Policy development can be guided by the Public Health Ontario’s Health Promotion Policy Development guide Policy is a plan used to guide decision making in professional settings (Buse, Mays, & Walt, 2005). “The activity of developing policy generally involves research, analysis, consultation and synthesis of information to produce recommendations” (Auditor General Manitoba, 2003, p.2). Evaluation is the final step of policy development to assess implementation and impact of the policy (Auditor General Manitoba, 2003). This article describes the development of a school nurse policy in Saudi Arabia using the eight-step model by the Health Promotion Center at the PHO (2004). Each step is identified and activities described related to the policy of requiring nurses in Saudi schools.

Step 1: Identify the Problem/Issue/Policy

The first step in policy development is identification of the issue (McFadden, Priest, & Green, 2010). School health in Saudi Arabia was identified as a problem in need of a policy. Chronic health problems such as asthma and diabetes and acute problems such as infection, fever, or allergy are experienced by school children in Saudi Arabia. Social problems, including bullying, require support and further follow-up (American Academy of Pediatrics [AAP], 2009) that is not currently available in these schools. To prioritize the health and safety of students in education, providing a school nurse in each school is essential (AAP, 2015; Magalnick, Mazyck, & AAP Council on School Health, 2008). In Saudi Arabia, there is no policy regarding mandatory school nurses (Alqallaf, 2016), therefore, a policy requiring nurses in Saudi Arabian schools should be established to provide comprehensive health services to students.

Description and Context of the Problem

“The aim of this process is to gain a better understanding of the potential policy issues within the environment and the relationship between stakeholders and these issues” (McFadden, Priest, & Green, 2010, p.8). In Saudi Arabia, the issue is apparent as increases in health problems among children have become commonplace (Alqallaf, 2016). Currently, these issues are not addressed routinely due to variation in health care accessibility outside of school and lack of nurses in schools (Alqallaf, 2016). The World Health Organization (WHO) revealed that obesity in Saudi Arabia increased between 1988 and 2005 (Alqallaf, 2016). The prevalence of obesity and overweight among Saudi children and adolescents is also increasing; nearly 14% of girls and 12% of boys are overweight or obese (Al-Hussaini, et al., 2019). Interventions are needed to reduce the likelihood of developing chronic conditions. School nurses can impact this issue by providing nutrition and exercise information in schools.

Additionally, there are many Saudi children who live with type 1 diabetes and need care at home and school. “Diabetes in children has increased globally, and the World Health Organization ranks Saudi Arabia 7th in prevalence and 5th in incidence of type 1 diabetes (T1D)” (Alaqeel, 2019, p. 125). While many factors contribute to chronic health problems, sedentary lifestyle and eating habits during childhood promote their development. “Thus, addressing health behaviors during childhood where attitude and habit formation is occurring is imperative to having a public health impact” (Alqallaf, 2016, p. 2).

In addition, some Saudi children and adolescents experience violence and bullying in school that impacts emotional health and academic performance. Thirty percent of Saudi students have experienced bullying and 25% experienced physical violence at school (AlBuhairan, 2015).

“School bullying is a serious and common type of violence that takes place inside or outside the school and is considered a global health issue” (Alrokban, Alzaidi, Alqahtani, Almoayad, & Fiala, 2019, p. 105). School bullying can be verbal or physical and may promote aggression, depression, suicide, and poor academic performance (Alrokban, et al., 2019; Alqallaf, 2016). Violence among children is costly in Saudi Arabia (Almuneef et al., 2012) as is type-one diabetes (Robert, Al-Dawish, Mujammami, & Al doDawish, 2018). “Estimated global healthcare expenditures to treat diabetes and prevent complications totaled $465 billion in 2011. By 2030, this number is projected to exceed some $595 billion” (Alhowaish, 2013, p. 2). School nurses have experience to deal with these common childhood issues. “Through their presence in the school system, school nurses not only provide for the safety and care of students and staff but are also the ideal teaching source for integrating comprehensive health solutions into the education setting” (Alqallaf, 2016, p. 8). The school environment influences health behaviors and attitudes that lead to health promotion and disease prevention among children, and a mandatory school nurse can guide interventions to impact behavior (Alqallaf, 2016).

Legal and Political Context

“The source of policy can be legislative, administrative, and constitutional” (Rayan, Elayyan, Qurneh, & Baker, 2016, p. 49). School nurses cooperate and work with leaders and teachers to change the health behaviors that lead to a positive impact on the students’ health (Alqallaf, 2016). A legal policy is highly recommended to ensure a licensed nurse in each school to address health issues, violence, and bullying among children (Alqallaf, 2016). “School nurses are important leaders and powerful advocates for children’s health and wellness in schools” (Alqallaf, 2016, p. 5). Most western countries provide a licensed nurse within each school to address the health issues among children and adolescents. In the United States and Canada, each school has health teams that consist of health educators and school nurses. Saudi Arabian families would also benefit from the addition of a nurse to the school team.

Formulate the Problem Statement

School nurses can impact health behaviors and address common childhood problems, including bullying, diabetes, nutrition, and exercise interventions. All children in schools have the right to learn in a safe and healthy environment. School nurses can impact health behaviors and address common childhood problems, including bullying, diabetes, nutrition, and exercise interventions. Hence, a policy on providing a licensed nurse in each Saudi Arabian school should be developed.

Gather Data and Analyze the Issue

The problem exists because licensed nurses are absent in schools which limits treatment of issues such as bullying and illness. The populations affected are Saudi children and adolescents (Alqallaf, 2016). One factor that may affect the problem is the nursing shortage in Saudi Arabia, which can be also related to Saudi cultural perceptions. “The Saudi literature links the shortage in Saudi nurses to socio-cultural factors found to influence the prevailing negative images and perceived low status of nursing” (Lamadah & Sayed, 2014, p.20). In general, Saudi society misunderstands the role of school nurses. “School health nursing is often seen as a job which fits in with motherhood, middle-class employment, and school hours, leading to perceptions that school nurses are women who provide services for ‘pin money” (Croghan, Sanders, & Aveyard, 2004, p. 380).

Moreover, Saudi culture sees the nursing profession as a female profession, with few Saudi male nurses. “Nursing is generally considered more as a female profession, and in Saudi Arabia, the participation of women in nursing is very limited” (Aboshaiqah, 2016, p. 501). Despite the shortage, it is essential that each school has a Saudi school nurse, because care provided by a non-Saudi nurse may lead to misunderstandings regarding the Islamic culture (Alqallaf, 2016). Community awareness about the essential role of nurses in schools is essential to the success of the policy.

Identify and Understand Stakeholders

Primary stakeholders are the Ministry of Health (MOH) and Ministry of Education (MOE) as well as representatives from teachers, nurses, public health, and funders. The MOE attempted to resolve the issue by training teachers on first aid but they were unable to provide comprehensive care, further supporting that each school needs a qualified nurse (Alqallaf, 2016). The MOH is negatively affected by rising rates and associated costs of childhood chronic diseases, obesity, and violence. Although the MOE provided health services programs in the past, they were not sustainable due to lack of resources (Khan, 2011). A challenge is helping the MOH and MOE to support a budget to address the nursing shortage as well as provide a school nurse for each school. This may be feasible as the training for the teachers and school staff to perform first aid (Alqallaf, 2016) was not sustainable. Secondary stakeholders are parents, children, nurses, and other school staff. Also, the community and government will benefit from this policy since the health care and outcomes will be addressed in the school setting, potentially reducing costs.

Step 2: Assess Community Support, Capacity, and Readiness to determine if a Policy is an Appropriate Strategy

Assess Community Support and Capacity

While some in Saudi society do not understand the need for school nurses, some support the role of a nurse in promoting the health of students and ensuring a safe and healthy environment in schools (Alqallaf, 2016). Community awareness regarding the role of school nurses in health promotion and illness prevention is needed (Lamadah & Sayed, 2014).

There are few educational programs in the Saudi community focusing on bullying and obesity among children. There are few educational programs in the Saudi community focusing on bullying and obesity among children. However, these programs or campaigns are new, and the problem still exists, suggesting need for further intervention. Awareness of the problem has increased and has been featured in media such as TV and newspapers. The increased number of children with infection, diseases, violence, and bullying at schools indicates a need for change. Social media influences societal awareness of the issue and may help to garner support among the community.

Decision Makers of the Issue

The potential decision-maker who has the power to implement policy is the MOE. The MOE will support this policy since other in-school interventions were unsuccessful and unsustainable.

Force Field Analysis (Climate for Change)

Policy proposals will be supported by MOE and the community since the issues among children at school will be decreased. Driving forces for consideration are: academic success, improved child health, and decreased bullying and violence. On the other hand, restraining forces might include opposition from physicians or others who believe only physicians should provide care.

Determine if Policy is an Appropriate Strategy

At this point, the problem was critically examined from many perspectives. A decision about whether to proceed with the policy was considered, and the decision to move forward with developing the policy was made. Providing each school in Saudi Arabia with a qualified nurse is the only solution to this problem. Additionally, it was determined that the necessary support to implement the policy is available from key stakeholders.

Step 3: Develop Goals, Objectives, and Policy Options

Setting Goals and Objectives

The goal of this policy is to meet the health needs of students by implementing the policy of providing a nurse in each school. The objectives are as the following:

• After 6 months from implementing the policy, bullying and violence among children within schools will be decreased by 80%
• After 6 months from implementing the policy, infection and complications from chronic diseases will be reduced by 80%
• After 6 months from implementing the policy, students’ academic performance will increase by 95%

Choosing the Policy Option (Alternatives)

The first option is to do nothing or remain “status quo”. No actions are taken, and no modifications take place. If this option is chosen, students will be at risk for violence, bullying, and infection at school. The second option is promoting change by developing a policy that meets the health needs of children in Saudi Arabia. This option will be supported since it addresses the issue.

Set the Evaluation Criteria

The policy alternatives will be compared based on seven criteria that were developed by the Health Promotion center at the PHO (2004). These criteria are economic criteria, equity criteria, efficiency criteria, political feasibility, sustainability, administration feasibility, and environmental criteria (PHO, 2004). The efficiency of the policy is essential and can be achieved by meeting the health care needs of students and protecting them from violence and bullying within schools. Other criteria such as political feasibility, equity criteria, and economics of implementing the policy are also important. Finally, sustainability, administration feasibility, and environmental criteria are evaluated to determine community support of the policy.

Analysis of Policy Options and Scoring

Option 1. The first option is to continue with the “status quo” where no action is required. This will impact the health of Saudi school children. This policy is applicable, not costly, and politically feasible. However, this option violates the equity criteria because children’s health will be at risk. This option is socially unacceptable as children will face harm and potential poor health.

Option 2. The second option is promoting change by developing a grassroots policy that meets the health needs of children in Saudi Arabia. This option is applicable, socially acceptable, and it will decrease the cost of compensation for children who are affected by infection, chronic disease, bullying, and violence, which likely outweighs the cost of policy implementation. Ensuring political feasibility is essential to make this a viable option.

After creating the two options, it is important to select only one option which meets the evaluation criteria. Table 1 compares the options using a scorecard based on the evaluation criteria. It is obvious that option one is applicable, low cost, and politically feasible, but it violates the equity criteria and is not socially acceptable. However, option two has a higher total score than option one because it is effective, low cost, fair, efficient, and socially acceptable. Hence, option two is chosen.

Table 1 Policy Analysis Scorecard

Steps 4 and 5: Identify Decision Makers and Influencers and Build Support

Policymakers and community members are two groups needed to support the policy. The primary decision-maker who has the power to implement policy is the MOE. The MOE will support this policy since other in-school interventions were unsuccessful and unsustainable. This decision-maker should be approached and educated regarding the goals of the policy. Furthermore, gaining support from others impacted by the issue, such as parents, families, teachers, and nurses is essential to implementing the new policy. Understanding that some will disagree with the policy and goals is necessary to overcome obstacles related to implementation. The media can be used to support the viewpoint of children and parents who are affected by the issue. Educational campaigns and brochures can be used to increase awareness and support of the policy.

Step 6: Write and Revise the Policy

This policy is high level legislation because as it affects the entire nation. The policy will be:

• Preface: there is a high prevalence of chronic disease, obesity, infection, bullying, and violence among children in schools. The role of school nurses is to maintain the health and well-being of children within the school. Also, to provide a safe and healthy environment for children to achieve high academic performance. Therefore, this policy was developed to mandate nurses in each school in Saudi Arabia.
• The goal of this policy is to meet the health needs of students by implementing the policy of providing a nurse in each school.
• The objectives are as the following:
  • After 6 months from implementing the policy, bullying and violence among children within schools will be decreased by 80%
  • After 6 months from implementing the policy, infection and complications from chronic diseases will be reduced by 80%
  • After 6 months from implementing the policy, students will improve academic performance by 95%
• Associated activities:
  • Provide direct care for children with injury and infection
  • Develop a leadership role in the school environment
  • Create a healthy and safe environment at school
  • Establish health education programs within schools
  • Act as a liaison between parents, other healthcare providers, and school staff.
• Regulations:
  • All schools must maintain a healthy and safe environment for children by providing an experienced nurse
  • The school nurse should provide a health care plan for each student
  • The school is responsible to make sure that the license of the nurse is renewed before 6 months from the expiration date
  • The nurse is responsible to encourage physical activity and develop a nutritional plan for children
  • The nurse is responsible to deal with cases of violence and bullying at school
  • The nurse is accountable to communicate with parents and families frequently regarding the health of the child
  • The nurse is responsible to refer the case to the hospital if necessary
  • The school will keep file for each child as evidence of follow up
• Sanctions:
  • If nurses do not follow the policy, points will be taken from their license which can affect renewal or lead to suspension.
• Failure to comply with the regulations:
  • Failure to comply with regulations will lead to negative consequences, including fines (500,000 to 1000,000 SR).
  • Failure to comply with regulations can lead to school closing as it is not providing a healthy and safe environment for children.
• Plan for promoting and disseminating the policy:
  • Conferences with school leaders to present the issue and policy
  • Increase awareness via campaigns to nurses, school staff, and families, including social media
• Plan for monitoring and evaluating the policy:
  • This policy will be monitored and evaluated every 6 months

Step 7: Implement the Policy

This stage is essential because if the policy isn’t implemented, something is wrong with the policy generator and the outcome may not be achieved as assumed (Buse, et. al., 2005). It is very important to identify the time, money, personal power, and expertise needed to implement the policy. Consultation and support from MOE is necessary to implement the policy. The timeline for implementing the policy may be one to two years, and the COVID-19 pandemic may extend this process since it is a primary concern for the MOH and MOE. The budget is likely the biggest barrier to implementation. This will be addressed by explaining that the cost of compensation for children who are affected by infection, bullying, and violence at schools will be decreased, and likely outweighs the cost of policy implementation. The draft policy will be shared with the key stakeholder who will be responsible for the implementation of the policy (MOE). Moreover, the appropriate time to start implementing the policy will be discussed as presently the COVID-19 pandemic is a primary concern for the MOE.

Step 8: Evaluate and Monitor the Policy

This stage “identifies what happens once a policy is put into effect – how it is monitored, whether it achieves its objectives, and whether it has unintended consequences. This may be the stage at which policies are changed or terminated and new policies introduced” (Buse, et al., 2005, p. 14). There are two types of evaluation which are process and outcome. In process evaluation, data is examined related to the effectiveness of the policy. Here, people who are affected by the policy will be asked to provide evaluative data. The quality of the policy will be assessed. In outcome evaluation, short-term and long-term goals will be assessed every 6 months to identify if they are feasible and effective. Intended and unintended outcomes will also be assessed. This policy is flexible, and modifications will take place as needed. Key stakeholders will be involved in the evaluation process.

Conclusion

Identifying an issue that can be addressed through policy development is a complex process that can be facilitated using the PHO Health Promotion Policy Development Guide Identifying an issue that can be addressed through policy development is a complex process that can be facilitated using the PHO Health Promotion Policy Development Guide (2004). The 8-step guide offers policy developers a template to ensure key considerations are accounted for throughout the process. Here, it was used to establish an effective policy that provides a framework to deliver high-quality health care for children within Saudi schools. Key considerations are examining the issue from multiple perspectives, raising awareness, garnering support, creating cooperative relationships with leaders, stakeholders, and social media to develop effective policy aimed to influence positive health outcomes.

Authors

Kholoud Alharbi, MSN, RN
Email: Kalharbi1@ksu.edu.sa

Kholoud Alharbi obtained her master’s degree in nursing education from Indiana University. She is an educator for the College of Nursing at King Saud University. Her areas of interest include policy analysis, education, simulation, and school health.