The Role of School Nurses-Not just Band Aids
The Role of the 21st Century School Nurse
It is the position of the National Association of School Nurses (NASN) that every child has access all day, every day to a full time registered professional school nurse (hereinafter referred to as school nurse). The school nurse serves in a pivotal role that bridges health care and education. Grounded by standards of practice, services provided by the school nurse include leadership, community/public health, care coordination, and quality improvement (NASN, 2016a).
The practice of school nursing began in the United States on October 1, 1902, when Lina Rogers, the first school nurse, was hired to reduce absenteeism by intervening with students and families regarding healthcare needs related to communicable diseases. After one month of successful nursing interventions in the New York City schools, she led the implementation of evidence-based nursing care across the city (Struthers, 1917). Since that time, school nurses continue to provide communicable disease management, but their role has expanded and is increasingly diverse.
A student’s health is directly related to his or her ability to learn. Children with unmet health needs have a difficult time engaging in the educational process. The school nurse supports student success by providing health care through assessment, intervention, and follow-up for all children within the school setting. The school nurse addresses the physical, mental, emotional, and social health needs of students and supports their achievement in the learning process.
Students who are medically fragile or who deal with chronic health issues are coming to school in increasing numbers and with increasingly complex medical problems that require complicated treatments commonly provided by the school nurse (Lineberry & Ikes, 2015). Chronic conditions such as asthma, anaphylaxis, type 1 and type 2 diabetes, epilepsy, obesity, and mental health concerns may affect the student’s ability to be in school and ready to learn.
The National Survey of Children with Special Healthcare Needs has determined that 11.2 million U.S. children are at risk for chronic physical, developmental, behavioral, or emotional conditions. These students may require health related services in schools (U.S. Department of Health and Human Services, Maternal and Child Health Bureau, 2013).
School nurses address the social determinants of health, such as income, housing, transportation, employment, access to health insurance, and environmental health. Social determinants are identified to be the cause of 80% of health concerns (Booske, Athens, Kindig, Park, & Remington, 2010). In the United States, nearly one quarter of children attending school live in households below the federal poverty level (United States Census Bureau, 2014). Children from lower income families have a more difficult time accessing medical treatment for chronic diseases (Perrin, 2014).
School nursing is a specialized practice of nursing that advances the well-being, academic success, and lifelong achievement and health of students. Keeping children healthy, safe, in school, and ready to learn should be a top priority for both healthcare and educational systems. With approximately 50.1 million students in public elementary and secondary schools, educational institutions are excellent locations to promote health in children (National Center for Education Statistics, n.d.) and the school nurse is uniquely positioned to meet student health needs.
LeadershipSchool nurses lead in the development of policies, programs, and procedures for the provision of school health services at an individual or district level (NASN, 2016a), relying on student-centered, evidence-based practice and performance data to inform care (Robert Wood Johnson Foundation, 2009). Integrating ethical provisions into all areas of practice, the school nurse leads in delivery of care that preserves and protects student and family autonomy, dignity, privacy, and other rights sensitive to diversity in the school setting (American Nurses Association [ANA] & NASN, 2011).
As an advocate for the individual student, the school nurse provides skills and education that encourage self-empowerment, problem solving, effective communication, and collaboration with others (ANA, 2015a). Promoting the concept of self-management is an important aspect of the school nurse role and enables the student to manage his/her condition and to make life decisions (Tengland, 2012). The school nurse advocates for safety by participating in the development of school safety plans to address bullying, school violence, and the full range of emergency incidents that may occur at school (Wolfe, 2013).
At the policy development and implementation level, school nurses provide system‐level leadership and act as change agents, promoting education and healthcare reform. According to the ANA (2015b), registered nurses believe that it is their obligation to help improve issues related to health care, consumer care, health, and wellness. Educational preparation for the school nurse should be at the baccalaureate level (NASN, 2016b), and school nurses should continue to pursue professional development and continuing nursing education throughout their careers (Wolfe, 2013).
Community/Public HealthSchool nursing is grounded in community/public health (Schaffer, Anderson, & Rising, 2015). The goal of community/public health moves beyond the individual to focus on community health promotion and disease prevention and is one of the primary roles of the school nurse (Wold & Selekman, 2013). School nurses employ cultural competency in delivering effective care in culturally diverse communities (Office of Minority Health, 2013).
The school nurse employs primary prevention by providing health education that promotes physical and mental health and informs healthcare decisions, prevents disease, and enhances school performance. Addressing such topics as healthy lifestyles, risk‐reducing behaviors, developmental needs, activities of daily living, and preventive self‐care, and the school nurse uses teaching methods that are appropriate to the student’s developmental level, learning needs, readiness, and ability to learn. Screenings, referrals, and follow‐up are secondary prevention strategies that school nurses utilize to detect and treat health-related issues in their early stage (NASN, 2016a). School nurses provide tertiary prevention by addressing diagnosed health conditions and concerns.
Student absences due to infectious disease cause the loss of millions of school days each year (Centers for Disease Control and Prevention, 2011). Based on standards of practice and community health perspective, the school nurse provides a safe and healthy school environment through control of infectious disease, which includes promotion of vaccines, utilization of school-wide infection control measures, and disease surveillance and reporting. Immunization compliance is much greater in schools with school nurses (Baisch, Lundeen, & Murphy, 2011).
The school nurse strives to promote health equity, assisting students and families in connecting with healthcare services, financial resources, shelter, food, and health promotion. This role encompasses responsibility for all students within the school community, and the school nurse is often the only healthcare professional aware of all the services and agencies involved in a student’s care.
Care CoordinationSchool nurses are members of two divergent communities (educational and medical/nursing), and as such are able to communicate fluently and actively collaborate with practitioners from both fields (Wolfe, 2013). As a case manager, the school nurse coordinates student health care between the medical home, family, and school. The school nurse is an essential member of interdisciplinary teams, bringing the health expertise necessary to develop a student’s Individualized Education Plan or Section 504 plan designed to reduce health related barriers to learning (Zimmerman, 2013). Creating, updating, and implementing Individualized Healthcare Plans are fundamental to the school nurse role (McClanahan & Weismuller, 2015).
School nurses deliver quality health care and nursing intervention for actual and potential health problems. They provide for the direct care needs of the student, including medication administration and routine treatments and procedures (Lineberry & Ickes, 2015). Education of school staff by the school nurse is imperative to the successful management of a child with a chronic condition or special healthcare need and is codified as a role of the school nurse in the Every Student Succeeds Act (2015).
Current school health practice models and school nurse workloads may require school nurses to delegate healthcare tasks to unlicensed assistive personnel in order to support the health and safety needs of students (Shannon & Kubelka, 2013). However, the availability of school nurses to work directly with students to assess symptoms and provide treatment increases students’ time in the classroom and parents’ time at work (Lineberry & Ickes, 2015).
Quality ImprovementQuality improvement is a continuous and systematic process that leads to measurable improvements and outcomes (Health Resources and Services Administration, 2011) and is integral to healthcare reform and standards of practice (Agency for Healthcare Research and Quality, 2011). Continuous quality improvement is the nursing process in action: assessment, identification of the issue, development of a plan of action, implementation of the plan, and evaluation of the outcome. Data collection through this process is a necessary role of the school nurse.
Formal school nursing research is needed to ensure that delivery of care to students and school communities by the school nurse is based on current evidence. School nurses utilize research data as they advocate and illustrate the impact of their role on meaningful health and academic outcomes (NASN, 2016a).
It is the position of NASN that school nurses play an essential role in keeping children healthy, safe, and ready to learn. The school nurse is a member of a unique discipline of professional nursing and is often the sole healthcare provider in an academic setting. Twenty‐first century school nursing practice is student‐centered, occurring within the context of the student’s family and school community (NASN, 2016a). It is essential that all students have access to a full time school nurse all day, every day (American Academy of Pediatrics, 2016).
Agency for Healthcare Research and Quality. (2011). National strategy for quality improvement in healthcare. Retrieved from http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.pdf
American Academy of Pediatrics. (2016). Role of the school nurse in providing school health services (Policy Statement). Pediatrics; originally published online May 23, 2016. doi: 10.1542/peds.2016-0852
American Nurses Association (ANA) and National Association of School Nurses (NASN). (2011). Scope and standards of practice: School nursing (2nd ed.). Silver Spring, MD: nursebooks.org
American Nurses Association (ANA). (2015a). Code of ethics for nurses with interpretive statements. Silver Spring, MD: nursebooks.org.
American Nurses Association (ANA). (2015b). Scope and standards of practice: Nursing. (3rd ed.). Silver Spring, MD: nursebooks.org.
Baisch, M.J., Lundeen, S.P., & Murphy, M.K. (2011). Evidence‐based research on the value of school nurses in an urban school system. The Journal of School Health, 81(2), 74‐80. doi:10.1111/j.1746‐1561/2010.00563.x
Booske, B.C., Athens, J.K., Kindig, D.A., Park, H., & Remington, P. L. (2010). Different perspectives for assigning weights to determinants of health. County Health Rankings Working Paper, University of Wisconsin. Retrieved from https://uwphi.pophealth.wisc.edu/publications/other/different-perspectives-for-assigning-weights-to-determinants-of-health.pdf
Centers for Disease Control and Prevention. (2011). Infectious diseases at school. Retrieved from http://www.cdc.gov/HealthyYouth/infectious/index.htm
Every Student Succeeds Act (2015), Pub. L. No. 114-95, S.1177 .Retrieved from https://www.gpo.gov/fdsys/pkg/BILLS-114s1177enr/pdf/BILLS-114s1177enr.pdf
Health Resources and Services Administration. (2011). Quality improvement. Retrieved from http://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf
Lineberry, M. J. & Ikes, M. J. (2015). The role and impact of nurses in American elementary schools: A systematic review of the research. The Journal of School Nursing, 31(1), 22-23. doi: 10.1177/1059840514540940
McClanahan, R. & Weismuller, P. C. (2015). School nurses and care coordination for children with complex needs: An integrative review. The Journal of School Nursing, 31(1) 34-43. doi: 10.1177/1059840514550484
National Association of School Nurses. (2016a). Framework for 21st century school nursing practice. NASN School Nurse, 31(1), 45-53. doi: 10.1177/1942602X15618644
National Association of School Nurses. (2016b). Education, licensure, and certification of school nurses (Position statement). Retrieved from http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/26/Education-Licensure-and-Certification-of-School-Nurses-Revised-June-2016
National Center for Education Statistics. (n.d.). Fast facts. Retrieved from http://nces.ed.gov/fastfacts/display.asp?id=372
Office of Minority Health. (2013). Cultural and linguistic competency? Retrieved from http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6
Perrin, J. (2014). Pediatricians need to take a community-based approach to addressing chronic diseases in children. Retrieved from http://www.rwjf.org/en/culture-of-health/2014/08/pediatricians_needt.html
Robert Wood Johnson Foundation. (2009). Clinical nurse leaders as agents of change. Retrieved from http://www.rwjf.org/en/library/articles-and-news/2009/02/clinical-nurse-leaders-as-agents-of-change.html
Schaffer, M.A., Anderson, L.J.W., & Rising, S. (2015). Public health interventions for school nursing practice. The Journal of School Nursing. Advance online publication. doi: 10.1177/1059840515605361
Shannon R., & Kubelka, S. (2013). Reducing the risks of delegation. Use of procedure skills checklists for unlicensed assistive personnel in schools, part 1. NASN School Nurse, 28(4), 178-181. doi: 10.1177/1942602X13489886
Struthers, L. (1917). The school nurse: A survey of the duties and responsibilities of the nurse in the maintenance of health, physical perfection and the prevention of disease among school children. New York, NY: G.P. Putnam’s Sons.
Tengland, P. (2012). Behavior change or empowerment: On the ethics of health-promotion strategies. Public Health Ethics, 5(2), 140-153. doi: 10.1093/phe/phs022
United States Census Bureau. (2014). Poverty: 2014 highlights. Retrieved from https://www.census.gov/hhes/www/poverty/about/overview/
U.S. Department of Health and Human Services, Maternal and Child Health Bureau. (2013). The national survey of children with special health care needs chartbook. 2001-2010. Retrieved from http://mchb.hrsa.gov/cshcn0910/more/pdf/nscshcn0910.pdf
Wold, S. & Selekman, J. (2013). Frameworks and models for school nursing practice. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp. 79-108). Philadelphia, PA: F.A. Davis Company.
Wolfe, L. C. (2013). The profession of school nursing. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp. 25-47). Philadelphia, PA: F.A. Davis Company.
Zimmerman, B. (2013). Student health and education plans. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed.) (pp. 284-314). Philadelphia, PA: F.A. Davis Company.
Who We Are
We Are School Nurses!
In 1897, health authorities in New York City hired doctors to examine public school students for infectious diseases—not to treat them, but to identify children who would be sent home so as not to infect their classmates. Five years later, in the wake of an outbreak of infectious eye diseases that prompted officials to send home thousands more children, local nurses volunteered to provide actual treatment. The effort was an eye-opener in more than one sense.
Permitted into the schools on a trial basis, nurses began solving a public health problem with long-term implications for children’s health and education.
“Many of the children needed only disinfecting treatment of the eyes, collodion applied to ringworm, or instruction as to cleanliness,” reported one of the nurses, Lina Rogers Struthers. Struthers went down in history as the nation’s first school nurse, and in the 118 years since, the profession she pioneered has become an increasingly critical, if often overlooked, component in the nation’s health care system.