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208 WWW.JOURNALOFTRAUMANURSING.COM Volume
24 | Number 3 | May-June 2017
RESEARCH
region is one of the worst affected, resulting in high num-
bers of deaths and injuries and a great deal of personal
suffering, economic loss, and environmental damage
( Usher & Mayner, 2010 ).
Japan is located in the Circum-Pacific Mobile Belt,
where seismic and volcanic activities constantly occur. Al-
though the country covers only 0.25% of the land area on
the planet, the number of earthquakes and active volca-
noes is quite high; nearly 20% of the world’s earthquakes
of magnitude 6 or greater have occurred in or around
Japan ( Cabinet Office, Government of Japan, 2015 ).
Throughout its history, Japan has experienced extensive
devastation caused by a multitude of natural disasters,
including earthquakes, tsunamis, volcanic eruptions, ty-
phoons, rainstorms, flooding, landslides, and snowstorms
( Early Warning Sub-Committee of the Inter-Ministerial
Committee on International Cooperation for Disaster Re-
duction, 2006 ). The number of deaths and missing per-
sons resulting from natural disasters between 1994 and
2013 was 27,368. In 1995, more than 6,400 people died in
the Great Hanshin-Awaji Earthquake, and in March 2011,
more than 21,000 people lost their lives in the Great East

Japan Earthquake and the subsequent tsunami ( Cabinet
Office, Government of Japan, 2015 ). In Japan, these kinds
of natural disasters occur on a larger scale than man-made
A
disaster is an extreme disruption of the function-
ing of a society that causes widespread human,
material, or environmental losses that exceed the
ability of the affected society to cope using only
its own resources ( International Federation of Red
Cross and Red Crescent Societies, 2000 ). A disaster is
defined as an acute, collectively experienced traumatic
event with a sudden onset; it can be natural or man-
made. ( Dominici, Levy, & Louis, 2005 ). Disasters affect
more people, destroy more property, and disrupt more
of the environment in which people live than ever before
( Ahayalimudin, Ismail, & Saiboon, 2012) . Worldwide dis-
asters are occurring more frequently, and the Asia-Pacific
ABSTRACT
The purpose of this study was to identify differences in
motivation for joining disaster relief activities as a nurse in the
future between Japanese and Korean nursing students.
A descriptive 2-group comparative study design was used.
The participants were 721 first- to fourth-year nursing
students (Japanese, n = 324; Korean, n = 397). From
June to September 2014, data were collected through a
researcher-administered questionnaire and self-reported

answers. The collected data were analyzed by descriptive
statistics, the χ 2 test, and the t test. No significant
difference
was found between Japanese and Korean students in
motivation to join domestic relief activities should a disaster
occur in the area in which they lived. Compared with
Korean students, Japanese students strongly agreed that
it is necessary to carry out relief work across borders when
disasters occur in foreign countries ( p = .001). Meanwhile,
Japanese students showed less motivation than Korean
students to join relief activities in other domestic areas
and foreign countries ( p = .020). The results of this study
suggest that the motivation of Japanese students to join
disaster relief activities as nurses in the future should
a disaster occur in other domestic areas and foreign
countries needs to be increased. The results also suggest
that undergraduate students should be well prepared for
disasters through disaster nursing education, including

practical training, disaster drills, and simulation.
Key Words
Disaster , Motivation , Nursing , Student
Author Affiliations: College of Nursing, The Research
Institute of Nursing
Science, Seoul National University, Seoul, Republic of Korea
(Dr Bang);
Oita University of Nursing and Health Sciences, Megusuno,
Oita, Japan
(Drs Kuwano and Choe); College of Nursing, Eulji University,
Seongnam-si,
Republic of Korea (Dr Cho); School of Health Sciences, Faculty
of
Medicine, Kagoshima University, Kagoshima, Japan (Dr
Yatsushiro); and
Toranomon Hospital, Tokyo, Japan (Ms Kawata).
The authors declare no conflicts of interest.
Correspondence: Myoung-Ae Choe, PhD, RN, FAAN, Oita
University of
Nursing and Health Sciences, 2944-9 Megusuno, Oita, Japan,
870-1201
( [email protected]; [email protected] ).
Japanese and Korean Nursing Students’ Motivation

for Joining Disaster Relief Activities as Nurses
in the Future
Myoung-Ae Choe , PhD, RN, FAAN ■ Noriko
Kuwano , PhD, RN, MW, PHN ■
Kyung-Sook Bang , PhD, RN ■ Mi-Kyoung Cho ,
PhD, RN ■ Rika Yatsushiro , PhD, RN ■ Yuki
Kawata , RN
DOI: 10.1097/JTN.0000000000000291
J O U R N A L O F T R A U M A N U R S I N G
WWW.JOURNALOFTRAUMANURSING.COM 209
disasters ( Japan Statistics Bureau, Ministry of Internal Af-
fairs and Communications, 2016 ).
In Korea, from 2000 to 2009, 115 disasters and 3,079
mass causality incidents (MCIs) occurred. Technical
disasters/MCIs occurred more frequently than natural
disasters/MCIs. The crude mortality rates for disasters and
MCIs were 2.36 and 6.78 deaths per 100,000 persons, re-
spectively, and the crude injury incidence rates were 25.47
and 152 injuries per 100,000 persons, respectively. The
leading causes for disasters in Korea were man-made,
such as road accidents, general floods, fires, and incidents
at mass gatherings. Statistics show that the incidence and
mortality rates of disasters/MCIs in Korea seem to be lower
than those of trends around the world ( Kim et al., 2013 ).
When disasters occur, nurses and nursing students can

play a significant role in caring for those who are affected
( Jennings-Sanders, Frisch, & Wing, 2005 ). In this regard,
nurses and nursing students have to be better prepared
for natural and/or man-made disasters. Earlier studies
have indicated that nursing students are ill-prepared for
disasters ( Schmidt et al., 2011 ). Nursing students have lim-
itations in finding information related to disasters, and this
leads to inadequate gains of knowledge associated with
disaster nursing ( Jennings-Sanders et al., 2005 ). Oztekin,
Larson, Yukisel, and Altun (2015) reported that under-
graduate nursing students in earthquake-prone cities in
Istanbul, Turkey, and Miyazaki, located in active earth-
quake zone in Japan were generally ill-prepared for dis-
aster events or had insufficient knowledge about disaster
preparedness and response.
One way to help areas become better prepared for
natural and/or man-made disasters is to educate under-
graduate nursing students about disaster preparedness
and response ( Oztekin et al., 2015 ). In recent years,
many academic institutions have introduced disaster
topics for students in disaster- or emergency-related
training programs. In addition, nursing education in-
stitutions have started to incorporate disaster-related
subjects into their curriculums ( Alim, Kawabata, & Na-
kazawa, 2015 ).
According to a previous study, self-regulation of be-
havior (motivation) was found to be a significant predic-
tor of perceived nurse competence to manage disasters
in terms of the nurse’s willingness to assume the risk of
involvement in a disaster situation ( Baack & Alfred, 2013 ).
In addition to education, motivation is important because
it causes a person to act. Motivation can be defined as
one’s behavioral direction, namely, what causes a person
to want to repeat a behavior ( Elliot & Covington, 2001 ).

The motivation of nursing students to join disaster relief
activities could help students to be better prepared for fu-
ture disasters as nurses. However, very little research has
been conducted on the motivation of nursing students to
join disaster relief activities.
Today’s undergraduate nursing students will become
future health care providers who play an important role
in the response to disaster events. Owing to the increased
incidence of natural and man-made disasters in recent
years, addressing the topic of motivation in undergradu-
ate nursing education has become essential.
Therefore, the aim of the present study was to explore
and compare the motivation of undergraduate Japanese
and Korean nursing students to join disaster relief ac-
tivities as nurses in the future. Furthermore, the current
study aimed to compare reasons for joining disaster relief
activities between Japanese and Korean nursing students
as well as to compare countermeasures against disasters
used by them.
The results of this study are expected to provide infor-
mation to help address both domestic and international
issues regarding the development of disaster nursing cur-
riculum as well as strategies to improve disaster prepared-
ness among nursing students.
PURPOSE
The purpose of this study of Japanese and Korean nurs-
ing students was to identify differences in motivation to
join disaster relief activities as a nurse in the future.
METHODS

Study Design and Setting
A descriptive two-group comparative study design was
used. A cross-sectional study of 1st- through 4th-year
students was conducted at four universities, two each in
Japan and Korea.
Sample
The total study population was 1,094 nursing students
(Japanese, n = 464; Korean, n = 630). All participants
consented and responded to a questionnaire survey, re-
sulting in a final return rate of 74.8% ( n = 347) in Japan
and 67.3% ( n = 424) in Korea. After excluding incom-
plete responses and missing data, the number of partici-
pants included in the final analysis was 324 (93.4%) in
Japan and 397 (93.6%) in Korea.
Questionnaire Development
A questionnaire was conceived and developed on the ba-
sis of a review of published work ( Baack & Alfred, 2013 ;
Lee, 2005 ; Matsukiyo, 2012 ). In developing the question-
naire, a “nurse in the future” was defined as postgraduate
registered nurse after completion of his or her nursing
program. The questionnaire items were designed and
developed for current undergraduate nursing students in
regard to their future as postgraduate registered nurses.
The questionnaire was composed of items regarding
the students’ demographics, their motivation for joining

disaster relief activities as nurses in the future in the
area where they lived and in domestic areas and foreign
countries outside where they lived, the reasons why they
wanted/did not want to join disaster relief activities, and
countermeasures against disasters. Each item of motiva-
tion for joining disaster relief activities was rated on a
4-point Likert-type scale ranging from strongly disagree
(scored as 1) to strongly agree (scored as 4).
To confirm the validity of the questionnaire, we con-
sulted with professors who had extensive expertise in
disaster nursing. The questionnaire was translated from
Japanese to Korean by a Korean graduate student who
had studied in Japan and was proficient in Japanese. The
Korean version of the questionnaire was back-translated
by a Japanese graduate student who had studied in Korea
and was proficient in Korean. Comparing the back-trans-
lation with the Japanese version, all items were found to
match. The Japanese version of the questionnaire was
finalized after validating its comprehensibility and clarity
in a pilot test with 10 students.
Ethical Considerations
The study was approved by our university institutional
review board before the start of data collection. The par-
ticipants were informed that the survey was voluntary,
that they were free to withdraw at any point without pen-
alty, and that the anonymity and confidentiality of the
collected data would be guaranteed.
Data Collection
Convenience sampling was used to collect data between
June and September 2014. The data were collected
through researcher-administered questionnaires and self-
reported answers. The questionnaires were administered

at the end of normal classes and were collected immedi-
ately after completion by the researchers.
Data Analysis
The data were statistically analyzed using SPSS for
Windows (version 17.0; SPSS Inc., Chicago, IL) and
Microsoft Excel (EXCEL Co., Ltd., Tokyo, Japan, 2013).
Descriptive statistics, the χ 2 test, and the t test were used
to compare differences between Japanese and Korean
students in regard to their characteristics and motivation
for joining future disaster relief activities. Statistical signifi-
cance was accepted as a p value less than .05.
RESULTS
Participants’ Characteristics
Table 1 shows the characteristics of the Japanese and
Korean nursing students who participated in the pre-
sent study. The majority of the participants were female
(93.2% in Japan, 88.7% in Korea), with a high propor-
tion of 3rd-year students in Japan (39.5%) and 1st-year
students in Korea (26.7%). About 34.9% of the Japanese
students had taken a disaster nursing course, compared
with only 2.8% of the Korean students. The majority of
the participants (89.2% in Japan, 90.7% in Korea) had no
disaster experience. In addition, 38.6% and 64.2% of the
Japanese and Korean students, respectively, had visited a
foreign country. Among those who had, 86.4% of the 125
Japanese students and 51.8% of the 255 Korean students
did not know which disasters occurred most frequently in
the countries they had visited.
Students’ motivation for joining domestic disaster re-
lief activities in the area where they lived is shown in
Table 2 . Almost all students (92.6% in Japan and 92.4%

in Korea) responded strongly agree or agree in regard
to the need to join disaster relief activities as a nurse in
the future should a disaster occur in the area where they
live. Regarding the reason to join disaster relief activities,
62% of 300 Japanese students and 49.9% of 367 Korean
students responded, “I want to help many people by
myself.” Concerning the question, “How would you like
to join disaster relief activities?,” 46.7% and 62.9% of the
Japanese and Korean students, respectively, responded,
“I want to be part of the rescue team as a nurse at disaster
sites,” and 36.0% and 22.1% of the Japanese and Korean
students, respectively, responded, “I want to care for in-
jured people at the hospital where I work.” Regarding
the question, “Why don’t you want to join disaster relief
activities?,” 50.0% of 24 Japanese students and 30.0% of
30 Korean students responded, “Because I have no idea
what I can do.”
Table 3 shows the students’ motivation for joining dis-
aster relief activities in domestic areas outside the areas
where they lived. Most of the students (75.0% of 324 Japa-
nese students and 82.4% of 397 Korean students) respond-
ed that they strongly agreed or agreed that they wanted to
join disaster relief activities as a nurse in domestic areas
outside where they lived. Regarding the reason to join
disaster relief activities, 63% of 243 Japanese students and
41.9% of 327 Korean students responded, “I want to help
many people by myself.” Concerning the question, “How
would you like to join disaster relief activities?,” 60.9%
and 68.2% of the Japanese and Korean students, respec-
tively, responded, “I want to be part of the rescue team as
a nurse at a disaster site,” whereas 15.6% and 19.3% of the
Japanese and Korean students, respectively, responded,
“I want to care for injured people at the hospital where I
work.” Regarding the question, “Why don’t you want to
join disaster relief activities?,” 40.7% of 81 Japanese stu-

dents and 17.1% of 70 Korean students responded, “Be-
cause I have no idea what I can do.”
The motivation for joining future international disaster
relief activities as a nurse in foreign countries is depicted
in Table 4 . Regarding the question, “Do you think that it
is necessary to carry out relief work across borders should
a disaster occur in a foreign country?,” 26.9% and 14.1%
of the Japanese and Korean students, respectively, re-
sponded that they strongly agreed, and 60.5% and 71.0%,
respectively, responded that they agreed.
Concerning the question, “Would you like to join dis-
aster relief activities as a nurse in the future?,” 40.4% and
60.6% of the Japanese and Korean students, respectively,
responded that they agreed, whereas 47.3% and 27.5%,
respectively, responded that they disagreed.
Table 5 shows differences between Japanese and Ko-
rean nursing students in motivation for joining disaster
relief activities. Regarding the question, “Would you like
to join disaster relief activities as a nurse in the future
should a disaster occur in the area where you live?,” no
difference in motivation was observed between Japanese
and Korean students (mean ± standard deviation: Japa-
nese students, 3.19 ± 0.57; Korean students, 3.17 ± 0.57).

However, Korean students (2.98 ± 0.63) were signifi-
cantly more motivated ( p = .020) than Japanese students
(2.87 ± 0.66) to join disaster relief activities in domestic
areas outside where they lived. Korean students (2.78 ±
0.64) were also significantly more motivated ( p < .001)
than Japanese students (2.52 ± 0.71) to join disaster re-
lief activities should a disaster occur in a foreign country.
Compared with Korean students (2.98 ± 0.59), Japanese
students (3.13 ± 0.65) significantly agreed that it is neces-
sary to carry out relief work across borders when a disas-
ter occurs in a foreign country ( p = .001).
A comparison of countermeasures against disasters be-
tween Japanese and Korean nursing students was shown
as multiple responses ( Table 6 ). More than 60% of the
TABLE 1 Characteristics of the Japanese and Korean Nursing
Students in the Present Study
( N = 721)
Items
Japan (n = 324),
n (%)
Korea (n = 397),
n (%) χ2 p
Gender
Female 302 (93.2) 352 (88.7) 4.372 .037
Male 22 (6.8) 45 (11.3)
Grade

Freshman 54 (16.7) 106 (26.7) 44.852 <.001
Sophomore 104 (32.1) 102 (25.7)
Junior 128 (39.5) 89 (22.4)
Senior 38 (11.7) 100 (25.2)
Disaster nursing course
I am taking the course 47 (14.5) 10 (2.5) 222.815 <.001
I had taken the course 113 (34.9) 11 (2.8)
I will take the course 34 (10.5) 19 (4.8)
I have no plan to take the course 14 (4.3) 113 (28.5)
I have no idea 116 (35.8) 244 (61.4)
Disaster experiences
Yes 35 (10.8) 37 (9.3) 0.436 .509
No 289 (89.2) 360 (90.7)
Have you ever visited foreign countries?
Yes 125 (38.6) 255 (64.2) 47.093 <.001
No 199 (61.4) 142 (35.8)
Do you know which disasters occur mostly in the foreign
countries where you had visited? (Japan [n = 125]a, Korea [n =
255]a)

Yes 17 (13.6) 123 (48.2) 43.796 <.001
No 108 (86.4) 132 (51.8)
aThe number of students who answered “yes.”
Japanese students participated in school disaster drills
as countermeasures against disasters. However, Korean
students demonstrated a higher percentage of participa-
tion than Japanese students in all other countermeasures
except school disaster drills. More than 60% of Korean
students confirmed that there were refugee shelters in the
area where they lived and that they had methods for con-
tacting their families in the event of a disaster.
DISCUSSION
This study compared the motivation of Japanese and Ko-
rean nursing students to join domestic relief activities as a
nurse in the future should a disaster occur in the area where
they live, in other domestic area, and in a foreign country.
Although no significant difference was observed between
Japanese and Korean students in motivation to join relief
activities as a nurse in the future should a disaster occur in
the area where they live, Korean students showed signifi-
cantly more motivation than Japanese students to join relief
activities in other domestic areas and foreign countries.

Other studies in Japan have reported similar findings
showing more motivation among Korean than among
Japanese nursing students to perform volunteer disaster
relief activities ( Lee & Nishikawa, 2011 ). This finding may
TABLE 2 Motivation to Join Disaster Relief Activities in the
Area Where the Nursing Students
Live ( N = 721)
Items
Japan (n = 324),
n (%)
Korea (n = 397),
n (%) χ2 p
Would you like to join disaster relief activities as a nurse in the
future should a disaster occur in the area where you live?
Strongly agree 86 (26.5) 101 (25.4) 0.157 .984
Agree 214 (66.1) 266 (67.0)
Disagree 22 (6.8) 27 (6.8)
Strongly disagree 2 (0.6) 3 (0.8)
Why do you want to join disaster relief activities? (Japan [n =
300]a, Korea [n = 367]a)
Because I want to apply disaster nursing knowledge I have
learned.
59 (19.7) 53 (14.4) 25.618 <.001

Because I want to help many people by myself. 186 (62.0) 183
(49.9)
Because I was damaged by the disaster in the past. 1 (0.3) 6
(1.6)
Because I think that manpower for the relief activities is
deficient at a disaster site.
45 (15.0) 105 (28.6)
Others 9 (3.0) 20 (5.5)
How would you like to join disaster relief activities?
I want to care for the injured people at the hospital where
I work.
108 (36.0) 81 (22.1) 20.067 <.001
I want to be part of the rescue team as a nurse at a disaster
site.
140 (46.7) 231 (62.9)
I want to be part of the rescue team as a volunteer at a
disaster site.
23 (7.7) 25 (6.8)
I want to be part of the psychological care team. 28 (9.3) 28
(7.6)
Others 1 (0.3) 2 (0.6)
Why don’t you want to join disaster relief activities? (Japan [n

= 24]b, Korea [n = 30]b)
Because I am personally busy. 5 (20.8) 4 (13.3) 9.526 .049
Because I want to stay with my families 6 (25.0) 5 (16.7)
Because I have no idea what I can do 12 (50.0) 9 (30.0)
Because I am afraid of the second disaster 1 (4.2) 8 (26.7)
Others 0 (0.0) 4 (13.3)
aThe number of students who responded “strongly agree or
agree”.
bThe number of students who responded “strongly disagree or
disagree”.
be due to Japanese students’ fear and hesitation result-
ing from their recollection of the destruction and mass
casualties that have been caused by recent earthquakes
in Japan. Lee and Nishikawa (2011) indicated that the
lower motivation of Japanese nursing students to perform
volunteer disaster relief activities could be attributed to
some extent to a vivid recollection of the Great East Japan
Earthquake and subsequent tsunami.
Japan has had large-scale natural than man-made dis-
asters, whereas this is opposite for Korea. Natural disas-
ters include droughts, epidemics, extreme temperatures,

earthquakes, floods, tsunamis, hurricanes, volcanic erup-
tions, ice storms, wind storms, landslides, and wildfires.
According to the International Disaster Database (EM-DAT,
2007), man-made disasters are regarded as technologi-
cal disasters resulting from emergencies such as those
in industry and transportation. Man-made disasters may
include complex emergencies, transport or industrial ac-
cidents, material shortages, contamination of food and wa-
ter, terrorist attacks, nuclear explosions/radiation, or wars.
It is unclear whether such differences in terms of dis-
asters could have led to the differences in motivation
TABLE 3 Motivation to Join Disaster Relief Activities in
Domestic Areas Outside From Where
Nursing Students Live ( N = 721)
Items
Japan ( n = 324),
n (%)
Korea ( n = 397),
n (%) χ 2 p
future should a disaster occur in other domestic areas?
Strongly agree 45 (13.9) 69 (17.4) 6.493 .090
Agree 198 (61.1) 258 (65.0)
Disagree 75 (23.1) 64 (16.1)

Why do you want to join disaster relief activities? (Japan [ n =
243] a , Korea [ n = 327] a )
Because I want to apply disaster nursing knowledge I
have learned.
39 (16.0) 59 (18.0) 28.728 < .001
Because I want to help many people by myself. 153 (63.0) 137
(41.9)
Because I was damaged by the disaster in the past. 3 (1.2) 5
(1.5)
Because I think that manpower for the relief activities is
deficient at a disaster site.
42 (17.3) 112 (34.3)
Others 6 (2.5) 14 (4.3)
How would you like to join disaster relief activities?
I want to care for the injured people at the hospital
where I work.
38 (15.6) 63 (19.3)
I want to be part of the rescue team as a nurse at a
disaster site.
148 (60.9) 223 (68.2)
I want to be part of the rescue team as a volunteer at a
disaster site.

34 (14.0) 19 (5.8)
I want to be part of the psychological care team 22 (9.1) 20
(6.1)
Others 1 (0.4) 2 (0.6)
Why don’t you want to join disaster (Japan [ n = 81] b , Korea
[ n = 70] b ) relief activities?
Because I intentionally do not want to go to the
dangerous area
16 (19.8) 18 (25.7) 11.668 .020
Because I have no idea what I can do 33 (40.7) 12 (17.1)
Because I am afraid of the second disaster 3 (3.7) 4 (5.7)
Because I think that my everyday task is a priority 26 (32.1) 28
(40.0)
Others 3 (3.7) 8 (11.5)
a The number of students who responded “strongly agree or
agree.”
b The number of students who responded “strongly disagree or
disagree.”

between the two countries. In the questionnaire, disasters
included both natural and man-made disasters ( Cabinet
Office, Government of Japan, 2000 ). Korean students may
have perceived natural disasters as vague and indirect
events, which might have influenced their motivation to
join relief activities in foreign countries. The lower moti-
vation seen among Japanese students may have derived
from their perceived incompetence regarding disaster re-
lief activities and their anxiety over causing the victims
more trouble ( Sachishima, Hatayoshi, Kawabata, & Michi-
hiro, 2014 ).
The present study showed that compared with Korean
students, Japanese students strongly agree that it is neces-
sary to carry out disaster relief activities across borders
when disasters occur in foreign countries. Meanwhile, in
this study, Japanese nursing students showed less motiva-
tion than Korean students to join disaster relief activities in
foreign countries. These findings may be due to a lower
motivation among students in Japan to participate in in-
ternational nursing activities. Yatsushiro, Lee, and Kadota
(2008) reported that the ratio of Japanese nursing students
who “wanted to work” in areas related to international
nursing activities was lower than the ratio of students who
had an “interest” in international nursing activities.
According to a survey conducted on new employees in
Japan ( Sanno Institute of Management, 2015 ; http://www
.sanno.ac.jp/research/global2015.html ), the ratio of the
new employees who “do not want to work abroad” was
63.7%, the highest since 2001; this result was interpreted
as being mainly due to a lack of confidence in language

ability and anxiety over daily life in foreign countries, as
well as a perceived incapacity for working abroad.
In the present study, Japanese students were found to
have less experience visiting foreign countries than Ko-
rean students. Furthermore, less than 15% of Japanese
students, but about 50% of Korean students, knew which
disasters most frequently occurred in the foreign coun-
tries they had visited.
TABLE 4 Motivation to Join Disaster Relief Activities in a
Foreign Country ( N = 721)
Items
Japan (n = 324),
n (%)
Korea (n = 397),
n (%) χ2 p
Do you think that it is necessary to carry out disaster relief
activities across borders should a disaster occur in a foreign
country?
Strongly agree 87 (26.9) 56 (14.1) 18.328 <.001
Agree 196 (60.5) 282 (71.0)
Disagree 36 (11.1) 53 (13.4)
future should a disaster occur in a foreign country?

Strongly agree 26 (8.0) 38 (9.6) 36.233 <.001
Agree 131 (40.4) 241 (60.6)
Disagree 153 (47.3) 109 (27.5)
TABLE 5 Differences Between Japanese and Korean
Nursing Students in Motivation to Join
Disaster Relief Activities ( N = 721)
Items
Japan ( n = 324),
M ± SD
Korea ( n = 397),
M ± SD t p
future?
Should a disaster occur in the area where you live 3.19 ± 0.57
3.17 ± 0.57 − 0.326 .754
Should a disaster occur in other domestic area 2.87 ± 0.66
2.98 ± 0.63 2.324 .020
Should a disaster occur in a foreign country, do you think
that it is necessary to carry out disaster relief activities
across borders?
3.13 ± 0.65 2.98 ± 0.58 − 3.209 .001
Would you like to participate in disaster relief activities as a

nurse in the future?
2.52 ± 0.71 2.78 ± 0.64 5.011 < .001
http://www.sanno.ac.jp/research/global2015.html
These results suggest that Japanese students have
more motivation to assist in activities for domestic than
international disasters. To improve their motivation to as-
sist in activities for global disasters, nursing programs in
Japan should work to foster students with a more inter-
national outlook. Through more active participation in in-
ternational activities and increased interrelationships with
culturally diverse and linguistically different people, stu-
dents in Japan could increase their confidence in their for-
eign language ability and reduce their anxiety about work-
ing abroad, ultimately developing a more global mind.
The present study also investigated the reason why
students do not want to join disaster relief activities af-
ter a disaster occurs; half of the Japanese and one-third
of the Korean students responded that they had no idea
what they could do to help. Japanese and Korean stu-
dents both felt that they were not adequately prepared
for a disaster. In addition, one-third and one-sixth of the
Japanese students had taken or were taking a disaster
nursing course, respectively, whereas only 2.8% and 2.5%
of the Korean students had taken or were taking such a
course, respectively.

These results indicate that compared with Japanese
students, Korean students have fewer opportunities to
learn disaster nursing. According to Lee (2005) , disaster
nursing was introduced in Korea in the early 1990s, but
people did not pay attention until around 2005. Disaster
nursing is a relatively new field in Korea.
Specialized courses for disaster nursing are still very
limited in the undergraduate nursing curriculum in Korea.
Generally, only emergency care is offered. Few nursing
students have experienced a disaster, and only 10.3% of
Korean students have taken a disaster nursing course
( Hur & Park, 2015 ). In another previous study in Korea,
the average disaster awareness score was 3.71 out of
5 points, and the average preparedness for disaster score
was only 0.54 out of 4 points ( Woo, Yoo, & Park, 2015 ).
Moreover, the average level of core competencies for
disaster nursing was 2.76 out of 5 points, and that for dis-
aster preparedness was 2.14 out of 5 points, suggesting
that Korean students are generally ill-prepared for a disas-
ter ( Woo et al., 2015 ). In the study by Kim (2015) , 85.8%
of students in Korea responded that a disaster nursing
course is necessary. The results of these previous studies
suggest that Korea urgently needs to develop a disaster
nursing curriculum.
In Japan, disaster nursing was formally incorporated
into basic nursing education in 2009 following the Great
Hanshin-Awaji Earthquake and the sarin gas attack in the
Tokyo subway in 1995. After these two large-scale disas-
ters, the Japan Society of Disaster Nursing was established
in 1998, and it has exerted great effort to develop and
incorporate disaster nursing education into the nursing

curriculum. Since that time, practice and research in dis-
aster nursing have been developing; however, a concrete
content regarding disaster nursing education and compe-
tencies has not been clearly defined ( Sato, 2014 ).
According to a study by Lee and Nishikawa (2011) ,
97% of Japanese nursing students have experienced an
earthquake, and 270 of 271 participants responded that
disaster nursing education is necessary. In another study
in Japan, nursing students were found to be lack of prep-
aration for disasters although they knew the importance
of preparation. In addition, most of them were interested
only in the emergency period, although they were high-
ly aware of disasters ( Nakamura, Fujii, Sugano, & Ono,
2013 ). In the study by Sachishima et al. (2014) , only 20%
of nursing students in Japan were prepared for a future
disaster. Sato (2014) reported that although interest in
disaster nursing is on the rise, students feel difficulty in
TABLE 6 Countermeasures Against Disasters Used by
Japanese and Korean Nursing Students
( N = 721)
Items
Japan ( n = 324),
n (%) a
Korea ( n = 397),
n (%) a
Which countermeasures do you use for disasters? (Multiple
responses)
Participation in school disaster drills 202 (62.3) 193 (48.6)

Participation in disaster drills in the area where you live 6 (1.9)
211 (53.1)
Confirmation of refugee shelters in the area where you live 60
(18.5) 275 (69.3)
Confirmation of refugee shelters near your home 61 (18.8) 275
(69.3)
Confirmation of refugee shelters near the school 30 (9.3) 182
(45.8)
Preparation of emergency disaster kit at home (foods, drugs,
and flash light) 62 (19.1) 197 (49.6)
Confirmation of methods on how to contact families in the
event of a disaster 58 (17.9) 243 (61.2)
a Multiple responses.
visualizing concrete disaster nursing activities, resulting in
a lack of disaster nursing competencies.
Recent studies in Korea and Japan have confirmed the
findings of previous studies reporting that nursing stu-
dents in each country are generally ill-prepared for dis-
asters ( Oztekin et al., 2015 ; Schmidt et al., 2011 ). These
findings also confirm those of other studies in which

nurses were shown to be unprepared for disaster work
( Baack & Alfred, 2013 ; Johnstone & Turale, 2014 ; Zhou,
Turale, Stone, & Petrini, 2015 ).
Zhou et al. (2015) emphasized that nurses, as signifi-
cant first responders, should be well prepared and edu-
cated to care for the victims of mass disasters. Every nurse
around the world should be well prepared by means of
education, training, and awareness programs ( Fung, Lai,
& Loke, 2009 ). Oztekin et al. (2015) suggested that one
way to become better prepared for disasters is to educate
undergraduate nursing students about disaster prepared-
ness and response. Findings from previous studies have
shown that disaster preparedness among nursing students
should be increased through education.
According to Baack and Alfred (2013) , disaster nursing
should be included in the undergraduate nursing curricu-
lum. Courses on disaster nursing should be a part of all
nursing curricula, whether it is a stand-alone course or
integrated content ( World Health Organization Regional
Offices for the Western Pacific and South-East Asia, 2012 ).
Nakamura et al. (2013) suggested several practical
training courses, such as attending disaster simulation
training to prepare for disasters, training for triage during
an emergency, and training for using an automatic exter-
nal defibrillator. Furthermore, it was suggested that stu-
dents should attend lectures from experts in the field of
emergency preparedness and participate in existing mock
disaster drills in their community.
Jennings-Sanders et al. (2005) recommended mock
disaster drills or tabletop exercises, Kaplan, Connor, Ferranti,
Holmes, and Spencer (2012) recommended disaster
simulations, and Alim et al. (2015) recommended disaster

preparedness training and disaster drills be introduced and
incorporated into disaster nursing education.
Faculty support and encouragement for nursing stu-
dents is essential in disaster preparedness education. Sato
(2014) indicated that nursing faculty should encourage
students to learn and think about their role in a postdisas-
ter period on their own initiative. Nursing faculties should
support and encourage disaster preparedness in nursing
education ( Baack & Alfred, 2013 ).
In the present study, the countermeasures used by
Japanese students were found to be different from those
used by Korean students, although most of the students
in both countries had no disaster experience. More than
half of the Japanese students participated in school disas-
ter drills as a countermeasure against disasters, whereas
more than half of the Korean students confirmed that
there were refugee shelters in the area where they lived
and that they had methods for contacting their families in
the event of a disaster.
These results suggest that Japanese students use group
countermeasures against disasters, whereas Korean stu-
dents use individual countermeasures. In Japan, it is com-
pulsory for schools, hospitals, factories, workplaces, and
many other facilities to conduct evacuation drills. From
the time they are children, Japanese people start taking
part in evacuation drills, so this is something they are
already used to.
In summary, both Korean and Japanese nursing stu-
dents had a high level of motivation and responsibility
for taking care of people in the event of a disaster, al-
though they did not feel confident about their prepared-

ness for disaster nursing. Especially for Japanese students,
more active participation in international activities would
promote their motivation to join disaster relief activities
around the world. In addition, disaster nursing education
including practical training, disaster drills, and simulation
should be provided to increase student preparedness for
disasters. This study provides information to help address
issues that could promote the development of disaster
nursing curricula and strategies to improve disaster pre-
paredness among nursing students around the world.
LIMITATIONS
The majority of the participants in the present study were
found to have no disaster experience. A larger sample
size and a more expansive sampling region from both
countries might have provided data yielding a broader
understanding regarding student motivation to join future
disaster relief activities.
CONCLUSIONS
This study found that motivation to join future disaster
relief activities as a nurse should a disaster occur in other
domestic area or a foreign country needs to be increased
among Japanese nursing students. The results of this
study also suggest that undergraduate students should
be better prepared for disasters through disaster nursing
education that includes practical training, disaster drills,
and simulation.
Implications for Education and Further Research
To increase motivation to join relief activities as a nurse
in the future should a disaster occur in a foreign coun-
try, Japanese nursing students should develop an interna-
tional outlook through more active participation in inter-
national activities and an increased interrelationship with
culturally diverse and linguistically different people.

In addition, to increase confidence regarding their
preparedness for disaster nursing, undergraduate nursing
students should receive adequate disaster nursing educa-
tion. Nurse educators need to develop strategies such as
disaster simulation to better prepare students for disasters,
and disaster nursing needs to be taught as a specialty in a
nursing program by nursing faculty.
Further research should explore how the motivation
of Japanese students to join future disaster relief activities
in foreign countries might be improved after participa-
tion in international activities at the undergraduate level
has been implemented. Investigating the effect of disaster
nursing competencies on the motivation of undergradu-
ate nursing students to join future disaster relief activities
is an additional area for further research.
REFERENCES
Ahayalimudin , N. , Ismail , A. , & Saiboon ,
I. M. ( 2012 ). Disaster
management: A study on knowledge, attitude and practice of
emergency nurse and community health nurse , BioMed Central
Public Health , 12 , A3 .
Alim , S. , Kawabata , M. , & Nakazawa , M.

( 2015 ). Evaluation of
disaster preparedness training and disaster drill for nursing
students , Nurse Education Today , 35 , 25 – 31.
Baack , S. , & Alfred , D. ( 2013 ). Nurses’
preparedness and perceived
competence in managing disasters . Journal of Nursing
Scholarship , 45 ( 3 ), 281 – 287 .
Cabinet Office, Government of Japan . ( 2000 ). Basic act
on disaster
control measures . Tokyo, Japan: Cabinet Office, Government
of Japan .
Cabinet Office, Government of Japan . ( 2015 ). Disaster
management
in Japan (pp. 1–13) . Tokyo, Japan: Cabinet Office,
Government
of Japan .
Dominici , F. , Levy , J. I. , & Louis , T. A.
( 2005 ). Methodological
challenges and contributions in disaster epidemiology .
Epidemiologic Reviews , 27 , 9 – 12 .
doi:10.1093/epirev/mxi009
Early Warning Sub-Committee of the Inter-Ministerial
Committee
on International Cooperation for Disaster Reduction . ( 2006 ).
Japan’s natural disaster early warning systems and
international
cooperative efforts, 1 . Retrieved September 2016, from http://
www.bousai.go.jp/kokusai/kyoryoku/pdf/soukikeikai.pdf
Elliot , A. J. , & Covington , M. V. ( 2001 ).
Approach and avoidance

motivation . Educational Psychology Review , 13 ( 2 ), 73 –
92 .
doi:10.1023/A:1009009018235
EM-DAT ( 2007 ). The international disasters database.
Retrieved
February 2017, from http://www.em-datemdat.netbe/
Fung , W. M. , Lai , K. Y. , & Loke , A. Y. (
2009 ). Nurses’ perception
of disaster: Implications for disaster nursing curriculum .
Journal of Clinical Nursing , 18 , 3165 – 3171 .
doi:10.1111/j.1365-
2702.2008.02777.x
Hur , J. , & Park , H. J. ( 2015 ). Nursing
students’ perception,
competency of disaster nursing and ego resilience . Journal of
Learner-Centered Curriculum and Instruction , 15 ( 8 ), 121 –
138 .
International Federation of Red Cross and Red Crescent
Societies
(IFRC) . ( 2000 ). Introduction to disaster preparedness—
disaster
preparedness training program . Retrieved September 2016,
from http://www.irfc.rog/what/dp/manual/introdp.pdf
Japan Statistics Bureau, Ministry of Internal Affairs and
Commu-
nications . ( 2016 ). Chapter 29. Disasters and accidents .
Retrieved
September 2016, from
http://www.stat.go.jp/data/chouki/29.htm
Jennings-Sanders , A. , Frisch , N. , & Wing ,

S. ( 2005 ). Nursing students’
perception about disaster nursing . Disaster Management and
Response , 3 , 80 – 85 .
Johnstone , M. J. , & Turale , S. ( 2014 ).
Nurses’ experiences of ethical
preparedness for public health emergencies and healthcare
disasters: A systematic review of qualitative evidence . Nursing
& Health Sciences , 16 , 67 – 77 .
Kaplan , B. G. , Connor , A. , Ferranti , E. P. ,
Holmes , L. , & Spencer , L.
( 2012 ). Use of an emergency preparedness disaster simulation
with undergraduate nursing students . Public Health Nursing ,
29 ( 1 ), 44 – 51 .
Kim , H. J. ( 2015 ). A study on disaster preparedness,
core competencies
and educational needs on disaster nursing of nursing students .
Journal of Korea Academia-Industrial Cooperation Society ,
16 ( 11 ), 7447 – 7455 . Retrieved from
http://www.Koreatimes .
co.kr/www/news/nation/2015/04/116- 77843
Kim , S. J. , Kim , C. H. , Shin , S. D. , Lee
, S. C. , Park , J. O. , & Sung ,
J. ( 2013 ). Incidence and mortality rates of disasters and
mass
casualty incidents in Korea: A population-based cross-sectional
study, 2000–2009 . Journal of Korean Medical Science , 28 ( 5
),
658 – 666 . doi:10.3346/jkms.2013.28.5.658
Lee , O. ( 2005 ). Disaster nursing education of Korea .
International
Nursing Review , 28 ( 3 ), 132 – 133 .

Lee , S. , & Nishikawa , M. ( 2011 ). Kannichi
Kangogakusei no saigai
to sono kyouiku ni taisuru ishiki chousa—cross-sectional
study—[Perception of Korean and Japanese nursing students
about disaster and disaster nursing education—cross-sectional
study—] . Mathematical Systems Incarnation , Retrieved from
https:// www.msi.co.jp/tmstudio/stu11contents/stu11_03.pdf
Matsukiyo , Y. ( 2012 ). Disaster prevention awareness
and disaster
prevention action of a nursing student living in the different
area of disaster properties . The Japanese Association of
Medical
and Nursing Education , 21 , 39 – 44 .
Nakamura , M. , Fujii , K. , Sugano , N. , &
Ono , T. ( 2013 ). Kangogakusei
no saigaikangogaku rishuubetu bousaiishiki to bousaikoudou
no kentou [Discussion on the disaster awareness and the
preventive action for disaster among nursing students who
learned disaster nursing or not] . Japanese Academy of Human
Care Science , 5 ( 1 ), 55 – 60 .
Oztekin , S. D. , Larson , E. E. , Yukisel , S. ,
& Altun , U. G. ( 2015 ).
Undergraduate nursing students’ perceptions about disaster
preparedness and response in Istanbul, Turkey, and Miyazaki,
Japan: A cross-sectional study . Japan Journal of Nursing
Science , 12 , 145 – 153 .
Sachishima , M. , Hatayoshi , S. , Kawabata ,
H. , & Michihiro , M.
( 2014 ). Kango gakusei no rediness wo ikasu saigaikango
kyouiku houhou no kentou [Discussion about how we improve
disaster nursing education by exploiting students’ readiness] .

Transcription of the Japan Nursing Association , 44 , 26 – 29 .
Sanno Institute of Management . ( 2015 ). Dai roku kai
shinnyuushain
no global ishiki chousa [ The 6th new employees’ global
attitude
survey ] . Kanagawa, Japan: Sanno Institute of Management .
Retrieved September 2016, from http://www.sanno.ac.jp/
research/global2015.html
KEY POINTS
• Most nursing students in Japan and Korea are highly
motivated to join domestic disaster relief activities, which is
derived from their mission to help others.
• Japanese nursing students need to develop a more global
mind in order to increase their motivation to join disaster
relief activities around the world through more active
participation in international activities.
• To increase disaster preparedness, adequate disaster
nursing education that includes practical training, disaster
drills, and simulation should be provided for nursing
students around the world.
http://www.bousai.go.jp/kokusai/kyoryoku/pdf/soukikeikai.pdf
http://www.Koreatimes.co.kr/www/news/nation/2015/04/116-

77843
http://www.sanno.ac.jp/research/global2015.html
Sato , S. ( 2014 ). Saigai no sukunai chiiki no gakusei
ga shutaiteki
ni torikumu saigaikango no gakushuuseika—Higashi Nihon
Daishinsai kara Manama saigaikango—[Outcome of disaster
nursing education of nursing students’ learning actively in the
area of few disaster—disaster nursing learned from the East
Japan Great Earthquake -] . Transcription of the Japan Nursing
Association , 44 , 302 – 305 .
Schmidt , C. K. , Davis , J. M. , Sanders , J. L.
, Chapman , L. A. , Cisco ,
M. C. , & Hardy , A. R. ( 2011 ). Exploring nursing
students’ level
of preparedness for disaster response . Nursing Education
Perspective , 32 ( 6 ), 380 – 383 .
Usher , K. , & Mayner , L. ( 2010 ). Disaster
nursing: A descriptive survey
of Australian undergraduate nursing curricula . Australian
Emergency Nursing Journal , 14 , 75 – 80 .
Woo , C. H. , Yoo , J. Y. , & Park , J. Y. (
2015 ). Experience, awareness and
preparedness of disaster among nursing college students .
Korean
Review of Crisis & Emergency Management , 11 ( 11 ), 19 –

35 .
World Health Organization [WHO] Regional Offices for the
Western Pacific and South-East Asia . ( 2012, August). An
all-
hazards preparedness approach to disasters . In Asia Pacific
Emergency and Disaster Nursing Network Meeting and the
Third International Conference on disaster nursing, Seoul
and Daejeon, Republic of Korea, 21–24 October 2011.
Retrieved October 2016 from http://www.wpro.who.int/hrh/
documents/2011_meeting_report.pdf
Yatsushiro , R. , Lee , S. W. , & Kadota , M.
( 2008 ). Nursing students’
perceptions toward international health and nursing . In The
2008 International Conference on Health People for a Healthy
World, Bangkok, Thailand.
Zhou , W. J. , Turale , S. , Stone , T. , &
Petrini , M. ( 2015 ). Chinese
nurses’ relief experiences following two earthquakes:
Implications for disaster education and policy development .
Nursing Education in Practice, 15(1), 75–81 .
doi:10.1016/j.nepr.
2014.06.011
http://www.wpro.who.int/hrh/documents/2011_meeting_report.p
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U.S. School Nursing Job Analysis
Brenna L. Morse, PhD, RN-BC, NCSN, CNE1 ,
Lori Anderson, PhD, RN, CPN-PC, NCSN2 ,
Laurie G. Combe, MN, RN, NCSN3 ,
Sandi Delack, MEd, RN, NCSN, FNASN4,
Lynnette Ondeck, MEd, RN, NCSN5, and Carissa Homme,
PhD6
Abstract
The complexity and demands of the school nurse role have
changed greatly over time. Our aims included determining tasks
and knowledge relevant to modern school nursing in the United
States, identifying continuing education needs of school
nurses, and describing anticipated changes to the professional
role. A secondary analysis of a cross-sectional web-based
survey
of 750 school nurses was performed. The study team evaluated
calculations of mean importance and frequency for school
nursing task and knowledge statements. Conventional content
analysis was used to analyze open-ended responses. School
nurses rated most tasks and knowledge as relevant to practice,
underscoring the great depth and breadth of education and
training school nurses need to meet the demands of students
today. The results of this secondary analysis may be leveraged
to
accurately describe the school nurse role, advocate for nursing
services, and support school nurses as they strive to better the
health of school communities.

Keywords
administration/management, leadership, school nurse
characteristics, school nurse knowledge/perceptions/self-
efficacy,
school nurse education
School nursing was born out of legislative mandates in the
late 19th century that supported student success through
identification of communicable diseases and other health
problems affecting attendance and learning. School nurses
have stood at the intersection of health and education for
over 120 years, working to keep children healthy and ready
to learn (Johnson, 2017). However, over the past century,
the role of the school nurse has evolved in response to
social, cultural, and political influences. This has led to a
change of the ways in which school nurses must carry out
their work to meet the goal of keeping children healthy,
safe, and ready to learn.
The school-based care of students has increased the com-
plexity and demands of the school nurse role (Davis et al.,
2019). School nursing duties have both maintained consis-

tency, as in the arena of disease surveillance and improving
student attendance, and progressed as school nurses now
address complex physical and emotional needs of students.
Today, school nurses are the only providers that most of the
nation’s public schoolchildren may access for health care
without barriers such as insurance, transportation, appoint-
ments, and fees (Fleming, 2011). As such, school nurses are
strategically placed and uniquely qualified to provide care to
schoolchildren and other members of the school community
in support of student health and academic success (Butler &
Diaz, 2016; Leroy et al., 2017).
Student needs are evolving quickly: Researchers recently
identified a 35% increase in the number of students receiv-
ing case management services for conditions such as asthma,
diabetes, and seizures over only 1 academic year (Daughtry
& Engelke, 2018). This increase in care need was in part due
to improved school nurse staffing, which allowed students to
actually receive the care. Although, in some regions,

increases in the complexity of student needs have been fol-
lowed by decreases in school nurse student caseload through
1 Solomont School of Nursing, University of Massachusetts
Lowell, MA,
USA
2 School of Nursing, University of Wisconsin–Madison, WI,
USA
3 Klein Independent School District, Houston, TX, USA
4 Johnston Public Schools (Retired), RI, USA
5 Nooksack Valley School District, Everson, Washington, DC,
USA
6 Competency and Credentialing Institute, Denver, CO, USA
Corresponding Author:
Brenna L. Morse, PhD, RN-BC, NCSN, CNE, Solomont School
of Nursing,
University of Massachusetts Lowell, 113 Wilder Street, Suite
200, Lowell,
MA 01824, USA.
Email: [email protected]
The Journal of School Nursing
ª The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1059840520930075
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2022, Vol. 38(2) 126–137
Original Research Report
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https://orcid.org/0000-0002-0248-6580
https://orcid.org/0000-0002-0796-3390
https://orcid.org/0000-0002-0796-3390
mailto:[email protected]
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https://doi.org/10.1177/1059840520930075
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support of additional school nurse positions (Best et al.,
2020), this is not widespread practice. Care for some stu-
dents is complex enough to require care coordination, which
is typically more complex than case management and
involves school nurses leading communication among fam-
ilies, teachers, health care providers, and other individuals
responsible for students’ medical and academic needs
(McClanahan & Weismuller, 2015).
As school nurses and other stakeholders have realized
that the bulk of the work done in health offices is not neces-

sarily direct care, leaders of the specialty have called for a
focus on workload over caseload (Jameson et al., 2018).
Student caseload reflects the number of students, and at
times, the clinical acuity of student needs. Workload, on the
other hand, may describe the work of school nurses today in
a more comprehensive manner (Endsley, 2017). In addition
to direct care provision, factors such as documentation,
reporting, and leading communication with the interprofes-
sional team are included in school nurse workload (Combe
et al., 2015; Davis et al., 2019). Further, inequities in access
to care as well as the increase in both evidence and aware-
ness of social determinants of health and social injustices
have contributed to increases in school nurse workload.
School nurses must spend more time caring for families
without resources for optimal care or adequate community
supports in order to help these families be healthy (Daughtry
& Engelke, 2018).
Purpose

Despite evidence of student health needs increasing, a mis-
understanding of the school nurse role continues to create
barriers to funding and availability of school nursing posi-
tions in communities across the United States (Houlahan &
Deveneau, 2019). This is ultimately harmful to populations
at large, as students, families, and other members of the
school community need to access a school nurse who can
support physical, emotional, and academic well-being.
There is a critical need for school nurses to identify and
publicize what we do, what we need, and where we are
going. To that end, the purpose of our study was to deter-
mine tasks and knowledge relevant to modern school nur-
sing in the United States, identify continuing education (CE)
needs of school nurses, and describe anticipated changes to
the professional role.
Method
The present study is a secondary analysis of a job analysis
(also known as a practice analysis or role delineation study).

A job analysis identifies specific key responsibilities, knowl-
edge, and competencies required for effective performance
in a job (Prometric, 2019). The primary study was conducted
as market research to validate concepts for the National
Board for Certification of School Nurses (NBCSN) volun-
tary exam and was not externally published. The University
of Massachusetts Lowell Institutional Review Board
deemed the study exempt from full review.
Instrument
A national cross-sectional job analysis survey conducted in
April 2018 was developed and implemented according to
certification industry standards (Chinn & Hertz, 2010) and
in accordance with regulations set forth by the Accreditation
Board for Specialty Nursing Certification (2019). The sur-
vey was developed with input from subject matter experts
who volunteered their time during focus groups, cognitive
interviews, and pilot tests. Subject matter experts also served
as volunteers for the review and confirmation of results

during the primary study. Figure 1 displays a flow diagram
of survey development activities and results verification. A
review of respondent subgroups was also conducted for each
demographic group of the primary study (e.g., practice set-
ting) holding at least 30 respondents. Indices of agreement
(IOA) were calculated from each subgroup’s ratings of the
task and knowledge statements. IOA values were then com-
pared to identify any differences in how subgroups rated
statements. A threshold of 0.80 was selected to indicate
strong agreement between subgroups. All calculated values
for the primary study were above the threshold, indicating
agreement among nurses with different personal and profes-
sional characteristics.
As the survey was lengthy and the credentialing organi-
zation national, the questionnaire was sent to large groups of
practitioners representative of the professional community
(Chinn & Hertz, 2010). A total of 4,070 nationally certified
school nurses and approximately 16,000 members of the

National Association of School Nurses who were not
included in the mailing to certified school nurses received
the survey by email.
The survey instrument included a total of 684 quantitative
items, which prompted participants to rate the importance
and frequency of school nursing tasks and the importance of
school nursing knowledge. Participants rated the importance
of task and knowledge statements on 5-point scales, with 0
representing of no importance and 4 representing very
important. Participants rated the frequency of performing
each task on a 5-point scale, with 0 representing never and
4 representing very often. In addition to task and knowledge
statement rating opportunities, the survey contained two
open-response opportunities: (1) what additional profes-
sional development and/or CE could you use to improve
your performance in your current work role? and (2) how
do you expect your role to change over the next few years?
Further, what tasks will be performed and what knowledge

will be needed to meet changing job demands?
Data Analysis
For the primary analysis, mean importance ratings were cal-
culated for each task and knowledge statement, as well as
127Morse et al.
median frequencies for task statements, using SPSS statisti-
cal software (IBM Corp, 2017, version 25). The study team
evaluated these calculations for the secondary analysis.
Responses to open-ended survey items were provided in
unanalyzed form. We exported these responses to NVIVO
(QSR International [Americas], 2015) for a descriptive con-
tent analysis adapted from Hsieh and Shannon (2005). Anal-
ysis of the open-ended responses used an iterative process to
develop themes, categories, and codes. Coding and analysis
of the data were done by one researcher and themes were
confirmed by four study team members.
Results

Respondents
The primary study included 750 complete responses from
school nurse participants. These complete responses repre-
sented a 3.73% response rate. Most respondents were White
(93%) females (98%) who practiced as nurses for over 21
years (69%) and school nurses for 11–20 years (34%) in
elementary schools (31%) serving between 501 and 750
students (19.5%). Table 1 displays characteristics of the sur-
vey respondents.
School Nursing Tasks
Of all of the tasks school nurses are charged with, select
activities were rated as more important than others. School
nurses considered maintaining privacy in accordance with
HIPAA/FERPA (3.91), practicing according to state and
national guidelines, policy, licensure (3.88), documenting
medication administration (3.87), protecting student (per-
sonal/body) privacy (3.87), and communicating with par-
ents/guardians (3.86) as job tasks with the highest

importance. School nurses rated administering fluoride
treatments (1.61), administering immunizations to staff
(1.82), serving as advisor for student activities (2.06), con-
ducting home visits (2.21), and leading support groups
(2.21) as least important to their role.
Job tasks were performed with varying frequency. School
nurses reported performing 124 specific tasks very often, 6
tasks often, 33 tasks occasionally, 19 tasks seldom, and
never performing 60 tasks. Table 2 displays the three tasks
rated as most important across each professional practice
category with frequencies.
School Nursing Knowledge
School nurse participants rated all included job knowledge
components as important or very important. Knowledge com-
ponents rated on the higher end of importance included
knowledge of anaphylaxis (3.93), prescription administration
(3.92), medical authorization for prescriptions (3.92), head
trauma (3.91), and documentation (3.91). Although respon-

dents did not indicate that any knowledge components were
irrelevant to their job, some areas scored on the lower end of
importance. These components include health education of
communities/stakeholders (3.1), assistive technology (3.15),
gender identity (3.19), special health needs assistive care
(3.2), and pregnancy/parenting (3.2). Table 3 displays the
Figure 1. Survey development and results confirmation flow
diagram.
128 The Journal of School Nursing 38(2)
three most important knowledge items across each knowledge
domain. A complete listing of ratings of the school nursing
knowledge areas is available as an Online Supplement.
CE Needs
Respondents were asked to identify CE topics that would be
helpful in improving their work as a school nurse. Following
analysis of 277 responses, three themes were identified:
course topics, no time to learn, and anything.
Course topics. Participants reported a need for CE topics spe-

cific to care delivery, such as individualized health plan
(IHP) development. Even when respondents felt confident
in developing IHPs, they called for education on how to
increase efficiencies around the work, noting “students are
enrolling with more complicated issues . . . [I am] spending
more and more time coordinating and implementing plans.”
Participants want to know how to best support students
experiencing mental illness or adverse childhood experi-
ences (ACEs), including training specific to fostering colla-
boration between school nurses, clinical specialists,
administrators, educators, and outside providers to ade-
quately address mental health concerns. One participant
reported,
due to the increase in incidences of students with complex
health needs and concerns such as violence, bullying, human
trafficking, homelessness, drug and substance abuse, school
nurses need interdisciplinary collaboration with school social
workers, school counselors, and school psychologists as well as

community health care providers to enhance the ability of stu-
dents, families, classroom teachers, and school personnel to
recognize and respond appropriately to the physical and mental
health of students.
Table 1. Participant Characteristics.
Characteristic n a % a
Nurse years
0–4 17 2.3
5–10 56 7.57
11–20 155 20.95
21þ 512 69.19
School nurse years
0–4 139 18.66
5–10 195 28.17
11–20 258 34.63
21þ 153 20.54
Highest level of education
Diploma 14 1.87
Associates 52 6.96
Bachelors 393 52.61
Masters 265 35.47
Doctorate 8 1.07
National certification 281 37.47
State certification 385 52.38
Age

20–30 15 2.02
31–40 68 9.14
41–50 71 22.98
51–60 326 43.82
61þ 164 22.04
Gender
Male 9 1.21
Female 730 98.52
Other/decline 2 0.26
Race
White 692 93.39
Black 32 4.32
Asian 4 0.54
American Indian/Alaska Native 3 0.4
Other 10 1.35
Weekly school nurse hours
0–20 27 3.63
21–30 27 3.63
31–40 512 68.91
41þ 177 32.82
Student caseload
1–250 55 7.42
251–500 126 17
501–750 145 19.57
751–1,000 112 15.11
1,001–2,000 143 19.3
2,001–3,000 49 6.61
3,001þ 52 10.79
Schools served
1 359 49.31
2–4 186 25.55

5–6 52 7.14
7–8 20 2.75
9–10 11 1.51
11þ 75 10.3
District type
Suburban 352 47.5
Urban 166 22.4
(continued)
Table 1. (continued)
Characteristic n a % a
Rural 27 26.45
Entire state, county, or region 27 3.64
Practice setting
Pre–K 15 2.01
K–12 586 78.66
Administrator or state consultant 62 7.51
Other 82 11.82
Geographic region
Northeast 1,694 26.29
Southeast 149 18.71
Southwest 91 13.82
Midwest 172 23.32
West 123 10.45
International 9 1.22
aDue to missing data, n and % may not equal the respondent
population size
and 100%, respectively.

129Morse et al.
School nurses would like to learn about leadership topics,
such as how to best work with nonnursing administrators,
and best practices to employ when working with a student or
family who may be seen as challenging, defiant, or
Table 2. School Nursing Task Ratings—Three Most Important
by
Professional Practice Category.
Task Statement
Mean
Importance a
Median
Frequencyb
Assessment and diagnosis
Assess blood glucose 3.83 4.0
Interview student regarding chief
complaint
3.73 4.0
Assess respiratory status 3.72 4.0
Practice and treatments
Protect student privacy 3.87 4.0
Provide first aid 3.84 4.0

Document all health office visit 3.83 4.0
Health education and promotion
Educate and support staff regarding
specific health care needs of
students
3.77 4.0
Train staff to recognize and respond
to life-threatening health
problems
3.71 3.0
Teach and promote infection
control practices
3.64 3.0
Planning
Communicate with parent/guardian 3.86 4.0
Develop an emergency care plan 3.77 4.0
Develop an individualized health
care plan
3.66 4.0
Professional performance
Maintain privacy in accordance with
HIPAA and FERPA
3.91 4.0
Practice according to state and

national guidelines, policy and
licensure
3.88 4.0
Maintain professional boundaries c 3.81 4.0
Obtain continuing education to
maintain school nursing
competencies c
3.81 4.0
Management
Document medication
administration
3.87 4.0
Document and report suspected
child abuse and/or neglect
3.85 2.0
Document communications with
parents
3.82 4.0
Personnel
Delegate tasks according to Nurse
Practice Act
3.61 3.0
Monitor performance of delegated

task
3.54 3.0
Mentor new school nurses 3.48 2.0
aImportance rated on scale of 0–4: 0 ¼ of no importance; 1 ¼ of
little
importance; 2 ¼ of moderate importance; 3 ¼ important; 4 ¼
very important.
bFrequency rated on a scale of 0–4: 0 ¼ never; 1 ¼ seldom; 2 ¼
occasionally;
3 ¼ often; 4 ¼ very often. c Tie for third highest mean
importance.
Table 3. School Nursing Knowledge Ratings—Three Most
Important Across Knowledge Domains.
Knowledge Statement
Mean
Importancea
Health appraisal
Intervention/referral-general physical health 3.72
Respiratory intervention/referral 3.71
Respiratory data collection 3.70
Emergency health problems and nursing management
Anaphylaxis 3.93
Head trauma 3.91
Respiratory system 3.88
Acute, episodic, chronic conditions, and nursing management
Respiratory system 3.81
Allergies 3.78

Cardiovascular system 3.75
Communicable/noncommunicable diseases and nursing
management
Bacterial infection 3.71
Viral infection 3.70
Fungal infection 3.55
Risk reduction and infection control
Immunizations 3.88
Identification of risk factors 3.68
Self-care skills for prevention 3.55
Health education
Students 3.76
Staff 3.41
Families 3.42
Health promotion/disease prevention
Safety education 3.55
Disaster preparedness 3.54
Cultural considerations 3.41
Special health issues
Emergency action plan 3.81
Abuse and neglect 3.80
Individualized health care plan 3.75
Professional issues
Job description 3.79
Documentation 3.89
Scope of school health services 3.77
Electronic and hard copy health records
Confidentiality 3.89

Accuracy 3.86
Authorization for release/exchange of information 3.82
Medication policies and procedures
Prescription administration 3.92
Medical authorization 3.92
Documentation b 3.91
Nonprescription administration b 3.91
Safety and storage b 3.91
Treatment policy c
Authorization for treatment 3.90
Protocols and procedures 3.89
Legal issues
Confidentiality (e.g., HIPAA, FERPA) 3.86
Individual rights to privacy 3.81
Child abuse/neglect reporting of a minor 3.78
aImportance rated on scale of 0–4: 0 ¼ of no importance; 1 ¼ of
little
importance; 2 ¼ of moderate importance; 3 ¼ important; 4 ¼
very important. b
Tie for third highest mean importance. c Only two knowledge
statements
in domain.
noncompliant. One nurse reported, “so many times educa-
tional goals and medical goals are not in tandem and can

lead to confusion, miscommunication, or frustration on the
part of the parents.”
School nurses are calling for CE regarding legal issues in
school health. New school nurses as well as those with many
years of experience seek such opportunities, stating
I wish there was one place to find all the laws and rules for
school nursing . . . . I fell into my position 9 years ago and am
still trying to learn all the things that need to be done beyond
nursing care.
Courses including information on legal issues surround-
ing delegation to unlicensed staff members would be helpful
to school nurses, as many participants shared statements
such as “professional development surrounding efficient
delegation would be helpful.”
While online CE courses are convenient, respondents are
seeking opportunities for hands-on skills training. Partici-
pants reported, “there are lots of lectures and online courses,
but it is really hard to get hands-on skills performance and

training.” Participants cited tracheostomy appliance care,
accessing ports, head-to-toe assessment, and use of contin-
uous glucose monitors as specific skills they would like to
practice.
No time to learn. Many respondents reported having little or
no time to participate in CE. Sentiments such as “when you
are caring for students all day and we are hourly employees,
how are we supposed to do [CE]” and “time is limited during
work hours, so it is always done on my own time [and with]
no pay” were common. Respondents reported feeling over-
whelmed by their workload, travel between school build-
ings, and that the hours needed to thoroughly complete
their work exceeded their paid hours without considering
CE time.
Anything. Despite limited time available to engage in profes-
sional development activities, a common response to this
survey prompt was “anything.” Respondents stated “any
CE is welcome and important” and “I’m interested in learn-

ing as much as I can” especially if the course was held after
work hours and for low or no cost. Such responses were
commonly entered enthusiastically, as evidenced by the use
of capital letters and exclamation marks.
Anticipated Role Changes
Following analysis of 338 responses to a survey item
prompting respondents to share expectations of how the pro-
fessional role will change in the future, three themes were
identified: student complexity, staffing, and technology.
Student complexity. Respondents reported caring for a greater
number of students with complex medical issues over time.
Participants commented on needs requiring technical skill
intervention (such as managing implanted devices) as well
as student mental health needs. Regarding the acuity of stu-
dent needs, one respondent said, “the needs of our students
are becoming more and more complex with each year, both
physically and emotionally.” Many respondents expected to
spend more time identifying and addressing socioeconomic

factors, often circling back to the need for specific training,
such as
a school nurse almost needs to have a social work degree, not a
nursing degree in order to meet the demands these days. I have
very few [visits that are] first-aid issues. The problems [I] see
are related more to breakdown of family structure, absent par-
ents, and [emotional/behavioral] issues.
Staffing. Despite an increase in student caseloads and
acuity, school nurses noted a decrease in supports (e.g.,
school nurse hours, wages, clinic assistants). Sentiments
such as “we seem to be an expendable position that often
is asked to cover and do much more than is feasible and
we are stretched and asked to do more with less” were
common across responses. Respondents remained cau-
tiously optimistic about the future, hoping for support and
respect:
I would hope that as the general public realizes school nurses
are becoming an area of nursing that needs very skilled nurses

[with] extremely high responsibility levels . . . . [school nurses]
will be adequately compensated so the high turnover rate will
stabilize.
Technology. Respondents forecast that the use of technol-
ogy will grow in health offices beyond the use of elec-
tronic documentation systems, such as communication
with providers using video chat and other telehealth
applications. Respondents again linked the role changes
to a need for education, stating “technology will be more
and more part of our role. Many school nurses have basic
computer and technology skills and will need to know
much more.”
Discussion
Changes to student well-being have broadened both the
scope and practice of school nursing (Combe et al., 2015;
Daughtry & Engelke, 2018; Davis et al., 2019; Houlahan,
2018; Jameson et al., 2018). Through a secondary analysis of
a nationwide school nursing job analysis, we have deter-

mined tasks and knowledge relevant to modern school nur-
sing in the United States, identified CE needs of school
nurses, and may describe key anticipated changes to the
professional role.
131Morse et al.
Tasks and Knowledge Relevant to Modern School
Nursing in the United States
While some tasks, such as following laws and regulations,
were identified as more important than others, school nurses
identified 130 tasks they perform very often or often. These
tasks crossed all areas within the school nursing scope (i.e.,
direct care, health promotion, management and leadership,
public and community health). Similarly, school nurses did
not rate any areas of knowledge that were not relevant to the
job today. This is consistent with the finding of another
research team that determined school nurses thought prac-
tice activities across all five categories of the Framework for

21st-Century School Nursing Practice were important to the
role and were performed frequently (Davis et al., 2019;
Maughan et al., 2016). With the great deal of knowledge
and skills school nurses are responsible for, it is important
to remember that no single professional—even a seasoned
expert—knows everything. School nurses can learn from,
delegate to, and collaborate with interprofessional col-
leagues to strengthen their own skills and ameliorate feel-
ings of being overextended. Given the broad scope of tasks
and knowledge school nurse respondents considered essen-
tial, combining efforts with other school professionals is
crucial to fulfilling the modern school nursing role.
Interprofessional collaborations among school teams is
one way to address barriers to student health (Bates et al.,
2019). Working as an effective member of an interprofes-
sional group is an important skill for all members of a
student team. To the same degree that teachers can provide
valuable input to school nurses about student health (Quinn

& Serna, 2019), school nurses can make valuable contri-
butions as school teams create student accommodation
plans. School nurse respondents reported that collaboration
on interprofessional teams for at-risk students was impor-
tant (importance rating 3.46) and performed often (fre-
quency rating 3.0). Unfortunately, school nurses are often
overlooked as both a resource and intervention even when
student challenges are rooted in physical health. For exam-
ple, only 61% of students with persistent pain had a school
accommodation plan that included access to the nurse
(Logan et al., 2008). While school nurses frequently
address student mental health concerns, teams do not
always consider consultation or partnership with school
nurses when making student plans related to mental illness
(Bohnenkamp et al., 2015; Shannon et al., 2010). Even
when there are legal directives mandating school nurse
participation, nurses have been excluded from student
teams (Yonkaitis & Shannon, 2017).

School nurse participants reported frustration surround-
ing the mismatch of educational and health-related goals for
students, especially those with complex social and health
problems. This finding builds on other reports of school
nurses expressing frustration surrounding the misunder-
standings of their professional role (E. D. Maughan et al.,
2017). School nursing involvement on interprofessional stu-
dent teams can positively impact all students, including
those with disabilities (Pufpaff et al., 2015), concussions
(Weber et al., 2015), pain (Quinn & Serna, 2017), or who
are bullied (Kub & Feldman, 2015) and can even impact the
value parents and teachers place on school nurses (E.
Maughan & Adams, 2011). Whereas misunderstandings sur-
rounding the role of the school nurse may hinder interpro-
fessional collaboration (Fleming & Willgerodt, 2017),
school nurses should make clear their scope of practice,
professional role, knowledge of the problem at hand, and
tasks in which they are skilled that may contribute to student

success when joining an interdisciplinary team. In doing so,
assigned tasks may be more meaningful in terms of the role
of the school nurse and responsibilities they may take on
(Reuterswärd & Hylander, 2017).
Ultimately, the onus is on school nurses to inform school
administrators, teachers, parents, and other community
members of the knowledge and skills they may contribute
to a student team. School nurses must advocate for their own
seat at the table when other colleagues are developing a plan
to meet student needs, even when the needs are not of an
obvious medical nature. Research teams conducting future
job analysis surveys or other studies of school nurse
responsibilities and workload should consider adding items
regarding self-advocacy. Research on nurses’ professional
self-advocacy is limited; study teams have previously
explored nursing political advocacy (Taylor, 2016) and
advocacy skill building among student nurses (Doherty
et al., 2016). Leaders of our specialty field should aim to

determine how nurses are self-advocating, which methods
are most effective, and what skills school nurses may need to
better perform self-advocacy.
CE Needs of School Nurses
School nurses called for education regarding working with
interprofessional teams, as discussed in the previous section.
Understanding the importance and frequency of school nur-
sing tasks may help nurse educators and conference planners
select professional development topics that will improve
nursing competencies and therefore student outcomes.
School nurses may also leverage results of this study to
advocate for the presence of certain topics on conference
itineraries. Specific areas for CE development include
courses introducing nurses new to school health to some
of the common student concerns and promoting the specialty
role. Course planners should also consider a balance of
broad accessibility (e.g., web-based education and sessions
for large audiences) and the need for hands-on skills

training.
Transition to school health primer. Nurses may begin practicing
in the specialty of school nursing after finishing prelicensure
generalist training or following years of experience in
another setting. While generalist preparation and experience
years in other settings are certainly valuable to practice,
contemporary school nursing necessitates a change in the
job onboarding training as well as educational opportunities
for school nurses. Nurses often enter school health without
adequate training on critical student health issues such as
allergies and anaphylaxis (Tsuang et al., 2019). Addition-
ally, the inclusion of students with significant complex spe-
cial health care needs has increased the depth and breadth of
knowledge and skills school nurses must have to meet the
needs of these students (Singer, 2013).
Similarly, school nurses need education regarding

approaches to addressing the mental illness of students and
care of students with ACEs. The need for such training is
especially pertinent when considering school nurses indicate
mental illness as the most prevalent health issue among
students but also report that they do not have enough training
to adequately address it in school (Higson et al., 2017; Mug-
geo & Ginsburg, 2019; Pryjmachuk et al., 2012). School
nurses should also receive training on how to facilitate some
of the community factors that can ameliorate the impact of
mental illness and ACEs on school outcomes, such as safe
communities, supportive neighbors, and consistent meals
with family (Robles et al., 2019).
Promotion of the specialty role. School nurses felt they were
asked to do more with less, even feeling expendable to the
school community. Such expendability places the nurse in a
position where they are not able to meet their professional
and ethical obligations to ensure health and safety of the
school community. This is especially problematic in light

of the secondary analysis finding that the tasks school nurses
find most important to their work center around legal and
ethical principles. While state laws direct the scope of nur-
sing practice, few states have laws mandating the availabil-
ity of nurses (E. Maughan, 2009). As discussed previously,
school nurses are ultimately responsible for advocating for
their involvement on student teams and for the funding and
availability of school nurse positions. Educating parents,
educators, other nurses, and the general public on the role
and responsibilities of school nurses and needs of school-
children is one way to ameliorate expendability, as well as
solidify job positions for school nurses.
Given the increasing medical complexity and influence
of social determinants of health that school nurses must
address so students are healthy and ready to learn, school
nurses must work to change the misguided public perception
that school nurses are present for minor direct care needs
only. Survey respondents did not find it particularly impor-

tant to communicate with the media or policy makers
(importance ratings 2.24 and 2.99, respectively). In fact,
respondents denied communicating with the media and only
occasionally communicating with policy makers (frequency
ratings 0.0 and 2.0, respectively). School nurses must pre-
pare and disseminate data to administrators, colleagues,
parents, and other stakeholders demonstrating the care needs
of their school community. CE opportunities with a focus on
media and policy training can provide school nurses with
knowledge and skills needed to carry out such public advo-
cacy effectively. Efforts in this area will help promote the
professional role through providing transparency regarding
the responsibilities the school nurse holds, as well as inform-
ing the public of the essential role a school nurse plays in the
well-being of the entire community.
Earning specialty certification may be another method for
school nurses to inform the school community and general
public of the importance of school nursing. Across other

nursing areas, researchers have identified relations between
specialty certification and improved patient outcomes
(Boyle et al., 2014, 2015). School nurses should consider
pursuing certification as a nationally certified school nurse
and are encouraged to publicize their professional achieve-
ments across the school community.
CE accessibility. Despite an eagerness to learn and improve
their own practices, participants noted barriers to accessing
CE opportunities. Unfortunately, even when school nurses
are able to further their learning, they do not have time or
adequate resources to implement practice changes (Quinn &
Smolinski, 2018). Therefore, school districts must commit to
meeting the health needs of all students through appropriate
CE support. Such support should include time to complete
CE and registration fees.
Additionally, school nurses are seeking hands-on learn-
ing opportunities. With access to anatomical models, high-
fidelity simulators, and interdisciplinary expert instructors,

one group of college educators provided training to school
nurses on tracheostomy care, carbohydrate counting and
insulin pumps, vision screening, otoscopy, catheterization,
feeding tubes, and emergency seizure medication adminis-
tration (McClanahan et al., 2016). Simulation and practice
laboratories in nursing schools may go unused over week-
ends and college breaks. School nurses or professional nur-
sing organizations (such as state-level associations) may
consider partnering with universities for hands-on training
programs when the practical labs are not in use.
Anticipated Changes to the Professional Role
Despite all that is already required to effectively meet the
needs of students, school nurse respondents predicted that
the needs of future schoolchildren will increase in complex-
ity and that staffing issues will continue to be a threat to
providing adequate care. Increases in student complexity
will necessitate interprofessional collaboration, and the ade-
quacy of staffing may be addressed through professional

advocacy efforts: Both of these anticipated role changes are
addressed in earlier discussion sections. School nurse
respondents also reported that technology has the potential
to change the specialty. Additionally, we have identified
133Morse et al.
increasing diversity among school nurses as a priority fol-
lowing analysis of respondent and workforce demographics.
Utilization of available and emerging technologies. Capitalizing
on all that technological advances have to offer can create a
work environment in which technology is a useful, produc-
tive, and collaborative tool used to improve student health,
safety, and access to care. Two specific areas that have great
potential to improve school nursing practice are telehealth
and electronic record-keeping. Given a geographic misdis-
tribution of pediatric specialists, access to telemedicine can
have a great impact in rural and medically underserved areas
(Marcin et al., 2016). In some states, school nurses may

initiate a mental health services telehealth referral (North,
2020), which further removes barriers to accessing care. An
emerging model of telehealth involves school nurses as the
service provider for students who do not have a school nurse
during the entirety of the school day (Cogan, 2020; Johnson,
2020). Researchers and leaders in this field must ensure
school nurses not only have access to telehealth services but
also are involved in developments and planning for imple-
mentation of telehealth. Electronic health records provide
school nurses with the power of data to tell the story of the
work they do each day to support student health and aca-
demic success. School nurses must thoroughly document
care in order to track their own health office data and con-
tribute to national school health data sets. With access to
electronic recordkeeping, school nurses may harness the
power of data to create systems-level change.
Diversifying the school nursing workforce. While school nurses
may contribute to public health through immunization

administration and tracking, monitoring and reporting com-
municable diseases, and leading school communities in
emergency preparedness, addressing a lack of diversity
among the school nursing workforce is a clear priority emer-
ging from review of participant demographics. Respondents
were nearly homogenous in terms of gender and race (98%
female, 93% White) and resemble the gender and racial
makeup of school nurses in the United States (Willgerodt
et al., 2018). Such demographics do not reflect the commu-
nities school nurses serve.
The lack of diversity within nursing as a discipline con-
tributes to health disparities and decreases access to care and
care quality (Spetz, 2016). Additionally, many respondents
of the survey were nurses for over 21 years (69%). Diversi-
fying the workforce should include efforts to recruit nurses
who are earlier in their career trajectories. This may seem
challenging considering that promoting school nursing as a
specialty is not without barriers, given comparatively low
pay (Willgerodt et al., 2018) and misperceptions about the

importance and scope of school nursing work. However,
increasing diversity within the workforce is essential to
ensuring school communities can realize improvements in
care access and quality and a narrowing of the health care
disparities gap (Institute of Medicine, 2011). By welcoming
team members from underrepresented backgrounds, we will
gain unique ideas and perspectives to meet the needs of
diverse populations and decrease health inequities and bar-
riers to wellness rooted in racism and a lack of worker
diversity.
Limitations
Respondents of this survey provided a self-report of profes-
sional opinions and may have answered survey items based
on perceived best practices or socially desirable responses.
With a lengthy survey, there was also potential for survey
fatigue. Researchers of the primary study mitigated fatigue
by allowing respondents to close the survey and return at a
later time to complete the survey.

The data used in this secondary analysis were not col-
lected to address the aims of the present study. Therefore,
some variables that would have been helpful addressing the
study aims were not available. For example, the primary
study included very few survey items related to quality
improvement, population health, and policy work. While the
response rate for the primary survey was low and personal
characteristics relatively homogeneous, the respondents
shared professional experiences from all corners of the
United States, from different school levels and school sizes.
Respondent experiences and personal characteristics may
differ from nonrespondents.
Finally, the range of mean and medians across school
nursing knowledge and task statements was narrow. A nar-
row range of ratings speaks to the breadth and depth of
school nursing responsibilities and perceived importance
of many parts of the job. However, our ability to draw con-
clusions about tasks and knowledge items that are most

important or more important than others is limited.
Conclusion
While central tenets of school nursing practice are still
important in the present day, 21st-century school nursing
requires a different and continually evolving knowledge
base and skill set. Given the need to maintain competence
in a wide variety of knowledge and skills and anticipated
increasing complexity of the job, school nurses are seeking
professional development opportunities to better their pro-
fessional practices in support of student health. School
nurses, leaders, and other stakeholders may leverage the
results of this study to accurately describe the modern school
nurse role, advocate for nursing services, and support school
nurses as they strive to better the health and well-being of
school communities.
Data Availability
The data that support the findings of this study are available
from the NBCSN, but restrictions apply to the availability of

this data set, and it is not publicly available. Data are avail-
able from the NBCSN upon reasonable request with permis-
sion of the executive director of the NBCSN. A table
displaying ratings of the importance and frequency of all
school nursing tasks is available as an Online Supplement.
Author Contributions
All authors contributed to the conception of the manuscript as
well
as prepared the drafts. B. Morse and C. Homme contributed to
the
acquisition, analysis, and interpretation of the data, while B.
Morse
and L. Anderson were involved in the subsequent revisions of
the
manuscript. All authors gave final approvals and agreed to be
accountable for all aspects of work ensuring integrity and
accuracy.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with
respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
author-
ship, and/or publication of this article.
ORCID iDs
Brenna L. Morse, PhD, RN-BC, NCSN, CNE https://orcid.org/
0000-0001-9876-4700
Lori Anderson, PhD, RN, CPN-PC, NCSN https://orcid.org/
0000-0002-0248-6580
Laurie G. Combe, MN, RN, NCSN https://orcid.org/0000-0002-
0796-3390
Supplemental Material
Supplemental material for this article is available online.
References
Accreditation Board for Specialty Nursing Certification. (2019).
Accreditation standards for examination-based certificate pro-

grams. https://absnc.org/accreditation-standards-examination-
based-certification
Bates, S. M., Mellin, E., Paluta, L. M., Anderson-Butcher, D.,
Vogeler, M., & Sterling, K. (2019). Examining the influence
of interprofessional team collaboration on student-level out-
comes through school–community partnerships. Children &
Schools, 41(2), 111–122. https://doi.org/10.1093/cs/cdz001
Best, N. C., Nichols, A. O., Oppewal, S., Pierre-Louis, B.,
Waller,
A. E., Zomorodi, M., & Travers, D. (2020). An appraisal of
school nurse health services and programs in North Carolina
public schools, 2006–2016. The Journal of School Nursing.
https://doi.org/10.1177/1059840519899439
Bohnenkamp, J. H., Stephan, S. H., & Bobo, N. (2015).
Supporting
student mental health: The role of the school nurse in coordi-
nated school mental health care. Psychology in the Schools,
52(7), 714–727. https://doi.org/10.1002/pits.21851
Boyle, D. K., Cramer, E., Potter, C., Gatua, M. W., & Stobinski,
J.

X. (2014). The relationship between direct-care RN specialty
certification and surgical patient outcomes. AORN Journal,
100(5), 511–528. https://doi.org/10.1016/j.aorn.2014.04.018
Boyle, D. K., Cramer, E., Potter, C., & Staggs, V. S. (2015).
Long-
itudinal association of registered nurse national nursing speci-
alty certification and patient falls in acute care hospitals.
Nursing Research, 64(4), 291–299. https://doi.org/10.1097/
NNR.0000000000000107
Butler, S., & Diaz, C. (2016). Hospitals and schools as hubs for
building healthy communities. Brookings Institution. https://
www.brookings.edu/wp-content/uploads/2016/12/hospital
sandschoolsashubs_butler_diaz_120516.pdf
Chinn, R. N., & Hertz, N. R. (2010). Job analysis: A guide for
credentialing organizations. Council on Licensure, Enforce-
ment and Regulation.
Cogan, R. (2020). Future of nursing 2020–2030 Philadelphia
Town
Hall: Lessons shared from a relentless school nurse. NASN

School Nurse, 35(2), 74–78. https://doi.org/10.1177/
1942602X19896836
Combe, L. G., Bachman, M. B., Dolatowski, R., Endsley, P. E.,
Hassey, K., Maughan, E., Minchella, L., Shanks, B., Trefry, S.,
& Zeno, E. (2015). School nurse workload: Students are more
than just numbers. NASN School Nurse, 30(5), 283–288. https://
doi.org/10.1177/1942602X15596582
Daughtry, D., & Engelke, M. K. (2018). Demonstrating the rela-
tionship between school nurse workload and student outcomes.
The Journal of School Nursing, 34(3), 174–181. https://doi.org/
10.1177/1059840517725790
Davis, D., Maughan, E. D., White, K. A., & Slota, M. (2019).
School nursing for the 21st century: Assessing scope of practice
in the current workforce. The Journal of School Nursing.
https://
doi.org/10.1177/1059840519880605
Doherty, C., Landry, H., Pate, B., & Reid, H. (2016). Impact of
communication competency training on nursing students’ self-

advocacy skills. Nurse Educator, 41(5), 252–255. https://doi.
org/10.1097/NNE.0000000000000274
Endsley, P. (2017). School nurse workload: A scoping review of
acute care, community health, and mental health nursing work-
load literature. The Journal of School Nursing, 33(1), 43–52.
https://doi.org/10.1177/1059840516681423
Fleming, R. (2011). Use of school nurse services among poor
eth-
nic minority students in the urban Pacific Northwest. Public
Health Nursing, 28(4), 308–316. https://doi.org/10.1111/j.
1525-1446.2010.00929.x
Fleming, R., & Willgerodt, M. A. (2017). Interprofessional
colla-
borative practice and school nursing: A model for improved
health outcomes. OJIN: The Online Journal of Issues in Nur-
sing, 22(3), 2.
Higson, J., Emery, A., & Jenkins, M. (2017). Improving
children’s
nurses’ knowledge of caring for people with mental health prob-
lems. Nursing Children and Young People, 29(1), 25–29.

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