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
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.
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).
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 (www.gnofn.org).
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.
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.
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.
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).
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 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 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.
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.
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).
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.
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).
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 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 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.
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.)
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.
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D.C. (2002). Enhancing school nurse visibility. The Journal of School
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