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RoleofSchoolNurseAAPPolicyStatement.pdf
FROM THE AMERICAN ACADEMY OF PEDIATRICSPEDIATRICS Volume 137 , number 6 , June 2016 :e 20160852
Role of the School Nurse in Providing School Health Services COUNCIL ON SCHOOL HEALTH
This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (American Academy of Pediatrics) and external reviewers. However, policy statements from the American Academy of Pediatrics may refl ect the views of the liaisons or the organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.
DOI: 10.1542/peds.2016-0852
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
abstractThe American Academy of Pediatrics recognizes the important role school
nurses play in promoting the optimal biopsychosocial health and well-being
of school-aged children in the school setting. Although the concept of a
school nurse has existed for more than a century, uniformity among states
and school districts regarding the role of a registered professional nurse
in schools and the laws governing it are lacking. By understanding the
benefi ts, roles, and responsibilities of school nurses working as a team with
the school physician, as well as their contributions to school-aged children,
pediatricians can collaborate with, support, and promote school nurses in
their own communities, thus improving the health, wellness, and safety of
children and adolescents.
INTRODUCTION
Traditionally, the school nursing role was designed to support
educational achievement by promoting student attendance. The first
school nurse, Lina Rogers, was appointed in 1902 to tend to the health of
8671 students in 4 separate schools in New York City. Her early success
in reducing absenteeism led to the hiring of 12 more nurses. Within 1
year, medical exclusions decreased by 99%.1
Over the past century, the role of the school nurse has expanded to
include critical components, such as surveillance, chronic disease
management, emergency preparedness, behavioral health assessment,
ongoing health education, extensive case management, and much more.
Although the position has taken on a more comprehensive approach, the
core focus of keeping students healthy and in school remains unchanged.
School attendance is essential for academic success.
School nurses provide both individual and population health through
their daily access to large numbers of students, making them well
positioned to address and coordinate the health care needs of children
and adolescents. The impact of social determinants of health are
felt in the school setting and well known to school nurses.2, 3 School
POLICY STATEMENT Organizational Principles to Guide and Define the Child Health
Care System and/or Improve the Health of all Children
To cite: AAP COUNCIL ON SCHOOL HEALTH. Role of the School
Nurse in Providing School Health Services. Pediatrics.
2016;137(6):e20160852
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FROM THE AMERICAN ACADEMY OF PEDIATRICS
nursing is a specialized practice of
professional nursing that advances
the well-being, academic success,
and lifelong achievement and health
of students. To that end, school
nurses understand and educate
about normal development; promote
health and safety, including a healthy
environment; intervene with actual
and potential health problems;
provide case-management services;
and actively collaborate with
physicians who work in schools,
such as medical advisors and team
physicians, families, community
service providers, and health care
providers, to build student and
family capacity for adaptation, self-
management, self-advocacy, and
learning.4, 5
School nurses and pediatricians,
both community- and school-based,
working together can be a great
example of team-based care, defined
as the provision of comprehensive
health services to individuals,
families, and/or their communities
by at least 2 health professionals
who work collaboratively along
with patients, family caregivers,
and community service providers
on shared goals within and across
settings to achieve care that is
safe, effective, patient-centered,
timely, efficient, and equitable. The
principles of team-based health
care are as follows: shared goals,
clear roles, mutual trust, effective
communication, and measurable
processes and outcomes.6, 7 As a
health care team member, school
nurses connect students and their
families to the medical home and can
support coordination of care.8–10
As more children with special health
care needs attend school, the school
nurse plays a vital role in disease
management, often working closely
with children and their parents
to reinforce the medical home’s
recommendations and provide
treatment(s) during the school day.
Feedback mechanisms regarding
student response to the treatment
plan in school are critical to timely
medical management in areas such
as attention-deficit/hyperactivity
disorder, diabetes, life-threatening
allergies, asthma, and seizures as
well as for the growing population
of children with behavioral health
concerns. School nurses play an
important role in interpreting
medical recommendations within
the educational environment and,
for example, may participate in
the development of action plans
for epilepsy management and
safe transportation of a child with
special health care needs.11, 12 School
nurses may also provide insight
to a student’s pediatrician when
attendance concerns, parental
noncompliance with medical home
goals, or even neglect or abuse is
suspected. In addition, with increased
awareness recently about such issues
as head injuries, the school nurse is
poised to offer on-site assessment
of the student’s postconcussion
progress and adaptations required in
the educational plan.13
School nurses are also participants
in public health arenas, such as
immunization, obesity prevention,
substance abuse assessment, tobacco
control, and asthma education. Their
daily presence in the school setting
further augments and potentiates
the pediatrician’s professional
interventions with individual
children and adolescents.14
Collaboration among pediatricians,
families, school staff, school
physicians, and school nurses is
increasingly critical to optimal
health care in both office and
community settings. This policy
statement describes the crucial
aspects of the school nurse’s role,
its relationship to pediatric practice,
and recommendations to facilitate
productive working relationships
benefiting all school-aged children
and adolescents. An important and
more detailed reference for school
health, School Health: Policy and Practice, provides a more in-depth
description about health and schools,
including a comprehensive chapter
on school health services, including
school nurses.15
BACKGROUND
During the past few decades, major
legal, medical, and societal changes
have critically influenced the need
for registered professional nurses
(hereafter referred to as school
nurse) in the school setting.
Legal Changes
Social attitudes that promote
inclusion, as well as state and federal
laws such as the Individuals With
Disabilities Act (Pub L No. 101-
476 [1990]) and section 504 of the
Rehabilitation Act of 1973 (Pub L No.
93-112), specify disability rights and
access to education, resulting in more
children requiring and receiving
nursing care and other health-related
services in school.16, 17
The Privacy, Security, and
Breach Notification Rules of the
Health Insurance Portability
and Accountability Act of 1996
(Pub L No. 104-191) and Family
Educational Rights and Privacy
Act (Pub L No. 93-380 [1974])
laws impose important privacy
protections for a student’s health
information. However, myths and
misunderstanding among parents,
pediatricians, and school nurses
about these laws can inadvertently
hinder efficient, efficacious, and
cost-effective case management of
student health care needs. School
nurses work with parents to educate,
facilitate, and expedite necessary
communication between schools
and the medical home. School nurses
facilitate parental permissions for
information exchange and serve as a
link between parent and pediatrician
to establish essential and effective
individualized health care plans for
students at school.
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PEDIATRICS Volume 137 , number 6 , June 2016
Medical Changes
Survival rates of preterm infants
have increased to more than 80% of
infants born at 26 weeks’ gestation
and to more than 90% of infants born
after 27 weeks’ gestation, resulting in
an increase in the number of children
with moderate to severe disabilities
and learning or behavioral
problems.18, 19
Chronic illnesses also are on the rise.
In 2010, 215 000 people younger
than 20 years in the United States
had a diagnosis of either type 1 or
type 2 diabetes.20 The prevalence
of food allergies among children
younger than 18 years increased
from 3.4% in 1997–1999 to 5.1% in
2009–2011.21 An average of 1 in 10
school-aged children has asthma, 22
contributing to more than 13 million
missed school days per year.23 As
the number of students with chronic
conditions grows, the need for health
care at school has increased.24 The
rise in enrollment of students with
special health care needs increases
the need for school nurses and school
health services.25
Caring for children with chronic
conditions in schools requires
registered professional school
nurses. However, the reality is that
school nurse staffing patterns vary
widely across the United States.14
When a school nurse is not available
at all times, the American Academy of
Pediatrics, the National Association
of School Nurses, and the American
Nurses Association recommend
that delegated, unlicensed assistive
personnel be trained and supervised
in the knowledge, skills, and
composure to deliver specific school
health services under the guidance
of a registered nurse. The delegation
of nursing duties must be consistent
with the requirements of state nurse
practice acts, state regulations, and
guidelines provided by professional
nursing organizations.26 Delegation
does not obviate the need for
continued advocacy for full-time
professional school nurses in each
building. American Academy of
Pediatrics’ policy has previously
supported ratios of 1 school nurse
to 750 students in the healthy
student population and 1:225 for
student populations requiring
daily professional nursing services.
However, the use of a ratio for
workload determination in school
nursing is inadequate to fill the
increasingly complex health needs of
students.27, 28
Societal Changes
Families face multiple barriers to
adequate health care, including
accessibility, availability, and
affordability. Many working parents
also fear job loss if they are absent
from work to attend a child’s medical
appointment, forcing them to leave
illnesses and chronic conditions
unattended.29 The availability
of school nurses to children and
families helps to increase access to
the medical home for comprehensive
care as well as to essential
public health functions, such as
immunization or obesity prevention.
Schools and school nurses can
partner with medical homes and
public health agencies to increase
access to or to deliver vaccines.
The presence of registered nurses
in schools is correlated with fewer
immunization exemptions in
schools.30 School nurses can improve
vaccine uptake among students
and staff by providing accurate
information about vaccines. They can
also remind students, families, and
staff of immunization schedules and
retrieve and update immunization
records for state-specific reporting
requirements.
Increasing rates of obesity over
the past several decades represent
alarming risks for the current
and future health of children and
adolescents. The percentage of
children 6 to 11 years of age with
obesity increased from 7% in 1980 to
nearly 18% in 2012, with more than
one-third of children now overweight
or obese.31
The immediate and long-term
effects on health range from
cardiovascular disease and diabetes
mellitus to social problems
because of stigmatization.31 The
school nurse, with his or her daily
presence in school and access to
large populations of students, is
well positioned to prevent and/
or intervene on this health issue
through (1) implementing BMI
screenings and referrals to the
medical home as needed, (2)
collaborating with food service
personnel and administrators
to advocate for and to provide
nutritional meals and snacks,
(3) working with school staff to
promote opportunities for physical
activity, (4) educating parents about
healthy lifestyles, and (5) involving
the community providers and
organizations in these efforts.
School-based health centers
complement school nursing services
by delivering a continuum of
diagnostic and treatment services
on-site and collaborating for
prevention, early intervention, and
harm-reduction services. To be most
effective, school nurses and school-
based health center staff need to
develop close communication and
referral systems, similar to school
nurses and any medical home.32
Another societal change is the
increase in students identified with
mental or behavioral health issues.
One in five young people between the
ages of 4 and 17 years experiences
symptoms of minor to severe
mental/behavioral health problems.
One in ten children and adolescents
has a mental illness severe enough to
cause some level of impairment; yet,
in any given year, only about 12%
of children in need of mental health
services actually receive them.33
Pediatricians, both community- and
school-based, and school nurses
need to collaborate to advocate for
professional resources addressing
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FROM THE AMERICAN ACADEMY OF PEDIATRICS
this burgeoning problem that affects
both their practices.9
Health care reform, including how
health care is financed and delivered,
is a significant societal change. In
addition to improving quality of
health care, cost containment is a
major aim of health care reform.
Working closely with parents, school
staff, and community pediatricians,
school nurses are well positioned to
help contain costs. Initiatives such
as chronic disease management,
early detection of behavioral health
issues, and obesity prevention are
just a few examples of how school
nurses contribute to significant cost
savings for the health care system.
There is growing evidence that full-
time school nurse staffing results in
cost savings for society. In 1 study,
for each dollar spent on school
nurses, $2.20 was saved in parent
loss of work time, teacher time, and
procedures performed in school
rather than in a more costly health
care setting.34
Healthy Students Are Better Learners
Understanding the complex
factors that lead to academic
underachievement, poor school
attendance, student drop out, and
poor health outcomes is critical
for the practicing community and
school pediatrician, the educational
community, and lawmakers alike.
Physical and emotional health
problems rank high among the
factors contributing to chronic
absenteeism (missing 10% or more
of school days for any reason),
a key risk factor for failing to
complete school.35 Health-related
problems contributing to academic
underachievement are a primary
responsibility of the medical home,
the family, and the school health
services team led by the school nurse
in the health office on a daily basis. A
growing body of research indicates
that school nurses can improve
attendance by reducing illness rates
through education about preventive
health care, early recognition
of disease processes, improving
chronic disease management, and
increasing return-to-class rates.36
Of the students seen by the school
nurse for illness or injury, 95% were
able to return to the classroom.
Without a school nurse, unlicensed
personnel who are uncertain what
to do medically are at risk of sending
children home from school or to the
emergency department needlessly.37
The presence of a coordinated
school health program, often led
by school nurses, contributes to
both educational achievement and
the educational system.38 School
nurses can provide key leadership
in all the components of the Whole
School, Whole Community, Whole
Child model.39 Direct health services
provided by a school nurse are linked
to positive academic achievement.
With a nurse in the school, other
school staff, including teachers, divert
less time from their primary job
responsibilities to deal with student
health issues.40
CONCLUSIONS
School nurses, working with pediatric
patient-centered medical homes,
school physicians, and families, are in
a critical position to identify unmet
health needs of large populations
of children and adolescents in
the school setting. Promoting the
presence of a qualified school
nurse in every school and a school
physician in every district fosters the
close interdependent relationship
between health and education.
Academic achievement, improved
attendance, and better graduation
rates can be a direct result of a
coordinated team effort among the
medical, family, and educational
homes all recognizing that good
health and strong education cannot
be separated.
RECOMMENDATIONS
1. Pediatricians can advocate
for a minimum of 1 full-time
professional school nurse in every
school with medical oversight
from a school physician in every
school district as the optimal
staffing to ensure the health and
safety of students during the
school day.
2. Pediatricians can ask school-
related questions, including about
health problems contributing to
chronic absenteeism, at each visit
and provide relevant information
directly to the school. Electronic
health records should include the
name of the patient’s school and
primary contact at the school.
Health Information Exchange
requirements, as defined in stage
3 of Meaningful Use, should permit
the direct exchange of school-
related information collected in
the pediatrician’s office at each
visit, including attendance and
health problems contributing to
absenteeism.
3. Pediatricians can establish
a working relationship with
school nurses to improve
chronic condition management.
Establishing an agreed-upon
method of communication with
the use of standardized forms
and securing permission to
exchange information are ways
to facilitate this relationship.
Communication and collaboration
will also aid in the development of
Individualized Health Care Plans,
care coordination, and planning
for transition from pediatric to
adult health care.
4. Pediatricians can include school
nurses as important team
members in the delivery of health
care for children and adolescents
and in the design of integrated
health systems, including school-
based health centers.
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PEDIATRICS Volume 137 , number 6 , June 2016
LEAD AUTHORS
Breena Welch Holmes, MD
Anne Sheetz, MPH, RN
COUNCIL ON SCHOOL HEALTH EXECUTIVE COMMITTEE, 2015–2016
Breena Welch Holmes, MD, FAAP, Chairperson
Mandy Allison, MD, MEd, MSPH, FAAP
Richard Ancona, MD, FAAP
Elliott Attisha, DO, FAAP
Nathaniel Beers, MD, MPA, FAAP
Cheryl De Pinto, MD, MPH, FAAP
Peter Gorski, MD, MPA, FAAP
Chris Kjolhede, MD, MPH, FAAP
Marc Lerner, MD, FAAP
Adrienne Weiss-Harrison, MD, FAAP
Thomas Young, MD, FAAP
CONSULTANT
Anne Sheetz, MPH, RN
LIAISONS
Nina Fekaris, MS, BSN, RN, NCSN – National
Association of School Nurses
Veda Johnson, MD, FAAP – School-Based Health
Alliance
Sheryl Kataoka, MD, MSHS – American Academy
of Child and Adolescent Psychiatry
Sandra Leonard, DNP, RN, FNP – Centers for
Disease Control and Prevention
FORMER EXECUTIVE COMMITTEE MEMBERS
Cynthia DiLaura Devore, MD, FAAP, Past
Chairperson
Jeffrey Okamoto, MD, FAAP, Immediate Past
Chairperson
Mark Minier, MD, FAAP
FORMER LIAISONS
Carolyn Duff, RN, MS, NCSN – National Association
of School of Nurses
Linda Grant, MD, MPH, FAAP – American School
Health Association
Elizabeth Mattey, MSN, RN, NCSN – National
Association of School Nurses
Mary Vernon-Smiley, MD, MPH, MDiv – Centers for
Disease Control and Prevention
STAFF
Madra Guinn-Jones, MPH
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DOI: 10.1542/peds.2016-0852 originally published online May 23, 2016; 2016;137;Pediatrics
COUNCIL ON SCHOOL HEALTH Role of the School Nurse in Providing School Health Services
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DOI: 10.1542/peds.2016-0852 originally published online May 23, 2016; 2016;137;Pediatrics
COUNCIL ON SCHOOL HEALTH Role of the School Nurse in Providing School Health Services
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