Nursing in the Public Schools of the United States of America

Maria Applewhite,RN

April 2003



A Historical Perspective of School Nursing in the United States


  1. The Beginnings
  2. The 1950’s, 60’s and 70’s
  3. The Role of the School Nurse Today


Health Issues


  1. The Medically Fragile Child and the Student With Special Health Care Needs
  2. Infectious Diseases
  3. Asthma
  4. Obesity
  5. Attention-Deficit/Hyperactivity Disorder (ADHD)
  6. Pregnant and Parenting Teenagers
  7. Substance Use and Abuse
  8. Eating Disorders
  9. School Violence
  10. Gay Teens – Preventing Self-Harm



Professional and Legal Issues


  1. Documentation
  2. Research
  3. Issues of Confidentiality
  4. Who Has Access to a Student’s Health Record?
  5. Accessing Health Care


The Future

  1. Pediatric Nursing Advances
  2. Creating a Coordinated School Health Program
  3. Participation in Public Policy, Legislative and Regulatory Government Relations







School Nursing: A Historical Perspective

The Beginnings

The late 19th century change from an agricultural to an industrial economy profoundly influenced the health of children in the United States. Children were hazardously employed along side their parents in mines, mills and factories. They were overworked and underpaid. They went home at night to crowded and often filthy and dangerous living conditions. Undernourishment was the norm. Healthcare was generally out of reach. Epidemics became commonplace, and the number of preventable deaths, particularly among children of the poor, soared. Nowhere was the urgent need to stop the spread of communicable diseases, particularly tuberculosis, more apparent than in the New York City, where in 1902, 15 to 20 children were being sent home from every public school each day.

            It was clear to Lilian Wald, a prominent public health nurse and social reformer, that the protocol for school health in NYC, one of inspecting and dismissing children from school, was not only failing to stop the spread of epidemics, but it was in fact making the situation worse. Though children were being sent home with notes to their parents, these notes could either not be understood by the immigrant community, or in those cases where the notes were understood, the health measures indicated were not within their reach. As a result, excluded children simply ran the loose in the community, and contagion continued to be rampant. Wald went to the New York City Board of Health, and asked them to examine the quandary of contagion versus absenteeism. She proposed a new model for school health for NYC schools, one that focused on treating children and keeping them in school.

The NYC Board of Health reluctantly agreed to a one-month trial period in four NYC schools, with one nurse, Lina Rogers. Rogers would treat students for their disorders and return them to the classroom. When the one-month timeframe was up, there was no question that significant improvements had been made. The students in these four schools appeared healthier and had missed significantly less classroom time, when compared to those students in other schools where no nurse was present. Rogers was subsequently appointed by the NYC Board of Health, to be the first municipality-sponsored school nurse in the United States.


School Nursing in the 1950’s, 60’s and 70’s:

Over the next several decades, by the middle of the 20th century, along side the great strides made in housing conditions and urban sanitation, and the development of vaccines and antibiotics, the role of the school nurse began to shift. Duties evolved away from the model of treatment and towards one of illness prevention and health education.

With the 1950’s and ‘60’s, many new health and welfare programs emerged.  This marks the beginning of the overextension of the role and responsibilities of the school nurse (Schumacher, 2002). School nurses began to use those in the educational community to help them – administrators, teacher, parents and at times, students. Often school nurses found themselves performing non-nursing tasks, and those in the educational community found themselves performing nursing duties (as the number of school nurses were few) (Shumacher, 2002).

Then came the 1970’s, and issues such as sexually transmitted diseases, teenage pregnancy and drug dependency emerged. School health programs were forced to expand and adapt even further, and the professional duties of school nurses, once again, became increasing overwhelming. With this rapid over-extension of responsibilities, time constraints forced school nurses to cope only with the immediate health problems of their students and only meet minimal state mandates. They were stuck between models of education and nursing. They worked under non-medical norms, and had few universally accepted goals and means for achieving them (Shumacher, 2002, Wolfe, 2002). They were no longer able to produce tangible health outcomes that proved their worth, such as those produce by Lilian Wald in 1902.

A congressional finding in 1975 found that one half of the 8 million disabled children in the U.S. did not receive appropriate educational services and that one million children had been excluded entirely from the public school system. This prompted the passing of the Public Health Law 94-142, also known as the Education for All Handicapped Children Act.  This law ensured that all students – regardless of physical or mental disabilities – the right to a “free and appropriate public education” in the “least restrictive environment.” The passage of this law was yet another watershed event in the history of school nursing, as school nurses were asked to take on the complex health care needs of this new population of students that was rapidly expanding due to continuing medical strides in fields from neonatal care to medical technology. New school nursing duties now included gastro and nasogastric feedings, oxygen administration, oropharyngeal, gastric and tracheostomy suctioning, respiratory care, urinary catheterization, ostomy care, and monitoring of shunt functioning. School nurses, once again, found themselves even more overworked, under funded and in their catchall positions (Constante, 2002).


The Role of the School Nurse Today

As school nursing enters the 21st century, the composition of today’s student population continues to change, particularly in relation to the number, complexity and acuity of medical and psychiatric problems with which students come to school. Students come to school with every actual and potential physical and mental health condition, disability and treatment modality possible except those requiring acute, in-patient treatment in a hospital. Additionally, much of today’s school population is rife with poverty, homelessness, single-parent households, working parents, drug and alcohol abuse, eating disorders, teenage pregnancy, suicide and violence. Other factors that affect the health of the American student is that he or she has a one in four chance of living in a home with substance abuse and/or drug addiction (Lowrey, 1995), a one in five chance of not having health insurance, a one in 12 chance of suffering from asthma, and the greatest chance of the 10 most industrialized nations in the world, to die in adolescence from medical or social causes (

In response to the diverse needs that challenge school communities today, the National Association of School Nurses has specified seven specific roles for the school nurse of the 21st century.

  1. The school nurse provides direct health care to students and staff:  Health care may involve treatment of health problems that are a result of injury, acute illnesses or a chronic health condition. Chronic health conditions involve the development of an individualized health plan (IHP) that should include an emergency action plan. The school nurse is responsible for medication administration and the performance of health care procedures that are within the scope of nursing practice. The school nurse also assists faculty and staff in monitoring chronic health conditions.
  2. The school nurse provides leadership for the provision of health services:  The school nurse must take into account the nature of the school environment, including available resources. This leadership role includes developing a plan for responding to emergencies and disasters and training staff to respond appropriately. It also involves the appropriate delegation of care within applicable laws.
  3. The school nurse provides screening and referral for health conditions:  In order to address potential health problems that are barriers to learning or symptoms of underlying medical conditions, the school nurse often engage are screening activities. Screening activities may include vision, hearing, postural, body mass index or other screening. Determination of which screenings should be performed is based on several factors, including legal obligations, the validity of the screening test, the cost-effectiveness of the screening program, and the availability of resources to assure referral and follow-up.
  4. The school nurse promotes a healthy school environment:  The school nurse provides for the physical and emotional safety of the school community. The school nurse monitors immunizations, assures appropriate exclusion from and re-entry into school, and reports communicable diseases as required by law. The school nurse provides leadership to the school in implementing precautions for blood borne pathogens and other infectious diseases.
  5. The school nurse promotes health:  The school nurse provides health education by providing health information directly to individual students, groups of students, or classes or by providing guidance about the health education curriculum, encouraging comprehensive, sequential and age appropriate information.
  6. The school nurse serves in a leadership role for health policies and programs:  The school nurse participates in and provides leadership to coordinated school health programs, crises/disaster management teams, and school health advisory councils. The school nurse participates in measuring outcomes or research, as appropriate, to advance the profession, and advocates for programs and policies that positively affect the health of students or impact the profession of school nursing.
  7. The school nurse serves as a liaison between school personnel, family, community and health care providers:  The school nurse participates as the health expert on Individualized Education Plans and 504 teams and on student and family assistance teams. As case manager, the nurse communicates with the family, community health providers and community health care agencies. The school nurse ensures appropriate confidentiality, develops community partnerships, and serves on community coalitions to promote the health of the community.


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 in nursing (BSN) from an accredited college or university. The growing complexity of nursing in the school environment is mandating and increasing number of states to require master’s level education.  In addition, school nurse certification or licensure is recommended or required depending on the individual state board of health.

Despite these expanded roles for the school nurse, as well as the many changes that have occurred in school nursing and student health, the role of the school nurse today is fundamentally no different that the role of Lina Rogers in 1902. It remains a practice that uses nursing knowledge and skills to intervene effectively in order to improve the health and educational outcome of children and adolescents.  


Specific Health Problems That Effect the School Nurse Today

Students Who are Medically Fragile, or Who Have Special Health Care Needs:

The school nurse has a unique role in the provision of school health services for children with special health care 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 an individualized Health Plan (IHP) for management of health related problems in the school setting. The school nurse also assists the school staff and pupils to understand the handicapped students special needs, and serves as the liaison with physicians and allied health personnel relating to the evaluation and provision of services to handicapped children. Naturally, part of working with a special needs population is helping them understand, accept and adjust to their special needs.

The school nurse must safely and effectively provide specific health care procedures. This includes tracheostomy suctioning, bladder catheterization, ostomy care, nasogastric feedings, maintenance of orthopedic devices and ventilator care, for students who need them.  The school nurse also should collect important information, such as special needs, modifications to routine medical procedures, allowance to administer medications in school, emergency measures and parent permission to interact with the student’s health care providers.

The courts are currently divided about how much responsibility school districts bear for children who require constant and extensive nursing services in order to benefit from their education (AFT, 2001). Generally, if the care required is intermittent and can be provided by a regular school nurse, the service is an eligible service, but if the care required is more like private duty nursing, the service is an excluded medical service. Because of conflicting interpretations by the courts, school district obligations vary from state to state.



The school nurse is in a position to assess immunization needs and serve in a leadership capacity to develop school immunization programs and promote community awareness of the value of immunizations in the primary prevention of disease throughout the lifespan. Specific immunization issues include, but are not limited to the following:

Lapsed or Uncertain Immunization Status:

            This is a common situation in a mobile society. Families move to new communities. Children are moved to live with relatives or to foster care. Children are adopted from foreign countries. Records are lost or their validity cannot be ascertained. These are a few of many possible examples than can throw a child’s immunization status into the categories of lapsed, unknown or uncertain. The terms “unknown” or “uncertain” are self-evident and dictate the same course of action: assume that none has been given and initiate an immunization schedule that is appropriate for age. No reliable evidence exists that giving “extra shots” to someone who is already immunized does any harm; in fact, the booster effect may do some good to enhance immunity.

Vaccine shortages:

            Currently both the tetanus and the DTP vaccine supplies are almost depleted. This is a scenario that is bound to become more common in the future. Fewer and fewer pharmaceutical houses are producing vaccines for several reasons: hugely expensive development costs, small profits because vaccines are purchased in bulk at discounted prices, and outlandish jury awards to persons injured by vaccines. One or two manufacturers produce most vaccines in the US. When a production problem arises, there may be inadequate reserve supplies to cover the period until full production is resumed. During such periods, vaccine doses have to be rationed to those most at risk and routine immunizations have to be deferred by the school nurse and other health care providers.

Bacterial Meningitis Clusters:

            A case of bacterial meningitis requires notification by the school nurse to the parents of exposed classmates.  When a second case occurs, public health authorities should be notified immediately by the school nurse in order to help determine the best course of action. Currently is recommended that meningococcal vaccine be considered for freshmen college students living in dormitories, because of their increased risk of meningococcal disease, but no recommendations are made for routine use of meningococcal vaccine in other school groups.



According to the American Academy of Allergy, Asthma and Immunology (1999), asthma is the most common chronic disorder in children and adolescents, affecting about five million youngsters under 18 years of age. Each year, children with asthma miss more than 10 million school days, accounting for 60% of school absences (AAAI, 1999). Chronic absenteeism, whatever the cause, has been shown to negatively affect grades, academic achievement, self-esteem, and future life successes (Lenny, 1997).

Asthma is completely controllable. When students suffer from poorly controlled asthma, it is actually the fault of noncompliant parents/guardians. The many reasons for this range from poor parenting skills, low control of social and economic circumstances, to lack of energy to maintain the often-rigorous schedule to control asthma symptoms. This is why the control of asthma, particularly in the school setting is the implementation and adherence to an asthma management plan. Unfortunately, poor adherence to a child’s asthma management plan may constitute medical, and subsequent educational neglect. When clear and immediate risk is present for the child, referral to the appropriate child protective agency must be made by school nurses (O’Toole, 2002).



            The single fastest rising public health problem in our nation is obesity (NASN, 2002). Over the last two decades, the percentage of overweight adolescents has almost tripled. Currently in the U.S., 13% of children 6 to 11 years of age, and 14% of teens 12 to 19 years of age are categorized as overweight (NASN, 2002). Being overweight or obese is associated with several health risks. Children who are overweight have an increased risk of high blood pressure, coronary heart disease, diabetes, musculoskeletal disorders, early sexual maturation, psychosocial issues, and asthma. The also have a greater risk of becoming obese adults than their classmates who are not overweight or obese.

            The school nurse has the capacity to reach a large number of students, as well as parents, school personnel and health care providers in identifying those individuals who are at risk for being overweight or obese. Screening tools include height and weight measurement, skin fold testing and measuring BMI (Constant, 2002). Weight issues are often dealt with by referring a child to his or her health care provider and a subsequent nutritionist. They can also involve special doctor’s requests for special meals to be provided by the school food services department. By helping students deal with the problem of being overweight in a proactive manner, the impact of poor nutrition on learning outcomes can be minimized (Costante, 2002).

            Numerous studies over the past decade have provided evidence that girls in the United States, especially African-American girls, are starting puberty at increasingly younger ages. Because nutritional status is known to affect timing of puberty and there is a clear trend for increasing obesity in US children during the past 25 years, it was hypothesized that the earlier onset of puberty could be attributable to the increasing prevalence of obesity in young girls.  Over the last couple of years, this link has been found to be statistically significant (Kaplowitz, 2002). The results are consistent with obesity’s being an important contributing factor to the earlier onset of puberty in girls.


Attention Deficit/Hyperactivity Disorder (ADHD)

            The first medical description of ADHD appeared in literature in 1902, were it was described as a defect in moral character and an unwillingness on the child’s part to inhibit his or her behavior (Spear, 2002). Today ADHD is defined as “a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development” (APA, 2000). Much of the literature now calls ADHD the most commonly diagnosed psychiatric disorder of childhood (Spear, 2002). It is now thought that somewhere between 5% and 10% of American school-age children (ages 5 to 18) have been diagnosed with ADHD, with some studies going as high as 21% (Spear, 2002).

It is estimated that 12 to 50% of children with ADHD have also been diagnosed with other psychiatric conditions from depression and anxiety disorders, to sleep difficulties, enuresis and encopresis (Speer, 2002). Also significant to a diagnosis of ADHD, is that 25% of the students who have been diagnosed with this condition also have a learning disability. Likewise, 25% of those with a learning disability have been diagnosed with ADHD (Spear, 2002). [These are two completely different conditions. Learning disabilities affect the brains ability to learn, whereas ADHD interferes with an individual’s availability for learning (ADHD, 2002).]

            Although some parents do not want their child to be labeled as having ADHD, the diagnosis is the key to receiving treatment and school accommodations The school nurse is an integral member of the necessary multidisciplinary approach in the assessment and diagnosis and treatment of ADHD (Spear, 2002). And as they work with more children with ADHD than any other health care provider and are knowledgeable about the symptoms, challenges, and treatment options for ADHD, then they are in the best position to help these children and adolescents become healthy and productive adults (Spear, 2002).


Pregnant and Parenting Teenagers

            Teen pregnancy is an enormous and well-documented problem in the U.S., with about four in ten teenage girls becoming pregnant before they reach the age of twenty.  This translates to approximately 890,000 teenage pregnancies in the U.S. each year, making it the highest teenage pregnancy rates among industrialized nations (Hoyt, 2002; Spear, 2002). These pregnancy rates include live births, induced abortions and fetal losses. They occur among almost all races and ethnic groups (Hoyt, 2002, Clifford & Brykczynski, 1999).

            The primary negative consequence of adolescent child bearing is decreased adolescent attainment. Extensive research points out the links between adolescent childbearing and school failure, low attendance, poor grades and school dropout rate (Casserly, Carpenter & Holcom, 2002). Generally found to reduce schooling by 1 to 3 years, teen mothers have approximately a 60% chance of graduating from high school by age 25, compared with 90% for those who postpone childbearing (Casserly, Carpenter & Halcon, 2002). Other negative consequences include poverty, unemployment, and children at risk for a variety of social and behavioral problems (Spear, 2002).

            Many interventions and school health education programs have been put into place in schools across the U.S. in hopes of reducing the soaring teen pregnancy rate. Research studies evaluating these programs have these programs to be marginally successful. In fact, presently no program exists that demonstrates significant delay of sexual intercourse, or affects contraceptive practices among middle and high school students (Hoyt, 2002; Spear, 2002).

            School nurses are in a unique position to make a difference in the substantial morbidity and social problems that result from the pregnancies (Spear, 2002). They are in the logical position to select and then implement programs that vary not only in length and intensity, but also in the populations they target that vary according to age, culture and level of risk exposure. Should nurses are in the prime position to evaluate both the short- and long-term outcomes of teen pregnancy reduction campaigns, and becoming active participants in following pregnancy rates and identifying teen pregnancy trends (Spear, 2002).

            Additionally, a more comprehensive approach to school-based education is needed to meet the complex needs of pregnant and parenting teenagers. School nurses should promote vocational training, health services and on-site day-care, education on parenting and psychosocial support for mothers and fathers, and their children. Additionally, they need to advocate for the completion of high school and further education, economic independence and healthier outcomes for particularly young mothers and their children (Spear, 2002).

Substance Use and Abuse

            Substance use and abuse is a problem that impacts students from pre-school through high school. Children of all ages may experience problems either related to living in a drug or alcohol affected home or to abusing substances themselves. Family problems can include child abuse, fetal alcohol syndrome, a change in the family dynamic that co-opts children in keeping the family secret, depression, somatization, feelings of guilt, learning and academic problems, as well as genetic and environmental factors that increase their own probability of substance abuse (Sullivan, 1995; Kinney, 1996). Problems related to personal substance use and abuse can include legal difficulties, academic difficulties, truancy, dropping out of school, family difficulties, addiction, health problems, and morbidity and mortality related to accidentally injury, homicide and suicide (Sullivan, 1995, CDC 2000). These students put their academic achievement at risk and can be a profound challenge to the school nurse as a number of these students will present with behavior problems, health problems or neglect (Sullivan, 1995). Because school nurses often participate in primary, secondary and tertiary prevention activities in schools, they appear approachable and informed to students seeking help. Therefore, the school nurse plays a key role in identification, support, and possible referral of students impacted by substance use and abuse. Specific school nurse interventions would include making appropriate referrals to agencies such as Social Services, Drug and Alcohol Treatment Services, Mental Health services and the Child Protection Team; providing primary prevention/education to individual students and classrooms; recognizing that students living in alcohol-affected homes may have a multiplicity of alterations in academic achievement, social skills, affect and health; and evaluating and referring students for concurrent mental health issues such as suicide risk. The needs of students affected by substance use and abuse utilize a broad range of a school nurses nursing and community health knowledge.

Eating Disorders

            Eating disorders are among the leading health problems in the US. Typically diagnosed during adolescence, initial symptoms of eating disorders “are becoming more prevalent…in elementary and middle school years” (White, 2000). The most common eating disorders – anorexia nervosa, bulimia, and binge eating – involve issues and behaviors around body image distortions, food and interpersonal relationships. Eating disorders are serious, complex and sometimes fatal.

            School nurses are uniquely prepared to assess and to formulate a nursing diagnosis and plan of care for a student diagnosed with an eating disorder. As appropriate, the school nurse involves the family or outside referral agencies for further evaluations. Surveillance for risk factors and prevention through health education/support groups with at-risk youth provides an opportunity to identify students early. The school nurse can play a vital role in the promotion of greater therapeutic success and greater school success in the treatment of students with eating disorders.


School Violence

            High profile violent incidents in schools make headlines and are sensationalized in news reports. Lawmakers, parents and community leaders call for action to “make our schools safe again.” The role of the school nurse is to collaborate with school and community members to implement programs that will proactively change behaviors and lead to the creation of a positive, healthy and safe environment.  School nurse are active members of the crisis intervention teams and as such, assure that their school community has an effective program in place. School nurses are also able to identify issues related to self-esteem and self-worth, which can lead to isolationism and feeling of rejection among students. School nurses address problems holistically, including examining the physical,

Emotional and social perspective of school violence. They are also able to contribute insight into developmentally appropriate behaviors. and to recognize the early warning signs that may lead to violence.

            School nurse are also able to lobby for appropriate interventions and controls to address violence against children, including local and national efforts to establish safe schools and communities. This may lead to a coordinated interdisciplinary program that would include prevention and early recognition and treatment of mental health issues.


Gay Teens – Preventing Self-Harm

            As children and adolescents, gays (this term is used to refer to gay males, lesbians and bisexuals of both sexes) go through the same developmental stages as heterosexual youth with the additional task of trying to resolve the conflict between their sexual and/or gender feelings and society’s messages. Not all gay teens resolve this conflict successfully. Suicide is the leading cause of death in gay youth (30% of adolescent suicides are estimated to be committed by gay youth). Gay youths account for 30-35% of the homeless youth in the US, with a four times greater incidence of being “kicked out’ or “forced out” of their homes. HIV positivity is also high, particularly among gay male teens.  Physical violence toward gays is high in most areas, and a majority of bisexual and gay males report being verbally abused by classmates on a regular basis.

            The role of the school nurse is to find a way to signal gay students that their office/clinic is “gay friendly” (displaying a gay poster or symbol). The school nurse needs to use non-biased language, such as partner instead of girlfriend or boyfriend. A thorough sexual history is important and should include questions about gender identify, sexual identity, age of first sexual intercourse, number of male and female partners and history of sexual abuse or survivial-sex, keeping in mind that the gay person remains gay regardless of his or her sexual behavior (Nelson, 1997).



Professional and Legal Issues that Face the School Nurse Today


Documentation and School Nursing Research

Historically, the contributions of school nurses to the achievement of positive educational outcomes have been largely invisible. This is because nursing documentation issues within the school setting lag substantially behind other nursing settings. It is not that standardized nursing documentation languages don’t exist, it is simply that they have for the most part, failed to be implemented in the school setting. With no one universal standardized school nursing vocabulary, school nurses are unable to describe and measure children’s health issues and the complex nature of professional school nursing practice, not to mention how school health services contribute to educational outcomes. This lack of standardization of data has made school nursing research very difficult. It is no wonder that there is poor public comprehension of the value of school nursing, particularly as it relates to educational outcomes.

      School nurses need to move towards a research-based practice that is able to scientifically measure the cost-effectiveness, and the quality of outcomes of school health services and school nursing (Hootman, 2002). Only when there is sufficient hard data to verify the connection of school nursing services to educational outcomes for children, will school health services receive the funding it needs to provide the educational outcomes that are mandated (Costante, 2002). School nurses must be able to scientifically prove that health is fundamental to the educational process (Costante, 2002). Once again, this begs for the practice of school nurses, to join other nursing specialties, and becomes research-based. 

Nationally there are approximately 30,000 nurses caring for 42 million students. That averages to one nurse for every 1400 students. This is the situation despite the fact and the U.S. Department of Health and Human Services, in its publication, Healthy People 2010, and the National Association of School Nurses have issued recommendations for student to nurse rations to be 750:1 for the general school population; 225:1 for the mainstreamed population; and 125:1 in special needs/medically fragile populations (HHS 2002, NASN, 2002). It is doubtful that the poor student to nurse ratios that exist today will change until school nurses can produce statistically significant data that proves the cost-effectiveness of lower student to nurse ratios. School nurses are in a powerful position in the school district, but only by expanding visibility can it be a viable one.

If school nurses cannot prove that what they do makes a difference or show what nursing interventions are needed to ensure optimal student performance, then how can school nurses advocate for increased school health services? Improved documentation systems will lead to smaller school nurse to student ratios, the validation of specific school nursing interventions, and provide the basis for establishing credible nursing services as they relate to positive educational outcomes.


Issues of Confidentiality

One of the most conflicting issues for school nurses is confidentiality of health information. Conflicts about confidentiality exist between members of the school staff and the school nurse, between parents/guardians and the school staff, and minors and their parents. School staff often believe they have a right and responsibility to know all about a student’s personal health issues, whereas school nurses are committed to protecting each individual student’s privacy related to health information (Costante, 2002). Often a parent/guardian will not permit certain information to be shared with the education team, despite the fact that school nurse might believe that some members of the school staff  could benefit from knowing about a student’s health status in order to serve him or her appropriately. And thirdly, while parents generally hold legal authority to make health care decisions for their children, there are sometimes divergent interests between what minors may want their parents to know and parents/guardians feel is their right to know.

      There are those who believe that minors with decision-making capacity, regardless of their age, should be involved in their health care decisions (Dickey, 2002). There are those who believe the opposite is true. The school nurse is often in a unique position to promote the inclusion of minors in their day-to-day health care decisions, particularly as the health office is a “safe” place where students can go for a variety of concerns without parental presence.

      When a minor is married, pregnant, or a parent of his or her own child there are often state statutes that allow for them to make autonomous decisions regarding health care for a variety of service, including family planning, testing and treatment for HIV and other sexually transmitted disease, prenatal care and delivery service, treatment for alcohol and abuse, and outpatient mental health care (Dickey, 2002). This could, depending on the state, allow a 14 year old mother of an infant leave school without parental permission to go to her 6-week post-partum check-up, or allow her to be tested for a sexually transmitted disease, or even allow for the 16 year old father of the infant to leave school without parental permission to accompany the mother and infant to a pediatrician’s appointment (Schwab, 2002).

      Let’s say a minor is not married, pregnant, or a parent of his or her own child, what statutes allow for them to make autonomous decisions regarding their own health care? Their rights to seek health care independently of their parents are generally in proportion to the age and competence of the minor, the type of health care the minor seeks (how invasive), and potential consequences to the minor and the community if her or she refuses to seek care (such as the treatment of an STD, or the refusal of to seek treatment for drug and alcohol problems) (Guidelines, 2002).

      There is an active movement to ‘restore’ parental rights and to legislate parental control over minors’ reproductive health care decisions. With the exception of abortion, lawmakers have generally revisited attempts to impose parental consent or notification requirement on minors’ access to reproductive health care and other sensitive services (Boonstra & Nash, 2002). Further complications may arise with independent consent when parents are held liable for financial debt incurred by their children when they did not have a say in the decision-making process (Dickey, 2002).

In health care, on the other hand, the legal rights of parents to make decisions for their children gives way, in part, to the right of competent minors to seek and make their own decisions regarding certain types of health care. In education, however, the legal right of parent to make decisions for their minor children is upheld almost without qualification (guidelines, 2001). In this litigious age, this paradox is not likely to be resolved, as it is becoming increasingly difficult for school nurses to defend the autonomous health care decisions of minors as ethically valid (Dickey, 2002).


Who has Access to a Students Health Record?

The Federal Education Rights Privacy Act, also known as the Buckley Amendment, which was passed in 1975, is a federal law that requires that students consent to parental access to their education records. Are school health records education records or health records? FERPA does not provide special protection for health information that a competent minor student may want to keep confidential, even though, under state health laws, the information may be protected from access by others, including parents. If a school nurse protects student health information, it often puts him or her at odds not only with a federal law, but also with the expectations of school administrators and teachers regarding what student health information school nurses can or should share with them.

      Exceptions to FERPA are personal notes of the school nurse. In order for a notation to be classified as a personal note, however, they must not be included in the health record, and they must not be shared with any member of the education team. In other words, if a student discusses possible date rape with a minor, he or she may choose not to document in the health record, and instead choose simple to write a “personal note.” But in order for a ‘personal note’ to stay confidential, the school nurse must not share its content with anyone, not even a social worker currently working with a family. Once the ‘personal note’ is shared with anyone,’ it falls under the education law, FERPA, and allows full parental access.

Currently there are no provisions, despite recommendations from the Centers for Disease Control, to hold ‘personal notes,’ and/or health education records, to the same standards of confidentiality observed in health care settings outside the office of the school nurse (guidelines, 2001). Further complicating the issue is that in the school setting, is the fact that school nurses typically have non-nursing on-site supervisors, most often the school principal.


Accessing Health Care

Accessing health care is broader than accessing medical care. In addition to medical care for acute and chronic illness, health care includes health promotion and disease prevention services. Unfortunately, not all children have an ideal connection with the health care system for comprehensive health care. Multiple barriers to accessing comprehensive health care exist, including geographic, financial, transportation, sociocultural, coverage criteria and availability of services.

Ensuring access to quality health care is an important component of school nursing practice. Knowledge about the health care system (e.g. legal mandates, funding sources, and programming), specific regional resources and health policies can bridge the gap between the health care needs of students, their families, and school staff and accessibility to services. The school nurse can assist in the elimination of geographic, transportational, sociocultural and financial barriers to accessing health care by suing his/her knowledge and expertise about health needs and the health care system.


The Future of School Nursing

The Advanced Practice Nurse

            The dynamic, expanding and comprehensive nature of the practice of school nursing demands an educational and skill level that enables nurses to meet the complex health needs of students. As the specialty of school nursing evolves, the requirement for a master’s degree will become increasingly appropriate. Advanced Practice Nurse is a term used to identify the professional registered nurse functioning in an extended role. This nurse must have a baccalaureate degree, as well as a master’s degree, and/or certification as a nurse practitioner or a clinical nurse specialist.

The Advance Practice Nurse in the school setting will always be challenged by issues such as teen pregnancies and medically fragile students, downsized staffing, and cultural diversity of school populations. Costs prompt shorter hospital stays so that children are discharged earlier to home and schools. School nurses need to keep pace with technological advances particularly those that address students with special health care needs.  Participation in professional organizations is paramount. These not only include state and national school nurse associations, but also organizations that deal with specific health care issues such as the American Diabetes Organization, National Education Association, National Association of Nursing Research, and even the national Pediculosis Association.  The Advance Practice Nurse will promote improved quality of health services in schools. Educational programs to expand the skills and scope of practice of the Advance Practice Nurse in the school setting should be established in each state.


Coordinated School Health Program

Although the traditional childhood diseases have diminished, new health problems that have a negative influence on student achievement and success have emerged. These “new morbidities” include an increase in chronic health conditions such as asthma, allergies, diabetes, addictions, teen pregnancies, HIV/AIDS, STDs, suicide and auto accidents.  Many of these health problems are the result of poverty, homelessness, poor nutrition, lack of exercise, smoking, early and/or unprotected sexual activity, substance abuse, stress, and depression.

The national Coordinated School Health Initiative has emerged in response to the state of children’s health and education. It is an organized set of policies, procedures, and activities designed to protect and promote the health and well being of students and school staff. It is a holistic approach to health an education. The school nurse participates actively in each of the eight components of a coordinated school health program. (The eight components are: school health services, health education, health promotion programs for faculty and staff, counseling psychological and social services, school nutrition services, physical education services, health school environment and family and community involvement.)


Participation in Public Policy, Legislative and Regulatory Government Relations

School nurses need to continue to promote public policy, and legislative and regulatory action, which are favorable to students. It is imperative that professional school nurses continue to be involved in the policy arena to impact the health and education of students and the practice of school nursing. They need to advocate for the removal of health related barriers to educational success. Past successes include the Supreme Court mandated inclusion of school nursing services in the federal law, IDEA, and the inclusion of lower school nurse to student ratios in the objectives of Healthy People 2010. It is up to the professional school nurse to take direct action regarding public policy that directly affects the well-being of students as well as the his or her professional status.




























American Academy of Allergy, Asthma and Immunology (AAAAI). (1999). Pediatric asthma: Promoting best practice. Guide for managing asthma in children. Milwaukee, WI: Author.


American Academy of Pediatrics. (2001). The role of the school nurse in providing school health services. Pediatrics, 108, (5), 1231-1232. Accessed 1/13/2003.


American Academy of Pediatrics. Subcommittee on Attention Deficit/Hyperactivity Disorder Committee on Quality Improvement. (2001). Clinical practice guideling: Treatment of the school-aged child with Attention-Deficit/Hyperactivity Disorder. Pediatrics, 108, 1033-1044.


Boonstra, H., & Nash, E. (2000). Issues in brief: Minors and the right to consent to health care. Retrieved February 9, 2002 from the World Wide Web:


Brandt, D.C. (2002). Enhancing school nurse visibility. The Journal of School Nursing, 18 (1), 5-10.

Clifford, J., & Brykczynski, K. (1999). Giving voice to childbearing teens: Views of sexuality and the reality of being a young parent. Journal of School Nursing, 15(1), 4-15.


Casserly, K.R., Carpenter, A.S. & Halcon, L. (2002). Adolescednt parenting: Relationship to school attendance and achievement. The Journal of School Nursing, 17, (6), 329-335.


Costante, C.C. (2002). School health nursing: Framework for the future part I. The Journal of School Nursing, 17, (1), 3-11.


Costante, C.C. (2002). School health nursing: Framework for the future part II. The Journal of School Nursing, 17, (2), 64-72.


Dickey, S.B., Kiefner, C. & Beidler, S.M. (2002). Consent and confidentiality issues among school-age children and adolescents. The Journal of School Nursing, 18 (3), 179-186.


Hootman, J. (2002). The importance of research to school nurses and school nursing practice. The Journal of School Nursing, 18 (1), 18-24.


Hoyt, H.H.,& Broom, B.L. (2002). School-based teen pregnancy prevention programs: A review of the literature. The Journal of School Nursing, 18(1),11-17.


Kaplowits, P. et at. Al (2002). Earlier Onset of Puberty in Girls. Pediatrics, 108(8), 347-353.


Kolar, K.R., Haynie, L., Wilkerson, R. & Fisher, W. (2002) Type 1 Diabetes in children and adolescents: What’s new? The Journal of School Nursing, 18, (3), 344-348.


Lowry, A. (1995). Caring for America’s Children. The Maginnis Communique, February.


National Association of School Nurses. (1998) Standards of professional school nursing practice. Scarborough, ME: Author.


National Association of School Nurses. Position statement: Caseload assignments. Accessed 2/24/03.


National Association of School Nurses. Position statement: Overweight children and adolescents. Accessed 2/24/2003.


National Association of School Nurses. Position statement: School nursing yesterday and today. Accessed 1/14/2003


Nelson, J.G. (1997). Gay, lesbian and bisexual adolescents: Providing esteem-enhancing care to a battered population. Nurse Practioner, 22(2), 98-109.


Schumacher, C. (2002). Lina Rogers: A pioneer in school nursing. The Journal of School Nursing, 18, (5), 247-249.


Schwab, N.C. & Pohlman, K.J. (2002) Legal and ethical issues: Questions and answers. The Journal of School Nursing, 18, (5), 301-305.


Selekman, J. (2002). Attention-Deficity/Hyperactivity Disorder. The Journal of School Nursing, 18 (5), 270-276.


Spear, H.J. (2002). Reading,writing and having babies: A nurturing alternative school program. The Journal of School Nursing. 18 (5), 293-300.


Stock, J.L., Larter, N., Kleckehefer,kG., Throsonn, & G. Maire, J. (2002). Measuring outcomes of school nursing services. The Journal of School Nursing, 18, (6), 353-359.


Wolfe, L.C. (2002). School nursing: The next hundred years. The Journal of School Nursing, 18, (5), 250-251.