Articles

School Health Services in the United States: A View from the United Kingdom June Thompson

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ABSTRACT: Despite sharing both a common heritage and a common language, differences exist between life in the United States and the United Kingdom. During spring 1988, the author, who formerly served as editor for the Health Visitor, published by the Health Visitor’s Association, completed a six-week study tour of school health services in the United States. In this article, she gives her impressions from the experience, including observations regarding salary, working conditions, professional preparation, and professional recognition. She concludes by identifying several poignant questions to clarify the school nurse’s role and to set priorities for the optimal use of time and expertise. (J Sch Health 1989;59(6):243-245)

nevitably, one goes to a country such as the United I States of America with some fixed ideas. I assumed, for example, the salary and resources available to school nurses would be much more in the U.S. than in the United Kingdom, especially since I went at a time when the U.K. National Health Service had been going through a prolonged crisis. However, though we may be “divided by a common language,” I was surprised by the similarity between problems facing U.S. school nurses and those facing health visitors and school nurses in Britain. I include health visitors here because some of the functions carried out by U.S. school nurses, such as involvement in infant program schemes, would be carried out by health visitors in Britain, and some health visitors also work as school nurses.

The similarity first struck me when I attended a con- ference of the California School Nurses Organization. Complaints of lack of resources, lack of time, no one understanding their role, and other professionals usurp- ing that role made me feel I was back at a meeting of health visitors and school nurses in the U.K. Discussions throughout the remainder of my tour inevitably center- ed on government cut backs and their effects in both countries. Salaries in the U.S. were not as high as I expected, and in some cases they were lower than in Britain. New York nurses were surprised to learn that Britain had a growing problem with homeless families and with poor quality bed and breakfast accommoda- tion; they thought these problems only existed in New York. The causes were similar: lack of public housing, lack of low rent accommodations, high housing prices,

June Thompson, RGN, RM, RHV. former editor, Health Visitor, Health Visitors’ Association, 50 Southwark St., London, SEI IUN. During spring 1988. Ms. Thompson spent six weeks examining school health services in [he United States aspart of a study tour funded by a scholarship from [he National Florence Nightingale Memorial Awards Committee. This article presents some of her observations from the tour. Ms. Thompson currently is undertaking a feasibility study on the school health services from the Department of Health, United Kingdom.

and upscale development of former working class neigh- borhoods.

COMPARISONS AND CONTRASTS As in the U.K., quality of U.S. schools and funding

for them depend on the area, with boards of education in more middle class areas providing better facilities than in the poorer areas and being more likely to employ more school nurses. In both California and New York, however, state lotteries are held with around 40% of the profit going toward school funds - an idea presently being considered for the U.K. National Health Service.

The American system of education differs substan- tially from the U.K., and an associate or baccalaureate degree is the norm for nursing. Education and further qualifications appear to be much more valued in the U.S. than in the U.K., though at times the emphasis placed on obtaining degrees seems somewhat obsession- al, and less stress seems to be placed on the importance of clinical practice. Even the smallest town appeared to have its own university, some within a couple of miles of each other, and I felt there was a danger of a degree be- coming devalued. Qualifications such as the Health Visitor Certificate probably would be equivalent to a bachelor of arts degree in the U.S. and apparently an American master’s degree is equivalent to a BSc (Hons) in Britain.

Nevertheless, the fact that nurses pursue further degrees and post registration training in their own time on a part-time basis while working full time and at their own expense is most admirable. Surprise was expressed that nurses in Britain get paid while training and that university students can get free grants. The enthusiasm for further education and the fact that nurses are expected to continue their professional development also helps ensure they remain stimulated by their work and are up-to-date.

I also admired the more positive attitude that the U.S. has toward age compared to a more negative atti-

Journal of School Health August 1989, Vol. 59, No. 6 243

tude in the U.K. In the U.S., discrimination against employing school nurses on the grounds of age is illegal, and there appears to be no expectation that nurses should retire at 55 or 60 years as in Britain. Indeed, one 60-year-old school nurse with a master’s degree was studying for a school administrator’s credential - a change of career which would be unheard of for a 60 year-old in the National Health Service in the United Kingdom.

The British tradition of retiring early to enjoy life and undertaking voluntary work did not appear to be a factor with any of the older nurses I spoke with, but financial considerations such as health insurance was evidently a problem in some cases. Though job security for life is no longer a certainty with the frequent re- organization of the management structure of the National Health Service, nevertheless field workers in the U.K. do not normally face the insecurity of a yearly job tenure as happens in California, though money may be saved by health authorities in other ways such as not filling vacant posts.

I was particularly impressed with advances that the U.S. appears to have made integrating handicapped children in normal schools or classrooms on these sites. The U.S. education act was passed almost a decade before the one in the U.K., and many of the most severely handicapped children still attend special schools.

By contrast, in some U.K. districts as the education act is implemented gradually, difficulties have occurred in re-orienting health services away from a focus on special schools toward the needs of individual children in mainstream schools. I Considerable variation exists between local education authorities in the number of children with statements, and their integration into ordinary schools; and some parents opt to keep their children in special schools because they are guaranteed access to therapy which might not be available in ordin- ary schools.’ However, some American parents are now demanding highly specialized normal school settings for their handicapped child. School budgets also are being affected by having to provide special equipment, and it will be interesting to see if similar problems become commonplace in the U.K. in a few years.

Perhaps in the difference between the preschool services and school health services in America and Britain, I found the biggest contrast. Obviously, six weeks is a short time to reach any categorical conclu- sion, but the overall impression I got was that in the U.K., state emphasis is placed on preventive child health services for the under fives and less on school health services. In the U.S., more emphasis seems to be placed on the health of the school child compared to the pre- school child. For example, in California, infant pro- grams for children handicapped from birth were avail- able free of cost. Similar free services have been avail- able and taken for granted in the U.K. for many years.

It is not appropriate to discuss the British Health Visitor Service in this paper, but certainly there was no comparable universal home visiting service for mothers and children up to five years in the U.S. or a tradition of mothers visiting child health clinics regardless of social class. The U.S. nurses found it amazing that every child

in the U.K. had a health visitor and a health record. On the other hand, compared with numerous publications that appear on U.S. school health services, a dearth of data exists about school health services in Britain. Indeed, when questioned in the House of Commons, Ministers have been unable to say what services are being provided and the school health service in Great Britain has been called the “invisible service.yyz No doubt many U.S. school nurses would argue that the same could be said for the school health service being “invisible” in their area, but from my observations and reading of the American literature, overall the school health service seems to have developed considerably more in the U.S. compared to the U.K. and the school nurses enjoy a higher status.

ISSUES IN PROFESSIONAL PREPARATION School nursing is viewed as a profession in its own

right in the U.S. School nurses appear to have a remark- able degree of autonomy, and in many schools, a physi- cian does not regularly visit. Indeed, little mention was made of the school physician, though in contrast to school nurses, a school physician is mandatory and could be a physician at a medical center or a pedia- trician. School nurse practitioners also can undertake work carried on by physicians in schools, such as full physical examinations.

The school nurses I spoke with were confident and articulate about their work, and it does not appear to be a stepping stone to another career outside school nurs- ing. If school nurse managers are not school nurses (though the majority were) they are directly involved in schools as a school superintendent. By contrast, in the U.K., school nurses can still work under the direction of a health visitor or health visitor manager who may not have a school nurse background or experience, and physicians may have’considerable involvement in physi- cal examinations in schools in many areas.

School nursing in the U.K. may be considered by some as a dead-end job, without a proper career struc- ture, or as a stepping stone to a career in health visiting. In California, from World War 11, nurses working in public schools were required to have a public health nurse certificate. In 1970, this requirement was elimin- ated and replaced with a requirement of a credential equivalent to a master’s degree.3 In Rochester, N.Y., school nurses or community health nurses are registered nurses with a bachelor of science degree in nursing from a university with a public health nurse course. Nurses usually have experience in the public health field before being accepted as community health nurses for schools. A similar system existed with public health nurses in New York City.

Similarly, in the U.K., from 1944, school nurses were required to have the health visitors’ certificate.‘ By 1974, almost half the nurses working in schools did not have this certificate and, in 1988, the majority of school nurses did not hold the health visitors’ certificate. Elim- ination of the Health Visitors’ Certificate requirement has not been replaced with a mandatory requirement for further education and training for U.K. school nurses as the public health nurse qualification has in California.

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As the Health Visitors’ Association points out, schoolchildren need access to skilled and knowledgeable health care at school. School nurses are the key workers in the school health service. They must be trained, man- aged, compensated, and employed in sufficient numbers to ensure they are competent to practice safely and effectively, and are confident of their role and function.’ The Association believes a national policy is required to establish the objectives for school health services and to specify how these should be met for individual health authorities to implement in accordance with local needs and circumstances.

Though the U.S. does not have a national policy or school health service, the fact that many states encour- age or mandate school nurses to obtain further training or qualifications has helped raise the status of school nurses and establish it as a profession in its own right. It would be ironic if U.S. schools are attempting to find the least expensive alternative to certified school nurses and if the number of certified school nurses is de~lining,~.’ while in the U.K., it is increasingly being recognized that the present three-month course for school nurses is inadequate and recommendations are being made for development of a year-long course.

CONCLUSION A variety of problems threaten the health and emo-

tional well-being of today’s schoolchildren. If the school nurse is to offer appropriate health education and counseling to meet these children’s needs, more research into their present role and function is needed both in the U.K. and the U.S. For example, what is the most effective use of the school nurse’s time? While screening for scoliosis is mandatory for certain grades of U.S. schoolchildren, and this task is mainly under- taken by school nurses, such screening has largely been abandoned in the U.K.’ Is the American detection rate for scoliosis any higher than that in the U.K.?

Likewise, vision and screening testing, though main- ly conducted by school nurses both in the U.S. and the U.K., is carried out in Rochester, N.Y., and New York City by trained ancillary workers. In the words of one New York school nurse, this practice leaves them free to concentrate on more important matters, such as home visits. Should vision and hearing screening by techni- cians be considered in other parts of the U.S. and in the U.K., or is the school nurse the most appropriate person to undertake these tests? Do school nurses in some parts of the U.S. need to be responsible for maintaining the attendance register and for following up absenteeism, or could this work be undertaken by a clerk? Is first aid given by a teacher or secretary trained in this area any less effective than that given by a school nurse?

In the words of the American School Health Association, “Every kid needs a school nurse.” How- ever, in today’s cost-conscious era, school nurses and their professional associations in both the countries may need to do much more to convince legislators that not

only do children need school nurses but that these nurses must be highly trained professionals. A much more intensive study than the one undertaken here, which looks at U.K. school health services and at the educational and training systems for the profession both in the U.S. and the U.K. would, in my view, be invalu- able. Finally, in both countries the foundation for the health of the school child should be laid down with good preventive health care from conception and throughout the preschool years. w

References 1 . Changing School Health Services. Primary Health Care Group.

King’s Fund Centre. January 1988. 2. School Health, The Invisible Service, in Harrison A, Grettor J

(eds): Economic, Social and Policy Audit. 1986. 3. Standards of Quality and wfectiveness for Developing and

Evaluating Programs of Professional School Nurse Preparation in California. California Commission on Teacher Credentialing. January 1988.

4. Fit for the Future. The Report of the Committee on the Child Health Service. HMSO 1976.

5. Meeting Schoolchildren’s Health Needr: The School Nurses Role. London, Health Visitors’ Association. 1988.

6. Zanga JR, Oda DS: School health services. J Sch Health 1987;57(10):413-416.

7. Hill-White D, Christansen HT: The declining status of the school nurse in New York. J Sch Health 1987;57(4):137-142.

8. School screening for scoliosis. The Lancet Aug 13, 1988.

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