https://orcid.org/0000-0002-4174-7675
Figures
Abstract
Objective
School nurses are engaging worldwide to promote and protect children’s health. Many researchers who examined the effectiveness of the school nurse criticized the inadequate methodology employed in many of the studies. We therefore carried out an evaluation on the effectiveness of school nurses based on a rigorous methodological approach.
Methods
In this overview of reviews we performed an electronic databank search and global research results on the effectiveness of school nurses were sought. We identified 1,494 records through database search. Abstracts and full texts were screened and summarized using the dual control principle. We summarized the aspects of quality criteria as well as the significance of the effectiveness of the school nurse. In the first step, k = 16 systematic reviews were summarized and evaluated following the AMSTAR-2 guidelines. In a second step, j = 357 primary studies included in these k = 16 reviews were summarized and assessed following the GRADE guidelines.
Results
Research results on the effectiveness of school nurses show that school nurses play a key role in improving the health of children with asthma (j = 6) and diabetes (j = 2), results on combating obesity are less certain (j = 6). The quality of identified reviews is mostly very low with only six studies of medium quality, of which one identified as a meta-analysis. A total of j = 289 primary studies were identified. Approximately 25% (j = 74) of identified primary studies were either randomized controlled trials (RCT) or observational studies, of which roughly 20% (j = 16) had a low risk of bias. Studies with physiological variables such as blood glucose or asthma labeling led to higher quality results.
Conclusion
This paper represents an initial contribution and recommends further evaluation of the effectiveness of school nurses, particularly in the areas of mental health or children from low socioeconomic backgrounds. The general lack of quality standards in school nursing research should be integrated into the scientific discourse of school nursing researchers to provide robust evidence for policy planners and researchers.
Citation: Pawils S, Heumann S, Schneider SA, Metzner F, Mays D (2023) The current state of international research on the effectiveness of school nurses in promoting the health of children and adolescents: An overview of reviews. PLoS ONE 18(2): e0275724. https://doi.org/10.1371/journal.pone.0275724
Editor: Mohammed Saqr, University of Eastern Finland: Ita-Suomen yliopisto, FINLAND
Received: December 22, 2021; Accepted: September 22, 2022; Published: February 22, 2023
Copyright: © 2023 Pawils et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting information files.
Funding: SP and DM 01EL2025A (SP) 01EL2025B (DM) Bundesministerium für Bildung und Forschung (BMBF) https://www.bmbf.de NO - The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
1 Introduction
School nurses are medically trained professionals who work in both the school and healthcare sectors, with the aim of making the school a health-promoting environment for teachers and pupils [1–3]. School nurses play a pivotal role in improving the health and well-being of children and adolescents by providing health promotion, health counseling, referral to other sources of help, active treatment, education, family support, care coordination, and multiagency work [1,4–6]. School nurses have a wide range of roles and responsibilities that cover three core aspects of school health 1) health literacy, 2) medical care, and 3) health promotion [7–9]. These three areas of school nursing complement each other in terms of the common goal of making the school a health-promoting environment but differ in their approaches and strategies to achieve this goal. Health literacy has the aim of enabling students and teachers to find, understand, evaluate, and apply health information to health-related decisions in order to maintain or improve health and quality of life [10,11]. Health literacy holds the educational perspective with the goal of knowledge gain. In contrast, health promotion and medical health care share the aspect of medically oriented interventions but differ from one another in their perspective on health aspects. Medical health care at schools takes the pathogenetic perspective. Here, the focus is on assessing risks for disease progression and treatment of specific diseases that can be positively influenced by specific school-based interventions. Health promotion in schools, on the other hand, argues salutogenetically. Here, the focus is on the development and maintenance of health in children and adolescents. This can be achieved through resource-strengthening measures at schools, promoting healthy behaviors such as sports and nutrition and through preventive care services, e.g. care coordination by school nurses [11,12]. All three aspects of school health cannot be clearly distinguished from each other.
Most international research on school nurse interventions addressing the three aspects of school health originated in Anglo-Saxon countries [13–15] where the school nurse was first introduced and where most research has been conducted. Many of these studies evaluate school-nurse led interventions and refer to the number of days absent due to medical conditions [13,16], health risk factors such as obesity [17,18] and cigarette consumption [19,20], children with asthma symptoms [21,22], mental health conditions [23,24], the management of chronic diseases [3,25] or preventing various forms of child abuse [26–28]. Apart from more positive health outcomes for children, the support provided by the school nurse may lessen the burden on teachers confronted with such problems in the classroom [29–31].
The importance of the school nurse came particularly apparent when the COVID-19 pandemic hit and new health-related challenges for both pupils and teachers arose. Recent studies focused on an examination of the role of school nurses and their valuable input particularly on the question of the wisdom of closing schools or keeping them open [32]. Additionally studies also addressed how their work could help to minimize community-wide risk [33] through improved hygiene concepts [34] and effective immunization programs [35].
Besides the aforementioned health-related benefits, studies calculated financial savings in health care for society as a whole [36,37] by involving school nurses at primary and secondary schools. Wang and Vernon-Smiley [38] estimated that in one year alone, for every dollar invested in their program in the US, $2.20 is saved. Binder [36] investigated whether poor parental health awareness, poor integration in society as well as rising numbers of children with chronic health issues could ultimately cause higher follow-up costs than investing in prevention.
While there is a large body of research available about school nursing, it becomes apparent that despite the abundance of literature on the subject, scientifically sound conclusions regarding the effectiveness of school nurses are anything but clear-cut. Researchers [20,21] have repeatedly criticized the lack of methodological quality and the resulting lack of robust, meaningful research findings regarding the effectiveness of school nurses. The main points of criticism are the lack of evidence-based, quantitative data with randomized controlled trial designs and the predominantly descriptive study designs [39].
We see an urgent need to address this increasingly vocal criticism of school nurse research and to organize the miscellany of research findings. For this reason, we conducted an overview of reviews, the first of its kind in school nurse research. This paper is a response to the prevailing criticism of poor study quality, which is why reviews and primary studies are subject to strict methodological guidelines. By introducing methodological standards, our aim is to ensure clinical validity regarding school nurse effectiveness.
Our aim is to critically assess the current state of the relevant literature by applying rigorous and valid quality criteria. Well-established quality assessment tools such as AMSTAR-2 and GRADE guidelines were chosen and adapted to our purposes, as these tools are widely recognized among researchers and overcome the criticisms aimed at school nursing research. This paper will review studies which are in line with well-established methodological guidelines to arrive at sound conclusions on interventions and on meaningful results on health outcomes.
2 Materials and methods
Studies are divided into three categories: primary, secondary and tertiary level. Primary level studies are e.g. randomized controlled trial designs or observational studies. For the sake of simplicity, studies on primary level are called primary studies in this paper. Secondary level studies are e.g. meta-analyses or systematic reviews, and are called reviews. Tertiary level studies are e.g. overview of reviews or umbrella reviews. The present paper is an overview of reviews. Overview of reviews encompass reviews, which in turn encompass primary studie (Fig 1).
Notes. On tertiary level (e.g., overview of reviews) we synthesize studies on secondary level. On secondary level (e.g., meta-analysis) synthesize studies on primary level.
The methodological approach of conducting an overview of reviews is based on the guidelines of Biondi-Zoccai [40], who describe the research process and tools to summarize evidence relevant for policymakers in evidence-based medicine. Due to the lack of guidelines for overview of reviews in the educational or psychological field, this paper applies (to our knowledge for the first time in school nurse research) clinically relevant standards, which is intended to create solid and meaningful results and is a prerequisite for optimal decision-making. The methodological research standards were based on Zawacki-Richter, Kerres [41], who describe the methodological procedure of systematic reviews in the educational research field. The overview of reviews differs from reviews in only a few respects (e.g. databases are searched exclusively for reviews) [40]. For this reason, this study also followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) [42], including the recommended Cochrane Checklist (Attachment 1). The quality of included reviews was assessed according to the validated scale Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) [43]. The strict quality rating was adapted to allow the reader a comparison of our reviews. Biondi-Zoccai [40] recommended an analysis of primary studies that were summarized in each review, in order to be able to make authoritative statements regarding its informative value. To assess the body of evidence of primary studies the Grading of Recommendations Assessment, Development and Evaluation (GRADE) [44] was used. GRADE provides instructions for assessing the strength of evidence for each outcome in a review [44]. In our work, the GRADE assessment remains at descriptive level and risk of bias, imprecision, indirectness of evidence, publication bias and impact are described. Magnitude of effects, dose-response relations and the impact of residual confounding were removed, as these criteria are not relevant for studies from the educational and psychological field.
Our approach to this work is explained in a protocol that was created a priori and continuously updated during the research process and uploaded to the PROSPERO website on 08.02.2021 [45]. The protocol can be viewed on PROSPERO with the registration number CRD42021235152. All relevant data are within the manuscript and its Supporting Information files.
2.1 Inclusion and exclusion criteria
We outlined our inclusion and exclusion criteria in terms of the PICOS format. We included studies examining children aged 5 to 21 (IC1), with either the school nurse himself/herself being the intervention or a school nurse-led health program as the intervention (IC2). The criterion of the comparison group was not applicable for this work. Studies examining the effect of various health outcomes, school attendance, academic achievements, risky and difficult behavior in the school setting were included (IC3). Only research in English and German and reviews were searched (IC4) with no date restrictions. We excluded primary studies and studies with interventions that were not conducted by at least one school nurse or in the school setting. Studies without specific health outcomes for school children, as well as recommendations for school nurses, were also excluded (Table 1).
2.2 Information sources
We conducted a search of peer-reviewed literature in Medline, Cochrane Library, Cinahl, Web of Science, Scopus, PubMed, Subject portal Pedagogy [Fachportal Pädagogik], Educational Resource Information Center (ERIC) and German National Bank Catalogue [Katalog der deutschen Nationalbank] from November 2020 to January 2021. Additionally, we searched Google Scholar, reference lists, and also contacted leading researchers in the field of school nursing for additional overviews, finishing the search process in February 2021.
2.3 Search strategy
Before starting the search process, we conducted a pilot study of the scope of school nurse-related literature. For this purpose, we used the Medline database as a trial database, analyzing the first 150 results using the search term "school nurs*". The results of this pilot study were presented to an expert panel of eight members, optimizing our methodology and focus (e.g. deciding to only include reviews). In addition, the PROSPERO database was searched to exclude possible content overlap with studies not yet published [45]. Following the suggestion of Zawacki-Richter, Kerres (41), a record log was initiated to develop a search string (Table 2). Our final search string (“School-nurs* (only in title)” AND (“Review* OR meta-analysis”) NOT (“Barrier* OR framework OR role* (only in title))) was searched in 9 databases and had to be adapted for the database ERIC (“school nurse” AND “review” OR “reviews” NOT “barrier” NOT “barriers” NOT “framework” NOT “frameworks” NOT “role” NOT “roles”) and for German databases (“Schulgesundheitsfachkraft” OR “Schulgesundheitspflege”, which translates into school nurse).
Additionally, reference lists were searched (FM), Google Scholar was searched using the terms "school nurse and review" (SH) and the National Association of School Nursing and leading researchers (n = 9) in school nursing research were contacted (SH and SS).
2.4 Screening and study selection
Citations identified from the systematic search were exported to EndNote (EndNote 20.1, Bld 12060), a reference management tool. Duplications were removed and two independent reviewers (SH and FM) screened all titles and abstracts using the inclusion and exclusion criteria, adding an explanation for the exclusion of the excluded references. Articles that were labelled as “excluded” by both researchers were removed, while articles that received conflicting votes (ineligible vs. potentially or probably eligible) were discussed and a consensus was reached. Interrater reliability was calculated using IBM SPSS 23 (IBM Corp., Armonk, NY). The agreement rate was measured by determining the percentage of the sum of all matching “included” and “excluded” references, where the total number of references assessed equalled 100%. The same two reviewers (SH and FM) screened the full texts of all the probably eligible articles using the same inclusion and exclusion criteria. If consensus was not possible during the screening of title and abstract or full text screening, a third or fourth reviewer (SP or DM), who had the casting vote, would have been asked to independently screen the article. However, this was never necessary as consensus was always reached.
2.5 Data extraction process of reviews
The selection of characteristics to be extracted from reviews was discussed with the research team, consisting of five members, and unanimous agreement was reached. Data items included author, year, country, time-period covered, type of review, number of primary studies included, subject-matter and summary of findings. One reviewer (SH) and an assistant researcher (SS) independently extracted data from each study and were generally in agreement.
2.6 Data extraction process of primary studies
In order to extract data from primary studies, they first had to be identified in the respective reviews. Once identified, researchers exported references into EndNote, removed duplications, and searched full texts. The selection of characteristics to be extracted was discussed with the same research team, and unanimous agreement was reached. Data items included author, year, country, studied population, research design according to the Mixed Method Appraisal Tool (MMAT) [46], main topic, study subject-matter, intervention, data collection, outcome, and information value. The same reviewer (SH) and assistant researcher (SS) independently extracted data from each primary study. Due to the huge number of primary studies, references had to be divided up, so that no data extraction agreement could be measured. To counteract bias, the data extraction of the respective other was checked selectively. The description of primary studies is the basis for further data analysis and is discussed in the results. Due to the heterogeneity and the large and hence unmanageable amount of data, an additional criterion (information value) was added, which requires further explanation: This criterion represents a rating based on two dimensions: a) the study design used and b) the content covered. A matrix was developed to categorize each study. The first dimension represents the quality of the study design (I-V), based on the MMAT criteria. The second dimension classifies the relevance of the content (A-E), depending on the extent to which the primary study examines the effectiveness of school nurses (Fig 2).
2.7 Assessment of study quality of reviews based on AMSTAR-2
The AMSTAR-2 checklist [43] was used to assess the quality of reviews. One reviewer (SH) assessed all reviews, and the assistant researcher (SS) duplicated the appraisal with 80% agreement. AMSTAR-2 is a critical appraisal tool for reviews, such as meta-analysis, that include primary studies covering healthcare interventions. Because school nurse research is mainly comprised of descriptive literature, reviews included in this study cannot meet the strict guidelines according to AMSTAR-2. Despite these strict guidelines, we decided to differentiate between the quality of reviews by slightly adjusting the AMSTAR-2 criteria.
The following clusters were assessed): A) Research question & selection process, B) assessment of included primary studies, C) interpretation of results, and D) report of potential source of conflict.
Each cluster (A-D) consists of criteria which in turn contains sub-categories. Depending on the percentage of sub-criteria met in a criterion, numbers 0–4 were assigned for each quartile, with “0” no sub-criterion and “4” over 75% of sub-criteria met. The numbers in each category were then added together. The maximum score, 48 points, represents the best possible quality of reviews. The classification into low, medium and high quality is determined by dividing the maximum score by 3, so that studies with more than 32 points are of high quality, studies with 16 to 31 points are of medium quality and studies with less than 16 points are of low quality.
As a result, reviews were graded according to the number of sub-criteria actually met, and not downgraded if one sub-criterion was missing, and reviews that would have been downgraded under normal circumstances because a requirement was not met would in our study only be downgraded if less than 75% of the required sub-categories had not been met (Table 3).
2.8 Assessment of body of evidence of primary studies based on GRADE
The body of evidence was only conducted for primary studies with randomized controlled trials (RCTs) or observational studies, i.e. non-randomized studies (Obs), based on the GRADE assessment tool [44]. Because information relevant to the assessment, such as the confidence interval, was often not included in primary studies, the body of evidence remained on a descriptive level. Relevant characteristics to evaluate the body of evidence such as the indirectness of evidence (population studied, type of intervention, measures and desired measures), publication bias, risk of bias, imprecision (number of participants, confidence interval) and impact are described for each health outcome.
2.9 Assessment of risk of bias
Our assessment of the level of effectiveness and the resulting recommendations are less credible if the studies have significant limitations, such as the risk of bias (RoB) [44]. For this reason, we assessed the RoB for RCTs and Obs. All other study designs may not be applicable for RoB assessment. The GRADE handbook [47] for grading the quality of evidence was used as a guideline and limitations that influence the risk of bias were identified. The magnitude of an effect decreases when studies suffer from major limitations that are likely to lead to a biased assessment of the intervention. Lack of allocation concealment, lack of blinding, incomplete accounting of patients and outcome events, selective outcome reporting, failure to develop and apply appropriate eligibility criteria (inclusion of control population), flawed measurement of both exposure and outcome, failure to adequately control confounding and incomplete or inadequately short follow-up were considered when assessing the risk of bias for each RCT or Obs study.
Authors of this study developed a scale to determine the degree of risk of bias: low (0 to 2 points), unclear (3 to 7 points) and high risk (8 to 10 points). Starting point for RCTs is “Low Risk” with 0 points. Starting point for Obs. is at “Unclear Risk” with 5 points. For each limitation, the risk of bias increases by the corresponding grade (+1, +2, +3) on the scale (0 to 10), which results in the categorization of the RoB (Low, Unclear, High) (Fig 3).
Note. Starting point for RCTs is “Low Risk” with 0 points. Starting point for Obs is at “Unclear Risk” with 5 points. For each limitation, the corresponding downgrade (+1, +2, +3) is made on the scale (0 to 10), which results in the categorization of the risk of bias (Low, Unclear, High). Downgrading scores and categorization to low, unclear, and high risk were defined by authors.
2.10 Narrative synthesis of results
During the evaluation of the pilot study, we found that primary studies and reviews, on the school nursing subject-matter were qualitatively deficient, in the sense that hardly any meta-analyses were conducted, and most studies used descriptive designs rather than RCTs or Obs. In order to find out to what extent conclusive statements can be made regarding the effectiveness of school nurses, a comprehensive and transparent analysis of the studies was conducted, using well-validated and acknowledged clinical research methods, such as the AMSTAR-2 [43] and GRADE assessment tool [44].
The quality assessment of reviews was based on AMSTAR-2 criteria, whereby the scaling and subsequent grading of the quality of reviews was adapted by the research team (see 2.6). The body of evidence of primary studies was based on GRADE recommendations, and the evaluation did not go beyond a descriptive level (see 2.8). Characteristics to evaluate the body of evidence are study design, the measurement instrument and the characteristic being measured, publication bias, risk of bias, number of subjects, confidence interval, effect size, and comparability of population groups and interventions. These characteristics were classified for each health outcome.
3 Results
3.1 Study selection
The study selection for this overview of reviews consisted of two parts: First, reviews were searched (Fig 4), later full texts of primary studies included in each review, were searched (Fig 5).
Notes: k = reviews; j = primary studies. A search f 9 databases identified 1,478 articles. The additional search yielded 16 more articles. After subtracting duplicates (k = l,077), abstract and title of 417 articles were screened. 33 articles met the inclusion criteria (k = 385 excluded). After full texts of the 33 articles were screened, 16 articles met the inclusion criteria (k = 17 excluded). Primary studies identified in 16 reviews were identified (j = 357). After subtracting duplicates (j = 39) and excluding reviews (j = 6), and a study that could not be found (j = l), 311 primary studies were identified, and full texts were searched for. Further 23 primary studies had to be excluded as full texts could not be found, which totaled in 289 included primary studies in this Overview of Reviews.
3.1.1 Selection of reviews.
In the first part of the study selection, 9 databases were searched identifying 1,478 studies, and an additional search yielded further 16 references. After removing duplications (1,077), two independent researchers screened titles and abstracts of the remaining 417 studies (interrater reliability = 0.505; agreement rate: 92%). Records that did not meet the inclusion criteria were excluded (384). The remaining 33 full texts were screened to assess eligibility (interrater reliability = 0.760; agreement rate: 88%). At the end of the first part of the study selection process, 16 records were included in the overview of reviews. The 17 excluded full texts can also be found in Table 4.
3.1.2 Selection of primary studies.
In the second part of the study selection process, 357 primary studies included in each review were identified. Some primary studies were used in more than one overview (S1 Table). Among 357 primary studies, there were 6 reviews (Table 5a), 1 missing literature and 10 not exportable literature (Table 5b) that had to be excluded, leaving 340 primary studies which were exported into EndNote (EndNote 20.1, Bld 12060; j = 340). A total of 39 duplications were removed. 44 references were ordered via the central medical library [Ärztliche Zentral Bibliothek] (Table 6). A further 12 primary studies had to be excluded, as full texts could not be found (Table 5c), which left 289 primary study full texts included for our data analysis of primary studies.
List of excluded studies.
3.2 Study characteristics of reviews
All of the reviews included in our overview of reviews focus on school nurse-led interventions and their impact on children’s health outcomes. Each of the research papers focuses on different aspects of the content. Studies that summarized the scope of school nurses’ interventions and general health outcomes were examined by two research groups [3,51]. Two papers summarized evidence on vaccination rates for students [54,55]. Child maltreatment and prevention [27], asthma care [56], school performance [57,58], obesity prevention [31], diabetes [49], epileptic seizures [29] and mental health [50,59] were also scrutinized. While one study focused on children with complex needs [53], another paper concentrated on general health promotion [39]. One German study summarized evidence on the school nurse, with implications for the German school system [48]. The time periods covered by reviews were 1976 up to 2021. About 50% of reviews were conducted in the USA [3,31,51–53,55,56,58], while the other references were from the UK [27,39,50,57,59], Italy [54], Poland [49] and Germany [48] (Table 7).
3.3 Quality assessment of reviews
Out of a total of sixteen references, six studies are of moderate quality (score: 16–32) [31,32,49,52,56,57], ten are of low quality [3,27,39,48,50,51,54,55,58,59] and no study is of high quality (Table 8).
3.4 Study characteristics of primary studies
Of the 289 primary studies included, there were 32 references (11%) that were identified as RCTs, 64 (22%) as Obs, a further 98 (34%) used a qualitative-descriptive design, 79 (27%) used a quantitative-descriptive design and 16 references (6%) could not be assigned to any study design. Studies were conducted in the USA (j = 210), UK (j = 59), Sweden (j = 8), Australia (j = 3), Finland (j = 3), Netherlands (j = 2), France (j = 2), Spain (j = 1) and Nigeria (j = 1).
A total of 77 references (27%) examined school nurse-led interventions, where a school nurse alone was involved, whereas 20 references (7%) examined interventions where a school nurse as well as other health professionals or teachers performed an intervention. Most studies (84; 29%) examined interventions conducted by other health professionals (not school nurses) or they described health outcomes without conducting an intervention. These studies focused on a program’s efficacy and school nurse’s efficacy from the perspective of teachers, parents or health professionals. A significant number of studies (50; 17%) focused on school nurses`training and described the school nursing job. The remaining studies (58; 20%) examined different aspects not relevant to the present study (S2 Table, Fig 6).
3.5 Selected primary studies to examine body of evidence
Relevant primary studies were selected according to two criteria: study design and content dimension (Fig 6). Studies with the study design RCT and Obs and content dimensions “D” and “E” were selected (total: 74 studies). There were eight references examining the outcome “school attendance” of which one study identified as an RCT [61]. From eleven studies investigating obesity prevention, six were RCTs [17,38,62–65]. Physical activity was investigated by three research groups of which one identified as RCT [66]. Researchers of eight studies investigated emotional health, of which two were RCTs [14,67]. Of 16 papers examining asthma care, six identified as RCTs [68–73]. One RCT examined smoking cessation [19] and one RCT investigated immunization rates as a health outcome [35]. Sexually transmitted virus prevention was covered by two RCTs [74,75] and evidence on teenage pregnancy, nutrition, and teasing and bullying, respectively, was investigated in one Obs [76–78]. Allergies [79], alcohol use prevention [80], hearing screening [81], cardiovascular health [82], psychosomatic headaches [83] and hygiene [34] were each assessed by one RCT. Two research groups investigating diabetes used RCTs [84,85]. Five research groups did not confine themselves to one specific outcome but addressed a range of different health outcomes in one primary study, of which one identified as RCT [86]. Assessing the RoB, 16 primary studies showed a low risk of bias, 33 showed a high risk and 25 showed an unclear risk of bias (Table 9).
3.6 Results based on health outcomes
3.6.1 Findings on somatic health.
Among the multitude of studies there are some significant results that are worth mentioning. One RCT study [61] with a low RoB showed that when a school nurse was available the number of days a student was absent was significantly reduced (on average two days per year) compared to the control group where there was no school nurse. Other studies examining school attendance were less reliable due to significant limitations (e.g. RoB).
Asthma. The majority of school nurse research examines asthma-related interventions, some providing meaningful results. The outcome variables studied vary greatly, which complicates the comparability of the results. Often research groups investigate more than one outcome such as the quality of life [69,106], school absenteeism [70,73,106,112,113], asthma knowledge [21,70,72,109,110], severity of asthma symptoms [21,108,112], quality of life [25], academic achievements [25,111], individualized goals [25], impairments and inspiratory flow rate [107], asthma control [72,107–109], symptom-free days [68,71], medication [69,112,113], health-care utilization [69–71,113], pulmonary function [72] and clinic process improvements [73]. While the heterogeneity in asthma research is striking (e.g. various health outcomes, populations, and types of interventions), a fair number of studies are of high quality with only a few limitations. One study with good reliability (low RoB) showed that preventive asthma medication for 530 students resulted in a significant reduction in symptoms compared to the control group. In addition, there were fewer night-time symptoms and rescue medication use and more peace of mind for the children [68]. Another study showed that nurse-administered inhaled corticosteroids (ICS) resulted in significantly fewer functional limitations, better adjustment to family life and improved sleep compared to the control group [69]. Results investigating asthma case management on medically underserved inner-city children show that there was less school absenteeism among children in the intervention group compared to the control group. They also experienced significantly fewer emergency department visits and fewer hospital days. A replication and follow-up in year 2 also showed continued significant improvements [70].
Obesity. In assessing the effectiveness of school nurse-led obesity prevention studies, j = 4 references with low risk of bias were of significance. All studies had in common that the BMI score was one of the main outcome measures, but the type of interventions to reduce the BMI score differed. One intervention consisted of educational programs on nutrition, an improved environment with healthy foods and more physical activity and screening procedures [17,62], but results showed no clear advantage for children in the intervention group. Although slight reductions in BMI were found, education and environmental strategies had no effect on BMI compared to the control group. Another intervention consisted of integrated health education for teachers and nutrition counselling for parents [63]. Risk of bias was unclear for this study due to lack of blinding and failure to adequately control confounding, so that results may be less reliable. However, results showed that overweight children achieved a significant reduction in weight after two years compared to the control group. School grades deteriorated in both groups, but the deterioration was less dramatic in the experimental group. In a third intervention conducted in 2013 [64] and replicated three years later [64,65], computerized cognitive behavioral counselling and an after-school physical activity program were implemented. In addition to BMI scores, diet, physical activity, sedentary behavior, self-efficacy, and perceived barriers were measured. Results showed no significant changes in BMI, body fat and waist circumference compared with control schools. A different way of looking at obesity prevention is to increase physical activity. One study investigated the impact of a Kids N Fitness intervention, with 45-minute physical activity sessions, nutrition education and wellness activities [66]. Children were asked to complete a questionnaire about their diet and anthropometric measures were collected. The study had a low risk of bias and the results showed that the intervention (delivered by school nurses) had a significant impact on BMI, sedentary behavior in boys and increased physical activity behavior in girls.
Diabetes. In assessing the effectiveness of school nurse-led diabetes management interventions, two references with low [84] and unclear [85] risk of bias were significant. One study used the hemoglobin A1c (HbA1c) value to measure long-term glycemic control. Results showed that monthly videoconferences between school nurse, child, and diabetes team showed significant improvements in the first 6 months. However, no further significant improvements were observed after the 6-month mark [84]. In the second study, blood glucose levels, HbA1c and BMI were measured and compared between experimental and control groups. Results showed that the HbA1c level remained unchanged in the control group but was significantly lower in the intervention group [85]. Neither group showed a significant change in BMI. Other investigated health outcomes such as teasing and bullying [78], resilience [125] and hyperactivity and peer problems [126] were not reliable due to limitations.
Sexually transmitted illnesses. Research groups that have set out to study sexually transmitted illness (STI) prevention interventions are consistent in that the interventions consist of educational programs for students. The outcomes measured by questionnaires relate to knowledge, beliefs, and behavioural intentions [74,75]. Despite the lack of adequate follow-up, both studies showed significant improvements in knowledge, attitudes and beliefs compared to the control group.
Vaccination. All studies on vaccination used immunisation rates as an outcome measure. Study interventions ranged from information brochures [35] to educational programmes [116] to free vaccination programmes [117,118] and results showed improved immunization rates across all studies.
Smoking. A reliable study on smoking cessation showed that properly educating teachers and school nurses had a significant impact on lowering smoking among school children [19]. Other studies examining smoking habits relied on self-reported questionnaires which however tends to lead to distortion [115,127].
3.6.2 Findings on mental health.
There are several studies that examine the impact of school nurse-led interventions on mental health. Only two studies were considered adequate for assessing the effectiveness of school nurse-led programs, since the others showed limitations that could affect the validity of the results.
Anxiety. One study examined the impact of a computerized cognitive therapy (cCBT) intervention on anxiety [14], the other the impact of screening and coping skill interventions on depressive symptoms [67]. Anxiety was measured with the Anxiety Scale (SCAS) and the Strengths and Difficulties Questionnaire (SDQ) and results showed a significant reduction in the total child anxiety rate after the cCBT intervention [14].
Depression. Depression and coping skills were measured using the Reynolds Adolescent Depression Scale (RADS) and the Jalowiec Coping Scale (JCS) but the risk of bias was unclear, as the study sample consisted of only 40 participants [67]. Nevertheless, the results of the RADS showed that almost 87% of the students in the intervention group experienced a reduction in depressive symptoms, compared to a 60% reduction in the students of the control group [67].
4 Discussion
With 16 reviews and 289 primary studies, the present study indicates a saturated field of research in the field of school nursing. However, in the quality analysis conducted, the opposite is observed, as the number of high quality and meaningful studies must be considered low. First, it is striking that there is no consistently established classification system of school nursing terms, which is why research is based on individual views of the effectiveness of school nurses. This results in a wide collection of literature that makes a judgment about the effectiveness of the school nurse very difficult. The present paper presents a standardized classification of school nursing work fields according to their approaches and strategies in their goals to make the school a health promoting environment. In addition, results of this paper will be discussed against the background of qualitative limitations, followed by an outlook for research in the field of school nursing.
4.1 Barriers in assessing the effectiveness of the school nurse
School nursing research faces many hurdles that need to be identified and discussed. The coverage ratio of school nurses in schools has a major impact on the effectiveness of school nurses in schools and has so far been inadequately represented in impact analyses. The background to this assumption is a study by Paterson and Zderad [128] who indicate that the supply key could highly impact successful care taking. Their results show that the key to successful patient care is the relationship between the nurse and the patient [128]. This humanistic theory can be applied to the school setting, which increases the importance of the school nurse’s supply key in schools. This assumption is supported by researchers who showed that smaller nurse-to student ratio lead to better student outcomes [129]. The recommended nurse-to-student ratio is 1:750 according to the Centers for Disease Control and Prevention (CDC) but hardly ever realized in most schools across America [55]. The effect of the coverage key on a school nurse intervention has so far been an understudied aspect and may be a relevant variable in evaluating the effectiveness of school nurse interventions.
A further hurdle in school nurse research is the ethical aspect of school nurse interventions. It is hardly ethical that children with high care needs are assigned to the control group and do not receive any intervention. On the other hand, the lack of a control group leads to a severe loss of study quality [44,101].
Furthermore, it is difficult to attribute the effectiveness of school nurse to a single intervention. Instead, a variety of factors may play a role that could influence the effectiveness of the school nurse intervention. Excluding confounding variables is nearly impossible in the school setting and in the research field of interpersonal interactions but a strict quality criterion according to the GRADE guidelines. The crux of the matter is whether school nurse research can find a way to satisfy both the holistic nature of school nurse work and meet the scientific criteria. Results show that this is possible in certain niches of school nurse activities. For example, school-nurse led immunization projects [35] and hygiene projects [121] show great success. This is especially important in a time of global pandemic, where high immunization rates are crucial for the overall health of society. In light of these findings preventative measures (aspect 3) through immunization and hygiene interventions by school nurses may be a future area of focus for school nurse efficacy analyses.
In contrast, studies focusing on the increasing trend of obesity, do not yet show sufficiently clear evidence in favor of appointing school nurses. This may be because measuring BMI is not a satisfactory way of assessing the body weight of children and adolescents, which naturally increases with age [17], but also that underlying variables such as depression or family difficulties (low socio-economic status) allied with poor nutritional understanding may be the underlying causes of obesity. This raises the interesting question of whether the increasing trend towards overweight can be reversed by education [65] (aspect 1) and physical activity programs [124] (aspect 3), or whether overweight children have other underlying problems, such as mental issues (aspect 2), which sometimes go unrecognized for a long time. For example, if children are already overweight, they are often bullied by their peers, which in turn puts the child under a lot of emotional stress, potentially causing mental health problems. Escaping this cycle and intervening early through preventive measures is a major challenge.
There are few well-designed studies examining mental health in school children. The reason for this needs to be explored in school nurse research. One reason might be that mental illnesses are very complex and take a variety of forms. Depending on the type and severity of the illness, effective treatment, which has to be tailored to the individual’s needs, often takes many years. On the other hand, the effectiveness of preventive measures can only be measured in long-term studies and research resources are often insufficient [130]. Furthermore, it is noticeable that in some studies the control group does not receive a pure placebo and screening procedures are often applied, which could indeed amount to an intervention effect [14,67]. This could possibly explain the lack of any significant difference between the control and experimental group [67]. Another difficulty in measuring mental health interventions is ensuring allocation concealment and blinding. Unlike medical trials, where a group may be given a placebo drug, in school nurse research it is obvious when a group is not receiving an intervention [67]. Attempts have been made to minimize this bias by randomly assigning whole schools to an experimental or control group [65], although this runs the risk of studying geographically or socio-economically disparate groups. Another difficulty in assessing the effectiveness of school nurses in dealing with mental health may be the different levels of qualification for the otherwise medical-oriented school nurse work. How and whether the school nurse has received specialized training differs in each research project, making comparisons downright impossible.
Research groups focusing on the implementation of asthma-care-related interventions for school children face other challenges. Here, the high degree of heterogeneity in these studies is striking and the research pool has so far been inconsistent regarding the measurement tools, interventions or populations studied. However, asthma research has a major advantage in efficacy analyses, namely the close proximity to medicine, where interventions are somewhat more controlled through the administration of medication by the school nurse, for example nurse-administered inhaled corticosteroids (ICS) [69]. Likewise, diabetes studies show promising results in that Hemoglobin A1c can be controlled by school nurses and the values to be measured (e.g. blood glucose level) are largely free of possible bias. Researchers are taking advantage of this fact and study results show that school nurses are of great benefit in improving diabetes management in children [84,85].
4.2 Effectiveness of school nurse interventions
In the presents paper the authors have examined the effectiveness of the school nurse. Based on a classification of school nurse strategies and approaches, the effectiveness of the school nurse was evaluated from two of the three aspects (see Fig 7), namely from the standpoint of medical health care interventions (aspect 2) analyzing the effectiveness of the school nurse for children suffering from asthma, diabetes, obesity, anxiety, depression, and students smoking, and also from the standpoint of health promotion (aspect 3) analyzing the effectiveness of the school nurse in combating sexually transmitted diseases (STD) and increasing vaccination rates. The evaluation of school-based interventions included a quality assessment. Present findings are largely consistent with findings by other researchers across the globe who have previously criticized the lack of methodological quality and therefore the lack of robust, meaningful results in this field [3,39]. The main point of criticism is the paucity of reliable, evidence-based, quantitative data using randomized controlled trial designs [39,40,47]. The present paper acknowledges this criticism and therefore presents a more nuanced discussion. Results of the present work show that there are indeed meaningful studies that are evidence-based with randomized controlled trial designs that cover a variety of health outcomes [17,19,35,38,61–67,71,72,75,79,80,82–85,121,131]. However, school nurse research lacks reliability because for most of the respective health outcomes no comparative studies were identified through our research findings. Contrary to the opinion of other researchers [3,39], the present paper allows conclusions about the effectiveness of the school nurse for students with asthma and diabetes. There are compelling studies that confirm the effectiveness of the school nurse in asthma care [70,71]. In the area of diabetes, the effectiveness of the school nurse can also be proven [84,85]. Results of the present work conclude that measurement methods based on physiological parameters, such as blood glucose in diabetes prevention or peak flowmeter scores in asthma care, yield more meaningful results. A possible key point could be the proximity to medical research.
Notes. Three core aspects of school health 1) health literacy, 2) medical health care, and 3) health promotion complement each other in terms of the common goal of making the school a health-promoting environment but differ in their approaches and strategies to achieve this goal.
This Overview of Reviews shows that there are some well- and many not so well-researched health outcomes in school nurse research. The general debate on quality assessment strategies and research approaches in school nurse research need to be addressed continuously. Despite scientific challenges results of the present paper speak for the implementation of school nurses, especially in countries where school nurses have not been established, such as Germany. Here, large-scale, long-term studies to evaluate the effectiveness of the school nurse in her various functions seem promising [29,132].
4.3 Methodological limitations of overviews of reviews
Overview of reviews is a suitable tool for summarizing evidence in a particular field. However, there are some methodological limitations that need to be mentioned. Although the most recent study in this overview of reviews was published in 2021 [54], it cannot be guaranteed that the compiled evidence is complete and up-to-date [133]. Furthermore, the strength of a review is only as good as the primary studies it is drawn from [40]. If relevant primary studies are missing from a review, because they were not available or could not be identified by the review team, these findings will also be missing from this paper. It is striking that school nurse research lacks adequate quality evaluations, for both primary studies and reviews. Reviews included in this paper could not meet the strict guidelines of the AMSTAR-2 criteria, which is why the quality rating had to be adjusted downwards in order to still allow a determination about the quality of the reviews. This change in quality rating is not validated and risks biasing the results. For future research in educational and psychological research, there is a need for quality assessment tools that includes quality requirements that can be realistically met by researchers in educational or psychological contexts.
Studies with study designs other than RCTs or Obs were excluded from this study due to high methodological demands. It is worth considering whether studies with other study designs (e.g., qualitative study designs) provide relevant results that could not meet the strict qualitative guidelines of this study but nevertheless contribute meaningful information to school nurse research on the effectiveness of school nurses.
Another problem in the methodology of overview of reviews is the scope of the included primary studies which deviates from the subject-matter of the overview of reviews, sometimes dramatically. Ballard and Montgomery refer to this problem as "scope mismatch" [133]. In this overview of reviews, all primary studies included in each review were listed and tabulated. It is debatable whether the decision to include all primary studies adds value to the results.
4.4 Additional strengths and limitations of this overview of reviews
This is the first overview of reviews on the effectiveness of school nurses and undertakes a detailed analysis of studies for both primary studies and reviews. It shows that there is a clear need for a rigorous examination of the evidence on school nurses and a critical appraisal of the quality of research. All reviews dealing with the effectiveness of school nurses were included in this paper, but additional recent primary studies were not included. This paper is based on a comprehensive search, rigorous selection and data extraction and contains an assessment of the risk of bias of the included studies. Risk of bias in this study was limited to RCTs and Obs. This paper conducted a detailed analysis of current research on the effectiveness of school nurses and provides a sound basis for future research.
However, there are several limitations to this overview of reviews. The quality of reviews included was disappointing, as the database of primary studies does not allow for meta-analyses. A large number of the primary studies failed to provide convincing evidence on the effectiveness of school nurses. A precise assessment of the body of evidence for each health outcome was not possible due to lack of data (e.g. confidence interval). It should also be noted that the majority of the studies do not specify the ratio between school nurses and children. The supply key could be a possible confounding variable that cannot be controlled due to the absence of more information on this point. Furthermore, it should be mentioned that in multifaceted interventions it is not possible to determine which components are responsible for the observed effects. This is a fundamental problem of school nurse research. Additionally, the lack of a classification system of school nursing terms also effects this paper. Future research projects should choose their approach based on the classification system presented so that study designs can be developed based on the classification system. The final limitation is that the wealth of literature provides a sense of the effectiveness and relevance of the school nurse concept, while yet not being sufficient for policy decision purposes.
However, it is worth mentioning that in this overview of reviews the circle of evidence is closed by linking all sources of evidence together—even literature of lower quality or with less important interventions are included in the scientific discourse [134].
5 Conclusions
It is clear that school nurses play a key role in improving the health of children with asthma and diabetes. Research results on the effectiveness of school nurses in the context of combating obesity is less certain and calls for more conclusive research. The analysis of the overviews shows that the quality of the included primary studies is poor (few RCT and Obs). The evaluation of the primary studies shows that variables such as blood glucose or asthma labeling led to higher quality results. This gain in knowledge is invaluable for policy planners and scientists.
5.1 Conclusions for policy planners
The concept of the school nurse is known worldwide, although it is implemented differently in each country, even in each school. Differences relate to school nurse training, staffing ratios, qualifications and responsibilities. The heterogeneous deployment of the school nurse and differences in the implementation of the studies (e.g. school nurse as part of regular care vs. school nurse as part of a research project) complicate the comparability of study results. Nevertheless, our study shows the effectiveness of the school nurse for children with asthma and diabetes. In order to elevate the school nurse to a permanent component of standard medical care, evidence-based results in different areas of children’s mental and physical health are needed. This paper represents an initial contribution and recommends further evaluation of the effectiveness of the school nurse in light of existing studies.
Areas that have been insufficiently studied or cannot demonstrate evidence of such effectiveness are those dealing with mental health or problems associated with children from low socioeconomic backgrounds. The reasons for this lacuna need to be identified in future studies. One reason for the insufficient number of studies could be that studies on mental health are lengthy and costly, and they also do not meet the strict qualitative standards of research (RCTs or Obs). For ethical reasons, a control group often cannot be justified, and the practicablity of a control group in mental health studies is in most cases not implementable (e.g. lack of allocation concealment, lack of blinding).
Research groups studying school nurse effectiveness with respect to mental health or social inequity should consider setting other qualitative standards, such as including qualitative study designs in evaluating school nurse effectiveness. Policy planners should be aware of the practicablity and implementability of studies in these areas so as not to overlook the potential effectiveness of school nurses.
5.2 Conclusions for scientists
Randomized clinical trials certainly have their place, but voices from the social research community (e.g., APA) are growing louder, arguing that researchers would get better results if they used other methods as well (Clay, 2010). Over the past two decades, a movement towards alternative guidelines for the design and evaluation of complex interventions has emerged from the Medical Research Council (MRC). These guidelines are intended to help researchers choose appropriate methods, make the design of evaluations understandable, and weigh the findings from intervention studies in light of methodological and practical limitations. The authors of this paper argue that school nurse research should also engage with the MRC guidelines with a view to standardizing school nurse research as well as to establishing universal standards of school nurse research. Thus, in addition to RCTs and Obs, studies with other study designs can be integrated into the scientific discourse and provide an evidence-based contribution to the field of school nurse research.
Supporting information
S1 Table. All identified primary studies (j = 352).
https://doi.org/10.1371/journal.pone.0275724.s002
(DOCX)
S2 Table. Characteristics of primary studies (k = 289) included.
https://doi.org/10.1371/journal.pone.0275724.s003
(DOCX)
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