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The Role of Nurses in Schools

School nurses are valuable members of the teams of professionals who educate our children (National Association of School Nurses (NASN), 2011). They share the goal of ensuring that children receive the education that is required by law and that will lay a strong foundation for becoming productive members of a community. The effectiveness and quality of this education is largely influenced by the students’ physical, social, and emotional health (NASN, 2011).

School nurses provide a variety of services to students to support good health. Historically, the focus of school nurses has been to prevent the spread of communicable disease. The first school nurse, Lina Rogers, was hired in 1902 into the New York City school system to contain outbreaks of diseases such as diphtheria, mumps, smallpox, scarlet fever, and measles (School Nurse News, 1999). This is still a main function for school nurses today. They monitor compliance with required immunizations and administer them as needed. They are part of the broader health care delivery system that aims for a high rate of immunization compliance to provide herd immunity against diseases that killed large portions of communities in the past (US Department of Health and Human Services, 2015).

As the prevalence of communicable diseases has decreased, the focus of school nurses has evolved to monitor and treat any condition that can interfere with learning or increase absenteeism (NASN, 2011). School nurses administer daily medications for students with conditions such as ADHD, asthma, depression, anxiety, diabetes, hypertension, and others. They screen for scoliosis, vision impairments, and hearing deficits. They manage emergencies and provide first aid. They are responsible for overseeing or giving care to students who require medical devices such as feeding tubes, tracheostomy tubes, blood sugar monitors, and urinary catheters (NASN, 2014a). They ensure that annual physical examinations are completed to allow students to participate in sports and they manage student care and reentry into school following a concussion (NASN, 2016). School nurses also act as health educators when they teach about puberty, hygiene, dental care, and healthy behaviors in the classroom and offer programs to faculty, staff, and families. Finally, school nurses are the liaisons between the school, a student’s family, and their primary care providers, and an important link in providing consistent, continuous, and comprehensive health care (American Academy of Pediatrics (AAP), 2008).

These responsibilities place nurses at the front lines of public health to detect, monitor, treat, and educate about conditions that affect students, families, communities, and beyond. Bullying is considered a public health problem because of its frequency and the effect it has on well-being (Srabstein & Leventhal, 2010). It creates an unsafe environment that may result in long-lasting health problems (Russell, Ryan, Toomey, Diaz, & Sanchez, 2011; Sourander et al., 2007). Thus, preventing bullying and dealing with it has become another responsibility for school nurses (NASN, 2014b). In this chapter, school nurses are quoted and share their insights about students, bullying, and the school nurse role.

Health Symptoms and Bullying Involvement

I had a student in my office one day because she was beat up by two girls who were tired of her bullying them. And students clapped because they were happy that someone stood up to her. This girl was crying and saying that no one wanted to be her friend. So, the bully was the victim.

Zoey W., School Nurse

In the school setting, students who are involved with bullying often present to the school nurse’s office with health symptoms (Vernberg, Nelson, Fonagy, & Twemlow, 2011). The students may be bullies, victims, or both bully and victim. The more frequent the involvement with bullying, the greater the risk that a student will present with health symptoms (Due et al., 2005; Williams, Chambers, Logan, & Robinson, 1996). Even bystanders can experience psychological distress from witnessing bullying behavior (Rivers, Poteat, Noret, & Ashurst, 2009).

Although the symptoms experienced by individual students may vary, the types of symptoms that accompany bullying are experienced by children around the world (Due et al., 2005). Victims who report being bullied sometimes or more frequently report not sleeping well, bed-wetting, feeling sad, and experiencing more than occasional headaches and stomach aches (Williams et al., 1996). Other symptoms can include backache, feeling low, bad temper, nervousness, difficulties in getting to sleep, dizziness, loneliness, tired in the morning, feeling left out of things, and feeling helpless (Due et al., 2005). The association between bullying and health symptoms was demonstrated in a study where students who had no health complaints at the beginning of the year, and were bullied during the year, were found to be more likely to develop depression, anxiety, bed-wetting, abdominal pain, and feeling tense (Fekkes, Pijpers, & Verloove-Vanhorick, 2005). In another study, girls, in particular, presented with abdominal pain from being bullied (Fekkes, Pijpers, Fredriks, Vogels, & Verloove-Vanhorick, 2006).

Mental Health Symptoms and Bullying Involvement

Sadness and suicidal thoughts are common symptoms for students involved with bullying as a victim, bully, or bully-victim (Camodeca & Goossens, 2005; Glew, Fan, Katon, Rivara, & Kernic, 2005; Klomek, Marrocco, Kleinman, Schonfeld, & Gould, 2007; Rigby & Slee, 1991). In one study, students who said they were sad most days had higher odds of being bullies or victims (Glew et al., 2005). Another study reported that the more frequently the student was involved with bullying, the more likely the student was reported to be depressed, have suicidal ideation, or have attempted suicide (Klomek et al., 2007). In another study, victims were found to be the saddest of all the groups, feeling sadder than bullies when something unpleasant happens (Camodeca & Goossens, 2005). High levels of suicidal ideation in victims were supported by peer and self-reports in another study (Rigby & Slee, 1991). Although weaker, the association between bullying and suicidal thoughts was also found to be significant for bullies (Rigby & Slee, 1991).

Anxiety and anxiety disorders have also been associated with bullying involvement. One study showed that girls involved as bullies or victims in either traditional bullying (verbal, physical, relational) or cyberbullying situations had higher anxiety scores than boys (Kowalski & Limber, 2013). However, boys who were both bullies and victims had higher anxiety scores than girls in that category. Students who were both cyberbullies and cybervictims had the highest anxiety and depression scores (Kowalski & Limber, 2013). Another study correlated anxiety and depression with abdominal pain, a common complaint of health office visitors. The study reported that pediatric patients in a primary care setting with recurrent and unexplained abdominal pain related to bullying also had significantly higher levels of anxiety, as well as depression, compared to control subjects (Campo et al., 2004).

Another study found that frequent victimization as a child predicted a diagnosis of anxiety disorder later in life (Sourander et al., 2007). The study followed eight-year-old boys in Finland until their military call-up examination at ages 18–23. It also found that being a bully predicted antisocial personality, substance abuse, and depressive and anxiety disorders, and being both a bully and a victim predicted anxiety and antisocial personality disorder. A later study by Sourander (2009) found that victimization of females at age eight “independently predicted psychiatric hospital treatment and use of antipsychotic, antidepressant, and anxiolytic drugs” when followed up between the ages of 13 and 24 (p. 1005).

These findings were reinforced in another study that followed children who were bullied between the ages of 9 and 16, until their early adulthood years (19–26) (Copeland, Wolke, Angold, & Costello, 2013). It demonstrated that after controlling for child psychiatric or family hardships, victims of bullying demonstrated higher levels of anxiety disorders than bullies, bully-victims, or students who were neither bullies nor victims (Copeland et al., 2013). Students who were bully-victims had higher levels of depressive and panic disorders, in addition to suicidality. Being a bully was shown to increase the risk of future antisocial personality disorder (Copeland et al., 2013).

Frequent Office Visits and Bullying

Students who are being bullied usually come in at the same time each day with a different complaint. Often they complain of headaches and stomach aches. Another key sign is that they are withdrawn.

Judith H-S., School Nurse

School nurses are often faced with students who are persistent and frequent visitors to the health office with symptoms that vary with each visit (Sweeney & Sweeney, 2000; Vernberg et al., 2011). While a single symptom may not indicate bullying involvement, persistent and multiple symptoms require investigation. One study used a case study method to examine the characteristics of students who are frequent visitors to the school nurse’s office at two middle schools (Sweeney & Sweeney, 2000). Of the 3014 visits made to the nurse’s office in the 3-month period, just 12% of the students made 56.1% of the visits. Health complaints included headache, stomach ache, dizziness, chest pain, sore/painful limbs, hyperventilation, gray pallor, sweatiness, crying, diarrhea, and complaints of not feeling well. Nurses categorized these complaints as students’ responses to stress/anxiety, somatic complaints, or learned illness behaviors and associated the symptoms with six areas of difficulties the students had: academics, teachers, home issues, personal constitution, stress/anxiety, and peer relations with a link to possible bullying involvement. The authors recommended that schools assist the frequent visitors by instituting educational workshops on how students can learn to deal with behaviors from other students that cause them to feel vulnerable, bothered, or embarrassed. Peer mediation was recommended as a means of helping students learn the skills needed to work out their own problems (Sweeney & Sweeney, 2000).

Another study demonstrated that bullying involvement as a bully, victim, or both significantly predicted visits to the school nurse’s office with health symptoms (Vernberg et al., 2011). The relationship between office visits and bullying involvement was demonstrated significantly enough that frequent office visits are recommended to be used as an indicator of bullying involvement (Vernberg et al., 2011).

Pre-existing Health Conditions and High-Risk Groups

The students who are bullied are usually the smaller children and those with the “not so cool” appearance. They are often hesitant to report the matter because they fear retaliation. They also still hold out hope of being friends.

Zoey W., School Nurse

Bullying behavior is based on a real or perceived imbalance of physical, emotional, or social power (National Bullying Prevention Center, 2015; Olweus, 1993). Children who are different are most likely to be bullied according to 10-year-olds in a study by Erling and Hwang (2004). Differences in physical appearance were most likely to lead to victimization, but other differences, including eating different foods, speaking differently, and thinking or acting differently, were also considered reasons for bullying (Erling & Hwang, 2004). Victims were also described as easily provoked or submissive.

Having a pre-existing health condition or disability has also been identified as a factor that can increase a child’s chance of being bullied (US Department of Health and Human Services, n.d.). In one study, children with special health-care needs were identified as being significantly more likely to be bullied than children without those needs (Van Cleave & Davis, 2006). Special health-care needs were defined as the need for prescription medication; the need for extra medical, mental health, or educational services; limitations in doing age-appropriate activities; the need for physical, occupational, or speech therapy; and emotional, developmental, or behavioral problems that necessitate treatment. In another study, children with autism spectrum disorder were identified as being at risk for being bullied or left out by peers (Twyman et al., 2010), as were children with epilepsy and diabetes (Hamiwka et al., 2009; Storch et al., 2004). Other studies have also reported that students who have physical or learning disabilities are bullied more often than their non-disabled peers (Carter & Spencer, 2006; Rose, Monda-Amaya, & Espelage, 2010).

Students with mental health issues can also be targets of bullying. In one study, students were followed from the beginning to the end of the school year (Fekkes et al., 2006). The study found that students who had psychological symptoms of depression and anxiety at the beginning of the school year had a significantly higher chance of being newly bullied during the school year. A prior study reported that children who are shy, withdrawn, anxious, fearful, insecure, and depressed and have low self-esteem or low social skills are more likely to be bullied through social exclusion or physical harm (Olweus, 1997). In addition to students who are victims of bullying, having an emotional, developmental, or behavioral problem has also been found to be significantly associated with students who bully others (Van Cleave & Davis, 2006).

Weight status also increases the risk of being bullied. This has been demonstrated for students who are either overweight or underweight (Wang, Iannotti, & Luk, 2010). In one study, both boys and girls who were underweight were at an increased risk for being bullied. However, boys were more likely to be physically bullied, while girls were more likely to be bullied through social exclusion or spreading of rumors. For overweight boys and obese girls, the risk for verbal bullying was increased (Wang et al., 2010). Another study reported that the odds of being bullied increased with the amount of excess weight (Janssen, Craig, Boyce, & Pickett, 2004).

Finally students who identify as gay , lesbian, bisexual, transgendered, or questioning (GLBTQ) are also at risk. They are more likely than students who identify as straight to have been involved in a fight that requires medical treatment or to have been violently attacked in the past year (Russell, Franz, & Driscoll, 2001). In a national survey of school climate, 89.1% of GLBTQ students reported verbal harassment and 18.3% reported being physically assaulted (Kosciw, Greytak, Bartkiewicz, Boesen, & Palmer, 2012). Because of the high rates of victimization, GLBTQ students have a higher risk of anxiety, depression, and suicidal thoughts (Russell et al., 2011).

The School Nurse’s Office as a Safe Haven

It takes a lot of courage for a student to go to the Assistant Principal or the Principal to report bullying. But students trust the school nurse and so some will come here first.

Judith H-S, School Nurse

The school nurse holds a unique position in the school system in that the nurse’s office carries no academic or disciplinary risk for students (Cooper, Clements, & Holt, 2012; King, 2014). The role is complementary to other personnel and consists of monitoring, nurturing, facilitating, educating, and intervening. This engenders trust and often leads to the school nurse being the first person to whom the student may report bullying (King, 2014). Many students underreport bullying because they feel that the situation will not be taken seriously (Barboza et al., 2009). In the school health office, however, they find a listening ear and someone with assessment skills and a desire to help.

When students confide in the school nurse, research shows that they benefit (Borup & Holstein, 2007). One study looked at five possible outcomes for students who talk with the school nurse about bullying. These outcomes included: (a) reflecting on the content of the dialogue, (b) discussing the dialogue with a parent, (c) following the advice of the school nurse, (d) doing what the student thought was best, and (e) visiting the school nurse again. Students who were bullied were more likely to do at least one of the suggested outcomes. The study also reported that students who were bullied at least weekly were more likely to visit the school nurse again (Borup & Holstein, 2007).

School Nurses and Their Role in Preventing and Dealing with Bullying

It’s the nurse’s responsibility to look beyond the immediate symptoms and the frequent visits and dig deeper about the possibility of bullying. I had one student who kept coming in with stomach aches and headaches. I finally sat down beside her and asked her pointedly about being bullied. She denied it at first, but then the tears started to roll. She admitted that she was being bullied and I was able to get mediation for the student and the bully. The student’s stomach aches and headaches have not returned.

Leslie B., School Nurse

In its position paper on school nurses and bullying, the NASN states that the role of the school nurse should include prevention of bullying, as well as identification of those who are involved (NASN, 2014a). School nurses should assume a leadership role in establishing school policies to deal with bullying. In general, these responsibilities include becoming knowledgeable about bullying and the students involved, assessing students, becoming part of the school-wide team to address the problem, coordinating care, and becoming involved with policy. The American Academy of Pediatrics (2008) also holds a position that school nurses should participate in planning and implementing school policies regarding school violence and bullying.

School nurses follow the nursing process when dealing with visitors to the health office (American Nurses Association (ANA), 2016). Assessment of the problem is followed by analysis of information obtained from talking to and examining the student. This information then guides the design and selection of nursing interventions . The interventions are subsequently evaluated to determine if they have been of benefit to the patient. Finally, the assessment, analysis, interventions, and evaluation are documented according to legal standards.

Assessment and analysis. The school nurse is responsible for evaluating student complaints of illness and injury and conducting a general or focused assessment (Massachusetts Department of Public Health, 2007). During the assessment phase, nurses collect information on the physical, psychological, social, and other factors that affect health as a way to evaluate the illness in a holistic manner (ANA, 2016; NASN, 2013). Assessment of illnesses involves talking to the student about when the symptoms began, how often they occur, what may be triggers, and what the student feels would improve the symptoms. This is followed by a focused physical exam, which provides objective information. Together, the subjective and objective information guides the actions of the nurse. For example, students who complain of a headache will be asked if other symptoms are present, how long they have had the headache, how painful it is, if it is due to an injury, and if anything makes it feel better or worse. Students will then have their temperature taken and throat examined to determine if the headache is part of an illness. Absent other physical symptoms, the nurse will then dig deeper to determine potential causes such as hormonal changes, vision straining, or hunger. One possible consideration will be if the headache seems to occur frequently at the same time of the day and is accompanied by anxiety or a feeling of sadness. This combination of symptoms and timing may indicate bullying involvement.

Assessment of injuries will include not only the type of injury, the location, and the severity but also the frequency, timing, and the cause (ANA, 2016). School nurses may be able to identify if injuries are happening away from school or during the same time period of the school day (NASN, 2014c; Shannon, Bergren, & Matthews, 2010). For example, if a child consistently comes in from recess with an injury, it is possible that the child is being bullied at that time. However, if the student visits the health office at the beginning of the day with a new complaint, the bullying may be occurring at home.

The holistic approach of the nursing process instructs nurses to assess students for factors beyond physical health that may contribute to illness complaints (ANA, 2016; Shannon et al., 2010). The National Association of School Nurses lists eight questions that school nurses should ask when deciding whether or not a student has been bullied. These questions add to the verbal information collected from the student and the physical assessment data to create a complete picture that will either confirm or rule out bullying involvement (NASN, 2014c, p. 1).

  1. 1.

    Are there any factors that particularly place the student at risk?

  2. 2.

    Are there behavioral changes?

  3. 3.

    Are there increased absences?

  4. 4.

    Are there more psychosomatic complaints or illnesses?

  5. 5.

    Are there unexplained injuries?

  6. 6.

    Has academic performance diminished?

  7. 7.

    Are selected activities avoided?

  8. 8.

    Are clothes torn or belongings “lost”?

Nursing interventions and the ecological perspective. After analyzing assessment data, the nurse’s role turns to determining effective interventions (ANA, 2016). The ecological perspective is often used as a framework to understand public health problems and create solutions (National Cancer Institute [NCI], 2005; Sallis, Owen, & Fisher, 2008). It describes health problems as occurring due to the influence of factors that are present on multiple levels—individual (intrapersonal), interpersonal, community, and policy level. It recognizes that the factors interact in both directions across the multiple levels of influence, that each level has specific factors that are most influential to the behavior, and that solutions to health behavior problems should address the multiple levels of influence (NCI, 2005).

Individual-level (intrapersonal) factors that affect health behaviors such as bullying include personal health habits, current health status, personality traits, attitudes, beliefs, and knowledge (NCI, 2005). Interpersonal-level factors include the relationships among family members, peers, and society that support a person’s social identity and the roles they establish. The community-level factors include rules, regulations, social norms, networks, and standards that deter or encourage a behavior, as well as the resources that are available to deal with a bullying problem. Public policy is also considered a community-level factor of influence and includes local, state, and federal laws that regulate violence and bullying, and those that provide funds for bullying prevention programs (NCI, 2005).

An example of an individual-level factor that may increase the chance of becoming a target of bullying may be that the student is frequently alone. On an interpersonal level, if violence is an accepted way to deal with problems in a family, a student is more likely to use that method for dealing with personal problems in school (Nansel et al., 2001). On a community level, training students to actively intervene during bullying episodes, termed bystander intervention, has been shown to significantly decrease victimization (Polanin, Espelage, & Pigott, 2012). Finally, on a policy level, a well-designed anti-bullying policy that is consistently enforced has been shown to decrease bullying (Fekkes et al., 2005).

The school nurse can use the ecological perspective to guide her interventions to prevent and manage bullying (Zinan, 2010). It can be applied to empower the student on multiple levels or to guide her/his own behavior. On an individual level, school nurses can help victims to understand their feelings in response to bullying, and to recognize that they have the ability to do something about it (Zinan, 2010). They can help students to understand the power issues involved and determine ways to increase their own personal power. They can encourage students to document the events and support them as they report it to the school administrators. They can also help students to address issues that decrease their self-esteem such as weight, acne, and physical strength. Regarding the factors that influence the nurse’s personal behavior, the school nurse can examine her/his feelings and biases related to bullying, become knowledgeable about the topic, identify strengths, and make a commitment to become part of the solution (Zinan, 2010).

On an interpersonal level, school nurses can help victims practice relationship skills (Zinan, 2010). They can also help the student to practice ways to respond to bullies. If the pace of the nurse’s office does not allow enough time, the student can be encouraged to seek help from school counselors and psychologists in practicing these social skills. School nurses can ensure that students receive the health care they need to improve their emotional state and decrease their risk of being bullied. They can also ensure that an educational plan for students with physical and learning disabilities includes an element of emotional support. School nurses can encourage high-risk students, such as GLBTQ students, to join support groups or receive outside counseling support. Regarding her/his own behavior, the school nurse can foster trusting relationships and create a welcoming and safe environment in the school health office.

On a community level, school nurses can encourage the student to speak out publicly as a way to have input into how bullying is handled in schools (Zinan, 2010). For example, the student may advocate for better supervision on buses, at recess, and in hallways and cafeterias. On a policy level, the student may advocate for a strong policy that is consistently enforced (Zinan, 2010). School nurses should also participate in these efforts and influence the local, state, and federal policies and laws pertaining to bullying. They should document visits to the health office that are associated with bullying and support educational events that encourage bystander and community involvement.

I think one of the reasons that students bully others is because they really don’t know each other well. I had a situation between a 7th and 8th grader where I had them both eat lunch with me for a couple of weeks. At the end of the two weeks, they knew each other and the bullying stopped.

Judith H-S, School Nurse

Evaluation and documentation. After implementing nursing interventions, nurses evaluate them to determine their effectiveness (ANA, 2016). With regard to bullying, nurses will document any healing of injuries or decrease in symptom patterns as a result of nursing actions. Indications that the intervention was not effective would prompt further investigation and a different intervention. For example, if health complaints and frequent office visits persist, the nurse will continue to explore the cause and bring the child to the attention of the school crisis team.

The Value of School Health Office Records

School health office records are a source of information about bullying on the school campus. They can indicate the types, frequency, and timing of complaints and visits to the health office. The information that nurses collect and report can provide proof of a potential problem and improvement of an existing problem (Zinan, 2014). It can guide program planning and determine if current efforts are having a positive effect. Health office records can also be used to document the association between bullying involvement and increased absenteeism (Steiner & Raspberry, 2015).

Identifying the extent and effect of bullying is valuable information that can be used to secure grants and resources to deal with the issue (Zinan, 2014). One possible use of the data would be to secure assistance in the school health office in order to decrease the school nurse workload. This would free the nurse to participate in broader bullying prevention efforts. It can also be used to justify additional school psychologist and counselor positions and secure resources to conduct educational programs.

School Nurses: Part of a Team

In high school, you might not find out about bullying until there’s a fight because students don’t report it. Our job at that time is to assess injuries and calm the student down. Then we direct the care they need by connecting them to the social worker or other services.

Maxine V., School Nurse

School nurses are part of a team that can address the issues that accompany bullying involvement (Bohnenkamp, Stephan, & Bobo, 2015; Dresler-Hawke & Whitehead, 2009; Kub & Feldman, 2015). They may be the first contact for students in distress and a continual support for ongoing issues (Cooper et al., 2012; Zinan, 2010, 2014). School nurses develop positive relationships with family members and thus may provide insight and understanding to both the family and school officials.

Teachers, principals, school psychologists, and school staff recognize the value of the school nurse in addressing complaints that have physical and mental health implications (Baisch, Lundeen, & Murphy, 2011; Bohnenkamp et al., 2015; Kub & Feldman, 2015). School nurses are considered vital to keeping students in the classroom, maintaining accurate school health records, and improving immunization rates. The time that school nurses devote to their assigned duties saves time that would be shifted to others. In one study, principals reported that school nurses save them an hour of time per day that may be devoted to health issues; teachers each reported a savings of 17 minutes, and school secretaries reported a savings of 47 minutes (Baisch et al., 2011). The presence of a nurse in the school also has economic benefits. The time saved from shifting the management of health complaints to others was estimated to save schools over $60,000 annually after accounting for the school nurse salary (Baisch et al., 2011).

As a member of the team, school nurses provide a holistic perspective in addressing student health issues, including bullying (NASN, 2013). They are the pediatric health experts on the school campus and understand that maintaining physical and mental well-being is essential to minimizing absenteeism and enhancing learning (NASN, 2014b). Their focus extends beyond the classroom to include the multiple components of health (physical, emotional, social) and the multiple influences on health (individual, family, community, and policy) (Dresler-Hawke & Whitehead, 2009; NASN, 2014b). They have the potential to broaden the capacity for schools to understand and intervene in bullying.

The NASN believes that school nurses should assume a leadership role in preventing bullying (2014b). The responsibilities of school nurses include becoming educated about the different roles (bully, victim, bystander) and how students are affected by bullying. School nurses are encouraged to be key players in identifying bullies and victims but are cautioned to avoid labeling them as such. They should provide leadership in educating other stakeholders about the lasting effects of aggressive behavior among students, assist in developing prevention and intervention strategies for bullying behaviors, and help to form connections between the school, students’ families, and the community. When treating students with unexplained health complaints, school nurses should provide a safe place where students can be assessed for bullying and where they will feel comfortable confiding in an adult. When bullying is suspected, school nurses have a responsibility to share this information with other stakeholders so that action can be taken to ensure that all students feel safe at school. Finally, NASN encourages school nurses to advocate for students by being active at the community, state, and national levels to help develop programs that prevent and/or intervene in bullying (2014b).

Barriers to Bullying Intervention

School nurses are motivated to help with the issue of bullying, and they see it as an element of their job (National Education Association, n.d.; Zinan, 2014). However, barriers may exist to prevent them from becoming involved. In one study, the most commonly cited barrier was that the bullying occurred in locations other than the nurses’ supervising area (Hendershot, Dake, Price, & Lartey, 2006). School nurses also cited as a barrier that they felt that someone else was more qualified to deal with bullies, victims, or bullying situations. Other barriers included not having enough time and not being prepared to handle the problem. Only 15% of nurses stated there were no barriers to dealing with bullying (Hendershot et al., 2006). In another study, the number of barriers to dealing with bullying decreased following a nurse-focused training (Zinan, 2014). However, the three most common barriers cited before and after the program included that bullying occurred in places not supervised by the nurse, the feeling that others were more qualified, and not having enough time (Zinan, 2014).

Lacking the time to deal with bullying is a reflection of school nurse workload. This may prohibit them from participating beyond addressing illnesses and injuries in the health office. One study reported that two-thirds of the nurses interviewed identified their workload as “too heavy” (Ball, 2009, p. 20). This may be particularly true of school nurses who are not employed full time, or who are responsible for more than one school. The recommended ratio of school nurses to students is 1:750 (NASN, 2015). Lower ratios are recommended for student populations with complex health needs (NASN, 2015). In addition to their mandates to screen students for vision and hearing deficits and scoliosis, and monitor immunization compliance, nurses must meet documentation standards required by law for these activities. Combined with the medication administration responsibilities, and the need to oversee the care of students with medical needs, managing emergencies, coordinating sports physicals, and conducting concussion assessments, nurses have little time to take on bullying prevention efforts.

Needs of School Nurses to Address Bullying

The belief that someone other than the nurse is more qualified to deal with bullying issues may reflect a lack of training for school nurses (Hendershot et al., 2006; Zinan, 2014). Professional training about bullying is required by law in many states (US Department of Health and Human Services, n.d.). However, few trainings are offered that are specific to school nurses. School nurses should receive training specific to their role in assessing and intervening with bullies and victims (Hendershot et al., 2006; Zinan, 2014). School nurses should be taught to recognize victims and bullies by their symptoms and learn intervention techniques that can be easily implemented in the health office (Zinan, 2014). They should be allowed time to process their own feelings regarding bullying, as they may have been victimized in the past, and to assess their own biases regarding bullying (Zinan, 2014).

Training improves school nurses’ knowledge levels and empowers them to deal with bullying issues (Zinan, 2014). Following a training designed for school nurses, the participants reported a significant increase in their ability to recognize the signs and symptoms of students who are bullies and victims (Zinan, 2014). They also indicated an increase in the number of strategies that they felt were effective in reducing bullying.

Training should also include a review of laws that address bullying and that apply to school environments (Deitch, 2012). Finally, training should provide the opportunity to explore the resources within and outside the school system, such as websites, national organizations, and community agencies, to broaden their role in preventing bullying.

In order to more fully participate in bullying prevention and intervention, school nurses need assistance in the school health office (Zinan, 2014). School nurses should receive administrative support to develop and maintain an accurate documentation system for health office visits. This may necessitate transferring some duties to administrative staff. As school health records become computerized, school nurses can run reports of the number of visits per complaint, per student and per time period. School nurses should also be allowed to hire substitute nurses to assist them in high-activity periods. These actions could free up time for them to participate in violence prevention task forces and child assistance teams, develop educational materials to be sent home, monitor data trends in health office visits, foster connectedness between schools and families, and influence policy.

In summary, school nurses need the following in order to fully participate in a bullying prevention program that addresses the problem with an ecological perspective:

  • Training specific to school nurses

    • signs and symptoms

    • effects of bullying

    • intervention techniques

    • laws related to bullying

    • addressing personal uncertainties and biases

    • working as a team member

    • online and community resources to address the problem

  • Computerized health record-keeping system and training

  • Administrative support

  • Flexible hiring of substitutes

  • Time allotted to participate in violence prevention task forces and educational programs

Summary

School nurses are valuable members of the teams of professionals who educate our children (National Association of School Nurses (NASN), 2011). Involvement with bullying as either a victim, a bully or both increases the likelihood of physical and emotional symptoms that can impair learning, increase absenteeism and bring the student to the school health office. High risk students are those who have poor social skills; are withdrawn, anxious or depressed; have learning difficulties; identify as lesbian/gay/bisexual/transsexual/questioning or who look and act “differently.” The school nurse can provide a safe haven for students who are involved with bullying, and assist in resolving the problem on a personal, interpersonal, community or policy level. School nurses should be supported to undertake a leadership role in bullying prevention efforts. They may need nurse-specific training in order to feel prepared and qualified to intervene with those involved (Zinan, 2014). Providing administrative assistance and the option to hire substitutes for high-activity periods may increase the time that a nurse can devote to bullying beyond assessing and documenting student injuries. This has potential to increase their involvement while minimizing any impact on school budgets, and potentially save money. Administrative assistance may be in the form of establishing a computerized health record-keeping system to monitor health office visits in order to correlate them with trends in bullying. The collected data can also be used for grant applications as a way to obtain additional resources to deal with bullying.