity, gender, age) were found between school nurses working in metropolitan and rural counties. Compared with school nurses from metropolitan counties, school nurses working in rural counties were less likely to have a baccalaureate degree or higher in nursing and less likely to be nationally certified as a school nurse (Table 1). Rural school nurses were twice as likely as metropolitan school nurses to work at multiple school campuses and were more likely to work in both elementary and secondary school settings (Table 1).
Children With Special Health Care Needs A majority of school nurses in both metropolitan and rural areas reported having at least one student in their school(s) with each of the following special health care needs: diabetes, asthma, history of anaphylaxis, and seizure disorder (Table 1). School nurses in rural areas were more likely to report having at least one pregnant student at their school(s); school nurses in metropolitan areas were more likely to report having at least one student with asthma, anaphylaxis history, and seizure disorder in their school(s) (Table 1).
Continuing Education Compared with nurses from metropolitan areas, rural school nurses were less likely to report having received CE within the previous 5 years on a number of physical health topics including anaphylaxis, asthma, body mass index (BMI) measurement/healthy weight, and diabetes (Table 2). Additionally, rural school nurses, in comparison with metropolitan school nurses, were less likely to report having had Helping Administer to the Needs of the Student with Diabetes in School (HANDS) training within the previous 5 years (33.9%, compared with 81.3%, respectively, P value < .0001). HANDS training is a full-day live continuing educational session on school-based diabetes management that was developed by the National Association of School Nurses.36 Finally, rural school nurses, compared with metropolitan school nurses, were less likely to have had CE within the previous 5 years on 2 behavioral health topics: suicide risk identification and prevention, and lesbian, gay, bisexual, and transgender (LGBT) health (Table 2). School district on-site, classroom-based in-services were the preferred means for both rural and metropolitan school nurses to receive CE (Table 3). Online courses accessed at home were the second most popular means of receiving education for both rural and metropolitan school nurses (Table 3). Teleconferencing was named a
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Ramos et al.
Table 1 Selected Characteristics of School Nurses—New Mexico, 2009
Nursing educational level No Bachelor degree in nursing Bachelor or higher in nursing National certified school nurse certificate Years worked as school nurse ≤5 years >5 years Serve more than one school campus School settings Elementary only Secondary only (6th to 12th) Elementary and secondary) Children with special needs in at least 1 school they serve Anaphylaxis history Asthma Bladder catheterization Diabetes Infants or toddlers Mechanical ventilation Parenteral feeds (ie, gastric tube) Pregnant student Requiring supplemental oxygen Seizure disorder Tracheostomy
Metropolitan (N = 200)
Rural (N = 111)
34/192 (17.7%) 158/192 (82.3%) 46/190 (24.2%)
41/110 (37.3%) 69/110 (62.7%) 5/102 (4.9%)
79/193 (40.9%) 114/193 (59.1%) 58/193 (30.1%)
37/111 (33.3%) 74/111 (66.7%) 74/110 (67.3%)
97/196 (49.5%) 62/196 (31.6%) 37/196 (18.9%)
39/110 (35.4%) 26/110 (23.6%) 45/110 (40.9%)
165/200 (82.5%) 193/200 (96.5%) 40/200 (20.0%) 136/200 (68.0%) 45/200 (22.5%) 10/200 (5.0%) 61/200 (30.5%) 51/200 (25.5%) 23/200 (11.5%) 171/200 (85.5%) 30/200 (15.0%)
78/111 (70.3%) 99/111 (89.2%) 14/111 (12.6%) 76/111 (68.5%) 20/111 (18.0%) 2/111 (1.8%) 24/111 (21.6%) 42/111 (37.8%) 18/111 (16.2%) 84/111 (75.7%) 3/111 (2.7%)
P valuea .0003
