School nursing services should be evaluated through health and academic outcomes of students; however, it is observed that the number of studies in this field is limited. The aim of this study is to evaluate the impact of comprehensive school nursing services provided to 4th grade primary school students on academic performance of students.

Methods: The quasi-experimental study was conducted with 31 students attending a randomly selected school in economic disadvantaged area in Turky. Correlation analysis, repeated measures analyses of variance, multiple regression analysis were used to analyze the data with SPSS software.

Results: At the end of school nursing practices, an increase was occurred in students’ academic achievement grades whereas a decrease was occurred in absenteeism and academic procrastination behaviors. Whilst it was determined that nursing interventions including treatment/ procedure and surveillance was associated to the decrease of absenteeism, it also was discovered that the change in the health status of the student after nursing interventions was related to the increase of the academic achievement grade and the decrease of the academic procrastination behavior score. THE IMPACT OF SCHOOL NURSING SERVICES

Conclusion: In this study, the conclusion that comprehensive school nursing services contributed positively to the academic performance of students has been reached. In addition, it can be suggested that effective school nursing services should include services such as acute-chronic disease treatment, first aid, health screening, health improvement-protection, health education, guidance and counseling and case management.


Today, the relationship between health and academic achievement has been shown. For the reason, it can be said that the interest in the evaluation of the impact of school health clinics on academic performance has increased.1,2 Comprehensive school health services, which comprises such components as health services, health education, healthy environment, physical activity programs, counseling, psychology, social services, nutrition services, improving employee well-being, family-society involvement approaches, are said to contribute to the academic performance of students in various ways.1-4 THE IMPACT OF SCHOOL NURSING SERVICES

Previous studies found that the health services provided at school can alleviate the problem of absenteeism, late-coming, and undisciplined student behavior, and increase graduation rate and Grade Point Average (GPA).2,5,6 Topics such as the evaluation of school health services and the contribution of nurses to the effectiveness of such services remain to be explored in the literature.7-9

It is suggested that the school nurses who take part in every level of school health services can play an important role in the assessment and management of health risks of students and in having students adopt healthy life behaviors, and that many nursing practices have a positive impact on attendance rates and overall education.10-14

Previous studies in the field show that in schools where nurses are employed, absenteeism associated with medical reasons are lower, and graduation rates, in-class participation, grades, and the rate of participation in social activities are higher. Leaving school early due to injury or sickness becomes a less common phenomenon when students are able to see a nurse at school.12,15-17 THE IMPACT OF SCHOOL NURSING SERVICES

Maughan12 emphasizes that there are findings contained in the literature in relation to a low rate of leaving school due to medical reasons and absenteeism because of illnesses and high rate of students graduation at schools, where school nurses work. However, in the same evaluation, it is stated that these findings do not commonly demonstrate the direct impact of school nurses on academic achievement due to methodological reasons and that there is a need for studies to be performed in this field. It is necessary that the effectiveness of nursing practices be evaluated in relation to student academic performance in order for school nurses to become more visible.

In addition, this evaluation is crucial for bringing school nurse job descriptions in Turkey in line with the modern roles and functions of nursing, opening positions for nurses at schools, and for creating the necessary infrastructure in education. For these reasons, this study was therefore conducted with the aim of evaluating the impact of comprehensive school nursing services, which comprises such activities as health education, counseling, case managements, follow-ups, and treatments/ procedures concerning environmental, psychosocial, physiological, and health-related behaviors of students as well as the relations between family-school and society, on the academic performance of students. THE IMPACT OF SCHOOL NURSING SERVICES

Materials and methods

The study was one group quasi- experimental study which interventions and assessments were repeated in time intervals. Data of this study was extracted from a thesis entitled, “the impact of comprehensive school health nursing services on students’ academic performance”. The data was gathered over 8 months. The selection of school was made by random among disadvantaged schools. The school where the study has been conducted is located in a region, which is low in sociodemographic terms, is a slum settlement and has a high rate of child labor.

There wasn’t school nurse or a health unit at the school where the study was conducted. In order to determine the study group, the size of the sample was calculated using the G*Power program. With the help of this program, the average change in academic achievement grades at schools where comprehensive school health services have commenced being provided,5 has been anticipated and an estimate sample size has been determined as 29 persons (ß=0.80, a=0.05). In this school, there were three classes in the fourth grade.

After the work program, the research process, and planned interventions were explained to teachers, the class of the teacher who accepted to participate in this study was included in the study and the 31 students in this class constituted the study group of this study. The reason for the study being conducted with primary school fourth grade students was the students having adequate experience with school life and the learning process; thus, it was possible to assess the impact of school nursing services on academic performance better. As health services provided to students in Turkey was not organized on a school basis, a health unit and school nursing implementation system was set up by the researchers. THE IMPACT OF SCHOOL NURSING SERVICES

The ethical permission for this research was received from the clinical research ethics committee (December, 9, 2009; No: 263). The students and school environment were evaluated with the “School Health Assessment Form”. The school health assessment form consists of three sections oriented at assessing “school/classroom environment”, “student health condition” and “student academic performance”. In the implementation of the nursing process, the “OMAHA System” and forms related to this system18-23 were utilized.

Assessment of the school – classroom and environment: In this section, there are questions including information about geographical characteristics of the school, environmental risk factors, physical characteristics of the school playground – the interior of the school and classroom, canteen and workers at the canteen.

Assessment of the student health condition: In the section on student health of the school health assessment form, there are domains that assess the socio-demographic characteristics of the student, definitive information about families, medical history, family history concerning chronic illnesses, immunization status, examinations concerning health, vital findings, physical examination results and healthy lifestyle behavior. In this section of the form there is the Pediatric Quality Of Life Inventory (Pedsql 4.0) On Turkish Children for the purpose of having students self-evaluate their health condition and the Child Health Questionnaire Parent Form (CHQ-PF)” for the purpose of having families evaluate the students.


The Pediatric Quality of Life Inventory 4.0, was developed by Varni et al.,18 for the purpose of assessing quality of life in healthy school children aged between 8-12 years and its Turkish reliability and validity was performed by Sönmez & Baçbakkal.19 In this five point likert type inventory consisting of a total of 23 items covering Physical functioning (8 Items), emotional functioning (5 Items), social functioning (5 Items) and school functioning (5 Items), it is possible to score “0” at the lowest and “2300” at the highest and thus a high level score indicates that life quality concerning health is better. The Child Health Questionnaire (CHQ) was developed to assess the general health condition of children between the ages of 5-18 and the questionnaire has two separate forms, which are the parent form and the youth form. The family form used in this study (CHQ PF- 50), consists of 50 items. The scale has 15 separate subscales consisting of global health, physical functioning, role/social limitations -due to emotional and behavioral difficulties, bodily discomfort, behavior, global behavior, mental health, self-esteem, general health perceptions, change in health, and emotional impact on parent-time impact on parent, family activities, and family cohesion. Every subscale has a value between 0-100 and the high score indicates good functioning. It isn’t possible to obtain a full score from the scale; however, physical and psychophysical summary scores are calculated. The Turkish reliability and validity works of the scale were performed by Özdogan et al.20 THE IMPACT OF SCHOOL NURSING SERVICES

Assessment of Academic Performance: In the section oriented at the assessment of academic performance, there is a part in which the achievement grades related to lessons and the status of absenteeism is recorded and also there is an “Academic Procrastination Behavior Scale”. The Academic Procrastination Behavior Scale is a form developed by Çakici21 consisting of 19 expressions, covering the duties students are responsible for fulfilling in their educational lives (such as studying, preparing for exams, preparing projects) of which 12 are negative and 7 are positive. The expressions in this scale are rated according to the five point likert scale as “it does not reflect me at all”, “it reflects me very little”, “it reflects me to some extent”, “it largely reflects me”, and “it completely reflects me”. A minimum score of 19 and a maximum of 95 can be obtained from this scale, which is a reliable and valid instrument in designating the academic procrastination behavior of students and the high score obtained indicates that the students have academic procrastination behavior.

The Omaha System is a classification system developed by the Visiting Nurse Association (VNA), which includes the basic nursing process elements such as nursing diagnoses, nursing interventions and assessment stages. THE IMPACT OF SCHOOL NURSING SERVICES

The Omaha System consists of three complementary sections, which are the Problem Classification Scheme (PCS), Intervention Scheme (IS), and the Problem Rating Scale for Outcomes (PRS). The Omaha PCS includes four domains determining nursing diagnosis, 42 problems and 312 symptom-findings. The domains are grouped in the scope of the (1) environmental, (2) psychosocial, (3) physiological, and (4) health related behavior domain and each problem can be evaluated as improving health, potential risk, and actual (symptom-finding).22

The Omaha IS groups the implemented nursing interventions. It provides the opportunity for grouping nursing activities such as (1) health education, guidance and counseling, (2) Treatment and procedure, (3) Case management, and (4) Surveillance. The Omaha Problem Rating Scale for Outcomes is a likert type scale, which explains the development related to the identified problem.

According to each diagnosis, knowledge behavior, and status criteria, there is a rating between 1 and 5. The knowledge criteria, is a domain which evaluates the ability of the individual to remember and construe knowledge and is evaluated as “No knowledge (1), Low level (2), basic level (3), Sufficient level, and (4) High level (5)”. The behavior criteria is the domain that evaluates whether or not the individual performs the expected behavior oriented at the observed response or target and can be rated as Not relevant (1), rarely relevant (2), Neutral (3), Generally relevant(4), and Always relevant (5).

The status criteria evaluates the existence of present objective and subjective symptoms and findings and status is rated as very severe (1), Severe (2), Medium level (3), Very low level (4), and None (5).22 The Turkish reliability and validity works of the Omaha System were performed by Erdogan & Esin. 23

During the implementation stage of the research, a health unit was opened at the school, where nursing services were delivered. In addition, home visits to families were scheduled in case of need. In this research, nursing interventions were implemented in the following order:

1.Data that were collected through data collection forms, observation, personal applications, acute occurrences, and notification by parents or teachers were evaluated, and nursing diagnoses were made according to PCS, using symptoms/findings associated with a particular health problem. The research also included diagnoses that did not include symptoms-findings for health improvement. THE IMPACT OF SCHOOL NURSING SERVICES

2. These diagnoses were evaluated according to PES, and the knowledge, behavior, and status of students were assessed. The diagnoses were then put in the order of priority.

3. Appropriate goals were specified using the Omaha System goals. In the research, the goals specified for the nursing care period generally required interventions at the level of students, families and society.

4. Nursing interventions were implemented in order to attain the specified goals. IS includes the categories of surveillance, teaching/ guidance/ counseling, treatment/ procedure and case management.

Surveillance intervention scheme involves monitoring symptoms and findings related to health problems, monitoring the healing process, identifying whether the health problem recurs, monitoring the implementation of treatment plan, followingup for any possible side effects or complications associated with treatment plan, monitoring whether students adopt the advised health behaviors, and repeating the necessary screening process periodically for students who have a family history for certain illnesses. Teaching, guidance, and counseling interventions concern managing health problems, health responsibility, life skills, healthy lifestyle behaviors, appropriate leisure activities, using correct resources, and developmental period needs.

Case management intervention scheme is used for diagnoses that extend beyond the role, responsibility of a nurse and the capacity of workplace facilities, and that require other professionals’ involvement. Case management interventions implemented in this study involves social aid organizations and local administrations in the environmental domain; guidance service, social service specialists, and psychologists in the psychosocial domain; health institutions and health professionals in the physiological domain; and all the abovementioned institutions and professionals in the domain of health behaviors. The treatment/procedure scheme involves interventions concerning acute or chronic diseases, accidents, injuries, and contagious diseases. THE IMPACT OF SCHOOL NURSING SERVICES

5. The status of students with regard to diagnosis was re-evaluated on the basis of PES, and some nursing interventions were repeated.

6. The status of students with regard to diagnosis was evaluated according to PES for the third time.

New care plans were prepared for diagnoses that did not attain the desired goals after repeated interventions and for newly identified or acute conditions.

In this study the change occurring in the student’s health status as a result of nursing services was evaluated by the nurse, student, and the family. The nurse evaluated the change in student’s health with the Omaha Problem Rating Scale for Outcomes score used uniquely for nursing diagnoses; the student evaluated the same with the Pediatric Quality of Life Inventory, and the family performed the evaluation with the Child Health Questionnaire Parent Form and these scores were accepted as independent variables. These evaluations were repeated three times in the beginning (first week of school-September), middle (four months later- January) and the end of the study (June). Academic performance was evaluated with the absenteeism status, academic procrastination status, and academic achievement grade and these variables were accepted as the dependent variables of the study. Academic procrastination status was evaluated three times as the first week of school, four months later and the end of the study, whereas academic achievement grade was evaluated twice as the end of the first semester and the second semester, and the absenteeism was assessment twice as the end of previous academic year and this academic year THE IMPACT OF SCHOOL NURSING SERVICES

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