Introduction
School nursing in the
United States has existed for decades for the purpose of supporting the
educational mission of schools by preventing, removing, and/or reducing
barriers to student learning. In recent years, school nurses have become
increasingly more integral to America’s schools. The deepening of that
relationship has been motivated and supported, in great part, by legal
initiatives such as Section 504 of the Rehabilitation Act of 1973, the
Individuals with Disabilities Education Act (IDEA and IDEA reauthorization of
2006), and its predecessor, Public Law 94-142. Each of these helped to make the
distinct missions of schools and school nursing more complementary.
While more recent laws
are now on the books and numerous excellent nursing-preparation programs exist
in the United States, a limited number of nurse-training programs include a
specialty with a focus on school nursing. Thus, nurses who undertake school
nursing after graduation or upon leaving traditional hospital/clinic work are
often unprepared for and overwhelmed by the unique demands of professional
practice in the school environment. A nurse’s related frustration can be
heightened by the unique distinctions between the mission of schools and the
mission of providing health care.
Nursing education teaches
nurses to understand and support their profession within a variety of
traditional health care settings, where the mission of intervening to preserve
and promote good health is consistent with the mission of nursing. A school’s
mission, however, focuses on and promotes academic learning, both creative and
disciplined. The nurse’s focus within a school system is to mitigate the
effects of students’ health concerns on their ability to learn. When the
effects of a student’s health conditions are managed during the school day,
that student is able to come to school and learning is optimized. Many studies
have documented the benefits of school nurse practice in reducing absenteeism
(Allen, G. 2003; Weismuller, P., et al. 2007).1, 2
This chapter gives an
overview regarding the school nurse and the practice of school nursing.
·
Important
Parallels
·
History
of School Nursing
·
School
Nursing Definition
·
Role
of School Nursing
·
Framework
of Nursing Practice
·
Code
of Ethics
·
Scope
and Standards
·
Culturally
Competent
·
Staffing
o
Patterns,
Ratios, and Roles
o
Health
Care Personnel for the School Setting
o
Special
Needs vs. Private Duty Nursing
o
School
Nurses Practicing Below Their Licensure
·
School
Nurse Education, Certification, and Licensure
o
Preparation
and Education
o
Certification
o
Licensure
o
DPI
School Nurse Licensure
o
Wisconsin
Licensure Program Content Guidelines
·
Funding
o
Special
Education Categorical Aid
o
Medicaid
Reimbursement for School-Based Services
o
High
Cost Categorical Aide
o
Local
Funding
·
Evaluation
of School Nursing
·
Programs
and Policies
o
Coordinated
School Health Programs
o
Wellness
Policies
o
Response
to Intervention
o
Positive
Behavioral Interventions and Supports
·
Conclusion
Important
Parallels
As with any profession,
school nurses must rise to the challenge of balancing professional
responsibilities with the quest to fulfill personal goals. Knowing how the
professional responsibilities of different positions will interact with one’s
own job can make that balancing act even more fruitful. When nurses and
teachers understand each other’s work, they have the opportunity to eliminate
confusion and more fully understand how their work interacts to support the
development of competence and academic success in children.
Just as nurses have
different styles and approaches to help promote the healthy development of
children and youth, teachers have different styles and strategies for helping
children learn. Those styles are usually defined or influenced by a unique mix
of factors from the realm of profession and practice.
Both the nursing and
teaching professions are influenced and shaped by outside forces and concepts,
including licensing, credentialing, education degree programs, and by standards
of professional practice and conduct. Such measuring devices help define the
professions as a whole and involve or affect large groups of people.
Conversely, practice
embodies the inner forces that drive the individual: background, training,
personal style, and individual strengths and weaknesses. These factors help
shape the individual’s performance and behavior within the professional role.
History
of School Nursing
The
disciplines of school and public health nursing have their roots in England in
the late 19th century. Through transatlantic contact between the Secretary of
London’s School Nursing Society and Lillian Wald, a nurse in New York City, the
idea of managing the health of the community was born in the United States. Lillian
Wald was concerned about the rampant transmission of contagious disease in the
school setting. Since the exclusion of sick children from school did not stem
the tide of illness in the communities, Ms. Wald suggested that nurses treat
the students at school. In 1902, Lillian Wald chose Lina Rogers to be the first
nurse in the schools in New York City as a public health experiment. Ms. Rogers
provided the needed food and clothing for children to come to school during the
school day and identified and treated children with communicable diseases. As a
result of Ms. Rogers’ efforts, the rate of illness and exclusion due to
contagious disease declined dramatically. Ms. Rogers’ public health experiment
was so successful that New York City became the first city to employ school
nurses in their schools. The work of school nurses continued with the
introduction of wellness and illness prevention programs, introduction of paper
towels for hand drying, and audiological and dental screening programs in
school. The early work of Lillian Wald and Lina Rogers in the New York City schools
was the start of school nursing in the United States.3
Today, the role of the
school nurse has evolved into a marriage between student health and optimizing
learning. In providing health care and resources, school nurses minimize the
impact of the child’s health on their ability to learn. When children are not socially,
mentally, and physically healthy, students are not able to academically
achieve.
Definition
of School Nursing
School nursing has come a
long way since the early days. In 1999, the National Association of School
Nurses Board of Directors developed a definition of school nursing, which
states:
School nursing was defined as the
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 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.4
This definition speaks to
the specialized role school nursing has in the profession of nursing. School
nurses use the nursing process in providing for the physical, social, emotional,
and psychological care for children in schools. Consistently, school nurses
look for strategies to remediate or minimize the impact of students’ health
problems on their ability to learn. See Chapter 2, School Nursing and Health
Services Laws, for legal definitions of professional nurses.
School nursing services
are primarily provided in local education agencies. School nurse services can
be provided by a school nurse who is employed through the local board of
education, or nursing services can be contracted through local public health
departments, hospitals, Cooperative Educational Service Agency (CESA), or home
health care agencies. If the nurse is employed by the school board, the school
nurse’s job description outlines his or her role, responsibilities, duties,
qualifications, and certification requirements. School districts that contract
for service with other agencies or organizations will want to have a contract
or memorandum of understanding that outlines the nurse’s duties and
responsibilities.
Role
of the School Nurse
The role of the school
nurse has evolved and follows the school nursing definition. The National
Association of School Nurses has developed seven roles of the school nurse. The
role of the school nurse includes:
- providing direct care to students and staff;
- providing leadership for the provision of health services;
- providing screening and referral for health conditions;
- promoting a healthy school environment;
- promoting health;
- serving in a leadership role for health policies and programs; and
- serving as a liaison between school personnel, family, community, and health care providers.
The school nurse may take
on additional roles based on the unique population demographic and community
health needs.
Provides
Direct Care to Students and Staff
School nurses provide the
knowledge and skill for provision of direct health care in the school setting. Direct
care involves the provision of care for accidental injury, illness management,
medication administration, and nursing procedures. The nurse acts as a health
care resource person in the planning for emergency care and disaster
preparedness in the schools. Delegation of nursing tasks to others involves
training, competency validation, supervision, consultation, and evaluation by
the school nurse. The nurse is instrumental in providing a system for care to
assure that the health needs of the students are addressed during the school
day and at all school-sponsored events.
Provides
Leadership for the Provision of Health Services
School
nurses should provide information and leadership regarding the model of school
nursing care employed at the local level. The model of school nursing practice
provides information regarding the role of nursing personnel, which may include
registered nurses, licensed practical nurses, nursing assistants, and
unlicensed assistive personnel. The school should develop job descriptions with
responsibilities, duties, and qualifications for each level of nursing
personnel employed by the school district. School nurses are involved in the
organization and implementation of education and training of nursing personnel.
School nurses can also be instrumental in the annual review and evaluation of
emergency nursing services by the school board.
Provides
Screening and Referral for Health Conditions
School nurses are
involved in the development of local policies and procedures for health
appraisals in the school setting. The school nurse participates in the identification
and referral of health concerns that affect an individual’s health and ability
to learn. Examples of health assessments in the school setting include:
developmental, physical, hearing, vision, growth, blood pressure, and scoliosis
screening. School nurses may provide information on health resources to referred
students and families. The school nurse makes appropriate referrals to the
medical providers for further assessment and treatment as necessary.
Documentation of significant findings and implementation of necessary school
accommodations minimizes the impact of the student’s learning.
Promotes
a Healthy School Environment
School nurses provide
technical support and guidance in the development of policies and procedures
related to environmental health. This may include blood borne pathogen training,
immunization compliance, communicable disease management, injury prevention,
air quality, pest management, and animal policies that impact the health of the
school environment. The school nurse can help provide the ongoing surveillance
to the obstacles to health and strategies to improve the health of the school
environment.
Promotes
Health
School nurses provide individual and
group health-related education of students and school personnel regarding
preventative health promotion measures and management of health conditions. In
order to promote health, school nurses develop health and education plans for
children with acute and chronic health needs in the school. Nurses provide
emergency and individual health care plans to outline how school nursing
services will be provided during the school day. The school nurse provides
essential health information for educational plans indicating how the child’s
health condition impacts their ability to learn.
Serves
in a Leadership Role for Health Policies and Programs
In
accordance with Wis.
Admin. Code PI 8.01(2)(g) or Standard G, a registered nurse licensed in
Wisconsin must be involved in the development of policies that address
emergency nursing services in school districts. The policies for emergency
nursing services must include protocols for dealing with student accidental
injury, illness, and medication administration. The statutory definition of a
professional nurse and the Standards of Practice of the Registered Nurse in Wis. Stats. ch. 441
or the Nurse Practice Act defines further leadership roles. (See Chapter 2 for
more information regarding definitions.) The school nurse is a leader on the
coordinated school health team, providing knowledge and skills for the
development and implementation of a coordinated school health program.
Serves
as a Liaison between School Personnel, Family, Community, and Health Care
Providers
Providers
The school nurse is the
communication conduit between schools and health care providers and community
health care organizations. The school nurse guards the confidentiality of all
students and families, sharing only the health information with the school
staff that have an educational need to know. The health information shared
should only be the essential information needed to provide for the health and
safety of the student. Communication with the family is provided by school
conference, written communication, emails, telephone calls, and home visits. The
school nurse can participate as a health expert on the Individual Education
Program and Section 504 Accommodation teams. Nurses
have the knowledge regarding how the health impairment or disability impacts
the student’s ability to learn. Nurses can serve as case managers for the
student, assuring that the student and family has access to all the available school,
health, and community resources.5 Adapted with permission from the
National Association of School Nurses.
Framework
for School Nursing Practice
The following
diagram identifies categories of interventions in community health nursing,
which may be applied to school nursing.
