School
Nursing: What It Was and What It Is
By: Linda
C. Wolfe and Janice Selekman
Published with permission by Pediatric
Nursing 28(4):403-407, 2002. © 2002 Jannetti Publications, Inc.
Introduction
Do you remember your school nurse when you were growing up? She probably
was a female wearing a white uniform, was limited in the interventions she
could administer, provided first aid, monitored your height and weight,
sent you home when you were sick, and may have organized a Future Nurses
Club. Maybe you didn't even have a school nurse. Do you remember your classmates
when you were growing up? They probably were a rather homogeneous group
of individuals with few of your classmates having special needs; those who
did were usually in an isolated classroom.
The changes in the responsibilities of today's school nurses are directly
related to the changes in the school setting. While the specific needs of
students, families, and communities have changed and continue to change,
the essence of the practice of school nursing remains the same. In 1902,
school nursing was established in New York City, based on a program in London
established in 1893 and the public health model of the Henry Street Settlement.
Emphasis was placed on measures to decrease the spread of communicable diseases,
increase hygiene, and decrease truancy by intervening directly with families.
This included "follow-up in the homes to insure treatment for children
excluded from school because of infectious diseases" (Grant, 2001,
p. 388). One hundred years later, school nurses continue to assure that
children enter the classroom free of communicable disease and in optimal
health.
Prior to the advent of school nursing, physicians monitored schools on a
weekly basis, sending children home if they demonstrated symptoms of contagious
disease. While the mere act of exclusion, without follow-up treatment and
care, did not reduce the spread of disease, it did increase absenteeism
in a city that had recently mandated school attendance. Absenteeism was
of great concern because it likely resulted in school failure and, ultimately,
an uneducated population. It was assumed that if children were in their
classrooms, they would learn.
That objective of assisting children to get into the classroom remains essentially
the same today. However, school nurses today go beyond that limited scope;
they assist students to achieve optimal wellness in order to enhance their
readiness to learn through a coordinated system that ensures a continuum
of care among students, school, home, health care providers and community
resources. While the students of today have very different health needs
than those in earlier days, the goal of individual success is constant.
Legislative Changes Affecting School Health
There have been significant legislative changes that have impacted on the
role of the school nurse. The Rehabilitation Act of 1973 and the Individuals
with Disabilities Act [IDEA] of 1975/1997 had the greatest impact on the
school nurse's scope of practice by expanding the definition of a "student"
and requiring schools to provide services. Section 504 of the Rehabilitation
Act prohibits discrimination on the basis of disability and mandates access
to public schools for children with disabilities. This law mandates that
accommodations be made and barriers removed so that children with disabilities
have access to public programs, including schools and services. They may
not be excluded from participation in or be subject to discrimination under
any program that receives federal monies (Section 504, 1973). It requires
that reasonable and individualized accommodations be made in the school
setting.
IDEA grew out of the Education for All Handicapped Children Act of 1975,
also known as Public Law 94-142. This law mandates that eligible children
with disabilities receive a free and appropriate public education in the
least restrictive environment based on the development of an Individualized
Education Plan (IEP). Children with disabilities must have educational opportunities
and benefits equal to those provided to their non-disabled peers (IDEA,
1997). While these laws mandate services, they do not provide sufficient
funding to meet the comprehensive health needs of children in the school
setting. In 1999, the Supreme Court upheld, in the Garret F decision, that
schools are financially responsible for providing nursing services required
of children with medical needs in order for them to access and benefit from
the educational program (Cedar Rapids Community School District v. Garret
F, 1999).
The Changing Focus of Health Care for Children
The focus of health care in the first half of the twentieth century was
on the treatment of acute illness. As science advanced, more technologies
were developed to treat disease and prolong life. Children born with chronic
conditions, who previously would have died in infancy or very early childhood,
now were living through the school age years. Previously, many children
were considered too ill, frail, or handicapped to attend school; yet, society
determined that although learning may be challenged by a physical condition,
the ability to learn was present in all children. Children with chronic
conditions who had been cared for in institutions rather than in the home
were transitioned back into public settings, including schools, homes, and
community programs.
As a result of all these changes, a group of children with a diverse health
status entered the schools. They brought with them their nebulizers, insulin
pumps, ventilators, catheters, monitors, wheelchairs, feeding tubes, and
medications. It is estimated that 10%-15% of school children currently have
a chronic condition (Passarelli, 1994), although many school nurses believe
this is a gross underestimation.
In addition to the treatment of acute and chronic conditions, there has
been a significant increase in the focus on both health promotion and disease
prevention. There is now a major emphasis on immunizations; bike and car
safety; screening for hearing, vision, and scoliosis; and decreasing high-risk
behaviors, such as sexual activity, smoking, drinking, and drug use. These
are now essential components of the health services provided in the schools.
A Coordinated School Health Program is more extensive than the health services
provided by a school nurse. This broader approach includes components that
address the child's health in a holistic manner and uses a multidisciplinary
approach. The components include health services, nutrition services, physical
education, counseling/psychological/social services, staff health promotion,
the school environment, and the community/parents (Duncan & Igoe, 1998).
The Changing Face of Today's Student
The school population is no longer homogenous; it represents a more diverse
population. Children come not only with different medical conditions but
also with different social and emotional needs. They represent all segments
of our society and are part of a huge array of family constellations. Much
research and attention has been directed at identifying and intervening
with special populations of children who are labeled "at-risk."
They may be at-risk for substance abuse, pregnancy, school failure, obesity,
suicide, or other morbidities. The reality is that all children are at-risk.
In the same classroom, children with acute conditions such as otitis media,
URIs, and gastrointestinal upset sit alongside children with cancer, asthma,
allergies, attention deficit/hyperactivity disorder (ADHD), child abuse,
and diabetes. Children in wheelchairs sit next to their able-bodied peers.
Children with sensory and visual alterations use various devices to assist
them in their communication and learning. Children with mental retardation
are in the classroom with their same-age peers.
One area that has seen the most recent change is the significant increase
in the incidence and prevalence of children with diagnosed psychiatric conditions.
Childhood depression; ADHD and learning disabilities; anxiety disorders;
and more serious conditions, such as bipolar and conduct disorder, have
challenged the classroom teacher and had a significant impact on the medications
administered by the school nurse.
The culture of poverty continues to impact on school health, as school nurses
respond to children who do not have access to or cannot afford health care.
These children may come to school without breakfast or without proper attire,
resulting in school nurses providing such basic items as food or a sweater.
Children who are homeless and living in shelters often miss school or change
schools multiple times in the same year, resulting in the school nurse needing
to connect families with social services and hunt down lost immunization/medical
records. Children in foster care bring with them the issues of who is the
legal guardian, resulting in the school nurse understanding and interacting
with the legal system to obtain required paperwork before treating and referring
children with identified needs. In addition, children now represent multiple
cultures, resulting in the school nurse having to communicate with non-English-speaking
families and to have knowledge of the health care and child rearing practices
of many cultures.
The Expanding Role of the School Nurse
While the essential role of the school nurse is constant, the responsibilities
and expectations of the school nurse have changed dramatically. The skill
level has increased commensurate with that occurring in inpatient care.
Ventilators, catheters, feeding tubes, chest physiotherapy, glucose monitoring,
and insulin pumps are just some of the daily skills required of the school
nurse. One ever constant challenge is that the children in any one school
are cared for by different health care providers; thus, the protocols and
equipment for the same condition may be different, requiring the school
nurse to be familiar with multiple technologies and protocols.
Just as the hospital/staff nurse has been developing individualized care
plans for years, school nurses develop Individualized Health Plans (IHP)
for children with chronic conditions to assure that their health needs are
being met in the school setting. These are separate from the IEP or 504
accommodations that are developed by interdisciplinary teams to meet the
educational needs of the child. IHPs are developed primarily by the school
nurse with input from the student and family. Based upon a nursing assessment
and diagnosis, goals are established to address such things as self-care
and increasing the child's knowledge based on their needs and abilities.
The increased number of children with life-threatening conditions has necessitated
the development of emergency care plans. These may include such things as:
"Do Not Resuscitate" orders for the child in the terminal stages
of muscular dystrophy who is still attending classes; evacuation plans in
the event of a school emergency for the child in a wheelchair; notification
protocols in the event of school conditions (i.e., infection) that may further
compromise an immunodeficient child; and a plan for responding to contact
with an allergen for the child with a food allergy.
School nurses are challenged to meet these ever-growing needs even though
the number of school nurses per number of students has not increased proportionately.
The National Association of School Nurses (NASN) recommends that the school
nurse to student ratio be 1:750 in the general school population; 1:225
in the mainstreamed population; 1:125 in the severely chronically ill or
disabled population; and in the medically fragile population, a ratio should
be determined based upon individual needs (NASN Position Statement, Caseload
Assignments, 1995). It is interesting to compare this to workload assignments
on inpatient units. Brener and associates found that approximately half
of the schools queried have either an RN or an LPN in the school at least
30 hours a week (Brener et al., 2001).
While advocates recommend a school nurse in every school, many schools are
still without any school nurse or even a school nurse who visits on a daily
basis. In order to meet the health needs of all school children, many school
systems require school nurses to delegate nursing procedures to less-qualified
individuals. These unlicensed assistive personnel (UAP) often receive limited
training. In the best-case scenario, UAPs are totally supervised by a professional
school nurse with established protocols for care. Unfortunately, some school
systems still designate the secretary or other school personnel to be responsible
for medications, treatments, and assessments; emergencies are then handled
by 911 calls. Delegating care to other nonnursing personnel may conflict
with individual state nurse practice acts, yet the practice is so common
place in schools that is goes unquestioned. It is important for staff nurses
to ascertain who is in the school nurse's office providing care. Just as
in the hospital setting, a person answering to "nurse" may not
be an RN.
While school nurses' technical expertise has increased, their professional
roles have also increased. In addition to ensuring compliance with children's
school entry health requirements and treatment protocols, school nurses
are now often responsible for case management, making and following-up on
referrals, assuring the overall health and safety of the school, providing
for staff wellness, and maintaining the security of medications. They are
responsible for the management of the school health office, maintaining
records, and assuring student compliance with state and local regulations
related to health and safety. They participate in the establishment of health-related
protocols and policies within the school and participate in the development
of IEPs and 504 accommodations as well as participate on crisis teams and
intervention teams for children identified at-risk.
School Nurse as a Component in the Continuum of
Care
The education system relies on the school nurse to be the link between the
medical and educational communities. The school nurse should be a partner
in a child's continuum of care, but this is often not the case. When a child
is discharged from the hospital, there is rarely communication between the
hospital and the school. This means the school nurse receives medical information
directly from the parent. Sometimes it is the child who shares the information,
and sometimes the school receives no information. Therefore, there is a
great risk that all of the work initiated in the hospital will not be continued
or will not be consistent. If hospitals, when developing discharge summaries
and discharge plans that include procedures and treatment protocols, could
designate one copy for the school nurse, it would greatly enhance the continuum
of care.
With this information, school nurses would be better positioned to insure
patient compliance and continuation of services. School nurses are an excellent
resource to monitor the child's condition in order to facilitate a good
outcome. They can assess the efficacy of seizure medication and the intervention
measures for ADHD. They can reinforce the teaching done to identify asthma
triggers and the measures a child should take when they think an attack
is imminent. They can reinforce self-care measures, such as self-catheterization.
Hospital discharge prides itself on direct patient and family education;
school nurses can reinforce these efforts. It is often forgotten that children
are in the school setting for 6-8 hours a day plus any before or after school
activities. This is half of their waking hours.
Traditionally, institutions have used the issue of confidentiality to justify
the lack of communication between schools and health care settings. However,
the child's right to receive a seamless delivery of care should never be
compromised. Take, for example, a case of a child with frequent admissions
for cancer who has a central line that is used for ongoing periodic hospital
treatments. Because no treatments were to occur in the school setting, the
school nurse was not informed that a central line was in place. However,
this child participates in gym classes and other after-school activities.
Any injury to his neck or chest could have significant ramifications. Confidentiality
has always allowed for the sharing of information on the need-to-know basis
between health care providers; school nurses need to know.
The school nurse can assure accommodations are in place if he or she is
a partner in the care of the child. School nurses should be participants
in the development of IEPs and 504 accommodations. Whether or not the child
is currently on treatment for their health condition, accommodations include
the use of the school health office.
As computer technology expands, it is hoped that communication between acute
care facilities and the school nurse and between primary care offices and
the school nurse will improve in order to enhance the care and health of
the child. School nurses are competent to continue that care. Effective
school nurse interventions may decrease the need for hospitalizations.
Scenarios
Following are several scenarios that represent the daily challenges school
nurses face in the delivery of health services within the school.
In all these situations, the school nurse is legally responsible for this
child in the school during school hours. If there is a problem, it is the
school nurse who must respond or have an emergency plan in place. To exclude
the school nurse from the loop of information puts the child at increased
risk for complications. To exclude the school nurse as a partner in the
care of the child, misses an opportunity to support the child in a holistic
manner.
How the Nursing Community
Can Assist School Nurses
In order for school nurses to be effective in assisting students to meet
their optimal potential in the classroom, the school nurse needs to have
knowledge of current trends and practices in medical/nursing care and have
open systems of communication to coordinate care.
The nursing community can assist school nurses by considering their educational
needs when providing continuing education. Unfortunately, there are few
course offerings that address the child in the school setting. While it
is helpful to learn about new conditions and treatments, education is needed
on how to work with the child after they return to school. Rarely are the
educators knowledgeable about the constraints and expectations of the school
setting. When hospitals orient staff to new equipment or skills, school
nurses should be invited so that they can continue the care of the child
in the school setting. Insulin pumps appeared in schools with children and
parents educated on their use, but without preparing the school nurse.
School nurses interact with a myriad of people on any given day: students,
faculty, parents, guardians, caregivers, medical providers, social service
agencies, the judicial system, emergency personnel, institutions, and the
community. They are positioned to be strong child advocates and to facilitate
quality care, but only if they are informed.
Nurses have always held in high esteem the nurse who can handle an emergency
room or monitor patients in a critical care unit. Collegial support is needed
for the school nurse who on a daily basis delivers emergency care, triages
the sick and injured, intervenes in psychiatric disorders, monitors technology-dependent
children, and provides routine medications and health assessments.
Certification for School Nurses and School Nurse
Organizations
State or local certification for school nurses is a usual requirement for
practice. Typically this is through the state education agency. Similar
to a nursing license, school nurse certification assures the public that
the practitioner has an educational background and experience to safely
and competently meet the needs of the client in his or her care. National
certification demonstrates excellence in practice and not just minimum entry
competence. National School Nurse certification is obtained through the
National Board for the Certification of School Nurses.
NASN has over 12,000 members. The 2000 National Sample Survey of Registered
Nurses indicates that there are over 61,000 public and private school nurses
in the U.S. (Health Resources and Services Administration, 2002). Therefore,
approximately 17% belong to the NASN.
Conclusion
NASN defines school nursing as "a specialized practice of professional
nursing that advances the well being, academic success, and life-long achievement
of students. To that end, school nurses facilitate positive student responses
to normal development; promote health and safety; intervene with actual
and potential health problems; provide case management services; and actively
collaborate with others to build student and family capacity for adaptation,
self-management, self-advocacy, and learning" (NASN, 1999).
The best picture of the current school nurse can be drawn from a 1998 survey
of NASN members attending the national conference. They reported that:
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67% had counseled
a depressed or suicidal student |
|
82% had identified
an abused child |
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98% had saved
the life of a child. |
It is no wonder that school nursing is a practice that yields high job satisfaction
and low turnover. To nurse in a specialty practice that focuses on the holistic
needs of a client with an interdisciplinary approach yields untold rewards.
The knowledge base needed by the school nurse must be extensive; they are
competent, knowledgeable, and solely responsible for the children in their
care. They are not only pediatric nurses, they are also community health
nurses, psychiatric nurses, emergency-room nurses, and home care/visiting
nurses. They are the primary and acute care providers, the educators, the
policy makers, and the social workers. They are office managers and nursing
administrators. In addition, they also provide care to adults who work in
their setting.
While they appear to "do it all," they are the only pediatric
nurses who truly see almost every child in the country. School nurses
know that at the heart of their practice is the belief that all children
have the ability to learn, all children have a right to an education, and
society is best served when its young people are educated. The role of the
school nurse is to assist children and families to achieve a level of wellness
that allows the children to participate in the educational process that
will prepare them for their future.
References:
Brener, N., Burstein, G., DuShaw, M., Vernon, M., Wheeler, L., & Robinson,
J. (2001). Health services: Results from the School Health Policies and
Programs Study 2000. Journal of School Health, 71(7), 294-304.
Cedar Rapids Community School District v. Garret F. (1999). 119 S.Ct. 992,29
IDELR 966 (U.S. 199).
Duncan, P., & Igoe, J. (1998). School health services. In E. Marx &
S. Wooley (Eds.), Health is academic: A guide to coordinated school health
problems (pp. 169-194). New York: Teachers College Press.
Grant, A. (2001). The nurse in the school health service. Journal of School
Health, 71(8), 388-389.
Health Resources and Services Administration. (2002). 2000 National sample
survey of registered nurses final report released. Retrieved April 15, 2002,
from www.bhpr.hrsa.gov/healthwork-force.
Individuals with Disabilities Education Act (IDEA). (1997). Retrieved April
6, 2002, from www.thelaughtongroup.com/
ppdsupport/idea/ideatext.html
National Association of School Nurses (NASN). (1995). Position statement:
Caseload assignments. Retrieved May 13/2002, from www.nasn.org/positions/caseload.htm
National Association of School Nurses (NASN). (1999). Definition of school
nursing. Retrieved April 8, 2002, from www.nasn.org
Passarelli, C. (1994). School nursing: Trends for the future. Journal of
School Nursing, 10(2), 10, 12, 14, 16-21.
Section 504, Rehabilitation Act. (1973). 29 U.S.C. Section 794; Regulations
at 34 C.F.R. Section 104.
Linda C. Wolfe, MEd, RN, NCSN, is Education
Specialist, Health Services, State of Delaware, Wilmington, DE; and President,
National Association of School Nurses.
Janice Selekman, DNSc, RN, is Professor, Department
of Nursing, University of Delaware, Newark, DE.
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