use of evidence-based practice in school nursing: prevalence, associated variables, and perceived...

Original Article

Use of Evidence-Based Practice in SchoolNursing: Prevalence, Associated Variables,and Perceived Needs

Susan Adams, RN, PhD, Sheila Barron, PhD

ABSTRACTBackground: Research on the adoption of evidence-based practice (EBP) in health care has been focused

mainly on hospital settings and primary care; little is known about EBP adoption and implementationamong school nurses in the United States (US).

Objectives: The objectives of this study were to (1) describe the prevalence of EBP use among schoolnurses, (2) describe demographic, individual, and organizational factors associated with EBP use, and (3)identify resources needed to enhance EBP use.

Methods: A survey designed for this study was mailed to all school nurses in Iowa in the US, with aresponse rate of 56.8% (n = 386). Descriptive statistics and t-tests were used to indicate and comparethe variables of interest. Multiple regression and analysis of variance (ANOVA) methods were used toidentify variables explaining the variance in the use of EBP.

Results: Information sources, professional membership, and district size explain 22% of the variancein current use of EBP. Identified resources needed to increase the use of EBP included networkingopportunities, predeveloped EBP guidelines, and education on outcome evaluation.

Conclusions: This study indicates important information on variables that affect current practice inschool nursing and also shows requested resources for increasing EBP use. These results can be used todevelop translation strategies to increase the use of EBP in the school setting. Because only 22% of thevariance was explained, further research is needed to identify additional variables.

KEYWORDS evidence-based practice, implementation, school nursing, context

Worldviews on Evidence-Based Nursing 2009; (6)1:16–26. Copyright ©2009 Sigma Theta Tau International

BACKGROUND AND SIGNIFICANCE

School nurses in the United States (US) provide a broadrange of services to over 52 million children, includ-

ing routine day-to-day health care services, management ofchronic illnesses, and development of screening programsfor groups of students and staff. School nurses also deliverdirect nursing care for children in need of procedures suchas gastrostomy tube feedings, tracheostomy care, and clean

Susan Adams, Associate Director, Research Translation and Dissemination Core,Gerontological Nursing Interventions Research Center, College of Nursing; SheilaBarron, Coordinator, Statistics Outreach Center College of Education; both at the Uni-versity of Iowa, Iowa City, IA.

Address correspondence to Susan Adams, College of Nursing, University of Iowa,4116 Westlawn, Iowa City, IA 52242; [email protected]

Accepted 19 June 2008Copyright ©2008 Sigma Theta Tau International1545-102X1/08

intermittent catheterizations (U.S. Department of Educa-tion 2004). They must be knowledgeable about psychoso-cial problems such as bullying, violence, and mental healthissues in addition to providing health promotion educationand prevention programs in the school (U.S. Departmentof Health and Human Services 2000; Koplan et al. 2005).

Research indicates that a consistent use of evidence-based practice (EBP) in traditional health care settings de-creases resource use and improves client outcomes (Insti-tute of Medicine 2001; Agency for Health care Researchand Quality [AHRQ] 2003, 2005; Berwick 2003). Avail-able evidence shows that EBP use in school settings couldhave a similar effect through appropriate use of nationalhealth care and educational resources, decreased absen-teeism rates, and improved health and educational out-comes (AHRQ 2002; Wolf et al. 2003; Hansen & O’Haver2004; Taras et al. 2004; Kearney & Bensaheb 2006).For example, conservative cost estimates for unnecessary

16 First Quarter 2009 �Worldviews on Evidence-Based Nursing

Use of EBP in School Nursing

exclusion from school of children with pediculosis(Hansen & O’Haver 2004) and medical follow-up forroutine scoliosis screening, which is no longer recom-mended, exceed $500 million annually (Yawn & Yawn2000). Additionally, 3.6 million missed school days are at-tributed to poorly managed asthma, with associated care-giver time valued at nearly $200 million annually (Smithet al. 1997). Increased absenteeism due to poorly man-aged health conditions has a significant negative effect onacademic performance because of reduced learning oppor-tunities (U.S. Department of Education 2002; Breuner et al.2004; Selekman 2006).

The model of school nurse practice in the US variesfrom state to state and presents unique challenges to thedissemination and implementation of EBP. The majority ofschool nurses in the US are hired by individual school dis-tricts and paid for by state educational funds (Smith 2004;Selekman 2006). Although officially a part of the healthcare system, the school nurse may be isolated from nursepeers who work in more traditional settings such as clinicalnursing or public health practice. In addition, there is noformal school nurse hierarchy or organizational structureto mandate consistent policies or standards, which leadsto inconsistent practice, varying client outcomes, and in-efficient use of resources (Titler 2002).

With a better understanding of this unique context,translation interventions could be developed to providecurrent evidence-based information in an appropriate for-mat through available channels to reach school nurses.

PURPOSE AND AIMS

The purpose of this study was to describe the prevalence ofEBP use among school nurses as well as the demographic,individual, and organizational factors associated with EBPuse by school nurses. The specific aim of the study was toanswer the following research questions: (1) What is thecurrent use of EBP by school nurses? (2) What sources ofinformation do school nurses use to guide their practice?(3) What are school nurses’ current knowledge levels andattitudes regarding EBP? (4) What barriers and facilitatorsare present for individual school nurses and the organiza-tions in which they work that might influence adoptionof EBP? (5) What assistance do school nurses identify asnecessary for implementing EBP? and (6) What variablesexplain the use of EBP in this sample of school nurses?

THEORETICAL FRAMEWORK

Rogers’ (2003) diffusion of innovation model indicates theprocess by which new ideas or innovations are diffused andadopted into use. Rogers proposes that the rate of adop-

tion of an innovation is influenced by the nature of theinnovation, the channel through which the innovationis communicated, the characteristics of the users, andthe social system into which the innovation is intro-duced. A central tenet of Rogers’ work is that diffusionof innovations follows a predictable pattern by peopleover time across various social systems (Rogers 2003;Greenhalgh et al. 2004). The implicit assumption is thatEBP, when viewed as an innovation, follows the same pat-tern as other tested innovations in Rogers’ theory (Titler &Everett 2001; Rogers 2003; Grimshaw et al. 2004; Green-halgh et al. 2005).

Research-based intervention strategies can be used toincrease the rate, extent, and sustainability of EBP use bytargeting each area of influence identified in Rogers’ the-ory (i.e., characteristics of the innovation, communication,users, and social system; Titler & Everett 2001). Strategiesthat have been effective in acute and primary care set-tings include: adapting the information into a format thatis acceptable, including providing practice prompts (Feld-man & McDonald 2004); using a variety of communicationmethods, such as opinion leaders, change champions, facil-itators, outreach visits and education (Guihan et al. 2004;Kitson et al. 1998; Stetler et al. 2006; Bero et al. 1998;Hendryx et al. 1998; Grimshaw et al. 2001; O’Brien et al.2001; Davis et al. 1995; Grimshaw et al. 2001; O’Brien et al.2001); providing individual audit and feedback (Grimshawet al. 2004; Hysong et al. 2006; Jamtvedt et al. 2006); andchanging organizational policies and expectations (Titler& Everett 2001; Greenhalgh et al. 2004; Guihan et al. 2004;Titler 2008).

Several aspects of the context of school nursing prac-tice indicate that alterations in previously tested strategiesmight be necessary. For example, Rogers (2003) empha-sizes the social and communicative processes that are es-sential to motivate individuals to adopt change. Researchalso indicates that many people do not adopt innovationson the basis of scientific merit alone, but are more likelyto do so after hearing about them from peers or colleagues(Titler et al. 1999; Rogers 2003). Because school nurses inthe US work in relative isolation from their peers, the effectof interpersonal information networks on their decision-making process is unclear.

In addition, according to Rogers (2003), early adoptersof innovations usually have more years of formal educationthan do late adopters. Although many studies in the healthcare field show the importance of years of formal nurs-ing education (Parahoo 1998; Tsai 2000; Bostrom et al.2007), the overall body of evidence is inconclusive aboutthis issue (Estabrooks et al. 2003). Other studies indicatethe importance of having access to an advanced practicenurse to provide the necessary skills for implementing EBP

Worldviews on Evidence-Based Nursing �First Quarter 2009 17


(Rutledge et al. 1996; Wallin et al. 2003; Cullen & Titler2004; Pepler et al. 2006). School nurses’ minimum re-quirements for practice in the US are dictated at the indi-vidual state level. In some states, a licensed practical nurse(1 year of vocational training) is eligible to be a schoolnurse, whereas others require licensure as a registerednurse (RN) as a minimum requirement. Still other statesrequire that school nurses be baccalaureate or master’sprepared, with some states requiring specialized schoolnurse certification in addition to a general nursing degree(Selekman 2006).

Although we know that organizations that are larger aremore frequently associated with an increased likelihoodof adopting EBP (Rogers 2003; Cummings et al. 2007;Estabrooks et al. 2007), it is not known if that effect ispresent in school settings. Although larger school districtsmay have more resources, these extra resources are likelyto be directed toward educational goals, not EBP healthcare needs.

METHODS

Design and SampleIn this study, a cross-sectional survey design was used toobtain descriptive information and identify context vari-ables that explain the use of EBP in a group of schoolnurses in a US Midwestern rural state. After obtaining in-stitutional review board approval, a comprehensive list ofschool nurses was obtained from the Iowa Department ofEducation, consisting of 680 school nurses, including bothfull- and part-time school nurses working in 360 Iowa pub-lic school districts. In the spring of 2006, all 680 publicschool nurses in Iowa were invited to participate and re-ceived a packet containing a cover letter explaining thestudy and the School Nurse Evidence-Based Practice (SN-EBP) questionnaire. The survey was confidential, with thequestionnaires coded to guide the second mailing. Con-sent was implied by completion of the questionnaire. After3 weeks, a second mailing was sent to nonrespondents.The questionnaires were returned from 386 school nurses,for an overall response rate of 56.8%.

A higher percentage of respondents (33.9%) werefrom smaller districts (less than 1,000 students) thanthe nonrespondents (20.5%), and conversely a lower per-centage of respondents (19.3%) were from the largestdistricts (greater than 10,000) compared with nonrespon-dents (24.2%). Although no information is available on thenursing education level of nonrespondents, data providedfrom the Iowa Board of Nursing show that fewer respon-dents in this study were educated at the diploma level(3 years of nursing education; 19.8%) compared withschool nurses practicing in the state (27.7%). Respondents

holding an associate degree (2 years of nursing education)or nursing baccalaureate (4 years) were consistent with thepercentages of school nurses in the state; 33% of nurses inthis study belonged to the National Association of SchoolNurses (NASN), slightly higher than the national rate of23% (NASN 2006).

InstrumentThe SN-EBP questionnaire was developed for this studyfrom theoretical concepts from Rogers’ diffusion of inno-vation model, literature review of translation science andEBP, a review of available instruments, and knowledgeof the author of current practice. The SN-EBP was struc-tured to gain information needed to adapt strategies usedin traditional health care settings to increase adoption andimplementation of EBP in school nursing.

The SN-EBP contains five sections: EBP (21 items),current practice (9 items), computer access and skills(14 items), information sources (10 items), implementa-tion barriers (15 items), and demographic information (15items), for a total of 84 items. A principal component fac-tor analysis with Promax rotation allowed identificationof 17 subscales in the five sections of the questionnaire,with Cronbach’s alpha coefficients for the sections rang-ing from 0.62 to 0.88. Composite scores were obtained foreach of the subscales, which allowed for data reductionto reduce the number of variables used in further analysis(Adams 2007; a full report of the instrument developmentis available by request from the author.)

Data AnalysisA descriptive analysis was completed using means andstandard deviations when data were continuous and nor-mally distributed, and using median and ranges when datawere nonnormally distributed. Categorical data were de-scribed using frequencies and proportions. When the studysample was stratified into groups, the differences were de-termined using independent t tests.

A multiple regression analysis was used to explore rela-tionships among a variety of nurse and school character-istics in order to explain the current use of EBP. Twentyrespondents were removed prior to the regression analysisbecause of missing data on one or more of the variablesin the regression analyses, leaving 366 school nurses fora response rate of 53.8% for the regression analysis. Thevariables used in the analysis were considered as predictorsof EBP alone and in combination. The categorical variableswere analyzed using dummy variable coding. For all hy-pothesis tests, the Type I error rate was set at 0.05 (α =0.05).

The variables analyzed in this study to explain theuse of EBP were those identified in the literature



review of previous research on diffusion of innovationsand implementation science and outlined by Rogers’ diffu-sion of innovations theory. They included size of the schooldistrict, location, educational level of the school nurse, ex-perience, professional membership, information sources,resources and support of the administration, knowledgeand attitude regarding EBP, and skill level (perceived abil-ity to read and understand research, implement and evalu-ate EBP; Parahoo 1998; Thompson et al. 2001; Estabrookset al. 2003; Rogers 2003; Greenhalgh et al. 2005; Wallinet al. 2006).

In some cases, substitutes were identified for those vari-ables that are not present in a school nursing setting buthave been shown to be influential in traditional health caresettings. For example, opinion leaders and change champi-ons are known to affect the adoption of EBP in traditionalnursing (Titler et al. 1999; Titler & Everett 2001; Titler2002; Greenhalgh et al. 2005), but US school nurses oftendo not work with other nurses. Questions regarding theuse of various information sources were substituted in aneffort to identify other sources of peer influence on adop-tion of EBP, such as school nurse “list serves,” chat rooms,and school nurse Web sites. A similar strategy was usedfor identifying stakeholders who might facilitate or inhibitadoption. Although nurse–physician collaboration influ-ences EBP adoption in hospital settings (Schmalenberget al. 2005; Rikli et al. 2006), this relationship typicallydoes not apply to school nurses in the US. Various stake-holder groups (e.g., school administrators) that are presentin the school setting, and may exert a similar influence,were substituted.

Current practice was defined as the use of a seriesof interventions on various clinical topics supported byresearch or expert opinion (Rycroft-Malone et al. 2004;Adams & McCarthy 2005). In the Current Practice sec-tion of the SN-EBP, nurses were asked to self-report thefrequency (1 = never to 4 = all the time) of commonlyperformed school nurse activities on topics such as man-agement of children with lice or nits, scoliosis screening,wound care, management of asthma, and handling of con-fidential information according to US federal regulations.The dependent variable, current practice, was the compos-ite score of the subscales in this section.

RESULTS

The demographic characteristics of the respondents areshown in Table 1. The respondents were predominately fe-male (98.4%), Caucasian (97.9%), working in rural schools(59.1%), and in small school districts (56% reported a dis-trict enrollment of less than 2,000 students). The partici-pants had a variety of educational degrees: the percentage

TABLE 1Descriptive statistics for the sample of Iowa nurses

(n = 386) n %

GenderFemale 376 98.4Male 6 1.6

EthnicityCaucasian 374 97.9African American 3 0.8Other/more than one race 8 2.1

School locationUrban 104 27.3Rural 225 59.1Suburban 52 13.6

School district sizeVery small (≤999) 130 33.9Small (1000–1999) 85 22.1Medium (2000–4999) 63 16.4Large (5000–9999) 32 8.3Very large (≥10,000) 74 19.3

EducationAD 70 18.2RN/diploma 76 19.8BSN 156 40.6Other baccalaureate 43 11.2MSN 17 4.4Other master’s 16 4.9Other 6 1.6

Professional membershipNo 254 66.7Yes 127 33.3

MEAN SD MINIMUM MAXIMUM

ExperienceYears as an RN 22.7 9.8 0.5 54Years as a school nurse 10.0 7.4 0.5 34

of associate degree (18.2%) and diploma (19.8%) nursescombined (38%) was approximately equal to the numberof baccalaureate nursing graduates (40.4%). RNs with bac-calaureate degrees in fields other than nursing (not spec-ified) made up 11.1% of the sample. Master’s-preparednurses made up 8.6% of the sample, with 4.4% specifyinga master’s in nursing degree, and 4.2% indicating a master’sdegree in a field other than nursing.

Current Use of EBPIowa nurses showed inconsistent adherence to recom-mended practice depending on the topic. For example,95% of Iowa school nurses were no longer excluding chil-dren from school for the presence of lice nits in theirhair, which indicates good adherence to recommendedpractice. Eighty-seven percent of nurses were allowingchildren with asthma to carry their inhalers with them,



which again indicates good adherence to recommendedpractice. Yet, over half (55%) of middle-school nurses werestill providing scoliosis screening, which is no longer rec-ommended. Forty percent of nurses continue to distributea list of health concerns of children to all staff, and 37%were using a written health log containing multiple stu-dents on the same page, neither of which is recommendedpractice.

Sources of InformationSources identified as guiding practice most or all of thetime were information from other school nurses (69%),followed by conferences (67%), and continuing educationclasses (67%). Independent t tests indicated that nursesworking in small or rural districts were significantly lesslikely (p < 0.001, p = 0.001, respectively) to use othernurses as a source of information than those in large orurban districts. The least used sources of information forall nurses were databases (16%), research articles (20%),and school nurse list serves (25%). The school nurses weremore likely to use Internet sources (59%) than textbooks(36%). Ninety-one percent of respondents had a conve-nient access to the Internet, with 65% describing them-selves as skillful at accessing professional information onthe computer. An additional 33% said that although theywere not skillful, they could “get by.”

Knowledge and Attitudes Regarding EBPSeventy-seven percent of school nurses indicated that theywere aware of EBP in general, yet only half believed theyunderstood the concept well enough to explain it to a peer.In spite of this inability to articulate the concepts of EBP,83% of nurses surveyed agreed or strongly agreed that theuse of EBP was important to them personally, with 64%stating they believed it was important to all school nurses.Almost 60% stated they actively sought EBP informationto guide their practice, with 63% stating they knew whereto find this information.

Barriers and FacilitatorsSeventy-six percent of school nurses were willing to tryout new ideas published in journal or research articles, yet

TABLE 2Differences in the means for stakeholder groups; low mean = less support

GROUP MEAN

External players (school board, administration, community MD’s) 2 3.15 Significantly different mean than groups 1, 3, and 4Support staff (food service, custodian, coach, school aides) 3 3.38 Significantly different mean than groups 2 and 4Principle players (principal, teachers, secretaries, parents) 1 3.39 Significantly different mean than groups 2 and 4Peers (other school nurses) 4 3.73 Significantly different mean than groups 1, 2, and 3

less than half of the school nurses had a convenient ac-cess to these articles. Although conferences were listed asa preferred source of information, only 56% were able toattend conferences with minimal out-of-pocket expenses.The majority (78%) rated the leadership of their princi-pals as supportive for implementing EBP changes in theirschools.

Section 5 of the SN-EBP questionnaire was designedto identify school nurses’ perceived support from vari-ous stakeholder groups (see Table 2) when implementingchange. A factor analysis indicated four subscales of stake-holder groups for use in the analysis. The school nurse wasasked to indicate if getting support from each stakeholdergroup was a problem, on a scale of 1 (to a great extent)to 4 (to no extent), when implementing new programs orhealth care practices. The responses to these four subscaleswere used to address the questions: “Do school nurses re-port differences in the level of support they receive fromdifferent stakeholder groups?” and “Do school nurses whoreport higher levels of EBP report differences in the barri-ers they encounter compared to nurses who report lowerlevels of EBP?”

To address these questions, two analyses were under-taken. An analysis of variance (ANOVA) was used totest for differences in support from the various stake-holder groups, and the results were significant (F =75.04, p < 0.0001). Tukey follow-up tests indicated sig-nificant differences between the means for all groups ex-cept groups 1 (Principle players) and 3 (Support staff).Group 4 (Peers) was seen as the most supportive, fol-lowed by group 1 (Principle players) and group 3 (Sup-port staff). Group 2 (External players) was seen as the leastsupportive.

For the second stage in the analysis of Section 5 ofthe SN-EBP, ANOVA was used to examine whether nursesperceive barriers differently if they are low (lowest quar-tile of current practice composite scores), moderate (twomiddle quartiles combined), or high (highest quartile) onadherence to best current practice. Separate ANOVAs wereconducted for each of the stakeholder groups. No differ-ences in perceived stakeholder barriers related to the levelof current practice were noted.



Requested ResourcesWhen asked to identify resources needed to improve prac-tice, 92% of respondents requested networking opportuni-ties with other school nurses. The second and third mostrequested resources were predeveloped EBP guidelines forschool nurses (89%) and information on ways to evalu-ate the effect of EBP on health care (87%), respectively.The least requested resources were learning techniquesfor searching databases (71%) and conducting literaturereviews (66%).

Explanatory VariablesA hierarchical multiple regression was used to explore therelationship between current use of EBP and nurse andschool characteristics. Variables entered into the analysiswere chosen by the researcher according to theory andprevious research. In this analysis, the selected variableswere entered with the demographic characteristics first,followed by the other chosen variables. Table 3 shows adescriptive summary of the variables included in the re-gression analyses.

The individual demographic characteristics consideredwere years of experience as an RN, level of education, andprofessional membership. The organizational characteris-tics included were school size and location. These variableswere examined alone and together before considering otherinfluences on EBP.

When considered alone, years of experience as a nursewas positively related to EBP (t = 2.5, p < 0.013). Ed-ucation was also related to EBP; zero-order correlationsindicate that having a diploma or an associate degree wasnegatively associated with EBP use, whereas having an

TABLE 3Regression analysis

β SE t p

Years as RN 0.074 0.002 1.520 0.125Diploma or associate degree −0.104 0.055 −1.920 0.056Master’s degree 0.050 0.092 1.010 0.312Professional membership 0.114 0.054 2.200 0.029∗

District size > 10,000 0.150 0.083 2.250 0.025∗

District size < 1,000 −0.063 0.058 −1.130 0.259Urban 0.036 0.087 0.454 0.650Rural −0.062 0.076 −0.809 0.419Skill subscale −0.107 0.052 −1.980 0.048∗

INFO1 subscale Research/ 0.066 0.058 1.070 0.285non-Web

INFO2 subscale Traditional −0.102 0.051 −1.970 0.049∗

sourcesINFO3 subscale School nurse 0.271 0.044 4.730 0.000∗∗

specific∗p < 0.05; ∗∗p < 0.01.

advanced degree was positively associated with EBP use.When considered along with years of experience, the ef-fects of education were no longer significant, possibly be-cause of the correlation between years as an RN and havingan advanced degree.

Belonging to a professional organization was signifi-cantly associated with an increase in EBP use (t = 4.0,p < 0.001), even after years of experience and educa-tion had been taken into account. When size and locationvariables were considered together, only the large schools(districts > 10,000) reached significance individually (t =2.2, p = 0.031). In summary, the individual and organi-zational demographic variables as a block accounted for18% of the variance in EBP use, with only large size andprofessional membership retaining individual significance(t = 2.25, p = 0.025; t = 2.20, p = 0.029, respectively).

Once the nurse and school demographic variables hadbeen examined, variables related to nurse informationsources and skills were considered. One of the three sub-scales in the Information Sources section explained a sig-nificant amount of variation in EBP use. In particular, thesubscale School Nurse Specific, which pertains to the useof school nurse list serves, the NASN Web site, and school–nurse-specific Web sites, was associated with an increasein EBP use, even after controlling for demographics (t =4.7, p < 0.001). A second information subscale was asso-ciated with a decrease in the use of EBP (t = −1.9, p =0.05). This subscale, Traditional, pertains to use of con-ferences, continuing education, or other school nurses asa source of practice information. Table 4 shows descrip-tive information on information subscales and individualitems.

The subscale Implementation Skills, pertaining to itemson perceived ability to implement and evaluate EBP andcritique research articles, showed a decrease in currentpractice (t = −1.98, p = 0.048). An additional 5% vari-ance was explained by the information sources and skillssubscales. A total of 22% of the variance was explained byall variables entered into the regression.

In order to avoid inadvertently missing variables thatmight be significant in this population but had not beenpreviously identified, a second regression was run with allsubscale composite variables entered (e.g., computer useand skill and knowledge and attitudes regarding EBP). Aspredicted in the original selection, none of these variableswere significant.

DISCUSSION

Although school nurses reported using recommendedpractice in some topic areas, 40% of nurses reported notusing recommended practice concerning confidentiality



TABLE 4Information subscales

SUBSCALES MEAN SD % ALL OR MOST OF TIME

1. Web/research based 2.15 0.54I use research articles for information to make practice decisions. 2.08 0.67 21.10I use journal articles for information to guide my practice. 2.19 0.71 27.40I use database searches for information to make practice decisions. 1.67 0.80 15.70I use Internet sources (Web sites) for information to make practice decisions. 2.67 0.67 59.10

2. Traditional sources 2.84 0.60I use information I learn from conferences. 2.81 0.72 67.00I use information learned in continuing education classes to make practice decisions. 2.80 0.68 67.70I talk with other school nurses (that I know personally) to get information. 2.91 0.76 69.10

3. School nurse specific 2.04 0.66I use information from a school nurse list serve or chat room to make practice decisions. 1.96 0.81 24.90I use school nurse Web sites for information to make practice decisions. 2.12 0.77 29.30I go to the NASN Web site to look for information about school nurse practice. 2.04 0.87 28.80

issues, and more than half were still providing scoliosisscreening, which is no longer recommended. The speed atwhich practice information is moving through the schoolnurse population suggests passive diffusion, not active dis-semination (AHRQ 2001). Information on recommendedpractice concerning pediculosis has been available for morethan 10 years. Even allowing for passive diffusion, mostnurses would be aware of this information, and as ex-pected, this is a topic school nurses on which performedwell. However, the recommended practice change for sco-liosis is fairly recent (2004), and half of the nurses werenot using recommended practice.

Knowing what sources of information have the greatestassociation with adoption of EBP is essential in achievingthe greatest impact when disseminating information to USschool nurses. Strong social networks that consist of partic-ipants having shared experiences, norms, and values (e.g.,nurses you know personally) exert a powerful influence onbehavior (Thompson et al. 2001; Rogers 2003; Greenhalghet al. 2004). In addition, previous research indicates nursesprefer receiving information from other nurses, a findingsupported by this study (Thompson et al. 2001; Estabrookset al. 2005). Although a majority identified school nursesthey knew personally as a preferred source of practice in-formation, this source of information was not associatedwith better practice. As might be expected, rural nursesreported relying on other school nurses less than on theirurban-based counterparts.

Only 25% of nurses identified the school nurse listserve as a frequent source of practice information, yetthose nurses had significantly better practice than thosenot using it. Although it may be that nurses who areactively seeking information to improve practice aremore likely to use the school nurse list serve or school

nurse-specific Web sites, it is possible that exposure toother school nurses with different experiences, values, andnew ideas influences practice (Greenhalgh et al. 2005). Thelack of correlation between general Web sites (as opposedto school nurse-specific Web sites) and current practicewould support the idea that it is the exposure to schoolnurses in other locations that might be providing an in-fluence on practice. Greenhalgh and colleagues discussthe value of boundary spanners, those health care workerswho are able to bring new ideas from other areas, in influ-encing the adoption of EBP. Interacting with nurses fromdifferent geographic locations, who have communicationsources and social networks that are different, might alsobe providing the cosmopolitanism that Rogers identifiedas associated with innovativeness.

The results regarding information sources and their as-sociation with current practice are encouraging. Peer con-tact and influence are known to be important in advancingthe use of EBP (Locock 2001; Rogers 2003; Doumit et al.2007; Titler 2008), and the concern was that more isolatednurses would have lower adherence to current practice,a situation that might be difficult to overcome. This wasnot the case. The use of the list serve and school-basedWeb sites may provide the peer support needed to ad-vance EBP. Encouraging an increased use of the list servemight provide an opportunity for school nurses to connectwith others who are using EBP, a need identified by 92%of nurses in this study.

Nurses showing higher means on the InformationSources subscale, Traditional, showed a small decreasein current use of EBP. This subscale contains items re-lating to conference attendance and continuing educa-tion classes. This finding supports other research, indi-cating these sources are not related to improvements in



practice (O’Brien et al. 2001). It is interesting that theyare associated with a slight decline in the use of EBP. Onepossible explanation is that although continuing educa-tion units are required for some Iowa school nurses, norequirement is in effect that these classes be related toschool nursing. Thus, nurses may not be getting infor-mation specifically related to improving school nursingpractice, but rather information on general health topics,which do not add to their current school nurse practiceknowledge.

LimitationsIn this study, only 22% of the variance in practice is ex-plained by the included variables. This is partially becauseof the complex interactive nature of the innovation and theindividual and contextual variables, but is also because ofdifficulty in measuring current practice. The type of mea-surement used in this study does not take into accountinformation uptake or changes in critical thinking skills.The individual situational limitations described by severalnurses indicated that they knew what EBP was for thegiven item but had valid reasons for indicating a variationin practice. These types of variations are not taken intoaccount in the analysis.

This sample was from a single Midwestern state in theUS; school nurse practice varies from state to state in im-portant ways such as ratio of nurses to students, nursepractice acts, and strength of the leadership within thestate. These variables were not included in this analysis.Thus, we are unable to generalize this information to otherUS states, and in fact, encourage similar state-specific stud-ies to identify dissemination strategies that would be mosteffective for a given context.

IMPLICATIONS FOR NURSING PRACTICE

Because school nurses in the US are often present in schoolson a daily basis, they offer great potential for affecting thehealth behaviors and health literacy of millions of childrenand their families. With more than 9 million uninsuredchildren in the US, the recent record influx of immigrantand refugee children to the country, and the continueddisparities in health status among poor and minority chil-dren, school nurses often become the primary entry pointinto the health care system (Lear 2007).

In order to provide school nurses with needed informa-tion and empower them to become change agents in theirorganizations, attention should be given to their contextof practice. It cannot be assumed that strategies that areeffective in other health care settings will achieve the de-sired goal of increasing the use of EBP by school nurses inthe US, or in other settings where nurses work in isolation

from their peers. Griffiths et al. (2001) studied commu-nity nurses in three community trusts in the United King-dom, identifying similar barriers and concerns for schoolnurses, including isolation and infrequent contact fromtheir community health colleagues. They recommendedfurther research into the particular difficulties of schoolnurses.

The most commonly used methods of communicatingpractice information to school nurses in the US are con-ferences and continuing education classes, both of whichshowed no positive effect on practice. Conferences andcontinuing education classes for school nurses are typ-ically focused on practice information, are often taughtdidactically, and seldom indicate an evidence base or out-come measurement and evaluation (NASN 2008). Educa-tion time would be better spent providing EBP informationaccompanied by hands-on training on how to implementthe practice in a school setting, how to engage stakehold-ers, and how to evaluate appropriate outcomes. Focusingeducational efforts on database searching and critiquingskills may be inefficient uses of resources. School nursesin this study showed less interest in learning these skills,preferring access to predeveloped EBP guidelines. Guidingthem to online connections with other school nurses, suchas the school nurse list serve, which has both US and in-ternational members, might provide the peer contact theyare lacking.

The most important policy implication is the need forfunding at the state or federal level to provide partner-ships needed for creation and distillation of knowledge.Local schools do not have the resources to provide theinfrastructure needed to support this endeavor. The fund-ing of a center for EBP in school health could provide theinfrastructure for locating, evaluating, and distilling infor-mation, and could also indicate research gaps that exist inthe area of children’s health issues.

Future research should be focused on the developmentand testing of multifaceted strategies to disseminate andimplement EBP among school nurses. Measuring contextvariables during implementation could provide additionalinformation that might explain the variance in the useof current practice which is not explained in this initialstudy.

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