The Role of the School Nurse in Providing School Health Services

SCHOOL NURSE ACTIVITIES

Changes in society, the provision of health care, education, and the family have increased the need and demand for school health services. New paradigms are evolving for school health services as school systems develop comprehensive school health programs to address the diverse and complex health problems of today's students.¹ In addition to health issues, schools must cope with problems caused by immigration, homelessness, divorce, remarriage, poverty, substance abuse, and violence.²

The school nurse has a central management role in the implementation of the school health services program for all children and youth in the school. Ideally, the school nurse collaborates with primary care physicians, specialists, and local public health and social service agencies to ensure a full spectrum of effective and quality services that sustain children, youth, and their families. All school health services are delivered in the overall context of the child, the family, and the child's overall health plan.

The goals of a school health program that relate directly to the health service component as outlined in the American Academy of Pediatrics (AAP) manual School Health: Policy and Practice³ are to:

• ensure access to primary health care (a medical home);

• provide a system for dealing with crisis medical situations;

• provide mandated screening and immunization monitoring; and

• provide a process for identification and resolution of students' health care needs that affect educational achievement.

These goals are a major component of the larger school health program and focus on prevention and early intervention. The school nurse has a critical role within this school health program and provides acute, chronic, episodic, and emergency health care. In addition, the school nurse provides health education and health counseling and advocates for students with disabilities. School nurses are well positioned to take the lead for the school system in partnering with community physicians, community organizations, and Medicaid and State Children's Health Insurance Program staff to assist families and students to enroll in the state health insurance programs and find a medical home for each student.

SCHOOL HEALTH SERVICES TEAM

The school nurse functions as a member and often the coordinator of the school health services team. The team may include a school physician, licensed practical nurses, health aides and clerical staff, school counselors, school psychologists, school social workers, and substance abuse counselors. A pediatrician often fills the school physician role because he or she is knowledgeable about general pediatrics, school health, and adolescent health. In some schools, a pediatric family nurse practitioner functions as the school nurse and may provide additional services. If unlicensed assistive personnel are part of the school health services team, their performance of skilled nursing procedures must be supervised by the school nurse in accordance with state laws.

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 coordinates 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.

THE SCHOOL NURSE AND CHILDREN WITH SPECIAL HEALTH NEEDS

The school nurse has a unique role in the provision of school health services for children with special health needs, including children with chronic illnesses and disabilities of various degrees of severity. These children 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 individual health care plan is part of the individual education plan or other written plan⁴ and that both plans are developed and implemented with full team participation, with parents and the child enlisted as partners. The school nurse's participation in the educational plan development heightens the potential for achieving the goals of the health care plan, which are to maximize the student's educational experience and to provide adequate preparation for responses to urgent situations. The school nurse develops this plan with the student, parents or guardians, and the child's primary care physician. Dialogue with subspecialists, community agency staff, and case managers can add important information. The school nurse must provide safe and effective direct services or facilitate the performance of special health care procedures, such as tracheostomy suctioning, bladder catheterization, ostomy care, nasogastric feedings, maintenance of orthopedic devices, and ventilator care, for all students who need them.

The school nurse should collect important information, such as special needs, modifications to routine medical procedures, allowance to administer stock over-the-counter medications in school (if offered), medical home, health insurance, emergency measures, and parent permission, to interact with the student's health care providers. The Emergency Information Form from the AAP and American College of Emergency Physicians, for example, could be used as a template for formulation of the individual medical plan.⁵

PROFESSIONAL PREPARATION FOR SCHOOL NURSES

The AAP supports the goal of professional preparation for all school nurses. 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.⁶ In addition, there should be a process by which certification or licensure for the school nurse is established by the appropriate state board. The AAP recommends the use of appropriately educated and selected school nurses to facilitate and provide school health services. In itsHealthy People 2010 objectives,⁷ the US Department of Health and Human Services recommends at least 1 nurse per 750 students, with variation depending on the community and the student population.