Healthy habits start at school: Role of public health nurses

Public health nurses working in schools can have a major impact on Ontario students, but reduced numbers and high caseloads are limiting their effectiveness.

By Daniel Punch

She came to Audrey Burns’ office with a secret. She was just 14-years-old, nearly eight-months pregnant, and scared. Her baby’s father was nowhere to be found, and she had hidden her pregnancy from her parents and peers. Burns, the public health RN for her Niagara Region high school, was the first health professional she told about her baby.

In tears, the girl asked Burns what she was supposed to do. “Let’s focus on right now,” Burns told her. “Let’s see if you and your baby are okay.”

Burns connected the girl with another care provider to get the proper medical examinations. She then set up a meeting with the girl’s parents, and was by her side when she told them she was pregnant. She also supported the teen as she made the decision to put her baby up for adoption, and facilitated the process.

The girl and her family were grateful for Burns’ guidance. Within a week of giving birth, she was back at school with her friends.

Burns counts this among the most memorable experiences of her three-decade nursing career. Helping the teen is also a concrete example of the essential role public health nurses can play in schools, and why she took the job as school nurse for Niagara Region Public Health four years ago.

Burns currently works with three high schools – about 1,500 students – where she is a visible presence and key part of the school communities. “The students like having access to a nurse (at school) because that’s where they spend most of their time,” she says. “You build up that trusting, caring relationship so they come back and see you – sometimes often.”

Since the early 20th century, public health nurses have been working with Ontario public schools to help students make healthy choices, access health services, and develop into healthy adults. Managing communicable diseases has traditionally been a large part of their role, but they also provide a myriad of other services, including health teaching, health promotion, one-on-one counselling, sexual health services, and addressing the social determinants of health.

Budget cuts in the 1990s led to a major reduction in public health nursing services in schools, and forced some of Ontario’s 36 health units to largely abandon their school-based programming. While there has been a significant resurgence of school nursing since then, limited resources have impeded the relationship between health units and schools. Today, an Ontario public health RN can work with as many as 35 schools, meaning they are responsible for between 400 and 14,000 students. That RN may only visit certain schools once or twice a month. The level of school services also varies widely from one health unit to another. As a result, many school staff, students and their families don’t understand the role of school-based nurses, and don’t fully utilize them.

Cindy Baker-Barill is past-president of the Registered Nurses’ Association of Ontario’s (RNAO) Community Health Nurses’ Initiatives Group (CHNIG), which has spent years advocating for an increased role for public health nurses in schools. A 29-year veteran of public health, who worked in schools from 1986 to 2000, Baker-Barill has watched the role change. “Before, you were an integral part of the school. You had relationships with staff and students in schools, and were part of ongoing discussions about health. Now, health promotion is sometimes seen by schools as additional work,” she says.

The diminished role for school-based nursing runs counter to evidence about childhood development, CHNIG says. Research shows the brain continues to develop dramatically from late childhood to young adulthood, making it a crucial time to learn healthy practices and coping skills. Nurses are also needed to tackle the ongoing problem of childhood obesity.

School years also encompass critical transition periods that can lead to anxiety and depression. The Mental Health Commission of Canada reported that one-in-four Canadian children have mental health challenges.

When a student comes to see public health nurse Doris Barkley feeling anxious, angry or depressed, she’ll often pick up her snow globe – with characters from the Disney animated film Frozen – and shake it. She points to the chaos of fluttering ‘snow’ inside. “When you’re really mad or upset, and your brain feels like this,” she explains, “…you can’t make a good decision.”

Working part-time at three elementary schools in Perth County, Barkley encounters a lot of anxiety and depression. She remembers one Grade 5 student who lived in her grandparents’ custody, but wanted desperately to be back with her mother – who she only saw on scheduled visits. On good days, she was bubbly and gave Barkley a hug. On bad days, her nails were dirty and uncut, and she clearly hadn’t bathed in quite some time. “She needed someone to talk to and she did not have that (at home),” Barkley says.

Principals and teachers do their best to fill that role for young students, but they often lack time and health expertise. But a public health nurse is able to offer that confidential ear, and build a therapeutic relationship. “When I call (students) down to meet with me, they generally have a big smile on their face. They know someone’s going to listen,” Barkley says.

One-on-one sessions are one aspect of Barkley’s role. She also does health teaching with larger groups, focusing on everything from planning for the future, to dealing with stereotypes, dating and relationships. But most school health issues can’t be addressed effectively with 500 students at a time. And when a public health nurse is assigned thousands of students, CHNIG says it compromises care. The

group’s recommendations for improving nurse-to-student ratios are outlined in its 2015 Healthy Schools, Healthy Children policy paper.

To start, they would like to ensure a public health nurse is assigned to all Ontario primary and secondary schools. The number of schools currently served by a public health nurse is difficult to determine because each health unit has a different school health model. A 2012 survey of Ontario’s 36 health units found 31 had health teams working in schools, and 15 had staff providing one-on-one services to students. CHNIG wants school-based nurses to act as a bridge between schools, families, the health system, and the broader community.

Burns is doing that back in Niagara. She engaged a number of organizations from her community for a ‘day of awareness’ on impaired driving this past spring. Statistics show that one-in-four Niagara Region students has already ridden in a car with a driver who has consumed alcohol, and more than 10 per cent of students who are licensed drivers have operated a vehicle within an hour of consuming marijuana.

Burns teamed up with Ontario Students Against Impaired Driving, Mothers Against Drunk Driving (MADD) Canada, and a local community health centre to hold an event at two Welland high schools. Each participating organization provided educational materials, and the schools’ student councils helped set up a number of activities designed to raise awareness about impaired driving.

The centrepiece of the day was a car, heavily damaged in a drunk driving accident, which they set up near the entrance of the schools. Students were shocked to see both ends smashed in, and a pair of men’s ice skates still hanging from the mangled trunk. “I think the visual component really struck home,” Burns recalls, adding the event is a great example of community collaboration, but it also shows the potential for public health nurses to reach students during a pivotal point in their lives. “There are all these transformations happening at this time in their lives,” Burns says. “Now’s the time to reach out to them… and embed health habits, because they’re still learning.”

This article was originally published in the July/August 2016 issue of Registered Nurse Journal, the bi-monthly publication of the Registered Nurses’ Association of Ontario (RNAO). Daniel Punch is staff writer for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit or follow us on Facebook and Twitter.