INTRODUCTION

The main issues surrounding in-school health management of students with chronic health conditions are:

Health care services must be provided for students who qualify for services under IDEA or Section 504 to meet requirements of federal laws.

State health laws, including nurse practice acts, and education laws decide who will provide the healthcare services (Schwab, Gelfman, & Cohn, 2001), and those laws in most states do not mandate that school health services are provided by registered professional school nurses.

Effective and safe management of chronic health conditions is complex, requires careful planning by a registered professional school nurse, and may involve delegation of nursing tasks.

Individualized health care planning is a nursing responsibility and standard of care that is regulated by State Nurse Practice Acts and cannot be delegated to unlicensed individuals (National Council of State Boards of Nursing, 2005).

A fulltime registered professional school nurse is essential to quality student health services.

Dependable funding is essential to quality student health services.

Increasingly, because of new technologies and treatments in health care as well as advancement in pharmaceuticals, students with chronic health conditions are able to attend school, instead of being educated at home or in special schools. The Council for Children and Adolescents with Chronic Health Conditions (CCACHC, 2005, ¶ 1) defines a chronic health condition as one that is biologically-based, lasts for a long period of time, brings about significant change in the life of the child, and requires more than the usual amount of medical care. According to the federal Maternal and Child Health Bureau, Division of Services for Children with Special Health Care Needs "Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally" (cited in Newacheck, et al., 1998, p. 117). The glossary in Schwab and Gelfman further defines a chronic health condition as "one that is long term (usually more than three months duration) and is either not curable or has residual features that result in limitations in daily living requiring adaptation in function or special assistance" (Schwab & Gelfman, 2001, p. 609). Chronic health conditions, by definition, are not curable, require continuous treatment, and may persist for a lifetime. Students with chronic health conditions may be well or ill at any given time, and they visit their doctors more frequently and have more hospitalizations than their healthy peers (CCACHC, 2005, ¶ 2).

Examples of chronic health conditions include, but are not limited to, asthma, diabetes, allergies, including life-threatening allergies, genetic disorders, immunological disorders, cancer, orthopedic disorders, neuromotor disorders, and mental health disorders. Chronic health conditions are not always immediately apparent and may lead to chronic disabilities for students, disabilities that require complex health care interventions and possibly the routine use of medical devices or equipment.

The right of participation of all students with disabilities, including eligible students with chronic health conditions, in the regular education program is protected by federal law (Gelfman & Schwab, 2001). To fully participate, students with chronic health conditions often require medical management at school that enables them to access education and have the same educational opportunities as their healthy peers. Providing educational access means that school districts must have the infrastructure and trained staff to insure that students with chronic health conditions have safe and effective medical management, including emergency care and administration of medications. The registered professional school nurse is the only school staff member who has the skills and knowledge base to fully meet the health care needs of students with chronic health conditions.

The professional school nurse performs individualized assessments of students, works collaboratively with teachers, parents, students, and health care providers to create individualized health care plans that include safe and effective provision of prescribed treatments and medications, health education, and ongoing monitoring and evaluation of health outcomes (National Association of School Nurses [NASN], 2002). In states where delegation is allowed by law, achievement of IHP goals may require delegation of certain nursing tasks to unlicensed assistive personnel (UAP) (NASN, 2004). The goal of school nursing services is to enable students to access academic programs in the least restrictive environment through safe and appropriate management of health conditions and to support student academic success. In addition, the school nurse teaches and supports students in development of self-care skills and instructs the teaching staff in how to assist the identified students and to prevent and handle emergencies in the classroom.

In a school without a full-time school nurse, there is a possibility that a student with a chronic health condition may experience a life-threatening event at school or at a school-related activity and not have appropriate care. In addition, lack of appropriate nursing care at school creates the possibility that a student will become medically unstable requiring absence from school for medical treatment. Comprehensive, safe, and effective nursing care can be provided only by professional registered school nurses.

The increasing obligations for schools to provide health care makes the professional school nurse staff position a basic necessity, not an extravagance. Yet, school nursing services are not available in all schools, and where they are available, it may be only on a part-time basis (NASBE, 2005). There is a need to eliminate the inequities in the availability of school nursing services among school districts, and schools alone probably cannot solve the problem. A healthy and educated citizenry requires the collaboration of many institutions (Costante, 2001).

BACKGROUND

Federal Laws

There are three federal laws that impact provision of school health services to students with chronic health conditions. One is a federal education law, Individuals with Disabilities Education Improvement Act of 2004 (IDEA [Short Title]), and the other two are federal civil rights laws, Rehabilitation Act of 1973, particularly Section 504, and The Americans with Disabilities Act (ADA) of 1990. IDEA provides the standards for distribution of federal funds to states for special education and related services for disabled students to receive a free, appropriate education in the least restrictive environment. This law, enacted in 1990, was actually a renamed and amended version of the 1975 Education of All Handicapped Children Act (EHA). Further amendments were added in 1997, and the final revised IDEA regulations were published in 1999 (Schwab, Gelfman, & Cohn, 2001). In 2004, IDEA was reauthorized, and the law was renamed Individuals with Disabilities Education Improvement Act.

Important changes to EHA in IDEA (1990), included requirements that states provide special education services to preschool children, provide for the recovery of legal fees for parents who prevail in due process proceedings, and include parents as members of Individualized Education Program (IEP) teams. The 1997 Amendments shifted the focus of the IDEA to one of improving teaching and learning, with a specific focus on the Individualized Education Program (IEP) as the primary tool for enhancing the child’s involvement and progress in the general curriculum (United States Department of Education, 1999). Students who qualify for services under IDEA have IEPs.

A significant change for school health in the 2004 reauthorization of IDEA was the new definition of "related services" to include "school nurse services designed to enable a child with a disability to receive a free appropriate education as described in the individualized education program [IEP] of the child" (Individuals with Disabilities Education Improvement Act, 2004). The 2004 IDEA reauthorization now includes "school nursing services" as a related service. For school districts in all states this means:

School nurses can be listed as a related service provider in the Individualized Education Plan (IEP) of students with a disability.

Students with a disability can receive school nursing services, and districts can be eligible for state, federal and third party reimbursements for these services.

School nursing services such as suctioning, tube feedings, medication administration and management, catheterizations, etc. can generate funding for that service when the service is listed in a student’s IEP.

School nurse positions can be funded through state, federal and third party reimbursements (Lowe, Sedgewick, & Will, 2005).

IDEA specifies that to be eligible for services under the law, a student must have a disability that interferes with learning and adversely affects educational performance (Schwab, Gelfman, & Cohn, 2001). Some, but not all students with chronic health conditions, may qualify for services under IDEA. School health services as "related services" under IDEA are not the same as routine school health services provided to all students, which are not mandated by federal law. Therefore, if an IDEA eligible student requires daily school health services and the school employs a part-time nurse only two days per week, then the school district will be required to provide the nursing staff needed for daily services (Gelfman & Schwab, 2001).

Section 504 of the Rehabilitation Act of 1973 prohibits discrimination against individuals on the basis of disabilities and guarantees access to federally funded programs, including public schools, for disabled students. The definition of disability under Section 504 is much broader than the definition in IDEA, and includes students with physical or mental impairments that substantially limit one or more major life activities. Many more students with chronic health conditions would fall into this definition of disabled. Students who qualify under Section 504 receive accommodations in a regular education program that are documented in a 504 Accommodation Plan (504 Plan) that is created by a team of people knowledgeable about the student, the disability, and possible accommodations, including the parents, if they choose to participate, and the student, if appropriate (NASN, 2005).

Section 504 regulations insure that disabled students will have the same access to educational opportunities as their non-disabled peers and supports them in achieving positive health and educational outcomes (NASN, 2005). The ADA of 1990 extends the mandate of Section 504 to broaden the scope of civil rights beyond public agencies to private businesses and organizations, including private daycare programs and private schools (Schwab, Gelfman, & Cohn, 2001). Unlike IDEA, Section 504 and the ADA have no funding attached to them, funding that would support schools as they provide special accommodations or services to disabled students.

State Laws

State laws relevant to school nursing services may include state education laws and state health laws (Schwab, Gelfman, & Cohn, 2001). State education laws seek to define the public education program and may include mandates related to many aspects of education such as teacher to pupil ratios, ratios of particular student support specialists (social workers, psychologists, nurses) to students, educational preparation for school professionals, ages for mandatory attendance, immunization requirements, health screenings, and bus transportation requirements. Education laws may also regulate mandatory requirements for school health programs and athletic programs (Schwab, Gelfman, & Cohn, 2001). For example, in the state of New Jersey, school nurses must be bachelor prepared (BSN) and must be certified as school nurses through the New Jersey State Department of Education, and each school district must employ at least one certified school nurse (NASBE, 2005).

State health laws include mandates and statutes related to the licensure of health professionals and are written to protect the public from harm. Nurse practice acts are licensure laws. State boards of nursing are agencies authorized by state statutes to regulate nursing practice, and they develop regulations to interpret nurse practice acts. Nurse practice acts define the qualifications for nursing practice and the scope and standards of nursing practice, and specify what nurses can do and what tasks they can delegate and to whom. If unlicensed assistive personnel (UAP) are used in schools to perform nursing tasks, then the nurse who delegates to UAP are regulated as to how and under what circumstances such delegation takes place (Schwab, Gelfman, & Cohn, 2001). Nurses must abide by their licensure regulations, even if employed in a setting other than a health care setting. School health professionals and school health administrators must become well informed about both education laws and health laws that regulate health services in schools.

Delegation

Delegation is "transferring to a competent individual the authority to perform a selected nursing task in a selected situation" (NCSBN, 2005, p. 5). It is a very important part of the nursing process and often necessary in implementation of an individualized health care plan. The primary provider of school nursing services is the registered nurse practicing in a school setting. Nursing is an "outcome driven, knowledge based, process discipline that is context dependent and requires critical thinking" (NCSBN, 2005, p. 5). Specialized education, knowledge, skills, and professional judgment are essential elements of quality nursing care in any setting. Delegation is a nursing function that should not be taken lightly, especially in light of the ratios of school nurses to students and the increasing medical complexity of managing students with chronic health conditions. Nursing care cannot be reduced to a list of tasks that anyone can perform. Therefore, school nurses must carefully perform and document the selection, training, competency measurement, and evaluation of delegates who will perform nursing tasks for students.

The school nurse’s decision to delegate must always be in line with the applicable state nurse practice act (NASN, 2004). State boards of nursing regulate nursing practice, and the nurse practice acts dictate which level of licensed nurse is authorized to delegate (NCSBN, 2005). In some states, nurses cannot legally delegate nursing care activities at all. However, the nurse practice act in most states does authorize nurses to delegate (NCSBN, 2005). If delegation is permitted by a board of nursing, usually the nurse practice act has specific language that defines who selects the delegate, who can delegate to whom, what nursing tasks can be delegated, and who trains and supervises the delegate (NASN, 2004).

Legal problems arise when schools do not recognize or abide by legal practice standards set by state law in regard to delegation of school nursing services. Federal laws mandate that school nursing services are provided to eligible students. An example of the federal mandate is the 1999 United States Supreme Court ruling in Cedar Rapids Community School District v. Garret F. which held that IDEA requires school districts to provide nursing services when such supportive services are necessary in order for students to access and benefit from their educational program. State nurse practice acts regulate who provides those health services. The decision in a due process hearing in Minnesota in 1994 (Special School District No. 6, 1994) illustrates the power of the nurse practice act. In this particular case, the parents of a student with multiple disabilities did not want their child removed from the classroom for tracheostomy care and suctioning by the school nurse. Instead, they wanted the teacher, or other UAP, to perform the procedures in the classroom rather than have the student miss class time. The hearing officer cited the state nurse practice act, and declined to require that the nurse delegate to UAP (Gelfman & Schwab, 2001). The decision of the hearing officer was upheld on appeal to the federal district court (Moye by Moye v. Special School District No. 6, South St. Paul, Minn., 1995). The court recognized the professional responsibility of the school nurse to use professional judgment in appropriate management of the student’s condition based on the nurse’s assessment of the needs of the student at a particular time as well as the needs of the other students in the classroom (Gelfman & Schwab, 2001).

In schools where there are no licensed school nurses, school administrators, in an effort to get health services provided where needed, may directly assign UAP, such as school secretaries or teaching assistants, to perform nursing tasks, or may demand that school nurses delegate in a manner that is in opposition to the dictates of nurse practice acts. The nurse’s legal, professional, and ethical responsibilities are different from those of the educational professionals and administrators who manage the school (Pohlman, 2001). It is the school nurse that defines and supervises the education, training, and utilization for any UAP involved in providing direct health care to students (American Nurses Association, 1992). The registered professional school nurse is the only school staff member competent to delegate, and never should a nurse delegate any activity that requires core nursing functions of assessment, planning, evaluation or judgment (NCSBN, 2005). Schools that employ a full-time registered professional school nurse provide for legal and safe delegation of nursing care.

Individualized Health Plan

The registered nurse practicing in the school setting is ultimately responsible and accountable for creating an individualized health care plan (IHP) and for the outcomes of the plan, even if certain nursing care tasks described in the IHP are delegated to UAP. Individualized health care planning is a nursing function that cannot be delegated. The IHP is a plan of action for management of actual and potential health care needs during the school day, on field trips, and at school-sponsored activities. The IHP provides a format to record each step in the nursing process, where the school nurse summarizes the assessment findings, synthesizes problem statements in the form of nursing diagnoses, formulates goals, formulates plans of action, and documents interventions and the evaluation of outcomes (Arnold & Silkwood, 1999, p. 2).

According to School Nursing: Scope and Standards of Practice, to complete the IHP process, the school nurse develops the plan collaboratively with the student, parents, health care providers, school community and others as appropriate and individualizes the plan to a specific student’s needs to provide for continuity of care (NASN & ANA, 2005). The standard for practice dictates that the IHP is evidence-based, provides direction to the school team, complies with current applicable laws and standards of practice, considers economic impact, and uses standardized nursing language (NASN & ANA, 2005). The registered professional school nurse manages the activities of the plan.

Emergency Care Plans

Whenever there is a known risk of an emergency, as there is in the management of students with the most common chronic health conditions in schools (asthma, diabetes, allergies), then the school nurse creates an Emergency Care Plan (ECP). The ECP is an outcome of the IHP and is listed in the IHP as such. It is a clearly written step-by-step set of instructions for what to do in a particular emergency situation. It is written in language that a layperson can understand because it is created to be used by non-nursing school personnel who may respond to an emergency. Unlike the IHP, the ECP is distributed to appropriate staff, and the school nurse trains those staff to respond to emergencies that may arise with individual students (Arnold & Silkwood, 1999).

The overall medical management goal for daily care of a student with a chronic health condition is maintenance of function and integrity of body systems to prevent early onset of serious complications and to prolong life. The IHP and ECP both contribute to achievement of the overall medical management goal, and school nurses are responsible and accountable for the continuous improvement of the systems that support the IHP and for integrating the IHP into the overall plan of care (NASN & ANA, 2005).

IEP, 504-Plan, IHP—How They Relate

The IEP is written by the IEP team for a student who has been found to be eligible for special education and related services under IDEA. A 504-Plan is written for a student who is not eligible for special education under IDEA, but still needs accommodations in environment or instruction in the regular education classroom to access an appropriate education in the least restrictive environment (Arnold & Silkwood, 1999). The school nurse writes an IHP for any student who has a chronic health condition or other specific short-term health issues.

If a student has an IEP and also has a specific health condition, then the student’s IHP can be incorporated or added into the IEP. Another option is to add the IHP to the IEP as an addendum. At times, certain IHP goals and outcomes may be attached to a specific IEP academic goal (Arnold & Silkwood, 1999). In any case, the school nurse is an important member of the IEP team.

In the case of a 504-Plan, the student is more likely to qualify under Section 504 for a health-related disability, and therefore, the IHP may be the foundation for the 504-Plan (Arnold & Silkwood, 1999). The 504 and IHP processes are both collaborative and include parents, school staff, including the school nurse, and health care providers. Many districts, therefore, consider the IHP to be a 504-Plan in a case where a student needs only the health-related accommodations outlined in the IHP to access education. The IHP in that situation would be subject to the Section 504 procedural requirements and parental safeguards (NASN, 2005).

Summary of School Nurse Ratios and Regulations

Availability of licensed professional school nurses to provide nursing services has important implications for all students, and can mean the difference between life and death for students with chronic health conditions. Numbers of school nurses and the numbers of schools to which one school nurse is assigned vary from school district to school district and from state to state. Delaware is the only state where state law mandates a full-time school nurse for every school building (NASBE, 2005). Even though most states do not mandate a school nurse for every school, many states do mandate the provision of nursing services related to administration of medication, special medical procedures, and health assessments.

Funding

The staff position of a fulltime registered professional school nurse is a prerequisite for provision of quality school health services for the management of chronic health conditions. Yet, there are wide disparities in the availability of school nursing services in the United States. Eliminating those disparities would benefit all of society and is a fiscal responsibility that schools cannot shoulder alone. Dependable funding is essential to quality school nursing services. Nationally, school nursing services are currently funded through multiple sources. Funding streams include general local and state revenues; categorical funds such as Title One and Special Education; federal participation programs such as Medicaid and Child Health Insurance Program (CHIP); and third-party payers, partnerships, and grants (Costante, 2001). None are reliable sources of funds.

Health is fundamental to the educational process, and the academic success of all children is fundamental to the success of our economy and our society. The overall effective management of students with chronic health conditions through quality school nursing services will improve the health and educational success of children. The budgetary commitment and collaboration of education entities, legislators, public and private health agencies, and community organizations will insure adequate, dependable funding.

Prevalent Chronic Health Conditions among School Students

The prevalence of chronic health conditions among school students continues to increase. The three most prevalent chronic conditions among school students are asthma, diabetes, and allergy (including life-threatening allergies). All three are treatable with medication and monitoring of symptoms to prevent and manage life-threatening emergencies and to prevent long-term complications. The successful prevention and management of emergencies requires judgment of a trained licensed nurse in regard to which medications should be administered and when, and in regard to when and how to use medical devices to monitor symptoms. Nursing supervision is necessary to enable students’ self-monitoring of symptoms and self-administration of medication when appropriate. In true emergency situations students are unable to self-administer or self-monitor, and nursing judgment and action is crucial to prevent loss of life.

Below is a table of common chronic conditions among school students and management activities.

The grid illustrates that not all students with chronic conditions have emergency risk, but the ones that do require safe management by a professional registered school nurse.

RATIONALE

Health care needs of students with chronic health conditions are complex, and those students increasingly are attending school. The results from the 1994 National Health Interview Survey (NHIS, 1994) were analyzed by Newacheck et al., and according to the researcher’s estimates, 18 % of children less than 18 years of age in the United States had a chronic physical, developmental, behavioral, or emotional condition and required health or related services beyond those required by children generally (Newacheck, et al., 1998). Further analysis of the data revealed demographic and socioeconomic correlates to prevalence of special health care needs:

Prevalence increases with age, such that school-aged children were twice as likely as pre-school children to have special health care needs.

Boys are one-third more likely than girls to have a special need.

Looking at race and ethnicity, African-American children were most likely to have a special need.

Children from families living at or below the poverty level were one-third more likely to have a special need compared to those living above the poverty level.

Children from less educated households had a higher likelihood of having a special health care need.

Children in single-parent families were about 40% more likely to have existing health care needs compared to children from two-parent families (Newacheck et al., 1998).

Other data from the National Center for Health Statistics estimates that 6-7% of all children under the age of 18 have limitation of activity due to chronic health conditions (NCHS, 2004). Limitation of activity suggests increased risk of illness and injury and the need for careful management at school.

Registered professional school nurses are responsible and accountable for assessment of and planning for safe and effective medical management of students with chronic health conditions, practice responsibilities that cannot be delegated. Therefore, it is the position of NASN that school districts should provide a full-time professionally prepared registered nurse in every school building. NASN recommends minimum ratios of nurses to students depending on the needs of the student populations:

1:750 for students in the general population,

1:225 in the student populations that may require daily professional school nursing services or interventions,

1:125 in student populations with complex health care needs, and

1.1 may be necessary for individual students who require daily and continuous professional nursing services.

Also recommended is additional school nurse staff to accommodate other student health needs including, but not limited to, special education evaluations, nursing services included in IEPs, nursing services for students with 504 Plans, and schools with large populations and large numbers of students with mental or social concerns (NASN, Caseload Assignments, 2004).

THE ADVOCACY ROLE OF THE SCHOOL NURSE

Given the school nurse’s understanding of the health care needs of students with chronic health conditions and the state of school nursing in the state and community in which the nurse practices, the registered school nurse is the most knowledgeable professional to advocate for school nursing and for provision of quality school health services for students with chronic health conditions. Important and appropriate advocacy activities may include, but are not limited to:

Educate school administrators in regard to the laws that regulate school nurse practice.

Make presentations to boards of nursing to illustrate the reality of practice issues in schools.

Volunteer to work on committees to develop position statements and advisory opinions to clearly describe how the nurse practice act relates to school nursing practice.

Participate in coalitions of education stakeholders to educate legislators and policymakers in regard to the need for an improved ratio of school nurses to students.

Interact with health care providers, education entities, community organizations and legislators to research new sources of funding for providing more school nurses.

Become active in professional nursing and school nursing organizations in order to promote school nursing and to continue to develop knowledge and skills for provision of school nursing services.

It is essential that students with health conditions have their health care needs met safely and competently in school. Having a registered professional school nurse available fulltime in every school will insure quality school nursing services for all students. That is not, however, the reality in many school districts. Yet, it is not an insurmountable goal. Reaching the goal of a school nurse in every school requires continuous collaboration among many stakeholders including school districts, state and national lawmakers, local elected officials, the business community, local health care providers and health care systems, and parent organizations. Equal access to education for students with chronic health conditions depends on quality school nursing services provided by registered professional school nurses.

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Adopted: June 2006