Purpose of the School Health Services Program

Adapted, and used with permission, from School Health: Policy and Practice ©1993. Committee on School Health, American Academy of Pediatrics, P.O. Box 927, 141 Northwest Point Blvd., Elk Grove Village, IL 60009-0927

The goals of the School Health Services Program are to:

1. Facilitate students' access to a regular source of primary health care
2. Provide a system for expert handling of emergency medical situations
3. Provide mandated health screening programs and monitor or improve immunization status
4. Assist in the identification and resolution of students' health and educational problems
5. Ensure comprehensive and appropriate health education is provided
6. Promote a healthful and safe school environment which facilitates learning
7. Provide a system for evaluation of the effectiveness of the school health program

These goals form a framework for the development of specific program activities. A school needs-assessment and inventory of existing and potential community resources will identify priorities most crucial to each unique school district. The outcomes of an effective School Health Services Program should have measurable impact on students, staff, and community.

The Continuum of Health Care

Health Services traditionally are the cornerstone of a comprehensive school health program. A qualified, registered professional School Nurse (RN) serves to identify, assess, and intervene in the treatment of a myriad of minor and major health problems.

These health services are not intended to supersede the parents' health care responsibilities nor to supplant the role of the physician.

Optimally, school health services are a significant component in a continuum of care from the family to the community health care system. This continuum is necessary to maintain students' health thereby promoting optimal participation in their educational process.

The Formal Health Services Plan

HUMAN RESOURCE REQUIREMENTS of the Health Services Plan

The formal plan of the school's Health Services program identifies human resource requirements essential to a quality program by:

• specifying staffing patterns,
• delineating individual responsibilities in job descriptions,
• designating supervision and evaluation requirements.

Staffing patterns are set in accordance with national standards for ratios of School Nurse to students (1:750).

Different ratios have been established for populations of students with special needs (1:225 -- mainstreamed, 1:125 -- severely/profoundly disabled)* wherein school nurses participate in the development of individualized education plans (IEPs) which explicitly address each unique student's health need.

(*Note: Although this ratio is the recommended standard nationally, Nebraska's School Health Advisory Committee recommends a ratio of 2:125 -- i.e., 2 nurses for every 125 severely/profoundly disabled students.)

MATERIAL RESOURCES REQUIRED by the Health Services Plan

The formal plan also identifies material resources which include appropriate facilities.

The school's health office must assure that the nurse has privacy for verbal communication with students and staff, as well as for confidential telephone communication with parents and medical providers.

It is also imperative that restrooms and handwashing facilities be within or immediately adjacent to the health room.

Funding must be designated for equipment, supplies, and professional educational materials.

Nebraska's Comprehensive School Health Education Plan

"Healthier Children -- Healthy Nebraska"

Professionally certificated School Nurses actively support all nine components of Nebraska's Comprehensive School Health Education Program:

1. sequential health instruction
2. health services
3. healthful school environment
4. staff health promotion
5. physical education
6. counseling-psychological services
7. nutrition-food services
8. parent-community partnerships, and
9. program management

References and Recommended Resources

RESOURCES for Additional Information on School Health Services

Confidentiality and Collaboration: Information Sharing in Interagency Efforts, (1992). No. AR-92-1. Education Commission of the States (ECS), Distribution Center, Suite 2700, 707 17th Street, Denver, CO 80202-3427

Evaluating School Nursing Practice: A Guide for Administrators, First Edition, (1987). American School Health Association, P.O. Box 708, Kent, OH 44240

Full-Service Schools Dryfoos, Joy; Jossey-Bass, 350 Samsome St., San Francisco, CA 94104

Guidelines for the Delineation of Roles and Responsibilities for the Safe Delivery of Specialized Health Care in the Educational Setting (1990). The Joint Task Force for the Management of Children with Special Health Needs, Council for Exceptional Children, 1920 Association Drive, Reston, VA 22091- 1589

Healthy People 2000: National Health Promotion and Disease Prevention Objectives (1990). No. PHS 91-50213, Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20220-1498

Healthy Youth 2000 (1992). American Medical Association, Department of Adolescent Health, 535 N. Dearborn St., Chicago, IL 60610

Recommendations for Delivery of Comprehensive Primary Health Care to Children and Youth in the School Setting (1988). American School Health Association, P.O. Box 708, Kent, OH 44240

School Health: Policy and Practice (1993). Committee on School Health, American Academy of Pediatrics, P.O. Box 927, 141 Northwest Point Blvd., Elk Grove Village, IL 60009-0927

School Nursing Practice: Roles and Standards (1993). Proctor, S.T., Lordi, S.L. and Zaiger, D.S.; National Association of School Nurses, Inc., P.O. Box 1300, Scarborough, ME 04074-1300

The Local and State Health Officer, and the Importance of the School Administrator's Support

A school-community Health Advisory Council should be formed to assure child health is a priority issue and to foster cooperation and collaboration among agencies serving families and children.

Members of the community at-large should be invited to serve on this Health Advisory Council, including representatives from health care, labor, business, government, and financial institutions along with student leadership, the parent-teacher association, school administrators and staff.

The Importance of School Administrative Support

Administrative support can create a comprehensive school health model which becomes a major initiator and promoter of health care in the community. Such school health models help assure:

• Children and youth routine preventive health services and promote access to regular health and dental care
• Self-care and responsibility for decision-making are encouraged in students
• Families are assisted in acquiring and modeling health habits which promote positive choices for children
• And schools provide an educational setting matched to the developmental needs and strengths of children.

References and Recommended Resources

Beyond The Health Room (1991). Resource Center on Educational Equity, Council of Chief State School Officers, Suite 379, 400 N. Capitol Street, N. W., Washington, D.C. 20001

Building a Healthy Future (1990). West Virginia Task Force on School Health, West Virginia Dept. of Education, Attention: Lenore Zedosky, Room B309, Capital Complex, 1990 Kenewil Blvd., Charleston, West Virginia 25305

Code Blue: Uniting for Healthier Youth, (1990). National Association of State Boards of Education, 1012 Cameron Street, Alexandria, VA 23314

Crossing the Boundaries Between Health and Education, (1990). National Commission to Prevent Infant Mortality, Room 2014, Switzer Building, 330 C Street, S.W., Washington, D.C. 20201

Healthy Kids for the Year 2000: An Action Plan for Schools, (1990). American Association of School Administrators, 1801 North Moore Street, Arlington, VA 22209

On the Right Track for Health: A Guide for Implementing Comprehensive School Health and Wellness Programs in New York State (1992). The University of the State of New York and The State Education Department, Division of Pupil Health and Fitness, Albany, NY 12234

Principles and Practices of Student Health: School Health, Volume 11 (1992). Wallace, H.M.; Patrick, K.P.; Parcel, G.S. & Igoe, J.B.; Third Party Publishing Company, P.O. Box 13306, Montclair Station, Oakland, CA 94661-0306

School Health: Helping Children Learn, (1991). National School Boards Association, 1680 Duke Street, Alexandria, VA 22314

The State of America's Children (1993). Children's Defense Fund, 122 C Street, N.W., Washington, D.C. 20001

The Healthful School:

Recognizing environmental factors play a major role in the health and safety of both students and staff, schools should attend to the social and emotional environment as well as to the physical environment .

Physical Environment /Health Office / Classroom Environment / Laboratories / Food Programs / Outdoor Activities / School Playground / Americans with Disabilities Act

Physical Environment

The School Nurse, in accordance with local administrative policy, and using OSHA guidelines as a resource (OSHA, Federal Register, 29 CPR, Parts 1910.1030, pages 64175 to 64182), should implement universal, precautions for all staff as an infection control measure against blood borne pathogens and other potentially infectious materials. Job descriptions should identify specific staff at risk for exposure to Hepatitis B. These staff should be counseled about Hepatitis B prophylaxis, and all staff must be made aware of the importance of immediately notifying administration and a medical provider should an exposure occur. All potentially infectious materials shall be disposed of in accordance with OSHA guidelines.

Biological Hazards

Biological hazards besides bacteria and viruses also exist, e.g., molds, parasites, poisonous plants, insects and animals. Therefore, science teachers must also follow universal precautions. Animals used in classrooms should be limited to caged varieties, e.g., rabbits, hamsters, guinea pigs, gerbils, or laboratory mice and rats. Only teachers or assigned students (with parental permission) using proper protective equipment should handle and feed animals. If bites occur, the local law enforcement officer should be notified and the health department may be contacted for advice on how to proceed.

Health Office

The health office should be located near the administrative offices where students, parents and staff may find easy access. The health office must provide toilet and hand washing facilities (soap and warm, running water) to ensure appropriate infection control procedures are maintained during the management of ill and/or injured students.

Adequate privacy, space, and cots (1:400 students) should be available to allow students who become ill students to rest. Students with contagious diseases must be excluded according to public health guidelines.

Students' right to confidentiality must always be protected; therefore, health records should be maintained in locked files and appropriate telephone services should always be available in the health office.

A model plan for structuring a health office is available from the Nebraska Health and Human Services, School Health Program. Guidelines for suggested materials and supplies are found later in this section. (See School Health Equipment & Supplies later in this section.)

The Classroom Environment

The plant management staff shall maintain appropriate environmental standards for temperature, humidity, noise, and light. They should perform preventive maintenance assuring adequate ventilation and removal of environmental contaminants such as pesticides, improperly diluted cleaning agents, combustion gases from cafeterias and laboratories, and cigarette smoke. It is critical that all schools establish a smoke-free and tobacco-free environment not only to address the air quality issue, but also to reinforce health teaching about the hazards of tobacco use and the dangers of exposure to second-hand tobacco smoke.

Classroom Temperature and Humidity

All staff should be aware that temperature extremes affect performance and health. Comfort depends on the simultaneous control of temperature, humidity and air movement. Classroom temperatures should be set at a minimum of 68 degrees Fahrenheit during the winter and at a high of 79 degrees Fahrenheit during the summer. Optimum humidity levels, taken at the level of the seated student, should be between 40 and 60 percent. (Refer to Nebraska Clean Indoor Air Act. 71-5701 to 71-5713.)

Science , Industrial and Fine Arts Labs

The staff responsible for science, industrial and fine arts labs must adhere to safety recommendations regarding proper storage of chemicals, availability of safety equipment and protective gear, and the use of safety practices. Teachers should complete each experiment themselves before assigning it to students. All students should be familiar with emergency procedures. Protective eye wear and proper eye washing facilities should be available. Material Safety Data Sheets (MSDS) on all chemicals should be provided to the health office.

All waste products should be disposed of in an environmentally safe manner. All asbestos fiber identification and removal must be in accordance with federal and local standards and guidelines. All schools must test for lead if they did not identify and replace water coolers containing lead components. (Refer to Nebraska Asbestos Control Act, 71-6301 to 71-6317; and Nebraska Safe Drinking Water Act, 71-5301 to 71-5313.)

School Lunch and Breakfast Programs

The health promoting quality of school breakfast and lunch programs must be assured. Foods should be prepared in a healthful manner and served attractively to provide powerful messages to students that equate nutritional choices with positive health consequences. Vending machines should be turned off during lunch hours. Indeed, school policy should support replacing vending machine 'junk food' with healthy food choices.

Outdoor Student Activities

The staff should utilize the heat and humidity index and wind-chill factor to determine whether conditions are safe for outdoor student activities. Sun stroke and heat exhaustion are likely to occur when the heat index reaches 105 0 (Fahrenheit). Bitter cold will cause human flesh to freeze in one hour at a temperature of 18 ° (Fahrenheit) and a wind speed of 22 miles per hour. Therefore, children should be kept indoors at a very cold wind-chill equivalent of 15 - (F).

School Playground

All school playgrounds should have adequate surface protection under equipment to soften falls. Playground equipment should be developmentally appropriate and inspected regularly to ensure proper maintenance and safety. Students should be supervised by adequate numbers of adults during play. Factors contributing to the largest number and most severe injuries on the playground should be reviewed regularly and addressed. Prevention should be taught in the classroom.

The Americans with Disabilities Act

The Americans with Disabilities Act of 1990 guarantees people with disabilities equal access to employment, transportation, public services, public accommodations, and telecommunications. School must either remove physical barriers or provide alternative methods of providing services. (See Section VII, for a summary of the Act.)

The Healthful School: Emotional Environment

Teaching practices like cooperative learning can foster social and emotional growth as students work in teams, sharing strengths and weaknesses, which benefit each other's learning style. Specific social skills, like sharing, apologizing, negotiating, avoiding fights, and dealing with peer pressure, can also be taught directly through cooperative learning activities. Role play allows students to practice such skills.

Planning and organization of the school day are also important aspects of the emotional climate. Scheduling should include time for students to take care of their basic physical needs. Emphasis on healthful living habits, such as appropriate handwashing after toileting and before eating, can influence students' current and lifelong health status.

Schools should have student assistance programs in place to identify students who are experiencing academic, social or emotional problems in school and to direct them to qualified persons for help. Appropriate discipline plans also enhance the school environment. The focus of such a plan should be on building student self-esteem and problem solving skills. Conflict resolution skills should be taught to all students at the earliest possible age in an effort to stem the trend toward youth violence.

Many events in the school community may affect the emotional well-being of students and staff. A crisis team composed of administrators, nurses, counselors, and teachers may be needed to intervene in such traumas as attempted suicide, death, violence or natural disasters directly affecting the school. A district plan should assure appropriate personnel are trained, confidentiality is protected, proper dissemination of information occurs so that individual emotional needs are served while minimizing rumor or over-reaction.

Nebraska Health and Human Services Policy for Schools

SITE SELECTION AND SAFETY

The school shall be so located as to provide the student with the maximum amount of health and safety possible as it relates to access and usage. In addition, the site shall be large enough to accommodate such things as playground area, water and sewage systems if community systems are not conveniently available. Consideration with regard to site selection should also be given to such things as noise and odors.

The grounds, including playground equipment and structures, shall be maintained so as not to present any unreasonable health and safety hazard.

STRUCTURE, PREMISE SANITATION AND VECTOR CONTROL

All school buildings shall be structurally sound and of such construction as to include materials which enables the facility to be properly cleaned.

Proper premise sanitation is to be practiced both within the school structure and the adjacent grounds so as to prevent the school area from being an attractant for rodents and insects.

Failure to follow such practices will eventually result in costly structural damage and pose a potential health hazard to school staff, students and visitors.

In relation to the proper storage and use of pesticides, schools having insect and/or rodent related problems or questions are to contact the Nebraska Health and Human Services, Division of Drinking Water and Environmental Sanitation for assistance.

HEATING, LIGHTING and VENTILATION

Adequate heating, lighting and ventilation systems are a must. An inadequacy of any of these three systems will affect the health of an individual, and in the case of a student, serve as an irritant, thereby preventing the student from getting the most out of the educational process.

The following minimum standards should be met:

• Heating System -- Must be capable of providing a room temperature of at least 68 degrees Fahrenheit during the winter months.
• Lighting System -- Must be capable of providing at least thirty foot­ candles in the classroom.
• Ventilation System -- Must be capable of removing stale air and eliminate moisture problems.

WATER SYSTEMS AND PLUMBING

Basic Water Systems

An adequate and safe water supply is of prime importance for every school. The best source is a safe municipal supply. In the absence of a municipal supply, it will be necessary for the school to develop its own pressurized water supply. For schools located in areas where pressurized water supplies are not possible, alternate means of supplying water will be considered on an individual basis.

Water Systems Serving a School:

1. Shall be located so as to be protected from any source of contamination, both surface and sub-surface;
2. Shall consist of water wells, distribution piping, or storage facilities which are constructed of materials specifically approved and designed for such use, and constructed according to state regulations and local standards to include plumbing codes.

Water supplies must meet the physical, chemical and biological requirements set forth in the current accepted state and/or federal potable water quality standards.

1. Water quality shall be monitored through a water sampling program* consisting of two bacteriological analyses during the school year (one sample prior to the beginning of the school year, and the second sample at mid-term); and one nitrate analysis every year. Additional sampling may be required by the Nebraska Health and Human Services.

2. *Note: The Water Sampling Program does not apply to schools which use water systems serving villages, cities, or a rural water district, as these systems are presently involved in a water sampling program.

3. Any water supply serving 25 or more individuals shall comply with the sampling and quality provisions of the Nebraska Safe Drinking Water Act.

These samples are to be submitted to the State Department of Health Laboratory or any other laboratory approved by the Department.

Detailed information relating to proper water system construction is available from the Nebraska State Department of Health, Division of Drinking Water and Environmental Sanitation upon request.

Dispensing of Drinking Water

Where water under pressure is available, the number of water fountains provided shall be based on the ratio of one unit for every 90 students. At least one fountain should be located on each floor. There should be one or more drinking fountains in the school lunchroom, shops, and locker-dressing rooms. In schools where a pressure system is not possible, the dispensing of water will be considered on an individual basis. The use of a common drinking container is prohibited.

SEWAGE DISPOSAL SYSTEMS

Wherever possible, the school shall be connected to the municipal sewage collection system. If this is not feasible, then an alternate form of sewage treatment must be determined. However, regardless of the methods of disposal, sewage shall be disposed of in a manner which will protect the health of the general public and members of the immediate school community.

This requires that wastes be disposed of as follows:

1. Sewage disposal systems shall be located, designed, constructed, and maintained in accordance with Title 124 Rules and Regulations for the Design, Operation and Maintenance of Septic Tanks.
2. Systems shall not give rise to public health hazards by being accessible to children, insects, rodents, or other potential disease vectors (carriers).
3. Systems shall not contaminate any surface waters of the state.
4. Systems shall not create a nuisance (odors, unsightly appearances, etc.) so as to serve as an annoyance to the citizens of this or of any other state.

Detailed information relating to the proper design, operation and maintenance of privies, septic systems and stabilization ponds is available from the Nebraska State Department of Environmental Quality upon request .

TOILET FACILITY

Each school shall be provided with at least one toilet room for boys and one toilet room for girls. Flush-type toilets, chemical toilets, earth-pit toilets or any other approved type of toilet facility will meet this requirement provided all flush-type toilets shall have sufficient pressurized water supply to properly operate such a toilet.

Facilities shall be conveniently located and provided on the ratio of one toilet for every 35 girls. The same ratio shall apply for boys except where urinals are provided at a ratio of one to every 30, one toilet for every 90 boys is adequate.

Provisions shall be made for adequate ventilation of the restroom area. The floors, walls, and ceiling of the restroom facility shall be of such construction as to allow proper cleaning of the area. Lighting of the area shall be such as to enable adequate cleaning and disinfection of the facility on at least a daily basis when in use.

HANDWASHING FACILITIES

Running water shall be provided for handwashing facilities. Handwashing facilities located in the restroom area, served by running water, shall be provided at the ratio of one lavatory for every 50 students. Both hot and cold water dispensed through a mixing tap -- or better still, tempered water -- should be made available. In all cases, the temperature of the hot water supplied to shower and handwashing facilities shall not exceed 120°(Fahrenheit). Soap and an approved method for drying hands shall be provided.

Provisions for handwashing facilities in schools not equipped with running water will be considered on an individual basis provided school with flush-type toilets shall provide hand-washing facilities in the restroom areas.

SOLID WASTE DISPOSAL

The outside storage of solid waste shall be accomplished with the use of an adequate number of containers which shall be cleaned as necessitated to eliminate odors and to prevent the container from serving as a breeding area for flies and other insects.

The refuse shall be disposed of at least weekly or more frequently if necessitated during the summer months in an approved manner.

FOOD SERVICE

The degree of food service which a school provides to the student(s) is optional.

However, those food services that are provided and used in relation to the school's food program (to include facilities, equipment, etc. ), must conform to the applicable portion of the then current standards and specifications approved by the Federal Food and Drug Administration or its successor association.

Copies of the food standards are available from the Nebraska Slate Department of Health, Division of Drinking Water and Environmental Sanitation, upon request.

SWIMMING POOL

The design and construction of swimming pools must be approved by the Department of Health before they are constructed or put into operation.

The Department of Health is charged with the responsibility of surveillance of school swimming pools, conducting training sessions for swimming pool operators leading to operator certification, and issuing and revoking permits to operate pools.

Swimming pools must comply with the rules and regulations and operational procedures as described in the "Rules and Regulations" embodied in the Nebraska Swimming Pool Act of 1969 as amended, copies of which are available from the State Department of Health.

For further information, contact the Nebraska State Department of Health, Division of Drinking Water and Environmental Sanitation.

References and Recommended Resources

Guidebook for Student Assistance Programs (1991)
Marquette: Eastern Upper Peninsula Substance Abuse Services
1500 W Washington St.
Marquette, MI 49856
Phone: 313-467-1399

Handbook for Public Playground Safety
US Consumer Product Safety Commission
Washington DC 20207

Journal of School Health
American School Health Association,
Dec. 1987, Vol 57, No. 10, pp 426-431

Play It Safe: A Guide to Playground Safety
American Academy of Orthopedic Surgeons
P.O. Box 738
Park Ridge, IL 60066

Tips for Improving School Climate
American Association Of School Administrators
1801 N. Moore St.
Arlington, VA 22209-9988
Phone: 703-528-0700

Wayne County School Health Manual (1993)
Wayne County Health Department
30712 Michigan Avenue
Westland, MI 48185
(313) 467-3300

Equipment & Supplies for the School Health Services Program

II. SCHOOL ADMINISTRATOR - SCHOOL HEALTH EQUIPMENT & SUPPLIES

Equipment and Supplies for a School Health Services Program Health Room

Local District Policies and Laws

Some local policies and procedures of which the school's health services Administrator should be knowledgeable are:

Comprehensive School Health Program

School Health Services

Healthy Environment

Health Promotion (Staff and Community)

Parent/Community (School Health Advisory Committee)

Guidance Counseling

School Food Service

Physical Education

Health Instruction (Curriculum)

Program Management

Personnel Policies of Local School Districts

Criteria for employment (job specifications)

Employee health examinations

Food service health policies

In-service obligations and opportunities

Policies regarding benefits, leave of absences

Student Policies

Prevention and control of communicable disease

Care of illness and injury

Emergency transportation of ill or injured students

Special Education needs -- role of school nurse -- policy regarding "Do Not Resuscitate" Orders

Physical education and sports examinations, excuses, adaptations, protective equipment

Injury prevention, legal liability

Environmental Policies

Sanitation codes and inspection

School safety and physical facilities

Playground safety

Bus Safety

Fire prevention and protection

Community emergency and disaster plans -- school district role

Hazards in the workplace

Infection control (universal precautions; blood-borne pathogens)

General Policies

District structure

Transportation

School Nursing Practice

Licensed Practical Nurse (LPN)

Associate Degree Nurse (AD RN)

Diploma Nurse (RN)

Baccalaureate Degree Nurse (BSN RN)

Masters Degree Nurse (MSN RN)

Advanced Registered Nurse Practitioner (ARNP )

Administrators of school health programs should be familiar with the different levels of educational preparation in order to select the nurse most appropriate for implementation of their programs. The degree of the nurse's academic achievement and the extent of the nurse's educational and experiential preparation will influence, if not directly determine, the comprehensiveness of the School Health Services program.

The Licensed Practical Nurse (LPN)

The Licensed Practical Nurse (LPN) attended a 10-12 month program preparing for practice in a structured setting where individuals with common needs and predictable outcomes are served. The LPN must practice under the supervision of a registered nurse (RN), licensed physician, dentist, osteopath, or podiatrist (NRS 71-1, 132-55).

The Associate Degree Nurse (AD RN)

The Associate Degree Nurse (AD RN) attended 2 (two) academic years, plus l (one)summer, preparing for technical nursing practice in medical, surgical, pediatric, and obstetrical areas.

The AD RN is prepared to function in acute and chronic care facilities serving clients with well defined needs. Settings must be controlled by organized nursing services and staff structures, professional nursing standards, policies, procedures and protocols.

This level of nurse should function only within a school health program which is under the direction of a school nurse administrator.

The Diploma Nurse (RN)

The Diploma Nurse (RN) attended 3 (three) academic years, plus 3 (three) summers, to become prepared not only with technical skills but also at the professional level with management and leadership skills.

This RN is prepared to function in acute, chronic, and psychiatric facilities and to care for clients with predictable as well as unpredictable outcomes.

The nurse educated at this RN professional level -- who consistently pursues continuing education developed for the school nurse specialty, who is supported by school nursing standards, policies, procedures and protocols, and who is under the supervision of a school nurse administrator -- is capable of implementing the school health program.

The Baccalaureate Degree Nurse (BSN RN)

The Bachelor of Science Degree Nurse (BSN RN) attended 4 (four) academic years which added theory, statistics, social groups, and community nursing experience to preparation at the professional level. This RN's focus of care is in acute, chronic, and community settings.

This nurse is prepared to develop school nursing standards, policies, procedures and protocols for full implementation and direction of the school health program.

The Masters Degree Nurse (MSN RN)

The Masters of Science Degree Nurse (MSN RN) attended 1-2 academic years, after obtaining the BSN degree, to specialize in a selected program of concentrated studies, for example, maternal and child health, nursing administration, nursing education, psychiatric and mental health, or public health.

This nurse specialist is prepared to serve individuals, groups, and communities through education, consultation, administration, direct clinical care and by implementing research. This nurse is prepared to function autonomously and should provide maximum leadership in the development of school health programs.

The Advanced Registered Nurse Practitioner (ARNP)

The Advanced Registered Nurse Practitioner (ARNP) refers to a nurse (RN) prepared by virtue of additional knowledge and skills gained through an organized post-basic program of nursing in a specialty area. These licensed nurses must also achieve national professional certification in their specialty, for example, psychiatric and mental health clinical nurse specialist, school nurse practitioner, family nurse practitioner, and pediatric nurse practitioner.

The Focus of Clinical Nursing Practice

While there are many levels of educational preparation for nursing, there is only one focus of clinical nursing practice.

The essence of this clinical nursing practice is the diagnosis and treatment of human responses to health and to illness.

The core of clinical nursing practice is dynamic and evolves as

... patterns of human responses amenable to nursing intervention are identified,

... nursing diagnoses are formulated, nursing interventions are made explicit, and

... responses (client outcomes) are evaluated.

The depth and breadth to which the individual nurse engages in the total scope of the clinical practice of nursing are defined by knowledge base, role, client population and practice environment.

The School Nurse's Clients: STUDENTS ... STUDENTS' FAMILIES ... and the SCHOOL STAFF

In the School Health Services Program, nurses' clients include not only the students, but the students' families and the school staff as well.

A conceptual framework for nursing which nicely illustrates school nursing practice is I. M. King's Dynamic Interacting Open Systems Theory (1981). This model accurately portrays the relationship between the School Nurse and the individual student as a unique unit within the school setting.

At this intra- personal intervention level the School Nurse assesses each learner-at-risk -- physically, developmentally, emotionally, socially, culturally, economically, geographically, and academically.

Inter -personal Level

The School Nurse then becomes part of an inter- personal system when interacting with other individuals -- students, parents, teachers, counselors, psychologists. These interactions may take the form of a dyad (teacher-nurse conference), triad (parent-child-nurse conference), or group (special education team).

At this inter-personal system level, the School Nurse may assume many roles: direct health care provider, health educator, health counselor, child advocate, case manager, and evaluator. The School Nurse may acquire these roles working with the comprehensive school health education team as well as with the early intervention and special education multidisciplinary team.

Inter -systems Level

Larger groups with common interests and goals create another level of system which King calls the inter-systems level. The systems with which School Nurses and students routinely interact are the health care system (medical, dental and mental health) and the social services systems. The school nurse must, therefore, be very knowledgeable about these and other community and regional resources currently available to serve students, parents, and staff.

The School Nurse must apply the nursing process -- assessment, nursing diagnosis, outcome identification, plan, implementation, evaluatio n -- in all three dimensions of King's open system.

It is the interaction of the phenomena of interest to the school nursing specialty -- society (education, school-community environment), client (student, family and staff), school nursing (clinical nursing practice), and health (promotion, prevention, maintenance, rehabilitation) -- which generates the multiplicity of roles the school nurse must assume in order to facilitate the educational process for students.

Each individual nurse is responsible for knowing and practicing within the scope of practice for which their nursing education and clinical experience have prepared them.

All registered nurses, irrespective of specialty, are held to the Standards of Clinical Nursing Practice (American Nurse Association, 1991).

All School Nurses are held to their specialty guidelines as promulgated in School Nursing Practice: Roles & Standards (National Association of School Nurses, 1993).

Every School Nurse should be knowledgeable about the content of these two ANA and NASN documents which create their current practice parameters.

STANDARDS of CLINICAL NURSING PRACTICE

A synopsis of the American Nurses Association Standards of Clinical Nursing Practice (ANA, 1991) follows. But the complete, necessary measurement criteria are found in the full ANA document -- which every School Nurse should have . for ready reference.

Standards in nursing practice are authoritative statements enunciated and promulgated by the nursing profession by which the quality of practice, service, or education can be judged.

The role of these standards of nursing practice is:

-- to describe the responsibilities for which nurses are accountable

-- to provide direction for professional nursing practice

-- to define the profession's accountability to the public

-- to define the client outcomes for which nurses are responsible

The Standards of Clinical Nursing Practice (ANA, 1991) includes both Standards of Nursing Care and Standards of Nursing Professional Performance.

6 Standards of Nursing Care

1. ASSESSMENT - The nurse collects client health data.
2. DIAGNOSIS - The nurse analyzes the assessment data in determining the diagnosis.
3. OUTCOME IDENTIFICATION - The nurse identifies expected outcomes individualized to the client.
4. PLANNING - The nurse develops a plan of care prescribing interventions to attain expected outcomes.
5. IMPLEMENTATION - The nurse implements the interventions identified in the plan of care.
6. EVALUATION - The nurse evaluates the client's progress toward attainment of identified outcomes.

1. QUALITY OF CARE - The nurse systematically evaluates the quality and effectiveness of nursing practice.
2. PERFORMANCE APPRAISAL - The nurse evaluates own nursing practice in relation to professional practice standards and relevant statutes and regulations.
3. EDUCATION - The nurse acquires and maintains current knowledge in nursing practice.
4. COLLEGIALITY - The nurse contributes to the professional development of peers, colleagues and others.
5. ETHICS - The nurse's decisions and actions on behalf of clients are determined in an ethical manner.
6. COLLABORATION - The nurse collaborates with the client, significant others, and health care providers in providing client care.
7. RESEARCH - The nurse uses research findings in practice.
8. RESOURCE UTILIZATION - The nurse considers factors related to safety, effectiveness, and cost in planning and delivering client care.

School Nursing Roles

The School Nurse's Role
The School Nurse's role should be as a:

1. Provider of Client Care
Focus is on the provision of direct clinical nursing services to students, families and staff using the theoretical body of knowledge fundamental to school nursing practice and framing the delivery of services within the nursing process context .

2. Communicator
Focus is on effective communication to demonstrate caring, competence, and consideration. Addresses recording, storage, and retrieval of health data and issues related to confidential data.

3. Planner & Coordinator of Client Care
Focus is on processes beyond delivery of direct services to individual students and families. Examines larger contexts of practice like community liaison, networking, program management, interdisciplinary collaboration, and influencing the political process. Facilitates delivery of direct school nursing services.

4. Client Teacher
Focus is on the school nurse as educator for individual students, classes, groups, staff, family, and community.

5. Investigator
Focus is on the school nurse observing the phenomena within the school setting, identifying issues, studying them, and sharing the findings, either formally or informally.

6. Role Within the Discipline of Nursing
Discusses issues of role delineation, communication and augmentation. Examines professional practice issues unique to nursing in the school setting. Encourages excellence in practice through evaluation of school nursing practice and continued professional development.

10 Standards of School Nursing Practice
The ten Standards of School Nursing Practice stated succinctly are:

1. CLINICAL KNOWLEDGE - The School Nurse utilizes a distinct knowledge base for decision-making in nursing practice.
2. NURSING PROCESS - The School Nurse uses a systematic approach to problem-solving in nursing practice.
3. CLIENTS WITH SPECIAL HEALTH NEEDS - The School Nurse contributes to the education of the client, planning and providing appropriate nursing care, and evaluating the identified outcomes of care.
4. COMMUNICATION - The School Nurse uses effective written, verbal, and nonverbal communication skills.
5. PROGRAM MANAGEMENT - The School Nurse establishes and maintains a comprehensive school health program.
6. COLLABORATION WITHIN THE SCHOOL SYSTEM - The School Nurse collaborates with other school professionals, parents, and caregivers to meet the health, developmental and educational needs of clients.
7. COLLABORATION WITH COMMUNITY HEALTH SYSTEMS - The School Nurse collaborates with members of the community in the delivery of health and social services, and utilizes knowledge of community health systems and resources to function as a school-community liaison.
8. HEALTH EDUCATION - The School Nurse assists students, their families, and the school community to achieve optimal levels of wellness through appropriately designed and delivered health education.
9. RESEARCH - The School Nurse contributes to nursing and school health through innovations in practice and participation in research or research-related activities.
10. PROFESSIONAL DEVELOPMENT - The School Nurse identifies, delineates, and clarifies the nursing role, promotes quality of care, pursues continued professional enhancement, and demonstrates professional conduct.

The School Nursing Practice: Roles and Standards document will clearly define the relationship of the ten School Nursing Standards to each of the six role concepts, and to the American Nursing Association's Standards of Clinical Nursing Practice . The text provides a working definition of the main theme for each standard, the rationale for the standard, criteria to measure if the standard has been met, and suggestions for achieving the standard in the School Nurse's work setting.

In addition to the two Standards of Practice documents described above, the School Nurse should also have the following for ready reference:

Code for Nurses with Interpretive Statements (American Nursing Association, 1985)

State of Nebraska: Statutes Relating to Nursing (1991)

State of Nebraska: Regulations Governing the Practice of Nursing (1992)

 

 

Certification for School Nurses

There are two types of certification for school nurses:

-- State Certification level: legal certification by the state educational agency, and

-- National Certification level: non-governmental certification by a professional nursing organization.

State Departments of Education may provide mandatory' or permissive certification. The Nebraska Department of Education provides permissive certification via a School Nurse Special Counseling Services Certificate issued to registered nurses already employed by a school system in Nebraska. (For further information, please call the Nebraska Department of Education, Certification Division: 1-402-471-0739)

States providing for mandatory certification require the registered nurse assuming the role of a School Nurse to first complete a credentialing program beyond their generic nursing degree.

Such a School Nurse credentialing program is designed to assure practice competencies relative to:

• growth and development of children and adolescents;
• health and nutritional status;
• vision, hearing, scoliosis, dental and immunization screening;
• epidemiological investigation;
• first aid and emergency care;
• child abuse;
• drug abuse screening;
• exceptional child and special education;
• evaluation, counseling, and crisis intervention;
• human relationship skills;
• health education and the use of audio-visual equipment;
• use of local, state and national health resources;
• environmental health and safety;
• community and family health nursing;
• sexuality and family life education;
• cultural competency;
• budgeting and accounting;
• legal aspects, management and supervision of school health programs

National Professional Certification

Professional certification requires passing a national examination measuring skills and knowledge based on the above mandatory certification competencies. It is offered by the American Nurses Association (ANA) for both the school nurse and the school nurse practitioner.

The National Association of School Nurses, Inc. (NASN), the specialty organization, also certifies school nurses through the National Board for Certification of School Nurses, Inc. (NBCSN).

Professional certification is a hallmark of excellence and verification of the school nurse's ability to function at a nationally recognized level.

Information on certification may be obtained by calling the individual professional organizations listed below:

American Nurses Association (ANA), Certification Division: 800-284-CERT (800-284-2378)

National Board for Certification of School Nurses, Inc. (NBCSN), Certification Division: 212-852-0400

REFERENCES & RECOMMENDED RESOURCES For Further Information on SCHOOL NURSING ROLES

A Theory of Nursing: Systems, Concepts, Process, King, I.M. (1981). New York: John Wiley & Sons.

An Evaluation Guide for School Nursing Practice: Designed for Self and Peer Review; National Association of School Nurses, Inc. (1985), Scarborough, ME.

Code for Nurses with Interpretive Statements, American Nurses Association (1985). Kearneysville, WV: American Nurses' Publishing.

Expanding School Health Services to Serve Families in the 21st Century; Igoe, J. B., and Giordano, B. P., (1992). Washington, D.C.: American Nurses Publishing.

Guidelines for Documentation for School Nursing Schwab, N. (1991). Scarborough, ME: National Association of School Nurses, Inc.

Implementation Guide for the Standards of School Nursing Practice Snyder, A.A. (Ed.), (1991). Kent, OH: American School Health Association .

Manual of School Health Lewis, K.D., & Thomson, H.B., (1986). Menlo Park, CA: Addison-Wesley Publshing Co.

Nursing Interventions Classifications (N.I.C.), Bulechek, G.M., & McCloskey, J.C. (1992). St. Louis, MO: Mosby Publshing Co

Nursing: A Social Policy Statement, American Nurses Association (1980). Kearneysville, WV: American Nurses' Publishing.

The Omaha System: Applications for Community Health Nursing. Martin, K.S., and Sheet, J.J. (1992). Philadelphia, PA: W.B. Saunders.

School Nursing: A Framework for Practice, Wold, S.J. (1981). North Branch, MN: Sunrise River Press.

School Nursing Practice: Roles and Standards. Proctor, S.T. (1993). Scarborough, ME: National Association of School Nurses, Inc.

Standards of Clinical Nursing Practice, American Nurses Association (1991). Kearneysville, WV: American Nurses' Publishing.

Initiating Activities for the New School Nurse

The school Superintendent, or designee, should:

1. Explain the school district's philosophy of the school health program.
2. Provide a current job description for the School Nurse.
3. Provide any written school health policies and procedures, school health manual or guidelines.
4. Orient the School Nurse to the buildings and grounds.
5. Introduce the nurse to key personnel in the school(s) and district.
6. Provide the nurse with the school calendar, building schedules and individual class rosters.

Before school begins, if possible, the nurse should try to accomplish the following activities:

• Meet the building principals and office staffs. Determine communication patterns for exchange of information (e.g., mail box, phone calls, referrals to nurse, notification of teachers).
• Locate the school health office(s). Determine how health office space will be utilized. Order supplies. (See "Suggested School Health Equipment and Supplies" in Section II.)
• Locate the health records. Be familiar with the type of information to be collected; what the district policy is on confidentiality; who records the information; how up-to-date the records are; which students have health problems; and how is that information shared with those who need to know .
• Develop a School Nurse schedule to meet the identified nursing needs based on the number of schools, number and type of students, number of grades per school, days of special education staffings, and individual building schedules.
• Meet the faculty and describe the School Nurse's role and procedure for referral. Provide faculty with a copy of the Nurse's schedule.
• Meet the coordinator of special education services in each building. Find out when building level conferences are held, the procedure for referral services and how the Nurse is notified of students needing evaluation. Know who obtains permission for assessment and sets the date for team conferences.
• Get acquainted with the cafeteria manager and workers, bus driver's supervisor and the school custodian. Observe the physical facility for health hazards and determine how assistance in solving these problems might be rendered.
• Develop or update a community resource file. Become familiar with available emergency services. Ascertain local health resources such as the health and social services department, mental health services, the school health advisory council, service clubs and their areas of interest, and health care providers. Make a list of contact persons at each of the agencies.
• Become acquainted with the type of statistical data to be collected to document school nursing activities for accountability and quality assurance.
• Identify resources for professional support, such as in-service and consultation available through the local, district and state Department of Health and the state Department of Education as well as the state school nurse consultant. Request an opportunity to visit a school nurse in a neighboring district. It is an inexpensive continuing education activity and an opportunity to begin networking. Learn what printed materials, such as newsletters, mailings, and journals are available. Join the state school nurse organization.
• When familiar with this necessary information, the School Nurse should plan a tentative schedule of programs, including previously determined goals and objectives. The new School Nurse should continue the program currently in operation according to accepted policies and procedures until desirable changes can be made.

If no written procedures exist , the School Nurse should identify those with top priority and draft them for the Superintendent's approval.

School Nursing Activity Calendar

Recommended Journals and Periodicals for School Nurses

American Journal of Public Health. Published monthly and is the official journal of the American Public Health Association, 1015 18th St., NW, Washington, DC 20036.

Health Aims. Published quarterly by the National Center for Health Education, 30 E. 29th St., New York, NY 10016.

Health Education. Published bimonthly (seven issues) by the American Alliance for Health, Physical Education, Recreation, and Dance, 1900 Association Drive, Reston, VA 22091.

Journal of Adolescent Health. Published bimonthly by Elsevier Science Publishing Co., Inc., 52 Vanderbilt Ave., New York, NY 10017.

Journal of Community Health Nursing. Published quarterly by Lawrence Erlbaum Associates, Inc., 365 Broadway, Hillsdale, NJ 07642.

Journal of Nursing Administration. Published ten times yearly by The Journal of Nursing Administration, Inc., 12 Lakeside Park, 607 North Ave., Wakefield, MA 01880.

Journal of Pediatric Health Care. Published bimonthly by C.V Mosby, 11830 Westline Industrial Drive, St. Louis, MO 63146. This is the official journal of the National Association of Pediatric Nurse Associates and Practitioners.

Journal of School Health. Published monthly except June and July and is the official journal of the American School Health Association, P.O. Box 708, Kent, OH 44240.

Journal of School Nursing. Published bimonthly and is the official journal of the National Association of School Nurses, P.O. Box 1300, Scarborough, ME 04074.

Maternal Child Nursing Journal. Published bimonthly by the American Journal of Nursing Company, 555 W. 57th St., New York, NY 10019.

Nursing Digest. Published bimonthly Nursing Digest, Inc., 12 Lakeside Park, 607 North Ave., Wakefield, MA 01180.

Nursing '94 (or current year). Published monthly by Internal Communications, Inc., 132 Welsh Road, Horsham, PA 19044.

Pediatric Nursing. Published bimonthly by Anthony J. Janetti, Inc., North Woodbury Road, Pitman, NJ 08071.

The Nurse Practitioner. Published monthly The American Journal of Primary Health Care, Vernon Publications, Inc., 3000 Northup Way, Suite 200, Bellevue, WA 98004.

Reprinted with permission of the American School Health Association, Implementation Guide for Standards of School Nursing Practice, ©1991.

School Health Services

Recommended References and Resources

EPSDT, A Guide for Educational Programs. U.S. Department of Health and Human Services: Health Care Financing Administration, Medicaid Bureau. (HCFA Pub. No. 02192) (1992). Washington, D.C.: U.S. Government Printing Office.

Expanding School Health Services to Serve Families in the 21st Century. Igoe, J.B. & Giordano, B.P. (1992). American Nurses Publishing: Washington, D.C.

Guidelines for Adolescent Preventive Services. American Medical Association. (1992). (#NL 018292) Department of adolescent Health: Chicago, IL 60610 (1-312-464-5570).

Guidelines for Prevention of Transmission of Human Immunodeficiency Virus and Hepatitis-B Virus to Health-care and Public-Safety Workers. U.S. Department of Health and Human Services: Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health. Atlanta, GA

Guidelines for School Nurse Documentation: Standards, Issues, and Models. Schwab, N. (1991). Scarborough, ME: NASN.

Healthy People 2000: National Health Promotion and Disease Prevention Objectives and Healthy Schools. American School Health Association. (1991). Kent, OH.

National Guidelines for Administration of Medication in Schools. Igoe, J.B. (1991). Office of School Health Programs, University of Colorado Health Sciences Center.

Policy Compendium on Confidential Health Services for Adolescents. American Medical Association. (1993). Department of Adolescent Health: Chicago, IL 60610.

School-Based and School-Linked Clinics: Update 1991. Waszak, C. and Neidell, S. (1991). Center for Population Options. Washington, D.C.

"School Health Services: Issues and Challenges," Allensworth, D.D. In The Comprehensive School Health Challenge: Promoting Health Through Education, Volume One, Edited by P. Cortese & K. Middleton. (1994). Santa Cruz: ETR Associates.

The Red Book, Report of the Committee on Infectious Diseases. (1994). Elko Village, IL. American Academy of Pediatrics.

The School Nurse's Source Book of Individualized Healthcare Plans. Haas, M., Gerber, M.J.V., Kalb,K.M., Luehr, R.E., Miller, W.R., Silkworth, C. K., and Will, S.I.S. (1992). North Branch, MN: Sunrise River Press.

Health Screening Programs

Introduction

The school will establish and implement a screening program which will meet legal requirements for the provision of selected appropriate health screenings of students at mandated intervals (Neb. Rev. Stat. Sec. 79-4, 133 to 79-4, 138) *. The school provides this service directly or contracts with an agency, utilizing appropriate personnel to carry out the program.

RATIONALE FOR HEALTH SCREENINGS

Recognizing the adverse impact selected health related conditions may have on learning, the legislature has enacted laws which require that certain screening tests are provided for students attending schools. These and other health screenings are recommended by the Department of Health's School Health Advisory Committee.

STRUCTURE CRITERIA FOR HEALTH SCREENINGS

1. The School Nurse, in consultation with the school administration, manages the overall planning, organizing, implementing, and evaluating of the screening programs.
2. Parents and guardians of students are informed of the health screening program via the school's annual handbook, the school newsletter, or a special health memorandum.
3. Health education regarding screenings, is provided for the students by the School Nurse or the classroom/ health education teacher.
4. The School Nurse is responsible for instruction and supervision of volunteers or school health aides providing assistance during screenings.
   * (See State of Nebraska School Laws, Chapter 79 - Schools)
5. Screening equipment, environment, and procedures shall conform with the most recent recommendations and guidelines available regarding same. See suggested guidelines to use for each screening in the Recommended Screenings section.
6. Individual or mass screenings may be carried out, dependent upon nurse to student ratio and available time. Trained volunteers or school health aides providing the initial screening for height, weight, vision, and in some cases, hearing, can conserve the use of professional time for the more critical re-screening done by the school nurse for students failing the first screening.
7. Proper care will be taken to ensure confidentiality regarding any health concerns noted.
8. Parents/guardians will be sent written notification on an appropriate referral form of the student's failure to pass the re-screening performed by the school nurse.
9. Screening referrals are followed-up by the school nurse through written, phone, or home visit contacts with parents/guardians.
10. Recording of health screenings and their follow-up on the student health record may alert school staff to a student's special need for educational assistance. Documentation of these health screenings provides validation of the health services delivered in schools.

RECOMMENDEDSCREENINGS AND GUIDELINES FOR REFERRAL

See applicable Guideline sections on Vision (including Color-Vision), Hearing (including Audiometry and Acoustic Immittance), Height and Weight, Scoliosis, Blood Pressure, or Oral Health screenings following this Introduction.

PROCESS CRITERIA

The qualified School Nurse will:

1. Notify parent/guardian of intent to perform designated screenings as described in item two of the structure criteria.
2. Exempt those students whose parents/guardians submit a written waiver.
3. Conduct specific screenings as defined by state laws and/or as recommended by the Department of Health's School Health Advisory Committee.
4. Perform and/or supervise initial screening program and re-screen all failures.
5. Supervise recording and/or record all passed initial screenings onto the student's health record.
6. Analyze data and compare to referral criteria; refer to appropriate source for care, if indicated.
7. Interpret significant findings to student, parents, and teacher(s).
8. Plan with the student and teacher for temporary modification of educational program or environment pending recommendations of specialist, e.g. in the case of hearing or vision, check classroom seating arrangement.
9. Complete each referral, interpret recommendations and counsel student, parent/guardian, and teacher(s).
10. Record results of all re-screening, referrals and follow-up onto the student's health record.
11. Re-screen students with identified problems annually or more frequently if indicated.
12. Provide school administration with an evaluative report of the screening program.

OUTCOME CRITERIA

1. Students are screened for a specific health problem and referred for care as indicated.
2. The student with a potential identified health concern receives appropriate care for correction of his/her health problem.
3. The student demonstrates knowledge of their unique health problem and follows the health care provider's recommendations.
4. Students referred from the screening program and diagnosed with a health problem will participate in educational activities to the fullest extent possible in the least restrictive environment.