School Nursing Practice

Nursing's social contract with the public has resulted in the creation of several levels of nursing preparation in response to historical timeframes which demonstrated consumers' critical needs for nursing services. Thus, there are licensed nurses with varying levels of educational preparation and clinical experience.

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).

NOTE: Nebraska Board of Nursing has defined supervision. This definition is to be used as a guide for the Registered Nurse. Supervision is defined as personally observing a function or activity, providing leadership in the assessment, planning, implementation and evaluation of nursing care; delegating functions or activities while retaining accountability; and determining the nursing care being provided is adequate and delivered appropriately. Accountability of the supervising licensed practitioner means being obligated to answer for one's acts, including the act of supervision. Supervision does not mean the supervising licensed practitioner must be physically present. Depending upon the environment, number of clients and acuity of care, the supervision licensed nurse may provide supervision by telephone, policies, and protocols. The supervising licensed nurse must provide written parameters distinguishing situations which are acceptable from those situations which must be reported to the supervising licensed nurse before any needed further intervention can be started. Policies and defined parameters should be spelled out in writing and are of prime importance in dealing with emergencies and administering first aid.

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.

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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.

Intra -personal Level

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.

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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.

8 Standards of Professional Performance

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

School Nursing Practice: Roles and Standards (NASN, Proctor, 1993) enfolds the Standards of Clinical Nursing into six overall role concepts which serve as conceptual umbrellas for the ten specialty standards of practice around which the professional School Nurse may define a role and design a school nursing program within the educational setting.

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)

 

 

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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.

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Nebraska State Certification

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

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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

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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

How does a new School Nurse get started where there is no nurse supervisor or local plans for orientation?

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

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

AUGUST • Develop a written school health plan with District or Building Administrator • Prepare Health Office and supplies • Review with all health staff emergency plans and first aid procedures, universal precautions. • Identify and post a list of personnel trained in CPR and First Aid. • Review and have signed appropriate protocols. • Develop a time management system for School Health Services to document Nursing Activities. • Develop/devise a system to keep track of referral progress. • Update information regarding community health resources. • Attend regularly: Faculty Meetings PTA Meetings School Board Meetings • Send letter to parent or guardian regarding procedure to administer medication at school. • Prepare emergency and First Aid kits for classrooms. • Instruct or review Medication Aide Training for staff.	SEPTEMBER • Update student health records • Prepare emergency card file of students and staff. • Schedule visit to classrooms regarding Health Service program and how students can access health care. • Prepare worksheets to identify students in immunization non-compliance. • Schedule classroom health presentations. • Develop/update resource file on specific health issues and problems for use by students and/or staff. • Vision: Prescreening education Screen planned grade levels Rescreen individuals as needed and make referrals	OCTOBER • Continue follow-up for immunization compliance. • Set up conferences with individual students with identified health problems to jointly develop a health care plan. • Hearing: Prescreening education Screen planned grade levels Rescreen individuals as needed and make referrals. • Secure a health and developmental history for all Kindergarten and new students. • Classroom visits for: Personnel safety, infection control Nutrition (National School Lunch Month) Safety and First Aid (School Bus Safety Week) • Inspect building and grounds for health and safety standards. • Prepare health bulletin boards with timely information. Change at least once a month.	NOVEMBER • Complete Immunization Report and return to Nebraska Health and Human Services, Immunization Division by November 15. • Immunization follow-up • Vision and hearing rescreenings (absentees, new students). • Vision referrals completed -(50%) • Classroom presentations: Colds - Flu Sore throats Positive health practices
DECEMBER • Immunization follow-up • Scoliosis Prescreening education Screen planned grade levels. Rescreen individuals as needed and make referrals. • Review individual student health records for completeness. • Vision referrals - 75% • Hearing referrals - 50% • Plan activities for: Dental Health Month in February Dentist visits National Health Month in February Good Nutrition Month in March • Classroom presentations: Prevention of hypothermia Colds and Flu	JANUARY • Review absentee records to identify health problems requiring nurse's interventions. • Monitor communicable diseases. • Continue surveillance of immunization records. • Screen and rescreen new students for vision, hearing and scoliosis. • Plan fitness screening program (blood pressure, body fat composition and fitness) for 6 th Grade. • Classroom presentations: Girls: Grades 4, 5, and 6 Boys: Grades 5 and 6 • Review supplies and equipment • Make recommendations regarding orders for supplies for next year.	FEBRUARY - MARCH • Review absentee records. • Monitor communicable diseases. • Review records for completeness: Vision referrals - 90% Hearing referrals - 75% Scoliosis referrals - 50% Screen Grades 7-10 for: Cardiovascular fitness, stress, high blood pressure. Body composition Health appraisal • Dental Health Month • Heart Month • Nutrition Month	APRIL - JUNE • Plan and conduct pre-school screenings. • Prepare notices regarding immunizations and physicals due next school year. • Review individual health plan for children with special needs-and revise as needed. • Vision referrals - 95% • Hearing referrals - 90% • Scoliosis referrals - 90% • Review health education materials and make recommendations. • Develop tentative plan for next school year.

Recommended Journals and Periodicals for School Nurses

American Journal of Nursing. Published monthly by the American Journal of Nursing Co., 10 Columbus Circle, New York, NY 10019.

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.