School nurses are the bridge between healthcare and education, working with students, families, medical practitioners and the educational environment to meet the health needs of students. School nurses advocate and coordinate student health needs among diverse entities to provide and meet individualized health needs while promoting academic success. “Laws implemented in the 1970s established the rights for all students, even those with significant health needs, to attend public school, and led to recommendations for school nurse-to-student ratios. These laws included the Rehabilitation Act of 1973, Section 504 (1973), and Public Law 94-142, the Education for all Handicapped Children Act (1975), reauthorized in 2004 as the Individuals with Disabilities Education Improvement Act (IDEIA). Changes in these laws increased the role and responsibilities of the school nurse.” National Association of School Nurses (NASN) Position Statement: School Nurse Workload: Staffing for Safe Care, Revised June 2020.) The Individuals with Disabilities Education Act (IDEA) is the law making a Free and Appropriate Public Education (FAPE) in the least restrictive environment available for students with disabilities, ensuring special education and related services (U.S. Department of Education: Individuals with Disabilities Education Act (IDEA). School nurses provide care for medically fragile students, those with chronic conditions, acute illnesses, and medical emergencies occurring on school campuses.
The depth and breadth of nursing knowledge and assessment required of a school nurse are extensive. School nurses work with students requiring complex therapies including, but not limited to, mechanical ventilation, suctioning, G-Tube feedings, chronic care management including diabetes, cancer, asthma and more. Students with chronic medical conditions are required to have an Individualized Health Plan (IHP) created by the school nurse detailing the nursing care needed throughout the school day. School nurses attend Individual Education Plan (IEP) or Section 504 meetings, which are collaborative. The school nurse responds to medical emergencies on the school campus for students and staff. They review medical documentation, contact healthcare providers, review students’ vaccination status, provide vaccinations, and coordinate health screenings including vision, hearing, and height/weight. They are knowledgeable about current health trends, such as, but not limited to, Measles, COVID, and Influenza.
Collaboration
Nurses in the school setting know students need to be safe and healthy to learn, understanding the meaning of Maslow’s Hierarchy of Needs. School nurses collaborate with multiple disciplines in and out of the school setting to provide for the student’s basic physiological and security needs. School nurses coordinate health care and promote individual and community-based student health services. NASN recognizes that healthy and safe communities are crucial for the optimal health, well-being, academic success, and long-term achievement of school-aged youth. School nurses are in a unique position to safeguard and promote both student and community health, collaborate in addressing public and population health needs, and play a key role in creating an equitable culture of health that prioritizes well-being in every aspect of life, decision-making, and policy (NASN Position Statement: Healthy Communities, April 17, 2023).
School nurses appreciate the communities in which they work and understand the health needs of the students, families, and the community. They are familiar with many barriers to obtaining health care and how they impact accessing and receiving medical services; they are equally aware of how disease and illness can create obstacles. School nurses are the face of healthcare for many students and families, helping them navigate the intricacies of a complicated healthcare system. All too often, children are prescribed medication. The parent or guardian does not know why the child was prescribed the medication, how to use or take the medication, the side effects, and the expected outcome. Parents will provide an inhaler for their child, who was recently diagnosed with asthma, to the school nurse. Frequently, the parent obtains the inhaler but does not receive instructions on how and when their child should use the medication. The school nurse becomes the primary resource, educating students and parents on chronic conditions and inhaler use.
School nursing is synonymous with public or community health nursing. Nurses in school settings can provide vaccines to children in their community by establishing a Vaccines for Children (VFC) program in the school setting following the rules and regulations established by the Department of Health. Providing students access to required vaccines during the school day decreases absenteeism for students and parents. Providing vaccines for students in the school setting, where they know the environment, often experience decreased anxiety and angst. During the COVID outbreak, school nurses were leaders in their community, acting as resources, providing testing, vaccines, contact tracing for their district, and guiding the health needs of the students and staff working in conjunction with local Health Departments. During this time, a school nurse led the effort to purchase a used motor home to convert it into a mobile health clinic, providing resources for students, families and the greater community. The recent measles outbreak has once again required school nurses to take the lead in their school district, providing education, resources, and developing plans of action in the event of an outbreak in their community. School nurses track the vaccine needs of their students and provide vaccines and education to families and community members working to decrease the impact of the measles spread.
Nursing knowledge, expertise and respect are words associated with school nurses. Families and staff refer to the school nurse for education and resources. A favorite story told by a rural school nurse in New Mexico is one of a parent not knowing where to go and what to do during a health crisis. It was the end of a long day for the school nurse when a parent arrived asking the nurse for help regarding a health need. The parent left for a moment, returning with a very pregnant woman in active labor. The parent told the school nurse she did not know what to do as the woman had no insurance and had not seen a doctor, but she knew her child’s school nurse would know what to do. The school nurse knew exactly what to do, calming the women and activating EMS. During the lengthy wait for EMS, the pregnant woman followed the school nurse’s instructions and remained calm. EMS arrived transporting the woman to the nearest hospital where the baby was born, without complications, moments after arriving at the hospital. Stories like these are familiar in the school health setting where the school nurse is trusted as a healthcare resource. Parents will come with their child to the school health office first thing in the morning, looking for guidance from the school nurse on handling a situation with their child. Another school nurse from a rural community in New Mexico shares a story of a home visit she and another school employee made to check on a student’s and their family’s living conditions. The parents told the nurse they were renting a home from a nearby family on the family’s property. The nurse was knowledgeable about the community and knew one single-family home was on the property. Upon arrival, they found a hole in the ground with a ladder propped in the hole. Underground, there was an area approximately 12 X 12 feet, the landowner had dug out and was renting to those in need. The nurse and companion braved the elements and went down the ladder to view the deplorable living conditions. The nurse worked with community members to find resources and better living conditions for the students and their family.
These events are an integral part of the school nurses’ experiences and stories. School nursing is challenging, at times scary, and always rewarding, providing unique opportunities to work with students, families, staff, and whole communities; indeed, a combination of nursing experiences, including school, community, and public health. Working in schools, the nurse has a bird’s eye view of what families experience once their child is discharged from the hospital setting after surviving a devastating event of diagnosis. The school nurse is a witness to the after-hospital events, watching the families struggle to meet the health needs of the child and family as they try to move forward. The school nurse is in a unique situation as the liaison between the educational, family, and medical worlds, collaborating with many to educate, navigate, intervene and advocate for the health needs of our students and to support students and families with chronic or medically fragile conditions. School nurses are the extensions of the student and family, school system, medical community, and community public health to provide optimal health services to those in need.
Complexities and Obstacles
School nurses are not in the state education funding formula, meaning school nurse funding depends on individual school district support. There is no requirement for school districts to provide a school nurse, but they do have to meet the individual health needs of the students. The salaries for school nurses in the state vary from district to district and often are not competitive, making it difficult to attract nurses. One public health nurse mentioned she always wanted to be a school nurse but could not accept the salary of school nurses. School nurses are considered ancillary in the academic setting, and many are unsure of the school nurse’s role.
Strategies for overcoming
The best strategies are education and advocacy. Many school nurses have discovered power in numbers and have joined their professional nursing organizations. By joining forces, they have built a resourceful network across the state and solved problems together. In most legislative sessions, you will see/hear school nurses at the roundhouse as they continue to advocate for student health and safe workforce conditions in the schools.
References
Ballard, J., Ramirez, B., & Zantal-Wiener, K. (n.d.). Public law 94-142, section 504, and public law 99-457: Understanding what they are and are not. Council for Exceptional Children.
Congress, U. S. (2019). Rehabilitation act of 1973: As amended through p.l. 114-95, enacted december 10, 2015. Independently published.
Congress, U. S. (2022). The rehabilitation act of 1973 and the americans with disabilities act:. In Disability protests (pp. 160–191). Gallaudet University Press. https://doi.org/10.2307/j.ctv2rr3fg7.11
Enforcing the right to an “appropriate” education: The education for all handicapped children act of 1975. (1979). Harvard Law Review, 92(5), 1103. https://doi.org/10.2307/1340453
Nasn position statement: Healthy communities. (2023). NASN School Nurse, 39(1), 49–50. https://doi.org/10.1177/1942602×231168705
Nasn position statement: Student access to school nursing services. (2022). NASN School Nurse, 37(4), 223–224. https://doi.org/10.1177/1942602×221098463
NASN position statement: School nurse workload – staffing for safe care. (2015). NASN School Nurse, 30(5), 290–293. https://doi.org/10.1177/1942602×15594143
Rozalski, M., Yell, M. L., & Warner, J. (2021). Free appropriate public education, the u.s. supreme court, and developing and implementing individualized education programs. Laws, 10(2), 38. https://doi.org/10.3390/laws10020038
