Role of the Nurse in Maintaining Healthy Physical Environment in Primary Schools in Alexandria

Healthy school physical environment affects the day to day health and well being of the students. It should be organized in a way that reduces or eliminates safety hazards for all students and school personnel. The nurse collaborates with other school members to provide effective intervention to prevent the exposure of students to potentially physically harmful conditions. They must have the educational knowledge and background to be actively involved in promoting a safe healthy school environment. The present study aimed to know the role of the nurse in maintaining the healthy physical environment in primary schools in Alexandria. The study was conducted at the governmental primary schools in the seven educational zones. The study included all nurses working in 350 primary schools. The study was fulfilled through a cross-sectional approach. A total number of 251 nurses accepted to be included in the study, their mean age were 45.87±10.61 years, the majority of them (89.2%) were married and had children, about 57.0% had a certificate of health visitor diploma. The results showed that knowledge, attitudes and practices of nurses regarding maintaining healthy school physical environment are adequate in some aspects and inadequate in another. As regards knowledge, only one quarter of nurses has the required knowledge, while one third of them did not have enough knowledge. However, there were unsatisfactory attitudes and practices in maintaining healthy school physical environment. The study revealed that a significant positive relationship was found between knowledge of nurses and their qualifications and marital status.


INTRODUCTION
A healthy school environment is one that promotes optimum psychosocial and physical growth and development among school-age children and school personnel.
It provides an atmosphere that fosters sound mental health and favorable social conditions. (4)The school environment has both physical and psychosocial aspects.
Physical concerns include sanitation, heating, lighting, and safety issues. (5)ctors that contribute to the physical environment include the school building, biological or chemical agents that may be detrimental to health, and physical conditions such as temperature, humidity, electromagnetic radiation, mechanical vibration, noise, lighting, and heat play a negative role. (6)ysical aspects of the environment need to be monitored to ensure an optimal setting for student's learning.It should be organized in a way that reduces or eliminates safety hazards for all students and school personnel. (7)hool nurses are important members in the health team of the school.School nurses are not just bandage dispensers, first aid providers, and record keepers.The nurses' skills and training prepare for broader roles as health counselors, facilitators, and educators within the school and community. (8)The school nurse, through assessing the physical environment of the school, takes actions to improve health and safety. (9)She participates in healthy school environment by monitoring, reporting, and intervening to correct hazards, and collaborating to develop a crisis intervention plan. (10)e nurse assesses both the internal and external physical environment of the school. (11)They must have the To address this role, this study aims to assess the knowledge, attitudes and practices of the school nurses about the school healthy physical environment in the primary schools in Alexandria governorate.

SUBJECTS AND METHODS
A cross-sectional design was used.
The study was conducted in the governmental primary schools of the seven educational zones of Alexandria Governorate.The study included all nurses (251 nurses) working in 350 primary schools.

Data collection methods
The following tools were used for collecting study data:       A safe, clean, and well-maintained school with a positive psychosocial climate provides the students with good selfesteem and enhances the learning process.The school physical environment affects the day -today health and well being of the students. (13)e nurse collaborates with other school members to provide effective interventions to prevent the exposure of children to potentially physically harmful conditions.Management of the school physical environment is one of her important functions.She observes the physical hazards and is responsible for securing correction of undesirable and unsafe conditions. (14)e quality of the school health program operated within such standards of nursing care is dependent upon many factors.One of them is the proportion or ratio of the school nurse is very important, number of students in her responsibility.In

U.S.A the National Association of School
Nurses (NASN) in 1995 recommended the ratio of nurse to students as 1:750. (5,15)In California State it was recommended as one school nurse for every 1000 students. (15)n this study, the results revealed that the ratio is one nurse /1000 and more students for about 44.2% of the studied nurses.background to be actively involved in promoting a safe healthy physical school environment. (16)garding the overall knowledge score of the nurses, the present study revealed that the highest rate of nurses had average knowledge score while a quarter of them had very good and good knowledge score.

*Nurses
These findings are in harmony with Saleh (2007) (17) who reported that the majority of nurses scored an average level of knowledge.
The  (17) who found 88.9% of nurses had incomplete answers, and none of them gave correct answers.
Three components have persisted as a means of meeting the health needs of the school-age children are referred to as school health program; these are school health services, school health instructions and the healthful physical school environment. (18)The results indicated that the knowledge regarding to the components of the school health program, most of the nurses gave correct, but incomplete answers.On the same line, Mohamed' study, in Alexandria (1995) (19) revealed that the 68.1% gave correct answers about the components of the school health program.
The ideal school health team would include representation from: administrators, medical personnel, (especially a school nurse and school physician), social workers, counseling personnel, teachers, food service workers, maintenance workers, and parents. (20)The nurse must collaborate with other team members to insure the environmental safety at school.
As regards to the school health team, in this study, it was found that the highest percentage of the nurses had correct but incomplete answers regarding the member of the health team.In a study done in Alex (2007) (17) it was found that most of the studied nurses gave incomplete answers about health team members and only 10% of them nurses answered correctly regarding this issue.In Egypt, the school health team includes the physician, the school nurse or health visitor, teacher, the dentist, and the social worker. (21)lso, the results revealed that the majority of the sample gave correct but incomplete answers about the definition of healthy physical school environment.This may be considered satisfactory results although Pollock and Middleton (1991) . (22)ntioned that the healthy physical school environment is one that promotes optimum psychosocial and physical growth and development among school-age children.
Students spend most of the school day in the classrooms.When the classroom environment is healthy, the children are more likely to learn much more.Therefore, illumination, ventilation, and class furniture are very important elements for the learning process. (23)In the present study, the vast majority of nurses gave correct but incomplete answers regarding importance of good illumination and ventilation.This finding was in agreement with the results of similar study in Alex (2007) (17) which concluded that the majority of nurses gave correct and semi-correct answers concerning the importance of healthy physical school environment.
Fitness of the student's desk, good posture are necessary for preventing early fatigue causing distraction of the school child.Wheatly and Hallock (1965) (24) said that good position is necessary for preventing early fatigue, which causes spine deformities especially scoliosis.In the light of the data presented in this study, it was indicated that only 0.8% of the nurses knew the proper fitness of the desks to the students.The reason of that may be because they did not have enough authority in this aspect.
A minimal distance between the writing class-room board and first line of desks is required as a safe guard for prevention of eye strain and fatigue of children.In a study done in Alex, Fahmy et al., (1974) (25) found (1993) (26) stated that school authorities are responsible for providing a safe and adequate water supply for school use.In addition to being free from contamination, water should be palatable and sufficient. (27) the present study 96.0% of nurses gave correct but incomplete answers about the provision of the school with suitable safe water.
The study revealed that a significant Findings of this study are in harmony with Saleh (2007) (17) , who reported that the major score sector of nurses scored an average level of knowledge.
Creswell, and Newman (1993) (26) , As regards their performance in keeping records, the results found that the majority of nurses presented their reports to a specialized committee.On the same line, Saleh study (2007) (17) , indicated that the school nurses had adequate performances as regards recording and reporting data.
Shamma (1999) (28) (17) , who reported be available and so the telephone numbers of the district hospitals and parents. (29)e physical qualities of classroom among many other effective agents can be considered of the most important factors influencing the achievement of the attending school child. (30)On the site observation involving the physical environment of a sub sample of the schools, it was found that highest percentage of the schools had clean classes.Findings of this study are in harmony with Tawila et al., in Egypt (2000) (31) who reported that 72 % were clean.
However, the present study revealed that only 8.6 % of the sample of schools had clean water closets (WCs), this finding is in accordance with the study of EL-Din et al., (2006) (27) in Alexandria, which showed that more than 60% of the study sample perceived the WCs in schools as unclean.
As regards hand wash basins observation, only 22.9% were considered clean.This finding is in contrast with the previous study in Alexandria (1997) (32) who stated that 60% of hand wash basins were clean.
School playground must be kept clean and devoid of all hazards as pits and collections of stones.At the same time, there should be adequate supervision.
Unprotected posts, gravel-covered playing surfaces, poor drainage allowing mud to accumulate, slippery concrete surfaces, hedges and trees that scratch, uneven surfaces, and poorly constructed or supervised play equipment constitute significant environmental hazards. (26)The present study showed that most of the playground are clean and free from physical growth, neuromuscular refinement, and rapid expansion of cognitive and social skills.The school is the second home among the primary places that children spend their time. (1)The school environment when properly organized and well established Bull High Inst Public Health Vol.40 No.1 [2010] 123and maintained will have a promoting effect on students' growth and development.(1)(2)(3) educational knowledge and background to be actively involved in promoting a safe healthy school environment.They should also have formal training in health Ibrahim et al., 124 education and an understanding of the health needs of all children in schools. (4)

Figure ( 1 ):Figure
Figure (1): Distribution of nurses by their overall knowledge score about the school health program and healthy physical school environment.

Figure ( 2 ):
Figure (2): Distribution of nurses by their overall attitude score towards keeping healthy school environment 2-Inspection of playground to ensure:-A) General cleanliness B) Presences of covered garbage boxes C) Presences of plastic bags in garbage boxes D) Free from accidents agents 76.1 90.4 68.5 70.9 3-Inspection of school sanitation to ensure :-A) presence of potable water B) cleanliness of hand wash basins and water closets C) presence of soap in hand wash basins D) working flushing water of siphons E) Others ( bad odor) of classrooms environment to ensure:-A) Cleanliness of classes B) Absence of bad odors C) Absence of broken students desks D) Nonworking electric lamps E) Presence of broken window glasses F) Others (absence of uncovered wiresabsence of insects -illumination) If the nurses are able to recognize and identify the influences of school physical environment on the health and well being of the students, they can participate in the activities of promotion of the environment and prevention of hazards that might affect the health of the students.Nurses must have the correct knowledge and status.Nurses having bachelor degree of nursing and nurses having technical health diploma were able to answer the knowledge questions correctly.This may be due to the fact that they are wisely affected by their marital status and having children, they know how to deal and interact with the children and school physical environmental especially in the primary schools.*Nurses attitudes regarding healthy physical school environment:-"Attitude" is a predisposition or a tendency to respond positively or negatively towards a certain idea, object, person, or situation.School nurses participate in healthy school physical environment by monitoring and intervening to correct physical hazards.Nurses attitude influence their choice of action and responses to challenges. (9)Nurses must have good knowledge and attitude to be actively involved in promoting school environment.The present study showed that the majority of nurses scored fair attitude and 40% of them scored average knowledge in maintaining school physical environment.
, and behaviors are unclear.Although it is logical to assume that these relationships exist, it has not been shown.For example, the change in knowledge will result in a change in attitude or that a change in attitudes necessarily predicts a change in behavior.Attitudes can exist in the absence of supporting knowledge and behaviors can exist in the absence of attitude and knowledge as to why the behavior is carried out.
that a high percentage of nurses inspect the school playground.The nurse should detect hazardous conditions in the classrooms, in the playground, and else where in the school, she can take appropriate action to eliminate or correct such condition.There must be a suitable plan to provide a suitable measure to be Bull High Inst Public Health Vol.40 No.1 [2010] 141 used in emergency conditions and to ensure the absence of physical hazards, the presence of emergency kit, the maintenance and the prevision of student's records, safe playground and safe stairs conditions.Telephone communication must

Nurses knowledge regarding school health program and healthy school physical environment.
degrees.The nursing attitude total score equals "170" and was leveled as follows; good attitude had a score "114-170", fair attitude had a score "57->114" and poor attitude had a score "> 57 ".-Nurse's Practice by questioning them, they were asked about:-Keeping healthful school