Leading the way for more school health nurses in Ontario
This Equity in Action story is distilled from an interview with
- David Groulx, [Past] President, Ontario Association of Public Health Nursing Leaders (OPHNL), and Manager, Professional Practice and School Health, Public Health Sudbury & Districts
- Heather Lokko, Chief Nursing Officers Network Liaison, Ontario Association of Public Health Nursing Leaders (OPHNL), and Chief Nursing Officer & Director, Healthy Start, Middlesex-London Health Unit
- Irmajean Bajnok, Senior Policy Analyst, Registered Nurses' Association of Ontario (RNAO).
The interview took place in June 2021, and its details should be considered within the context of that time period.
This school health nurses initiative did not entirely level the playing field, but it certainly increased public health’s capacity to support our school communities in addressing COVID-19, and the myriad of associated challenges faced by students, their families and school staff and administration. Basically, it’s about increasing public health human resource capacity to more effectively and consistently address inequities within school communities across the province.
School health nurses promote health equity
Our organizations — Ontario Association of Public Health Nursing Leaders (OPHNL), including the Chief Nursing Officers Network within OPHNL, and the Registered Nurses' Association of Ontario (RNAO) — have been working closely together on a school health nurses initiative. We see it as an opportunity for major system change, not as a temporary initiative that will come to an end post pandemic.
As we’ve all seen, the pandemic has exacerbated inequities. This increased the need for response from public health units across the province, now and for the foreseeable future. The issues exacerbated by the pandemic – mental health, substance use, violence, food insecurity – are challenges that require sustained efforts in prevention and response. In Ontario, there are 34 public health units that work to fulfill the public health mandate, including school health. In the same way that public health work differs somewhat across the province depending on community need and health unit resource allocation, so too does school health nursing. As a result of the pandemic (and even prior to it), it is clear that additional capacity is required to ensure public health can adequately support school communities and work to reduce and prevent growing inequities.
Many health units prioritize schools based on factors relating to the social determinants of health and particular health needs within the school community, with resources dedicated primarily to supporting higher priority schools. With the pandemic, the ability to prevent the spread of infectious disease was an additional factor influencing how schools were prioritized.
Although there are regional differences, all public health units use a comprehensive school health lens to guide their work in schools. School health nurses and the comprehensive school health program are intended to address inequities throughout the school year. Many people are unaware of the critical role of, and need for, school health nurses across the province and of the impact they have on the health of students, families, teachers and school administration. The pandemic drew attention to the school health nurse role as it revealed a crucial need for more support to students and families with a variety of challenges, including infection prevention and control. The school health nurse is a major contributor in enhancing the health of and reducing health inequities in school communities. It was important to leverage their role during the pandemic to highlight the COVID-specific and the entire range of services school health nurses provide.
Ensuring clear, consistent and solutions-oriented advocacy
In June of 2020, when we first heard about schools reopening in the fall, RNAO and OPHNL began to advocate for increased number of school health nurses across the province to provide the support teachers, families and students required. Our organizations quickly rallied to give input on how the initiative to increase school health nurses could be successfully implemented. Through liaison with the Provincial Chief Nurse and the Provincial Chief Medical Officer of Health, both RNAO and OPHNL made strong recommendations to the Ministry of Health, based on our knowledge and expertise. Our advocacy related to the qualifications and preparation of school health nurses, their role, and their employer – through meetings, letters, and social media – resulted in employment of additional public health nurses hired as school health nurses, by local public health units.
At the end of July 2020, the Ontario government announced funding of $50 million to hire 500 school nurses. The federal government later helped hire another 125 nurses, for a total of 625 new school nurses across the province. As recommended by our organizations, these new positions were registered nurses hired by local public health units to support schools in regards to COVID-19 and its complexities and, wherever possible, with broader school health.
Critical actions on our part helped make our advocacy efforts successful. We were united and consistent in our messaging that school health nurses be:
- Hired at the local level, by public health units.
- Hired immediately to be able to support school reopening.
- Registered Nurses with a nursing baccalaureate degree.
- Enabled to engage in the comprehensive school health nursing role, including infection prevention and control, and vaccine education and administration.
- Hired for 2 school years - and become permanent additions to public health base funding to support school health work.
Another significant factor was our solutions-oriented, collaborative approach to the challenges faced by the Ministry in relation to planning for school reopening. Our solutions were based on the known impacts of school health nurses in supporting safe and healthy learning environments for students, including in times of crisis. We showed how school nurses help administrators, teachers, families, and students. We positioned ourselves as collaborators, significantly contributing to successful school reopening and worked together to outline how school health nurses were part of the solution.
Supporting implementation with timely, targeted, and collaboratively developed resources
Following the announcement of funding to hire school health nurses, we quickly realized that recruitment was going to be a massive undertaking for health units. To support the process, we identified resources that might be helpful. We did a quick check with the field about what was needed, and in response, developed a sample job description and interview tool with selected questions.
Next, we formed a working group with representatives from our two organizations, the School Health Managers Network, and Public Health Ontario to develop a school health nursing orientation for use across the province. The orientation is presented on-line in five modules, including modules on public health, comprehensive school health and health equity. We recognized in hiring 625 new nurses, many would be new to Public Health. The orientation was readily accessible through the OPHNL website by health units, many of which added it to their local orientation. The goals were to contribute to excellence in public health nursing practice, highlight the importance of health equity in school health nursing, create equitable orientation opportunities for all health units across the province, and support workload capacity for the managers responsible for onboarding.
From conversations with those in the field as well as at the ministries of health and education, we were aware that clarification about the role of a school health nurse was required. In response, a working group with representation from OPHNL, the ministries of health and education, the school health managers network, and public health units, developed a guide for school administrators outlining the school-focused public health nurse role. It explained the role of a school health nurse within the particular context of the COVID-19 pandemic, and also highlighted the broad and comprehensive role of the school health nurse pre-COVID, providing foundational knowledge and outlining how school health nurses address health inequities. The guide, approved by education and health ministries, will continue to be leveraged to foster broader awareness, clarity, and support of the public health school nurse role into the future.
To assess the implementation and impact of the school health nurse role during the pandemic, OPHNL hired a consultant to conduct an evaluation. The evaluation advisory group formed by OPHNL to work with the consultant included representation from OPHNL, the school health managers network, the Association of Ontario Public Health Evaluators, the ministries of health and education, and academics. A monthly reporting mechanism provided information about how the school health nurse role has been implemented and what activities the school health nurses have engaged in throughout the pandemic. OPHNL and RNAO are planning to collaboratively provide recommendations based on the findings of the evaluation to inform policy decisions related to the school health nurse role and its implementation in Ontario schools.
Building relationships to make collective action possible
Essential to the success of this initiative are the relationships built prior to and during the initiative. We had regular meetings with the Provincial Chief Nursing Officer and Ministry of Health representatives. Relationships with respected and influential nurse leaders within the ministry and in the public health across the province were indispensable in advancing this work at all levels. For example, this initiative highlights the value of a Provincial Chief Nursing Officer, a professional association that is not bound by regulatory requirements or union contracts, and strong nursing leadership at the public health unit level coming together to work collaboratively on solutions that are good for the clients (students, teachers, families and administration), the nursing profession, and the system.
Relationship building across roles and organizations happens over time, resulting from professional and decision-making meetings, common educational events, regular open dialogue, collaboration and consultation to further policy decisions. As this situation demonstrates, the opportunity and the ability to build relationships with nursing and other individual and collective stakeholders yielded results in terms advancing the school health nursing role as a solution to safe timely school reopening in the pandemic. Further, it has resulted in other related policy considerations and decisions.
Without such relationships enabling unified, collective action to overcome challenges of the pandemic, we believe schools across the province would be in a very different place right now. As a result of our collective and deliberate efforts – and the responsiveness of the government – students, parents, teachers, and school administrators have benefited from substantial support provided through public health and the school health nurse role.
Efforts to inform healthy public policy are made stronger by speaking with a unified voice and providing consistent messaging among partners, focusing on solutions not just needs, and identifying concrete ways to be part of the solution.
Building relationships over time, with positive foundations of understanding and trust, with decision-makers, allies and partners is essential for successful collaboration (especially before there are challenges to overcome).
Professional nursing associations and nursing leaders are strategically positioned to effectively advocate for and support school health nursing, and to increase broader understanding and support for the school health nurse role and comprehensive school health program during and beyond the pandemic.
Addressing health inequities also involves identifying and addressing inadequacies in public health resource capacity, and challenges and barriers that hinder organizations from taking action.
Since 1925, the Registered Nurses' Association of Ontario, a voluntary professional association, has advocated for healthy public policy, promoted excellence in nursing practice and empowered nurses to actively influence and shape decisions that affect the profession and the public they serve.
The Ontario Association of Public Health Nursing Leaders promotes and protects the health of Ontarians through excellence in public health nursing leadership. Their members are public health nurses employed at the management level across Ontario. Formed in 2015, they are the combined voice for two original groups: the Association of Nursing Directors, Supervisors of Official Health Agencies and the Ontario Public Health Chief Nursing Officers Group.
- Orientation Overview
- Module 1 Intro to Public Health
- Module 2 Comprehensive School Health
- Module 3 COVID-19 and Infection Prevention and Control
- Module 4 SDOH and Health Equity
- Module 5 Child and Adolescent Health
To learn more about the initiative described in this story, contact the National Collaborating Centre for Determinants of Health, at [email protected].
Do you have an idea for an Equity in Action story? If you have heard of other health equity-promoting COVID-19 pandemic response initiatives in Canada that we should share, please let us know.