Don't sideline school nurses from debates about weight management in schools
A contentious proposal by the Australian College of Nursing (ACN) for nurses to weigh school children in the fight against rising obesity is at best disrespectful and at worst a doomed policy idea.
Let me explain.
No one denies the importance of the issue, and to their credit ACN have explained this throughout their plan. But existing school nurses have been excluded in the proposal, and in the media response to it. Feedback online and in traditional media has so far been overwhelmingly negative because of concerns students may develop shame, stigma and suffer psychological harm.
Several academic "experts", none of whom are school nurses or even nurses, were asked to respond to the question "Should school nurses weigh students?". All of them said no.
Shame and stigma is one thing but a big problem is there is no consistency in the way school nursing is funded or operated across Australian states and territories. Even within single jurisdictions there is inconsistency. For example, primary, secondary, and special schools in Victoria have completely different nursing models despite direct funding and operation by the state government. And, importantly, not every secondary school receives school nursing services.
Related to this, Deakin University's 2018 ACE Obesity Report on the cost-effectiveness of obesity prevention policies in Australia rightfully notes the "political realities" of prioritising interventions. An example of this is the federal government's new Better and Fairer Schools Agreement which contains a wellbeing objective stating the case for "structured initiatives that support wellbeing for learning and engagement, for example in-school wellbeing coordinators or access to school counsellors, psychologists, mental health workers and/or youth health nurse". Not even the agreement requires the states and territories to have a school nurse; it's just a mere suggestion.
The ACN's position statement from earlier this month - titled Working with Children Above a Healthy Weight: Nurse-led interventions - copped widespread condemnation, including from nurses. School nurses stopped weighing and measuring children - unless their parents raised concerns - about eight years ago.
The federal government's own National Obesity Strategy (2022- 2032) does not suggest school nurses measure and monitor student weight and, in fact, it does not identify any specific contributions by nurses. However, a recent US study found the proportion of students in primary schools with elevated BMIs increases with fewer nurses, indicating nurses are important to obesity intervention in schools. The UK Royal College of Nursing got it right in 2018 when it said: "To get to grips with the obesity crisis, ministers must reverse the decline in the number of school nurses." Whether or not we accept there is an obesity "crisis" in Australian schools, we have to make sure there are nurses in schools if we want them to do something about it.
So before nurses are positioned to address student weight concerns, let's first make sure there's at least a common policy and strategy, and in practical terms, a nurse in every school.
The Obesity Collective - an Australian peak body - released its A Time for Action report this year, which notes the important contribution of nurses and nurse practitioners in addressing obesity. The report also describes two effective school-based interventions targeting sedentary behaviour and increasing physical activity. The report does not suggest measuring and monitoring the weight of individual children.
Several research reviews of nursing interventions in child and adolescent weight have been published, and all share similar results. In 2021 nursing researchers from Australian universities found routine health promotion, upskilling nurses in behaviour change and nutrition education in schools are the ways to proceed - not measuring the height and weight of individual students.
It is unfortunate ACN has not integrated study results of school nurses providing care for students who are overweight. In the United States, school nurses reported workplace issues such as a lack of time, workplace demands, and the moral distress of providing intervention, knowing for obesity it is the right thing to do, but with institutional constraints making it difficult to pursue. There is no reason to think Australian school nurses would not report the same, especially as Australia faces the same challenges of getting a nurse into every school.
Another US review, from 2016, found school-based interventions for weight needed to include nutrition and physical activity components lasting more than a year, and involve parents, to be effective. But the authors are careful to highlight "the substantial body weight changes needed to help children shift from obese to overweight to a healthy weight may require more intensive intervention than can be provided solely in a school setting ... school-based interventions may be better-suited for obesity prevention".
So, in Australia, what are our goals for school nurses providing weight intervention if the impact nurses can have can only be relatively small?
In Norway and England school nurses were frustrated by the lack of prevention and treatment strategies that accompanied standardised guidelines for measuring weight and height, and also not having clear protocols for referral of students who needed care beyond what could be provided in the school.
In the end, just because school nurses can measure student weight doesn't mean they should. The nuances of school nursing have been lost in ACN's proposal and the media responses. If we want students to benefit from school nursing then we have to have nurses in schools, consistent policy and funding to allow nurses to do that work, and use appropriate interventions which work in schools.
And let's not forget to involve school nurses from the beginning. These things should be the focus of advocacy by nursing organisations.
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This article was first published in The Canberra Times