THE ROLE AND IMPACT OF SCHOOL NURSES AND INTENTIONS TO DELEGATE DIABETES-RELATED TASKS AMIDST BUDGET CUTS AND LEGISLATIVE CHANGES

OF DISSERTATION THE ROLE AND IMPACT OF SCHOOL NURSES AND INTENTIONS TO DELEGATE DIABETES-RELATED TASKS AMIDST BUDGET CUTS AND LEGISLATIVE CHANGES As the percentage of school children with chronic conditions such as diabetes continues to rise, funding for school nurses to keep those students healthy and safe is decreasing. This dissertation includes three studies: (1) a systematic review of the literature on the role and impact of American elementary school nurses, (2) a focus group study that further examined the role of Kentucky school nurses and described their reaction to a new regulation that necessitates delegation of diabetes-related nursing tasks to unlicensed assistive personnel (UAP), and (3) a quantitative study that examined Kentucky school nurses’ past behaviors and future intentions regarding the delegation of diabetes-related tasks. A systematic review of the literature revealed that activities of school nurses can be conceptualized into four major areas: (a) health promotion and disease prevention; (b) triage and treatment of acute issues (e.g., injuries and infectious diseases); (c) management of chronic conditions; and (d) psychosocial support. School nursing activities are associated with increased attendance, higher quality schools, and cost savings. Focus groups in three regions of Kentucky found that Kentucky school nurses fulfill the same major roles as their counterparts across the nation, and face similar challenges such as lack of time, limited resources, language barriers, and communication issues with families. School nurse participants described their biggest impact on students as identifying and addressing students’ physical and psychosocial barriers to learning. While recent legislation was passed in Kentucky necessitating the delegation of insulin administration to UAP, school nurses had not experienced many changes at the time of the focus groups. However, some nurses said that their districts were not planning to delegate insulin administration and intended to keep a nurse in every school. Others appreciated the prospect of having more trained staff in schools to recognize signs of distress in chronically ill students. A statewide survey of 111 Kentucky school nurses indicated that nurses’ past delegation behaviors and future intentions related to delegation are rooted in the level of skilled decision-making that must occur and the risk to the student if the wrong decision is made. Unfortunately, school nurses’ intentions to delegate higher-stakes tasks (e.g. carbohydrate counting, insulin dose verification, and insulin administration) were significantly stronger than their support for (attitude related to) delegation of those tasks, which is disconcerting both for the safety of students as well as for the liability retained by delegating nurses. This disparity between support and intentions indicated that school nurses anticipate that they will have to delegate certain tasks to UAP despite their discomfort with delegating them, most likely due to high workload and lack of resources. Additional studies should be undertaken to determine the impact of legislative changes on the delivery of school health services in Kentucky and other states, particularly once school districts and nurses have had adequate time to adjust to new laws. Such studies should investigate to whom nurses are delegating health services, what tasks are being delegated, and the extent and process of training that UAP receive. Future surveys should utilize perceived behavioral control items that assess situational control (e.g. policy, workload) over delegation rather than, or in addition to, efficacy of individual skills required for delegation of nursing tasks. Researchers must further explore the discrepancies between attitude and intentions; that is, why are nurses planning to delegate tasks to UAP if they do not support the delegation of those tasks? Kentucky school nurses are champions of health promotion for children, not only in their provision of health services and health education, but also in the area of school health policy. School nurses should train UAP so that more school staff can recognize signs of distress in students with diabetes, but at the same time should continue to advocate and seek funding for a nurse in every school with the help of the Every Student Succeeds Act.