INTRODUCTION

In Nursing, clinical training is an essential period in students’ training. It allows nursing students to learn as members of a team, in direct contact with healthy and ill individuals, and/or as part of a group in the planning, implementation, and evaluation of comprehensive nursing care based on the acquired knowledge and skills¹. According to the Guide to Clinical Training in Child Health and Pediatric Nursing¹, students are expected to develop skills in order to deliver comprehensive care to children and families. Students’ clinical training in this area takes place in hospital institutions and in nurseries/kindergartens.

Nurseries/kindergartens are places designed to accommodate children aged 0 to 6 years. The nursery is a socio-educational response aimed at children aged between 3 months and 3 years². It provides children with adequate conditions for an overall harmonious development during their parents’ work schedule, while collaborating with families throughout the whole education process. The kindergarten is a pre-school education institution for children aged 3 to 5 years. It aims at promoting children’s development, providing educational and family support activities. As the first stage of basic education, pre-school education focuses on the balanced development of children’s potential, giving them the opportunity to develop their autonomy and socialization skills, preparing them for a successful education path, and supporting the families in children’s education². Only professionals with a Bachelor’s degree in Early Childhood Education can provide educational services in nurseries and kindergartens². These professionals must ensure the pedagogical activities during the school period; extended service hours, which have no pedagogical purpose, can be ensured by other professionals, who must possess, at least, compulsory education².

In this context, since nursing students conduct their clinical training in nurseries/kindergartens and considering that this is an understudied topic in Portugal, a qualitative, descriptive, exploratory study was developed to answer the following question: what are nursing teachers’ perceptions of the most important aspects of nurses’ role in nurseries/kindergartens?

This study aims at identifying nursing teachers’ perceptions of the most important aspects of nurses’ role in nurseries/kindergartens.

MATERIAL AND METHOD

A qualitative, descriptive, exploratory study was conducted. The sample was composed of teachers who hold a specialization degree in Child Health and Pediatric Nursing (CHPN) and belong to the Scientific-Pedagogical Unit of Child and Adolescent Health Nursing (Unidade Científico-Pedagógica de Enfermagem de Saúde da Criança e do Adolescente, UCP-ESCA) of a Nursing School. The study was accepted by the President of the Nursing School where the study was conducted and approved by the Ethics Committee of the Health Sciences Research Unit: Nursing (Opinion No. P 336 - 03/2016).

The UCP-ESCA was established in the Statutes of the Nursing School, which were homologated by Order No. 50/2008 (9^th September) and published in the Official Portuguese Journal on 24 September 2008³. It has its own regulations, which were approved by the President of the Nursing School on 16 July 2013. It is composed of 14 members: 10 members of the Nursing School faculty and four visiting assistant teachers (three became members of UCP-ESCA in the 2015/2016 academic year and one in 2016/2017). All UCP-ESCA members are Nurse Specialists in CHPN; 13 hold a Master's degree; and 7 hold a Doctoral degree. One teacher holds a Post-doctoral degree in Nursing and four hold the title of Nurse Specialist (Decreto-Lei n.º 206/2009)⁴. The UCP-ESCA is coordinated by a Professor and a Co-coordinator. Ten of the 14 members integrate the Polytechnic Higher Education career teaching staff (seven as Coordinating Professors and three as Adjunct Professors).

The sample was selected through a convenience sampling technique. The following inclusion criteria were applied: teachers of the Nursing School where the study was developed; members of the UCP-ESCA; nurse specialists in CHPN; and agreeing to participate in the study.

Semi-structured interviews were conducted between December 2016 and February 2017. Although a guiding script was prepared, interviews had a flexible structure. Each participant was personally contacted and asked to sign an informed consent form in order to participate in the study. Interviews were scheduled to a date, time, and place that were convenient to each participant. They were conducted at the participant’s or researcher’s office. Participants were asked to agree with the audio recording of the interviews. Each interview lasted 30 to 45 minutes, uninterruptedly. Interviews were subsequently transcribed and organized into individual files, and the audio recordings were destroyed. Each individual file was coded by the researcher and a number was assigned to each interview: I1, I2, I3 ... I7.

The sample was composed of seven teachers who agreed to participate in the study (four women and three men), with a mean age of 56 years. On average, they had been working at the school for 23 years and were Nurse Specialists in CHPN for 22 years. All of the teachers belonged to the UCP-ESCA since its foundation. Five teachers had a Doctoral degree and five were Coordinating Professors. Four teachers had experience in supervising nursing students during clinical training in nurseries/kindergartens.

Bardin’s content analysis technique⁵ was used to process data based on the topic under study, the research question, and the study objectives. Categories and subcategories were identified using the hypothetical-deductive model as suggested by Bardin⁶. Data were analyzed using categorical analysis.

RESULTS AND DISCUSSION

From the analysis of the interviews conducted with the seven teachers, the following categories emerged: Nurse’s presence in the nursery/kindergarten; Nurse’s role in the nursery/kindergarten; and Interventions developed by nurses in the nursery/kindergarten.

Nurse’s presence in the nursery/kindergarten

Some teachers believe that nurseries/kindergartens should have a full-time nurse.

“Look (…) I can see nurses having a role there, working in a nursery.” (I1)

“Nurses in the nursery, I think it’s something to think about, it’s a relevant topic for the institutions that care for our children.” (I2)

“I think that a nurse would be important, if not full-time, at least 4 hours a day. I think it would be important. (…). It depends on the size of the nursery; I think it could happen, having a job, making an interesting work.” (I5)

“In my opinion, for the nurse to focus his attention on the child, the family, and other professionals who work in the nursery, he has to be in the nursery on a daily basis.” (I6)

In turn, other teachers question the need for the presence of nurses in nurseries/kindergartens.

“I’m not even sure if having a nurse in a nursery is that important, (…). For example, it’s a nurse from the CCU (Community Care Unit), from the Health Care Center, who has, let’s say, an extended place to deliver care in the nursery. (…) But as a full-time nurse, unless he also acts as a director of the nursery, a nursery manager working at the same time as health professional, but not as a full-time nurse at a nursery, to give children their medication. (…) Each nursery should have a nurse of reference, at the Health Care Center.” (I3)

“It can be and is a useful source of support, but having a full-time nurse is not technically feasible, it is unthinkable in today's society.” (I4).

According to the teachers’ accounts, not all of them share the same opinion about the presence of the nurse in nurseries/kindergartens as a member of the multidisciplinary team; however, the nurse’s integration into the permanent staff of a nursery aims at improving child care delivery⁷. The incorporation of health education in nurseries and pre-schools under nurses’ supervision is a priority since nurses possess a wide range of knowledge that can benefit children. In addition, Motta, Silva, Marta, Araújo, Francisco, and Junior (2012)⁸ argue for nurses’ presence in these institutions, stating that their training as nurses focuses on the delivery of holistic care to human beings, mostly aimed at health promotion. Nurses’ interventions in a nursery/kindergarten, or in any other setting, go beyond the administration of medication or interdependent interventions. In Spain, school health nurses have been working with children and young people in public and private nurseries, primary and secondary schools for more than three decades⁹. The school health nurse is capable of developing autonomous interventions, namely in the areas of health promotion, disease prevention, and assistance to healthy or ill children and their rehabilitation, within the scope of a multidisciplinary team and in collaboration with nurse specialists from other areas⁹.

In Portugal, the statutes of kindergartens integrated into the pre-school public system were approved by Decree-Law no. 542/79 of 31 December 2010¹⁰. With regard to technical staff, paragraphs 2 and 3 of Article 44 of Chapter XI provide that “kindergartens reporting to the Ministry of Social Affairs should include auxiliary staff to aid the technical staff” and that “kindergartens reporting to the Ministry of Education may also hire technical staff as set out in these Statutes.” Furthermore, paragraph 1 of Article 55 reads: “by joint ordinance of the Ministers of Finance and Education and the Secretary of State for Public Administration, professionals in the fields of health, psycho-pedagogy and others may be hired to provide temporary support in kindergartens.”

Nurse’s role in the nursery/kindergarten

According to the teachers’ accounts, they believe that nurses play a key role in nurseries/kindergartens.

“I think that nurses’ role in the nursery is just as important as any other professional.” (I1)

“I think that nurses’ role in a nursery can be somewhat important (...) nurses can play a very significant role.” (I2)

“OK, in my opinion, nurses’ role in the nursery is indeed very important.” (I6)

The school health nurse, when integrated into the educational community, is a valuable, effective, and efficient asset. Together with the faculty, the nurse works to normalize the daily lives of children and adolescents, whether healthy or ill, and promote healthy lifestyles for the whole educational community.⁹ With a responsible scientific attitude, the nurse leads the care provided to children and adolescents, whether healthy, acutely or chronically ill, or with a debilitating illness. The nurse is capable of planning, implementing, and evaluating health programs, and developing research and teaching activities with the purpose of improving the quality of the services and contributing to advance this specialized area⁹.

In addition, the 2015 National School Health Program reads that “all children and young people have the right to health and education and should have the opportunity to attend a school that promotes health and well-being.” (p. 20)¹¹. Therefore, nurseries and kindergartens must offer conditions that enable the child to grow in a harmonious environment with the lowest possible risk of becoming ill or suffering accidents. During their training, nurses acquire knowledge to provide holistic care to human beings, which is why they are capable of providing care to children in early childhood education institutions⁸.

Despite considering that nurses play a useful role, I4 believes that nurses’ intervention should be occasional:

“In my opinion, [the nurse] can play a useful role, as long as he integrates the health care center, the FHUs (Family Health Units) or previous organizations. His intervention is occasional and integrated into child health programs. It is useful when integrated into community health programs.” (I4).

Interventions developed by nurses in the nursery/kindergarten

According to the teachers, the nurse in the nursery/kindergarten works with children, families, and other professionals who work there and in collaboration with the health structure, the school, and the family.

The Associación Madrileña de Enfermería en Centros Educativos (2016)⁹ advocates that the skills acquired by school health nurses are not only those established in the general nurse’s competency regulation, but also in the skills profile of the nurse specialist in pediatric nursing, family and community nursing, and mental health nursing. According to this association, the school health nurse should have the necessary skills to provide comprehensive care to students, namely communication and care delivery skills, the ability to manage the health of the educational community, teaching and research skills, and interprofessional and relational skills (which include the nurse’s relationship with the school, its teachers and other professionals, students and parents, and external services)⁹.

Teachers’ accounts emphasize the promotion of growth and development as one of the nurses’ main interventions in the nursery/kindergarten towards children.

“The nurse’s role (…) is to monitor the child’s development, (…), and his role focuses, in fact, on prevention and promotion of the child’s healthy growth. (…) in terms of promoting both their healthy development and growth.” (I1)

“(…) firstly, [nurses] can work with teachers to promote child development. I think that, preferably, they can develop areas associated with the promotion of development because they always receive an interesting support from teachers. Also, they can easily do a more realistic, more contextualized assessment of the development, (…). Then, in terms of the promotion of development, there are certain areas that can clearly benefit children if nurses, parents and teachers work together. And we are talking about several areas, ranging from the more biological ones, such as nutrition, to other areas linked to education, discipline, boundaries (…).” (I2)

Nurses' work in the nursery is very complex and emphasizes the importance of knowing the specific characteristics of the child's development. It involves developing caring activities, monitoring the children’s development/growth, identifying childhood basic needs, providing nursing consultations, providing continuous training/education, performing multiprofessional work, offering health education, and managing resources¹². Nurseries and kindergartens must offer conditions that enable the child to grow in a harmonious environment - at the physical, psychological, intellectual, and social levels - and work in collaboration with the families¹². The child's well-being is assessed based on data obtained from a comprehensive analysis of family and health history, as well as from the child’s physical examination and developmental assessment⁷.

Teachers also emphasized the Prevention and treatment of diseases in their accounts.

“[The nurse] plays an important role (…) for example, (…) on disease prevention, monitoring, and even health surveillance in terms of vaccination, all of which, I think, are important factors (…).” (I1)

“(…) hence a very important role, from disease prevention, (…) to, eventually, treatment. (…) teachers often call parents to pick up their children; if there was a nurse managing the situation, this wouldn’t be necessary; therefore, it means that, even in terms of productivity, parents’ absenteeism would be lower if there was a nurse with deep knowledge in this area.” (I2)

“(…) not just to support the child who is ill or to help diagnosing some problems.” (I5)

“It’s trying to identify the child's health issues, pay attention to how it’s done, let's say, the emotional connection between the child and the family, how care is delivered to these children, (…). For example, if a child has a high-temperature peak, but shows no other signs or symptoms, a nurse could provide care to this child, by giving the proper medication, let’s say, for example, antipyretic medication (…).” (I6)

“The nurse’s role would be to detect, let’s say, changes in the child’s behavior that might impact on his/her health later on; being close to the child on a daily basis, we can intervene whenever we think it’s necessary.” (I7)

If a child has any signs or symptoms, nurses are able to use their knowledge to identify the underlying disease and take the necessary measures to improve or alleviate the symptoms, as well as decide whether the child can or cannot stay at the school.

In nurseries, the professionals’ lack of specialization and health-related scientific knowledge results in an inadequate assessment of the child's health condition, which compromises the early implementation of an action plan to minimize the situation⁷. If present in the nursery and kindergarten, the nurse is capable of providing comprehensive care to children and observing the other professionals’ care practices. In this way, an action plan can be implemented to identify these factors, reduce the number of episodes of disease that are common in childhood, and improve the family’s living conditions since the child becomes ill less frequently. In addition, the nurse cooperates with other professionals to create an environment that promotes children’s development and increases the quality of education since health is directly associated with learning⁸.

As part of the nursery and/or kindergarten staff, nurses would have more knowledge and control regarding the child's vaccination status, as well as therapeutic administration⁷. Anyone working at the institution can administer a given treatment if authorized by the parents or with a medical prescription; however, not everyone has adequate knowledge to do it. Nurses have the academic preparation that allows them to intervene in this area that requires responsibility and knowledge⁷.

Teachers also reported that health promotion is an important intervention.

“[The nurse] plays an important role in health education, for example, at multiple levels (…), and also other sessions on health education, nutrition, (…).” (I1)

“(…), from promotion to, eventually, treatment.”(I2)

“(…) [The nurse] works towards promoting children’s health, and this work that can be developed in direct contact with children, particularly through education sessions.” (I6)

Caring for a child care requires understanding their uniqueness as human beings who are going through a process of growth and development. The child’s first years of life are a period of learning experiences and development of habits that can last a lifetime, such as caring for ourselves and our health. Thus, the education institution is an excellent place for the implementation of health promotion programs that may contribute not only to improve child care delivery but also promote healthy behaviors since childhood¹³. In these institutions, the children’s contact with the teaching-learning process prepares them for future responsibilities. Therefore, health education will also contribute to create mindful and healthy citizens⁷. Children are great information multipliers; they take what they learn at school to their own homes and transform it into lifelong knowledge. It is obvious that family members must help children in this learning process to ensure that all of the topics addressed during health education sessions are implemented effectively.

Teachers also noted that the ability to intervene in case of emergency is an intervention developed by nurses when working with children.

“[The nurse] plays an important role (…) at various levels including, for example, in case of an emergency, (…).” (I1)

A nursery has children of different ages and at different moments of discovery; accidents or incidents are almost inevitable. Therefore, nurses’ presence in these places is essential to deal with high-risk situations such as burns, trauma, suffocation, choking, among others⁷.

In addition, teachers believe that nurses’ interventions can have an impact on the family by empowering parents.

“[Nurses] can also work with the family, play a proactive role in some situations that can be signaled, acting as liaison between the child and the nursery or the child's family, this should be the purpose. We think that we’re talking about a context or a child-family bynomial; if the child isn’t ok, then the family won’t be ok too, and perhaps the other way around.” (I1)

“(…) and possibly support parents, (…). Provide support to parents, situations that may be eventually diagnosed, for example, if the child doesn’t eat well or if the child has any; parents' usual doubts about sphincter control, depending on age, stages of development, the nurse can provide guidance to parents.” (I5)

“(…)the child, but also to the family, the family is and should be a focus of attention. Early screening, lack of connection and stimulation, even when the child is not at the nursery, and this is evident in many situations. Many problems are associated with the child’s relationship with the family and they can be screened, discussed with the family in a positive, constructive way.” (I6)

Educating children in a conscious and healthy way leads to a positive present and future. Prevention guidelines include providing not only information to families about normal growth and development, but also pedagogical practices that involve both parents and children and help them to live together and acquire and maintain healthy behaviors⁷.

According to the teachers’ accounts, the nurse’s presence in the nursery/kindergarten can also provide parents with a sense of security about their children’s well-being while they are working¹², which is beneficial to their professional activity and reduces work absenteeism.

“(…) If a nurse is caring for the children in the nursery, there’s no need for parents to miss work and children are well taken care of.” (I2)

“(…) clearly reducing, for example, parents’ absenteeism from their professional activities. On the other hand, I think it is also important that the nurse provides some sense of security to parents regarding the care provided to their children; parents feel more comfortable if they know that a health professional is working with their children, watching over them, taking care of them, etc. They feel safer to know that there’s someone with knowledge in that area at the nursery where their children.” (I6)

Teachers also reported that nurses develop Interventions together with other professionals working in the nursery/kindergarten.

“[The nurse] can play not only a complementary role within the team that cares for the child, but also a supervisory role, for example, in aspects such as children's diet.” (I1)

“But also in providing training to staff, (…), to the professionals working there about everything from the transmission of infections to guidance on issues related to child growth and development; I think that yes, it is obviously relevant.” (I5)

“But, particularly to the people who work in direct contact with the children, right? There are nurseries that actually work well, where their employees are trained to provide appropriate care to children. But there are others where employees may need to be supervised, it’s necessary to call attention to some aspects of care and some risks that are inherent to children, and also to provide training about immediate child care. And some care can be indeed provided early on to children.” (I6)

“Motivating the child to drink an adequate amount of water is another issue that can be found in certain nurseries; water intake after physical exercise or during meals is not valued enough, (…). Some employees still cannot and do not value the child’s position during sleep (…) underestimating the position (…). Another aspect that also comes up often is hand hygiene, washing hands after delivering hygiene care, after changing diapers between children. For example, they often use the same tissue several times to blow children’s nose…” (I7)

Professionals working in a nursery are responsible for educating, welcoming, feeding, performing the hygiene, and organizing the space, among other responsibilities. The nurse’s presence in the nursery/kindergarten brings about multiple benefits, not only for children and families but also for the development of a partnership with the other professionals. Professionals can feel more secure when they know how to act or are able to ask for help to address the child’s needs and other health concerns. The nurse acts as a point of reference for professionals, as a support system for all issues regarding the child’s health⁷. The nurse, as responsible for delivering health care at the nursery/kindergarten, can improve the quality of health care delivery by planning, implementing, monitoring, and evaluating the services provided⁸.

Finally, teachers believe that nurses in nurseries/kindergartens are also able to act as liaison between health structures, the school, and the family.

“Then there is a whole set of health-related areas (…) in which nurses play a key role, because they are capable of acting as liaison between health structures and the institution and they are always someone to take into account in this joint collaboration between school and the family.” (I2)

The nurse is seen as an important partner for achieving health care objectives. The partnership between the nurse and the institution allows bringing the child and the family closer to health services, providing opportunities to promote health, healthy behaviors, and vaccination, and prevent health problems, as well as providing timely care⁷.

CONCLUSION

This study concluded that not all teachers share the same opinion about the nurse’s presence and role in a nursery/kindergarten. Some teachers advocate for the presence of full-time nurses, while others question the need for nurses at these institutions. Most of the teachers consider that nurses play a key role in these settings. During their professional activity in the nursery/kindergarten, nurses work with children, families, and other professionals and cooperate with health structures, the school, and the family. According to the teachers, the nurse’s presence makes parents feel more secure about their children’s well-being while they are at work, which may reduce their work absenteeism.

This study aimed at contributing to improve teaching/learning practices and change the nursing paradigm based on scientific evidence. This project reflects the need for the integration of nurses in child care institutions.

Nurses’ full-time presence in child care institutions is an understudied topic and is still far from being a reality in Portugal. However, studies have identified multiple benefits, such as the response to basic child health needs and the promotion of the child’s growth and development. Nurses are capable of using the knowledge that they have acquired during their training to provide comprehensive assistance to children, their families, and other professionals working at these institutions. Nurses play a key role at the nurseries and kindergartens by working with children, their families, and other professionals from the management, research, and teaching areas.