School Nursing

School nursing is an integral part of the United States educational system. While the institution of school nursing began with the single purpose of improving public health through the treatment and containment of infectious diseases, it has evolved into a multi-dimensional profession. The most significant expansion in the role of school nursing during the second half of the 20th century was in the area of children with disabilities. Today, nurses also oversee school health service programs and help treat students with mental health issues. Because of a nurse shortage, many schools find themselves without a full time nurse. These schools have employed a number of innovative methods to ensure that they meet their students' medical needs.

Keywords Chronic Illness; Disability; Mental Health; National Association of School Nurses (NASN); Public Health; School Health Service Program; School Nursing; Terminal Illness

Overview

In the century that has passed since its inception in 1902, school nursing has become an integral part of the United States educational system. While the implementation of school nursing varies from school to school, the goal of school nursing remains the same everywhere: to support the overall health and wellness of school children, and thereby enable them to avoid absences, focus in the classroom, and achieve their full academic potential (Wolfe & Selekman, 2002). The National Association of School Nurses (NASN) defines school nursing as "a specialized practice of professional nursing that advances the well being, academic success, and life-long achievement of students" (Wolfe & Selekman, 2002, p. 406). School nursing is so critical because more than 53 million children living in the U.S. spend more than one-third of every weekday at school (Hootman, Houck, & King, 2003). School is often the central context within which children develop - physically, mentally, and socially. By monitoring these developmental tracks and providing timely interventions when necessary, school nursing helps to meet the fundamental health needs of the nation's children.

School nurses are the most commonly found healthcare providers practicing in schools today (Hootman & Desocio, 2004). As such, they provide an overall "health safety net" for the nation's children, ensuring that all students enrolled in public schools receive primary health care services, adequate nutrition, mental health care services, and disability services (Vessey & McGowan, 2006, p. 256). These services are especially valuable when poverty or other conditions at home compromise a child's access to outside medical care. For these students, school nurses often serve as de facto primary care physicians (Wolfe & Selekman, 2002).

While the institution of school nursing began with the single purpose of improving public health through the treatment and containment of infectious diseases, it has evolved into a multi-dimensional profession. School nurses are direct care providers, case managers, and consultants (Hootman et al., 2003). They must master skills associated with pediatric nursing, community health nursing, psychiatric nursing, emergency-room nursing, and home-care nursing, as well as health education, policy making, social work, and office management. When serving students with chronic medical problems, school nurses become liaisons who must coordinate between a child's parents, primary care physician, and teachers (Broussard, 2004). Often, school nurses manage and implement a larger school health service program, or coordinated school health program, which includes health education, counseling, physical education, nutrition, and immunizations, along with many other services (American Academy of Pediatrics, Committee on School Health, 2001; Wolfe & Selekman, 2002). Increasingly, school nurses are engaging in research as well. By documenting the positive outcomes and cost-effectiveness associated with their practices, school nurses hope to encourage districts to invest more funds in school nursing (Edwards, 2002).

History

School Nursing During the Early 20th Century

School nursing was first established in the United States in New York City in 1902 as a way to combat the rampant absenteeism that plagued the city's schools. During this period, New York was overcrowded and unsanitary. Large waves of immigration during the late 19th Century had resulted in slums and tenement neighborhoods where infectious diseases were widespread (Vessey & McGowan, 2006). Prior to the institution of school nursing, New York City schools were monitored by physicians who would visit one a week and examine children for symptoms of contagious diseases such as whooping cough, measles, and scarlet fever. Infected students were not treated, but sent home with their diagnosis written on a slip. It was assumed that parents would receive this diagnosis and seek medical care for their children. This policy was largely ineffective for several reasons. Immigrant parents were often unable to read English and thus could not understand their child's diagnosis if and when they received it. Even if parents wanted to seek medical treatment for their children, poverty often made this impossible. Finally, even though contagious children were removed from schools, they still interacted with and infected their classmates and peers at home, on playgrounds, and in the streets (Broussard, 2004; Wolfe & Selekman, 2002; Vessey & McGowan, 2006).

In order to address the widespread absenteeism that resulted from its current school health system, the New York City Board of Education and the City Health Commissioner turned to Lillian Wald, a social reformer and advocate for the city's immigrant poor. Using a program established in London in 1893 as a model, Wald commissioned the nation's first school nurse: Lina Rogers (Wolfe & Selekman, 2002). Rogers' primary goal was to contain the spread of communicable diseases in the city's schools. She achieved this goal by treating the illnesses she diagnosed, often making home visits in order to administer medicines and educate parents about preventative measures such as proper hygiene. Rogers' method was so immediately effective that within one month the city hired 14 more nurses. Within a year, absentee rates had dropped by 90%; within three years Los Angeles and Boston had begun their own school nursing programs (Vessey & McGowan, 2006).

School Nursing Today

While school nursing began as "one of the most successful experiments in public health" in U.S. history, its focus soon expanded outside of the domain of public health to include other pertinent student-health related issues (Vessey & McGowan, 2006, p. 255). The 1950's and 1960's saw a dramatic proliferation in school nursing, with schools across the nation hiring full-time nurses. During this period, the focus of school nursing shifted from public health to screening efforts and referrals to primary care physicians. Children were screened for scoliosis, hearing loss, and vision problems; parents were notified if their children tested abnormally and told to seek further care from a primary care physician. During the 1960's and 1970's, health classes were added to many high school curriculums. School nurses either taught these classes or consulted with teachers in order to help develop their content. During the 1980's, many high schools developed health services focused on an adolescent population. Reproductive health, HIV and STD infection, as well as mental health, all became the domain of school nursing (Broussard, 2004).

Applications

Students with Disabilities, Chronic Illnesses, & Terminal Illnesses

The most significant expansion in the role of school nursing during the second half of the 20th century was in the area of children with disabilities. During this period, advances in pediatric medical care and changing attitudes about children with disabilities resulted in decreased rates of institutionalization for children with physical, psychosocial, and developmental disabilities. Children who would have formerly been institutionalized were now being raised at home and attending public schools. These children often needed more medical care during the school day than their peers, and legislation was passed guaranteeing them the right to such care. The Individuals with Disabilities Education Act (IDEA) of 1975 and the Education for All Handicapped Children Act of 1975 (also known as Public Law 94-142) mandated that all children, regardless of physical or developmental disabilities, must be given access to and accommodated in the nation's public schools. The task of removing barriers that had formerly prevented children with disabilities from participating in school was allocated to school nursing services. This new role for school nursing was reinforced in 1999, when a Supreme Court ruling further stipulated that public schools are financially responsible for providing nursing services for children with special medical needs if they need these services in order to have access to, and benefit from, public education (Wolfe & Selekman, 2002).

It is estimated that 11% of school-aged children in the United States today have at least one disability (Hootman et al., 2003). Currently, the services provided by school nurses enable students in wheelchairs, students with digestive disorders, diabetes, ADHD, autism, depression, mental retardation, anxiety disorders, bipolar disorder and myriad other physical, psychological, and developmental issues to attend public schools alongside their non-disabled peers. School nurses address the special healthcare needs of students with disabilities and chronic conditions by creating Individualized Health Management Plans (IHPs), which detail the exact measures that will be taken in order to allow such students to participate as fully as possible in school (Hootman et al., 2003). For students with physical disabilities that could impede emergency evacuation, and for students with terminal illnesses or serious food allergies, emergency health plans are created as well.

The inclusion of children with disabilities and chronic illnesses in public schools has led to higher skill levels among school nurses. In order to care for students with special medical needs during the school day, school nurses must be trained to perform in-patient care methods (Wolfe & Selekman, 2002). School nurses must learn to perform such technical procedures as tracheostomy suctioning, nasogastric feedings, and bladder catheterization, among others; they must also provide ostomy care, ventilator care, and orthopedic device maintenance (American Academy of Pediatrics, Committee on School Health, 2001). Most school districts require school nurses to be certified in school nursing through the district's state education agency (Wolfe & Selekman, 2002).

Once a child with a disability or chronic or terminal condition has entered the public school system, it is the duty of school nursing services to advocate for him or her. If a student is in a wheelchair, for example, the school nurse must make sure that all school facilities are accessible by wheelchair so that the student can fully participate in all school activities. In recent years, there has been a trend towards the inclusion of children with autism, a development disability, into public school classrooms. School nurses must advocate for autistic students by assessing their special communicative needs, managing medication, and educating parents and school staff about autism (Cade & Tidwell, 2001).

School Health Service Programs

In addition to meeting the immediate medical needs of students, school nurses commonly serve an administrative function as well. In many schools and districts, school nurses manage the implementation of a school health service program, or a coordinated school health program. These programs are usually designed at the state or district level. They attempt to promote student health throughout the state or district by positive preventative measures, as well as through timely interventions. At the elementary level, such programs focus on immunizations, safety, as well as vision, hearing and scoliosis screenings. At the secondary level they tend to focus on prevention of risky behavior such sex, smoking, and drug and alcohol use (Wolfe & Selekman, 2002). In some high schools, school health service programs include school-based health centers that may or may not specialize in reproductive health issues (Broussard, 2004). Many programs now include health and nutrition services and physical education in order to target populations at risk for obesity (Wolfe & Selekman, 2002). Other programs use holistic measures such as biofeedback in order to help students with anxiety, stress, low self-esteem, and ADHD (Jones, 2004). Most programs include counseling and psychological services (Wolfe & Selekman, 2002).

Managing such programs requires school nurses to truly bridge the gap between the medical and educational communities (Wolfe & Selekman, 2002). School nurses must coordinate their activities with primary care physicians, specialists, local public health care agencies and school officials, all while caring for students and communicating with their families (American Academy of Pediatrics, Committee on School Health, 2001). They must serve as educators, either engaging in classroom instruction, consulting with teachers on how to structure health education classes, or sitting on curriculum planning committees. When not directly engaged in educational activities, school nurses should model healthy behaviors to staff, parents, and students (Broussard, 2004).

Students with Mental Health Issues

As the holistic nature of many school health services programs shows, school nursing today focuses not only on the physical, but also on the psychological and emotional well being of students. Mental health in particular has become increasingly important to school nursing in the past few decades as more awareness about mental health issues has been raised in American society. The U.S. Department of Health's 2010 Health Objectives include the goal of enhancing mental health services for youth, a goal that is met in schools through school nursing (Hootman et al., 2003).

Approximately one fifth of all children between the ages of 9 and 17 suffer from a mental or addictive disorder that affects their ability to function at school. Moreover, 70% of these children go undiagnosed and so untreated. This is because even students who have insurance and primary care physicians often lack access to mental health services. Evidence shows that school nursing can bridge this gap in medical care: 70% of children who are diagnosed with a mental health problem identify their school as the primary source of their mental health care (Hootman & Desocio, 2004). A NASN survey revealed findings that support this conclusion: 67% of school nurses have identified and/or counseled a depressed or suicidal teen; 51% have identified and/or counseled a student who has abused substances (Hootman et al., 2003).

School nurses can raise awareness about mental health issues throughout the entire student body. One study has shown that when a school nurse advocates mental illnesses as being 'no-fault' illnesses without a stigma, students became open about their or their friends' depression (Hootman & Desocio, 2004). School nurses can either personally lead classroom discussions about mental health or consult with teachers in order to devise a mental health education curriculum.

School nurses must also serve students who have already been diagnosed with a mental health issue. The school nurse is legally responsible for protecting the health of such a child during the school day, and so should be notified if he or she is suicidal. School nurses can also oversee the administration of medication, ensuring that students do not overdose on their medication or choose not to take it at all. School nurses are sometimes prevented from carrying out these duties effectively by parents who choose to withhold information about their children's psychiatric diagnosis (Wolfe & Selekman, 2002).

School Health Research

Until recently, school health research was not considered an integral part of school nursing. In the last two decades, however, many experts have called for school nurses to begin conducting health research on the job (Broussard, 2004). Numerous conferences and summits have been held on the subject of research and school nursing. The main reason for this turn to research is that school nursing currently lacks sufficient documentation of its effectiveness. Without proof that school nursing is a vital part of the public school system, school nursing services risk being cut out of over-strained budgets (Edwards, 2002).

School nursing professionals generally agree about what areas future research should address. Studies are needed to show how school health services affect student attendance, academic achievement, drop-out rates, and risky behavior (Broussard, 2004). School nurses must also document successful interventions in the areas of chronic illnesses, disabilities, mental health, and substance abuse prevention. Such research should demonstrate the overall value that school nursing adds to the education system and to student health. In addition, there is a need for research that focuses on school nursing as an independent discipline within nursing. Such research should investigate what types of professional training best prepares nursing students for the field of school nursing (Edwards, 2002).

The primary obstacles preventing school health research from becoming a standard aspect of school nursing are logistical in nature. Most school nurses are already overburdened. They lack the time, funding, and clerical assistance that would be necessary in order to take on additional duties (Broussard, 2004).

Viewpoints

Schools without Nurses

The NASN recommends a ratio of one school nurse for every 750 children in the general student population. This ratio increases to one school nurse for every 225 children with special needs who are mainstreamed in the general school population. Not all states, however, follow this recommendation; only 38% officially recommend that schools do so (Broussard, 2004). Moreover, some schools do not have a registered nurse at all. Instead, they use an unlicensed assistive personnel (UAP) to perform the functions of a school nurse (Wolfe & Selekman). In one school district in West Central Florida, for example, only 6 out of 19 high schools in one county have full-time nurses. The ratio of school nurses to students in this county is 1:6,460 (Perrin, Goad, & Williams, 2002).

Several factors have contributed to the lack of professionally trained nurses in schools. Many school districts have limited budgets and cannot afford to staff every school with a registered school nurse. Some administrators complain that the testing requirements in the No Child Left Behind Act of 2001 have overstrained their already stretched budgets. Additionally, a shortage of nursing school graduates during the 1990s has contributed to this problem (Smolkin, 2003).

Schools without school nurses are still legally required to meet the medical needs of their student populations. Administrators at these schools sometimes find creative ways to do so. Some schools ask a nursing club to volunteer at the school and carry out standard monitoring requirements. Others have an emergency nurse that can be called in to the schools on a contingency basis. In some schools, administrators themselves evaluate children's health needs (Smolkin, 2003). Other schools have taken a more innovative approach. These schools find the funds to hire school nurses by making the nurses available to faculty and staff as well as students. School nurses become cost effective by reducing employee doctor visits, sick days, injuries, disability days, and worker's compensation claims (Perrin et al., 2002). The American Cancer Society has launched its own innovative solution - a nationwide program that trains district-level health coordinators who can work in districts that lack a full school-nursing staff (Smolkin, 2003).

Many experts feel that school nurses themselves must work to ensure the future of their profession by carrying out school health research that demonstrates the vital need for school nursing in every school (Edwards, 2002).

Terms & Concepts

Chronic Illness: An illness lasting three months or longer. Common chronic illnesses include cancer, AIDS, autoimmune diseases such as LUPUS, and neurological disorders such as Parkinson's disease. A chronic illness may or may not be terminal.

Disability: A condition that impairs a person's ability to carry out certain functions in a normative manner. Disabilities can be physical, developmental, psychosocial, or affect any other part of a person's functioning.

Mental Health: A branch of medicine that seeks to establish the psychological, rather than physical, well-being of the patient.

National Association of School Nurses (NASN): The primary professional association for school nurses in the United States. The NASN supports and promotes the institution of school nursing by representing school nurses in the legislative and educational spheres.

Public Health: The branch of medicine concerned with protecting and promoting the health of a community as a whole. Focuses on risk assessment, prevention, and education. In the early twentieth century, the field of public health was most concerned with preventing the spread of contagious diseases.

School Health Services Program: Usually designed by the state or district; promotes the well-being of students through the prevention and treatment of medical conditions. Often includes a strong focus on health education.

School Nursing: A specialized practice of professional nursing that promotes the educational success and general well-being of students.

Terminal Illness: An active, malignant disease that cannot be cured and will eventually lead to the patient's death.

Bibliography

American Academy of Pediatrics, Committee on School Health. (2001). The role of the school nurse in providing school health services. Pediatrics, 108 , 1231-1232. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5579017&site=ehost-live

Broussard, L. (2004). School nursing: Not just band-aids any more! Journal for Specialists in Pediatric Nursing, 9 , 77-83. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=14762743&site=ehost-live

Cade, M., & Tidwell, S. (2001). Autism and the school nurse. Journal of School Health, 71 , 96-100. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=4333349&site=ehost-live

Edwards, L. (2002). Research priorities in school nursing: A Delphi process. Journal of School Health, 72 , 173-177. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=6918001&site=ehost-live

Faigenbaum, A.D., Gipson-Jones, T.L., & Myer, G.D. (2012). Exercise deficit disorder in youth: An emergent health concern for school nurses. Journal of School Nursing (Sage Publications Inc.), 28, 252-255.Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=77921313&site=ehost-live

Hootman, J., & Desocio, J. (2004). School nurses' important mental health role. Behavioral Health Management, 24 , 25-29. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=15027144&site=ehost-live

Hootman, J., Houck, G. M. & King, M. (2003). Increased mental health needs and new roles in communities. Journal of Child & Adolescent Psychiatric Nursing, 16 , 93-101. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=10935425&site=ehost-live

Jones, K. (2004). School nursing in search of the holistic paradigm. Creative Nursing, 10 , 11.

, 11. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=13470179&site=ehost-live

Perrin, K., Goad S., & Williams, C. (2002). Can school nurses save money by treating school employees as well as students? Journal of School Health, 72 , 305-306. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=7451161&site=ehost-live

Ramos, M.M., Greenberg, C., Sapien, R., Bauer-Creegan, J., Hine, B., & Geary, C. (2013). Behavioral health emergencies managed by school nurses working with adolescents. Journal of School Health, 83, 712-717. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=90167791&site=ehost-live

Singer, B. (2013). Perceptions of school nurses in the care of students with disabilities. Journal of School Nursing (Sage Publications Inc.), 29, 329-336. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=90378575&site=ehost-live

Smolkin, R. (2003). Rx for school nursing. School Administrator, 60 , 16-19. Retrieved April 4, 2007 from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=8653954&site=ehost-live

Vessey, J., & McGowan, K. (2006). A successful public health experiment: School nursing. Pediatric Nursing, 32 , 255-256, 213. Retrieved from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=21110254&site=ehost-live

White, G. (2005). Nurses at the helm: Implementing DNAR order in the public school setting. American Journal of Bioethics, 5 , 83-85. Retrieved April 5, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=16684281&site=ehost-live

Wolfe, L., & Selekman, J. (2002). School nurses: What it was and what it is. Pediatric nursing, 28 , 403-407. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=7228821&site=ehost-live

Suggested Reading

Grant, A. (2001). The nurse in the school health service. Journal of School Health, 71 , 388-389. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5578349&site=ehost-live

Paris, J., & Webster, G. (2005). Back to the future: Overcoming reluctance to honor in-school DNAR orders. American Journal of Bioethics, 5 , 67-69. Retrieved April 5, 2007 from EBCSO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=16684310&site=ehost-live

Taras, H., Wright, S., Brennan, J., Campana, J., & Lofgren, R. (2004). Impact of school nurse case management on students with asthma. Journal of School Health, 74 , 213-219. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=14369755&site=ehost-live

Weber, S. (2006). School health programs: A starring role for school nurse practitioners! Journal of the American Academy of Nurse Practitioners, 18 , 510-511. Retrieved April 7, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=22852916&site=ehost-live

Wold, S. & Dagg, N. (2001). School nursing: A framework for practice. Journal of School Health, 71 , 401-404. Retrieved April 4, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=5578360&site=ehost-live