CLINICAL NURSING ROLES
The health-promoting school: what role for nursing?
Dean Whitehead
MSc, RN
Senior Lecturer, College of Humanities and Social Sciences, School of Health Sciences, Massey University, Palmerston North,
New Zealand
Submitted for publication: 14 September 2004
Accepted for publication: 30 June 2005
Correspondence:
Dean Whitehead
Massey University
College of Humanities and Social Sciences
School of Health Sciences
Private Bag 11 222
Palmerston North
New Zealand
Telephone: 06 356 9099 (ext. 7227)
E-mail: D.Whitehead@massey.ac.nz
264
Journal of Clinical Nursing 15, 264–271
The health-promoting school: what role for nursing?
Aim. To review the existing literature on health-promoting schools and put forward
recommendations for continuing progress.
Background. The World Health Organisation’s Ottawa Charter for Health Promotion in 1986 sought to create a framework for health promotion action that
conveyed the notion of capacity building as it related to specific settings. It provided
the catalyst from which the health-promoting school movement emerged, against
the backdrop of health professionals adapting to the changing needs and demands of
clients and the evolving social context of the communities in which they live. Since
then, the international health-promoting school movement has been one of the most
successful of the settings-based projects and has expanded considerably over recent
years.
Method. An extensive review of available health-promoting school-related literature
provides the basis for critical discussion and recommendations.
Findings. Traditionally, the school nursing movement has provided the backbone
of nursing-related health promotion activity in the school setting. The literature,
however, is generally critical of its contribution over the years – especially as its
role is mainly confined to a ‘conventional’ health education function and has little
to do with health-promoting school projects. There are more and more calls now
for the school nursing service to either re-evaluate its function and processes or be
devolved back into a broader primary health care practitioner role.
Conclusion. Nurses should view the health-promoting school movement as
another opportunity to embrace evolving broad-based health promotion concepts
truly, as a means to forge and own their own health agenda and also as a means
to move beyond a traditional reliance on a limited health education role. Schools
also need to adapt and expand their efforts to focus on health promotion activities, in collaboration with the ever-widening community networks of health and
social agencies. This requires the commitment of all healthcare professional
groups. Nurses who practice in all settings, and not just school nurses, should be
aiming to initiate and promote radical health promotion reform as set out in the
health-promoting school movement.
Relevance to clinical practice. If health professionals wish to be at the forefront of
current health-promoting school strategies they must embrace the radical health
promotion reforms that are emerging from the current literature and put forward
in this article. Building such group capacity, through developing social interaction,
cohesion, participation and political action can only benefit the community at
large and further emphasize the health promotion role of nursing. The healthpromoting school movement is truly an international concept and, as such,
WHITEHEAD D (2006)
2006 Blackwell Publishing Ltd
The health-promoting school
Clinical nursing roles
deserves a concerted nursing representation and resourcing well beyond its current
commitment.
Key words: health education, health-promoting schools, health promotion, nursing
Introduction
In the mid-1980s, the World Health Organization’s (WHO)
Ottawa Charter for Health Promotion led to the development of a series of ‘settings-based’ health promotion strategies, where specific health-related settings were accorded
special attention (WHO 1986). In the WHO-European
context, these settings were originally designated as schools,
community (village), workplace and the home and family.
Subsequently, a number of other settings have been added to
the list over more recent years and now include the healthpromoting university (HPU) (Dooris 2001, Beattie 2002) and
the health-promoting prison (Watson et al. 2004). As one of
the original settings, the health-promoting schools (HPS)
movement is amongst the most established and has been
described as one of the most successful of the settings-based
arenas (St. Leger 2004). Other settings and, in particular, the
HPU movement, have particularly benefited from the lessons
and strategies learnt and adopted from the HPS project.
I have consistently argued, over recent years, that it is the
responsibility of all nurses to incorporate wide-reaching,
broad-ranging and socially orientated health promotion and
health education reform into their practice, regardless of the
discipline or where the activity takes place (Whitehead
2003a,b,c, Whitehead & Russell 2004). I have also tried to
clarify the conceptual and semantic traditions that have
dogged health promotion and health education practice,
making it difficult for nurses to identify what it is that their
health-related practice is and does and where its broader
context lies (Whitehead 2001a, 2003d, 2004a). Continuing
from this and in the vein of promoting the broader settingsbased health promotion movement to nursing, I have also
identified a range of other health-promoting settings (Whitehead 2004b,c,d). It is now proposed that it is the turn of the
HPS to come under similar scrutiny. This paper aims to
explore and clarify the current and possible future nursing
position in relation to school-based health promotion
activities. In particular the ‘school nurse’ role is examined
against that of other vested disciplines in and beyond nursing.
The reviewed literature was gathered using the bibliographical services of the Ovid, Web of Science, PubMed and
EBSCO Megafile databases – using the year ranges of 1995–
2004 for each database. The keywords used in each case
included ‘health promoting schools’, ‘health-educating
schools’, ‘health promotion in schools’, ‘health education in
schools’, ‘settings-based health promotion’ and ‘school nursing/nurses.’
The HPS – what does it do?
The HPS movement arose out of the concepts proposed in the
Ottowa Charter for Health Promotion which identified the
school as one of the settings key to population and public
health (WHO 1986). Following this, in 1995, an expert
WHO-commissioned committee proposed a set of HPSrelated guidelines, demonstrating six component areas. They
were:
• The physical environment of the school;
• Health policy of the school;
• The social environment of the school;
• Community relationships (inclusive of links to parents,
families and outside agencies);
• Personal health skills;
• Relationship with health services (WHO 1995).
From such guidelines, the HPS is supposed to demonstrate
how it achieves a healthy environment for its total population, through developing supportive health promotion structures. Traditional school structures cling on to the culture of
a dominant academic function, hierarchy and limited autonomy for all (Scriven & Stiddard 2003). In opposition to this,
there has been a concerted effort to move away from
inappropriate classroom-based/individualized disease prevention health education approaches towards much broader
structures and processes (Rowling & Jeffreys 2000,
Deschesnes et al. 2003). Where HPS-related interventions
have sought to follow a traditional health education route,
the results have identified very little impact on the health
attitudes and behaviours of the school population (Schofield
et al. 2003). The HPS is better served if it strives to be an
educational setting that is capable of a concerted capacity for
healthy learning, living and working through the taught
curriculum (WHO 1993). It should, therefore, be able to
demonstrate explicit health-promoting processes through the
adoption of such frameworks and concepts as eco-holistic
models and conceptual well-being modes (Stears 1998, Konu
& Rimpela 2002). A number of authors refer to the fact that
progressive and sustained HPS-related reform is based on the
principles of empowerment, democracy, partnership, equity,
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action competence, social capital and sustainability (WHO
1997, Jensen 2000, Rasmussen & Rivett 2000, Rowling &
Jeffreys 2000, Morrow 2004, Turunen et al. 2004, Noble &
Robson 2005). Alongside this, the student, school staff,
parents and health agencies are driven by a health-promoting
policy process that encourages participation, self-determination, citizenship and agency.
It is acknowledged that, despite the push to implement
wide-reaching health promotion reform in the school setting,
the implementation of HPS strategies are not without their
dilemmas and subsequently are rarely implemented as
intended (Deschesnes et al. 2003, Scriven & Stiddard
2003, Smith et al. 2004, Noble & Robson 2005). It would
be naı̈ve and unrealistic to suggest that the facilities and
resources, that are required to implement broad HPS-related
reform, would be available to all but a few nurses and allied
health professionals. Various reviews of HPS study evaluations have concluded that targeted ‘whole-school’ implementation of health promotion strategies have often not
been realized where the intention was to do so (Curless &
Burns 2003, Estabrooks et al. 2003). The closest example to
a collaborative whole-school and surrounding community
health promotion capacity and process is offered by Barnes
et al. (2004) – but still describes limitations and problematic
process, such as environment and developmental role needs.
Working away from conventional methods though and
towards broader social and policy reform in health promotion is still desirable, even if the outcomes are not as wide
reaching as intended.
Many of the problems that the HPS movement faces relate
directly to its immediate client base – that of child and
adolescent-orientated health promotion. In the literature, I
have directly addressed the issue of the school-age person’s
experience in relation to their ‘health journey’ as a prerequisite into adult life (Whitehead 2005). I suggest that
particularly adolescents will often need to experience negative health factors (such as experimenting with illicit drugs) as
an investigative and experimental position that allows them
to reflect on and establish their position as they strive to enter
adult society. Factors that are presented relate to the
individuals’ possible pursuit of the ‘pleasure principle’ –
where young people make rational assessments of health
risks, in whatever health behaviours they adopt, and simultaneously resist and react adversely to the paternalistic
interventions of health professionals. Crossley (2001a,b,
2002), for instance, reports that health resistance occurs as
a result of a mixture of health education interventions that
use ‘overkill’ (too many healthy practice messages over too
long a period of time), a general distrust of health professionals and their scientific findings, and the trait-like differ266
ences between individuals. Rofes (2002) similarly argues that
repeated health education strategies, which cosset the values
of good behaviour and resultant improved health, in many
cases serve to irritate the targeted individual and alienate
them from the health professional. School-age individuals, in
particular, do not respond well to paternalistic and patriarchal health interventions and are amongst the group most
likely to initiate a reactance (an unwelcome and uncomfortable motivational reaction to the threat or removal of an
individual’s freedom to determine their own health status)
response to delivered health interventions (Whitehead &
Russell 2004, Whitehead 2005). Thus Coveney and Bunton
(2003, p. 166) relate the earlier mentioned pleasure principle,
in stating that:
Pleasure thus can act as point or ‘clarion call’ to oppose the forces of
unwanted ‘authoritarian’ control of individual choice, and the
unwelcome incursion of expert reason into the life world.
The less health educating a health intervention is, however,
and the more health promoting that it becomes, the less likely
that the strategy is to be rejected by those that it targets.
Turunen et al. (2004), for instance, report on facilitating
reflective practices with children to turn negative healthrelated critical incidents into positive health outcomes.
Despite the fact that the WHO (2004) describes the school
setting as an ‘extraordinarily effective setting in which to
improve people’s health’, health and social professionals
should remain acutely aware that it is also one of the most
problematical areas for health promotion activities.
The role and position of school nurses and their
impact on the HPS movement
There is a nursing inference that the task of school-related
health care lies squarely in the domain of specialist community-based nurses – namely school nurses, school health
nurses and school-based youth health nurses (different terms
in different countries for similar roles). Combing the literature highlights the internationality of the school nurse
movement; being prevalent throughout the UK, New
Zealand, Australia, USA, Canada, South Africa, Sweden,
Denmark, Norway, Finland, Poland, Ireland, Lithuania,
Portugal, Romania, Macedonia, China, Singapore, Korea
and Taiwan. There may also be other countries involved that
are not mentioned in the literature. A relatively small body of
literature, however, debating the role, and arguing the case
for nurses based in the school setting, exists. Where the
literature does exist it is mainly clustered within two
specialist journals – namely the Journal of School Nursing
and the Journal of School Health. This does not reflect the
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fact that the school setting should be seen as one of the most
important health-related growth and front-line defence areas
for health promotion and health education intervention,
where health promotion policies should be a vital and
integrated part of the national curriculum (Tossavainen
et al. 2004). Early positive health interventions now equate
to the proactive ‘refocusing upstream’ activities that have
become the vogue in health promotion, rather than the
reactive and preventative later-in-life strategies that now
predominated much of the already mentioned literature.
Despite the relative dearth of school nursing-related
literature in the generic nursing-related literature, this is not
to say that a body of useful empirical literature does not exist.
Recent studies have been conducted that attempt to explore
the health-related role, effectiveness and expectations of this
discipline (Price et al. 1999, Guilday 2000, Borup 2002,
Clausson et al. 2003, Petch-Levine et al. 2003, Selekman &
Guilday 2003, Barnes et al. 2004, Bartley 2004, Croghan
et al. 2004, Guttu et al. 2004, Sunar 2004, Tossavainen et al.
2004, Yoo et al. 2004), or describe nurse-implemented
health-related programmes in the school setting (i.e. DeLago
et al. 2001, Larsson & Zaluha 2003, Berg et al. 2004, Eliason
& True 2004, Turunen et al. 2004). The main theme that
emerges from the literature tends to reflect observations that
the health-promoting role of the school nurse has been and
remains relatively limited – but that there is optimism for a
wider role to develop. It is interesting to note, of the studies
mentioned directly above, that many more studies have been
conducted by way of ‘navel-gazing’ exercises, as an attempt
to explore and define what it is that school nursing does or
should do, than actual health promotion/health promotion
programme interventions and evaluations. This is, perhaps, a
reflection of the current state of affairs in school nursing.
Wainwright et al. (2000) have already highlighted that there
is little evidence supporting the effectiveness of the school
nurse as a health promoter, while Edwards (2002), Natvig
et al. (2003) and Tossavainen et al. (2004) have stated that
school nurses tend to focus on conventional activities, such as
screening, immunization and health problem referral, but
that their actual health promotion role (in ecological and
environmental terms) remains ‘unclear and undefined.’
Maughan (2003) has subsequently called for much more
activity that directly links school nursing research to specific
health promotional and educational outcomes. In the UK, the
Department of Health has developed documentation that is
designed to impact directly on the development of strategies
that will help school nurses to emerge as a major force in
child-centred public health (Department of Health 2001).
The evidence, to date, suggests that this reform is yet to
happen.
This paper advises that any research-related reform in
school nursing should be underpinned by adopting the
principles and activities set down by the HPS movement.
Ironically, the concept of the HPS is virtually invisible, not
just in school nursing, but nursing per se. Thyer (1996) was
the first to mention the implications of the HPS movement for
nursing. The articles of Turunen et al. (2002), Chang et al.
(2003), Natvig et al. (2003), Tossavainen et al. (2004) and
Barnes et al. (2004) are the only nursing-related literature to
highlight the health-promoting schools framework. The first
three articles are examples of Scandinavian studies conducted
under the umbrella of the WHO-sponsored European Network of Health Promoting Schools. What these articles do
say is not always encouraging:
In terms of education for primary health care and health promotion,
participants focused on their work with young people through
individual consultations and health education. There appears to be
less emphasis on strategies to create a supportive, healthy school
environment within the health-promoting schools’ framework. (Barnes et al. 2004, p. 322)
The above-mentioned papers often cite evidence of a lack of
appropriate training and preparation, a lack of research
evidence and evaluated health programmes, confusion about
role and the discipline not being appropriately recognized,
valued or resourced by managers and other health professional colleagues (DeBell & Everett 1998, Larsson & Zaluha
2003, Selekman & Guilday 2003, Barnes et al. 2004, Croghan
et al. 2004, Yoo et al. 2004). This has not been good for the
morale, confidence or position of the school nursing discipline. Croghan et al. (2004) goes on to suggest that such
factors have led to a rapid turnover of staff in school nursing
and a feeling of a lack of defined career progression –
especially compared with other community-based nursing
disciplines.
This section describes a somewhat mixed picture for
school nursing. It appears to be working towards a consensus on what it is and what it does, but faces a number of
hurdles in demonstrating this against effective programme
outcomes. Almost a decade ago, Bagnall (1997) suggested
that school nursing was in a rut, in the sense that it was
caught between the divisions of both health and education
services and that it failed to fit in with the primary
healthcare team. More recent studies still identify that the
move towards creating the specialist role of school nurse, as
a subset of the community or family nurse role, has left the
discipline marginalized, in conflict and confusion and clouded by inconsistency (McKenna et al. 2003). DeBell and
Everett (1998, p. 114) have warned of the possible consequences of such marginalization:
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D Whitehead
The school nursing service is a resource that should not be lost but it
is entirely possible that it could be lost if there is not a clear sense of
how it is to be integrated into a child health strategy at both the local
and national levels.
It is felt here that a somewhat unrealistic target has been set
for the school nursing fraternity, especially in the absence of a
collective international child health strategy. The issue of
school-related health programming is too important an issue
for nursing as a whole, to be left to any one of its disciplines.
It would appear that school nurses have been set up to fail. If
this is the case then where do the solutions lie?
Developing the school nursing role further?
With regard to developing and expanding the school nursing
role, certain dilemmas are presented. To what extent should
we invest in and further develop a service that perhaps is not
working as well as intended? Recent studies have identified
that, in order for school nurses to move their health
promotion/public health position forward, they must develop
a coherent and collective health strategy alongside a body of
good quality outcome-based research evidence to measure this
activity (Price et al. 1999, Wainwright et al. 2000, Bartley
2004). I and some of my colleagues have sought to champion
the use of action research as one of the most effective means of
demonstrating settings-based health promotion programme
reform (Whitehead et al. 2003, 2004a,b). Here it is advised
that school nurses seriously consider action research as an
appropriate collaborative, participative and change-orientated method for programme implementation and evaluation.
Turunen et al. (2002) would, presumably, concur with this, as
they offer insight into a successful Finnish HPS programme
that was not only action research orientated, but nurse
directed as well. Furthermore, for school nursing to progress,
Newell et al. (2003) also put forward recommendations that
its school nurses will need to develop key roles as senior
administrators and mangers to lead and heavily influence
coordinated school health programmes. For this to happen,
Libbus et al. (2003) argues that school nurses have to firstly
empower themselves well beyond the current situation. None
of these recommendations will be easy or quick to implement
and, if pursued, will be costly and time consuming.
What of the role of other nursing disciplines and
health professionals?
Two possibilities are presented here. The first, and by far the
most controversial, would be to disband the school nursing
services. School nurses could then align themselves back into
268
a broader community health/public health role and, hopefully, retain a school health function as part of their overall
family health role. In a similar vein, it could be put to all
community nurses that they take on a school’s health
function and share the overall load. I would advocate a
systems theory approach that identifies the school as a subset
of wider community systems – such as that proposed by
Anderson et al. (2002) in their useful community health
nursing organizational model (Anderson et al. 2002). Jensen
(2000) also highlights that school nurses have been co-opted
to use their reported action-orientated knowledge model in
several Danish HPS projects.
Secondly, and perhaps more realistically, is that school
nursing seeks to align itself as one partner in an overall
collaborative health schools programme. Getting nurses to
collaborate with other health professionals in their health
promotion activities, however, has long been problematical
(Whitehead 2001b). DeBell and Everett (1998) suggest that
‘The Healthy Schools Award Scheme’ is the only example
that explicitly attempts to incorporate a multi-agency
resource that has included school nurses. This said, McGhan
et al. (2002) promote their successful school asthma policy
programme which includes community nurses working with
key stakeholders, such as pupils, parents, school staff, health
educators, paediatricians and environmental health specialists. Meanwhile, Tossavainen et al. (2004) highlight that
Finnish school nurses regularly worked with parents, school
staff and, most interestingly, with social and municipal
services – such as youth workers. This paper asserts that
school nursing must also look beyond the ‘traditional’
multi-disciplinary collaborations (i.e. other professions allied
to medicine) – towards the broader agency collaborations
that include social, business, voluntary and charitable
services. This mirrors several authors’ assertions that to
reflect true multi-sectorial cooperation, effective HPS programmes require partnership between all education, health
professional and social service agents (Rissel & Rowling
2000, Lee et al. 2001, Deschesnes et al. 2003, Sunar 2004).
Also of real interest, is Plews et al. (2000) observations that
nurses and other health professionals, working in Acute
Hospital Trusts, were developing links to school-related
health activities. This helps to support any argument that
might take the position that hospital-based nurse are just as
capable and well placed as community-based nurses to
develop school-based interventions. It has already been
suggested that this would represent a milestone in the
health-promoting settings movement, if nurses were seen to
be aligning the activities of Health Promoting Hospitals
against that of HPS framework (Whitehead 2004c).
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Conclusion
To date, the literature is critical of the overall contribution of
nurses to the HPS movement. Considering that, for instance
in the UK alone, 14 000 state schools are classified or are
working towards ‘healthy school’ status (with the UK
government aim of all schools achieving this status by
2009), should dictate that the nursing contribution is far
more visible than it currently is (Noble & Robson 2005). In
terms of other health-related disciplines and agencies, this
should also be the case. This paper calls for a radical reform
of the way that educational, health and social professionals
address the issue of school-related health promotion reform.
Active health promotion strategies require a conscious,
sustained and collaborative commitment from the whole
school community – and this must include all nursing
disciplines. Building such group capacity, through developing
social interaction, cohesion, participation and political action
can only benefit the community at large and further emphasize the role of the health and social professions. The HPS
movement is truly an international concept and, as such,
deserves a concerted nursing representation and resourcing
well beyond its current commitment. If over-stretched reactive and curative health services wish to avoid being further
stretched in the future, it seems sensible to focus the efforts of
its health professionals on the current school generation – so
as to reap future health rewards.
Contributions
Study design: DW; data analysis: DW; manuscript preparation: DW.
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