Characteristics Associated With School Nurse Childhood Obesity Prevention Practices

Susan B. Quelly


Pediatr Nurs. 2017;43(4):193-199. 

In This Article


Comprehensive strategies to prevent childhood obesity should include promoting school nurse involvement. School nurses can play an integral role in obesity prevention, thereby supporting the IOM (2012) recommendation to address obesity by focusing on schools and expanding the role of healthcare providers. Significant differences in school nurse practices were associated with age, professional, and job-related characteristics. Findings provide insight as to which groups may benefit most from interventions and policy changes aimed to increase school nurse participation in COP.

School nurses working in the poorest schools (as indicated by a higher percentage of students qualifying for free or reduced lunches) conducted significantly more child-level COP practices than nurses working in more affluent schools. One explanation for this finding may be that there is a greater need for COP because lower socioeconomic populations often include a higher percentage of racial/ethnic minorities, and both populations have an increased prevalence of childhood obesity (Koplan, Liverman, & Kraak, 2005; Kumanyika & Grier, 2006). Nurses in schools with lower socioeconomic populations may be more actively engaged in child-level COP practices than nurses working in more affluent schools where access to other healthcare providers may be more prevalent. Schools with large underserved populations may need school nurses to take an active expanded role in COP and in providing other forms of health care. Although school nurses working in lower socioeconomic schools are more engaged in COP practices than those in wealthier schools, additional interventions and policies that further promote participation in COP practices should target nurses in poorer schools with more students at higher risk for childhood obesity.

Previous studies indicated that heavy workloads, high student-to-school nurse ratios, competing health priorities, and insufficient time were deterrents to school nurses engaging in COP practices (Hendershot et al., 2008; Kubik et al., 2007; Morrison-Sandberg, Kubik, & Johnson, 2011; Stalter, Chaudry, & Polivka, 2010, 2011; Steele et al., 2011). This study did not support these earlier findings. As the number of students for whom care is provided increased, school nurses performed more child-level COP practices. A possible explanation for this unexpected finding may involve substantial differences in school nurse job descriptions, some of which involved conducting mass BMI screenings in numerous schools, which may elucidate this unanticipated outcome. Several items on the child-level COP practices scale involved BMI screening activities; therefore, it is possible that school nurses with this type of job description provided care for large numbers of students and still scored high on the child-level practices scale. Additional research with more detailed job descriptions might explain this unforeseen finding.

It is important that high student-to-school nurse ratios not be dismissed as a factor associated with performance of school nurse COP practices. These high ratios increase workloads, which may contribute to school nurses' perceptions of inadequate time for COP. Most school nurses reported that "not enough time" was a perceived barrier to engaging in COP activities, and perceived barriers were significantly (p < 0.05) negatively associated with school nurses performing child-level COP practices (Quelly, 2014). Further research with analyses of student-to-school nurse ratios with COP practices is still needed.

School nurse job descriptions and educational requirements vary throughout Florida, as well as across the nation (Sensor, 2007). Differences in state and local school policies involving organizational structures, budgets, staffing, mandates, and other factors may influence school nurse job descriptions that directly or indirectly impact COP practices performed by school nurses. For example, nurses working in school districts with a mandate to measure and report students' BMI engaged in COP practice more often than school nurses in schools without this mandate (Hendershot et al., 2008). The association between job-related characteristics and school nurse COP practices needs to be studied further to direct specific policy changes that will increase these practices.

School nurses with higher levels of education and participation in professional organizations conducted COP practices significantly more often than nurses with less education, no NCSN certification, or membership in these two professional organizations. The nearly one-third of school nurses who reported having no COP education participated less frequently in COP practices than school nurses who had any amount of COP education. These findings support funding and promoting opportunities for COP education for school nurses, so they may ultimately support the IOM (2012) recommendation. Further, nurses working in schools with populations at higher risk for childhood obesity may benefit most from educational programs and policy changes.

COP education interventions specifically for school nurses with characteristics associated with low participation in COP may increase their engagement in COP practices. Future research implementing a COP educational intervention targeting these school nurses is needed to expand and support outcomes of this current research.

COP education for school nurses is available from several sources. NASN offers a COP course online or a live half-day program using a school nurse childhood obesity toolkit specifically developed for school nurses (NASN, 2013). COP education should be extended beyond school nurses to include and benefit nurses caring for children in other healthcare settings. These continuing education opportunities are relatively convenient and available via online courses, webinars, and print sources (Children's Hospital Association, 2010;, 2016; Rubenstein, 2012).


Recruitment of participants was extensively facilitated by two professional organizations that may have resulted in a sample with characteristics not representative of most school nurses. The sample consisted mostly of FASN and/or FSHA members, groups that may be more inclined to seek professional development and additional education than non-members.

The sample was comprised solely of school nurses from Florida, which limits generalizability of these findings to school nurses in other states. However, characteristics reported in a large nationwide study of school nurses, including race/ethnicity, highest nursing degree, weight status, and school setting (Hendershot et al., 2008), were comparable to those found in this Florida study. Further, school nurse job descriptions and responsibilities vary in different regions of Florida as well as in different areas of the country (Sensor, 2007). These similarities provide support for using findings from this study to school nurses outside of Florida.

A survey response option about the school nurses' job description as "clinical practice and administrative/supervisory" may also pose a possible limitation of this study. This description does not clearly identify if a school nurse's job is 90% administrative/supervisory and 10% clinical practice, vice versa, or any number of other proportion combinations in the division of job responsibilities. The ambiguity in this response option could contribute to the lack of significant findings associated with this job-related characteristic. Clearly delineated response options that categorize job descriptions more accurately may reveal missed significant associations between school nurse job descriptions and COP practices.

Another limitation involves the use of both online and paper surveys to collect data. Although using different means to collect data from identical surveys could potentially cause different results, it is unlikely this occurred because there was no survey question identified that would prompt a socially desirable response from participants.

School nurse BMI was not found to be significantly associated with child-level or school-level COP practices in this study. However, BMI classification data may not be accurate due to self-reported height and weight, especially because weight is a sensitive personal issue for many people. Obese school nurses were found to perceive significantly more barriers to measuring BMI in elementary school children than school nurses with a normal BMI classification (Hendershot et al., 2008), and perceived barriers were shown to be associated with performance of fewer school nurse COP practices (Kubiket al., 2007; Quelly, 2014). Over 85% of school nurses believed that school nurses should be role models by maintaining a normal weight (Moyers et al., 2005). This belief may have altered school nurses' self-reported responses to height and weight questions in the survey. Inaccurate data may have resulted in missed significant findings related to associations between school nurse BMI classifications and COP practices, thus creating another potential limitation of this study.