Role of the School Nurse in Providing School Health Services

The school nurse has a crucial role in the seamless provision of comprehensive health services to children and youth. Increasing numbers of students enter schools with chronic health conditions that require management during the school day. This policy statement describes for pediatricians the role of the school nurse in serving as a team member in providing preventive services, early identification of problems, interventions, and referrals to foster health and educational success. To optimally care for children, preparation, ongoing education, and appropriate staffing levels of school nurses are important factors for success. Recommendations are offered to facilitate the working relationship between the school nurse and the child's medical home. This statement has been endorsed by the National Association of School Nurses.

1. The school nurse provides direct care to students. 13 The school nurse provides care for injuries and acute illness for all students and long-term management of students with special health care needs. Responsibilities include assessment and treatment within the scope of professional nursing practice, communication with parents, referral to physicians, and provision or supervision of prescribed nursing care. An individualized health care plan is developed for students with chronic conditions, and when appropriate, an emergency plan is developed to manage potential emergent events in the school setting (eg, diabetes, asthma). Ideally, this health plan is aligned with the management plan directed by the child's pediatrician and regularly updated through close communication.
The school nurse is responsible for management of this plan and communication about the plan to all appropriate school personnel.
The school nurse has a unique role in provision of school health services for children with special health needs, including children with chronic illnesses and disabilities of various degrees of severity. Children with special health needs are included in the regular school classroom setting as authorized by federal and state laws. As a leader of the school health team, the school nurse must assess the student's health status, identify health problems that may create a barrier to educational progress, and develop a health care plan for management of the problems in the school setting. The school nurse ensures that the student's individualized health care plan is part of the individualized education plan (IEP), 14 when appropriate, and that both plans are developed and implemented with full team participation, which includes the student, family, and pediatrician.
2. The school nurse provides leadership for the provision of health services 13 As the health care expert within the school, the school nurse assesses the overall system of care and develops a plan for ensuring that health needs are met. Responsibilities include development of plans for responding to emergencies and disasters and confidential communication and documentation of student health information.
3. The school nurse provides screening and referral for health conditions. 13 Health screenings can decrease the negative effects of health problems on education by identifying students with potential underlying medical problems early and referring them for treatment as appropriate. Early identification, referral to the medical home, and use of appropriate community resources promote optimal outcomes. Screening includes but is not limited to vision, hearing, and BMI assessments (as determined by local policy).
4. The school nurse promotes a healthy school environment. 13 The school nurse provides for the physical and emotional safety of the school community by monitoring immunizations, ensuring appropriate exclusion for infectious illnesses, and reporting communicable diseases as required by law. In addition, the school nurse provides for the safety of the environment by participating in environmental safety monitoring (playgrounds, indoor air quality, and potential hazards). The school nurse also participates in implementation of a plan for prevention and management of school violence, bullying, disasters, and terrorism events. The school nurse may also coordinate with school counselors in developing suicide prevention plans. In addition, if a school determines that drug testing is a part of its program, school nurses should be included in school district and community planning, implementation, and ongoing evaluation of this testing program. 15 5. The school nurse promotes health. 13 The school nurse provides health education by providing health information to individual students and groups of students through health education, science, and other classes. The school nurse assists on health education curriculum development teams and may also provide programs for staff, families, and the community. Health education topics may include nutrition, exercise, smoking prevention and cessation, oral health, prevention of sexually transmitted infections and other infectious diseases, substance use and abuse, immunizations, adolescent pregnancy prevention, parenting, and others. School nurses also promote health in local school health councils.
6. The school nurse serves in a leadership role for health policies and programs. As a health care expert within the school system, the school nurse is a leader in the development and evaluation of school health policies. These policies include health promotion and protection, chronic disease management, coordinated school health programs, school wellness policies, crisis/disaster management, emergency medical condition management, mental health protection and intervention, acute illness management, and infectious disease prevention and management. 16 7. The school nurse is a liaison between school personnel, family, health care professionals, and the community. 14 The school nurse participates as the health expert on the IEP 17 and 504 18 teams. IEP teams identify the special education needs of students; 504 teams plan for reasonable accommodations for students' special needs that impact their educational programs. 18 As the case manager for students with health problems, the school nurse ensures that there is adequate communication and collaboration among the family, physicians, and providers of community resources. This is a crucial interface for the pediatrician and the school nurse to ensure consistent, coordinated care. The school nurse also works with community organizations and primary care physicians to make the community a healthy place for all children and families.

SCHOOL NURSE ACTIVITIES
The range of school health services varies by school district. The following health services are the minimum that should be offered, according to the American Academy of Pediatrics (AAP) manual School Health: Policy and Practice: 19 • Assessment of health complaints, medication administration, and care for students with special health care needs; • A system for managing emergencies and urgent situations; • Mandated health screening programs, verification of immunizations, and infectious disease reporting; and • Identification and management of students' chronic health care needs that affect educational achievement.
The AAP recognizes the need for appropriate management of student health conditions in its policy statement, "Guidelines for Administration of Medication in School." 20 It also recognizes the need for policies for emergency medical situations that can occur in school and the school nurse's role in developing and implementing these policies. 21,22 The school nurse serves as an extension of traditional community health services, ensuring continuity, compliance, and professional supervision of care within the school setting.

SCHOOL HEALTH SERVICES TEAM
The school nurse functions as a leader and the coordinator of the school health services team. The team may also include a school physician, licensed practical nurses, health aides and clerical staff, school counselors, school psychologists, school social workers, and substance abuse counselors. The health team may also expand to create a coordinated school health team that integrates health services, health education, physical education, nutrition services, counseling/psychological/social services, healthy school environment, health promotion for staff, and family/community involvement. 23 Occupational therapists, physical therapists, and speech-language pathologists may also be part of the school health team. A pediatrician often fills the school physician role, because pediatricians are knowledgeable about general pediatrics, school health, and adolescent health. School physicians review guidelines, policies, and programs related to health care in schools. In some schools, a pediatric or family nurse practitioner functions as the school nurse and may provide additional services. Unlicensed assistive personnel (unlicensed individuals who are trained to perform as an assistant to the licensed nurse) may be part of the school health services team. Although they may possess state certification in medication administration as a nursing assistant or other nursing tasks, they must be trained and supervised by the school nurse in accordance with state nurse practice laws to perform delegated nursing tasks. Under this approach, the school nurse has the responsibility to decide which nursing tasks may be delegated and to whom within the school setting, in accordance with state laws and regulations. Some schools may have a school-based health center in or adjacent to the school, which may provide primary care and psychosocial services. The school nurse coordi-nates the activities of the school health services team with the child's primary care physician and/or with the school-based health center to provide continuity of care and prevent duplication of services.

PROFESSIONAL PREPARATION FOR SCHOOL NURSES
The AAP supports the goal of professional preparation for all school nurses and recommends the use of appropriately educated and selected school nurses to provide school health services. The National Association of School Nurses has determined that the minimum qualifications for the professional school nurse should include licensure as a registered nurse and a baccalaureate degree from an accredited college or university. There should be a process by which additional certification or licensure for the school nurse is established by the appropriate state board. The AAP supports national certification of school nurses by the National Board for Certification of School Nurses. 24

CONCLUSION
The AAP supports having a full-time school nurse in every school as the best means of ensuring a strong connection with each student's medical home. Interim steps toward achieving this ideal can be made by achieving the Healthy People 2010 goal, which states that districts should employ at least 1 nurse per 750 students, with variation, depending on the community and student population. 25 Schools with high percentages of students with special health needs would require more intensive ratios of nurse to students; for example, 1 nurse per 225 students when students require daily professional nursing services or interventions, and 1 nurse per 125 when students have complex health needs. 26 The presence of the school nurse in every school allows the school physician to work most efficiently in providing the coordinated care that each student requires.
The AAP recommends and supports the continued strong partnership among school nurses, school physicians, other school health personnel, and pediatricians. These partners serve the health of children and youth best by facilitating the development of a coordinated school health program, facilitating access to a medical home for each child, 27 and integrating health, education, and social services for children at the community level. School nurses, as part of a coordinated school health program, contribute to meeting the needs of the whole child and supporting their success in school. 28

Pediatricians should establish a working relationship
with the school nurses who care for their patients with chronic conditions to ensure that individual patients' health plans are executed effectively within the school. In addition, pediatricians' communications with school nurses concerning their patients should be sufficiently clear and detailed to guide school nurses in overseeing the care of individual children.
2. Pediatricians can offer direct support of school nurses by serving on school wellness policy committees, school health advisory committees, emergency preparedness committees, or other school-related decision-making bodies. In addition, local physicians may be asked to consult on or assist in writing school health-related policies.
3. School-based screening for vision, hearing, or other conditions may require coordination between local physicians and the school nurse to ensure students are referred for additional evaluation and treatment, and for communication with students, families, school administration, and the community. 4. Pediatricians should play an active role in supporting the availability and continuing education of the school nurse. This role may encompass updates on new AAP recommendations and research findings that would keep the school nurse's practice as aligned as possible with current AAP policy.