Parents’ perception of the school nurse’s role

School nurses play a vital role in the school system. As a student’s health can affect their ability to learn, the school nurse can support the learning process through assessment and management of the student’s physical, emotional, and social health needs [1]. School nurses have many roles. They provide preventive care, emergency treatments of minor injuries, make referrals, and are integral members of the healthcare team in chronic illness management. The school nurse develops and implements health plans, monitors and implements immunizations services, maintains a healthy and safe environment for students, and serves as coordinator and interdisciplinary liaison [2]. Additionally, they work with the health department in tracking illness and infectious diseases as well as providing education to teachers and school staff. According to the American Academy of Pediatrics (AAP) and the Council on School Health, school nurses promote health and a safe environment by providing education, interventions for acute and chronic illnesses, public health activities, and case management services to promote self-management and advocacy and decrease health-related barriers that affect student learning [3]. Abstract

Comprehension of the school nurse's role is essential to coordinated care. However, the role of the school nurse is poorly understood. Limited research exists on current understanding of the school nurse role. Therefore, the purpose of this study is to explore parents' perceptions of school nurses' role in the public school setting. The indings of this study will give insight into the perceptions held by parents. It is anticipated that by ascertaining this information, the school nurse role can be clearly de ined and disseminated to the public/parents. Understanding beliefs regarding the role of the school nurse will offer opportunities to educate parents and school personnel on the importance of school nurses and the multifaceted responsibilities they hold. An awareness of school nurses' roles may help parents feel con ident in the care their child receives while at school, and they may seek assistance from them.

Literature review
In the past, studies have examined the role of school nurses and parents' perceptions of school nurses' role but recently there is limited number of studies done in this area, especially in the United States. Studies have reported that majority of parents believe that the primary roles of the school nurse are providing irst aid, emergency care, giving medications, and checking students' health annually [4][5][6]. Other roles perceived as extremely important by parents are prevention of infectious disease and education of students on health issues [6]. Parents also highlighted the nurses' role in crisis response, screenings, immunizations, and health teaching [5].

Research questions
1. What are the parents' perceptions of the roles of the school nurse?
2. Is there a relationship between parents' perceptions of the roles of the school nurse and the demographic variables?

Design and sample
A convenience sample of 180 parents participated in this descriptive design study.
The population included all parents of students in grades K-12 in the South Plain ield Public School District, New Jersey and all parents of students in grades K-8 in the Warren Township Public School District, New Jersey. The inclusion criteria were parents of children attending K-12 grades in the participating school, parents who spoke and read English and Spanish, and parents who were willing to participate in the study. Out of a total of 196 questionnaires collected, 16 were discarded because of incomplete data information.

Instruments
Parents were invited to complete two questionnaires: demographic and their perceptions of school nurses' roles. The irst questionnaire was used for collecting demographic information such as age, ethnic background, educational level, job status, health insurance etc. The second questionnaire assesses parents' perceptions of school nurses' role. A perception of school nurses' role questionnaire was adapted from Kirchofer, et al. [7] study. It consists of 17 items, where each item is rated as not important (0), important (1) and very important (2). The participants were asked to check one best answer for each question. The face and content validity of this questionnaire was tested, and the reliability was reported to be .77 [7]. Questionnaires were available in English and Spanish. The original questionnaire was in English and it was translated to Spanish and back to English by an in-house staff member, who is luent in both Spanish and English.

Procedure
Permission was obtained from the researchers' Institutional Review Board and the targeted schools prior to data collection. Parents were invited to participate, voluntarily, via a message conveyed to them electronically by the school principals. Those who agreed to participate in the study and signed the consent form completed the questionnaire. The consent form and questionnaire were available in English and Spanish. The participants completed either a Qualtrics web-based questionnaire or a paper questionnaire. Paper questionnaires were sent home with students and returned to the student's teacher. Completed paper questionnaires were placed in an envelope in the school of ice for pick up by the study investigators.

Data analysis
SPSS version 21.0 was used to analyze the data. Demographic information and parents' perceptions of school nurse roles were analyzed using descriptive statistics. Correlation coef icients were calculated to examine the relationships between parents' perceptions of nurse roles with the demographic variables.

Results
The questionnaire was mainly completed by mothers (73.8%), followed by fathers (8.1%), and others (3.8%). Demographic information is presented in table 1. The majority of parents were married (74.8%). Parents' report of number of children attending school ranged from 1 to 7 children; many reported two children (46.7%) followed by one child (25.6%) and three children (20.6%). Ninety-seven percent of the children had a primary health care provider. They had either private insurance (91.1%) or Medicaid (7.2%). Only one parent reported having no insurance. Only 14.4% of children were reported to have a chronic illness. The majority of parents (86%) reported talking/meeting with the school nurse. Eighty percent of children are reported as seeing a school nurse for a problem. The majority of them saw the nurse at least once a month or twice a month.
The total parents' perceptions of school nurses' role ranged from 8 to 32 with the mean score 24.44 (SD = 6.22). The frequency and percentage of parents' responses on school nurses' role is reported in table 2. The four most important school nurses' roles perceived by the parents were providing irst aid and emergency care to children (96.7%), communicating with parents and health care providers in the presence of a problem (89.4%), providing medical treatment (83.9%), and preventing and controlling diseases (79.4%). The four least important roles perceived by the parents were conducting follow-up on referrals (36.7%), providing referrals (41.5%), follow-ups on students who miss school (43.3%), and administering over the counter medications (47.2%).
The total score on parents' perception of school nurses' role was associated with met/talked with school nurses (r = .167, p = .05). There was no other correlation between parents' perception and any other demographic variables.

Human subjects protection
All information obtained from the subjects was coded to ensure con identiality of the data. Using code numbers and coded forms for all data collection materials minimizes the risk of violating con identiality. These coded responses are protected in a secured locked ile in the of ice of the principal investigator. No identifying data, such as names and addresses of participants, was collected. Furthermore, the data will only be presented as grouped data in publication and presentation of this research.

Nursing implications
School nurses are essential members of the school team and are integral in managing and maintaining students' health. In order for excellent care to be provided, it is imperative that parents understand the role of school nurses and maintain open communication with them. It is an encouraging inding that parents were relatively knowledgeable about the school nurses' roles and the majority of parents communicated with school nurses. Their awareness of school nurses' roles could be due to the fact that most of the parents had college degrees and had access to the information. Additionally, parents may recognize the value in collaborating with school nurses in management of their child's care.
The irst most important school nurses' role perceived as very important by the parents was providing emergency care to the children which was consistent with previous indings [4][5][6]. This is also consistent with an earlier study by Gross, et al. [8], which indicated that providing irst aid was the most important role of the school nurse; the authors noted that parents also deemed evaluating hygiene in the school a very important responsibility. A third study also found similar indings where parents speci ied that school nurses respond to crises [5]. The next most important role perceived was communicating with parents and health care providers in the presence of a problem. This inding is supported by that fact that 86% of parents reported talking/meeting with the school nurse and the total score on parents' perception of school nurses' role was found to be associated with met/talked   [5] noted that parent perceptions were dependent upon the quality of interactions between parents and school nurses, and that parents indicated they only learned the various roles of school nurses by observing them directly during volunteer activities.
There was no correlation between the parents' perceptions of school nurses' roles and the demographic variables except one. The total score on parents' perception of school nurses' role was only associated with met/talked with school nurses. This inding was supported by that fact that more than three quarters of the parents reported talking/meeting with the school nurse in one of the demographic questions (Have you ever met or talked with your child's school nurse?).
Although this study indicates that parents were relatively aware of the school nurses' roles, they did not perceive some of the roles as very important. Roles that were not perceived as important by the parents include conducting follow-up on referrals, providing referrals, and follow-ups on students who miss school. These roles are equally important because by providing referrals and follow up, school nurses can effectively increase medical care coordination and hence support students' health. According to the National Association of School Nurses [1], the school nurse coordinates student health care between the medical home, family, and school. Numerous coordination efforts take place on a daily basis to ensure that a student's healthcare needs are being managed effectively during the school day and beyond. Educating teachers and other school team members is an essential component of this coordination of care, another role not recognized by parents.
School nurses are vital to the health and safety of students. Therefore, the multiple responsibilities that school nurses carry out should be highlighted and disseminated to parents and the public. As school nurses are partners with families in the care of their students, it is imperative that parents realize the multifaceted roles that school nurses possess. Without recognizing the various areas that school nurses are involved in, parents may be missing out on a valuable resource that is available to their children and family. School nurses, in conjunction with their principals, should make parents aware of all functions of the school nurse, how to access their services, the importance of informing the school nurse of any concerns or health issues parents and students may have, and the value of ongoing communication with the school nurse.

Conclusion
The results of this study indicate that parents recognize roles of providing irst aid and medical treatments, communication with parents, and disease prevention as highly important. However, follow-up with regard to missed school days and referrals, making provider referrals, and medication administration were viewed as less important. As the nurse plays an important role in coordination of care with providers and other members of the healthcare team, it is imperative that parents understand this essential component of a school nurse's responsibilities. The school nurses in collaboration with the school principal could set up an educational session or a meeting each year for parents to explain about the school nurses' roles and how they can help children and parents. During this session, nurses could also explore if parents have any speci ic needs or questions. Based on the need assessment, nurses could develop educational sessions for children and/ or parents.