HISTORY
New technologies and treatments in health care make it possible for students with chronic health conditions to attend school and participate in the regular education classroom; and their right of participation is protected by federal law (Gelfman & Schwab, 2001). A chronic health condition is defined by Schwab and Gelfman 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, Glossary).
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. A professional registered school nurse has the expertise to safely and effectively manage the health care of students with chronic health conditions to enable them to participate in school.
DESCRIPTION OF ISSUE
The main issues surrounding health management of students with chronic health conditions in schools 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 health care services (Schwab, Gelfman & Cohn, 2001) and those laws in most states do not mandate that school health services are provided by licensed professional school nurses.
Effective and safe management of chronic health conditions is complex, requires careful planning by a licensed professional school nurse, and may involve delegation of nursing tasks to both licensed and unlicensed assistive personnel (UAP).
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 professional licensed school nurse is essential to quality student health services.
Dependable funding is essential to quality student health services (NASN, 2006).
RATIONALE
Health care needs of students with chronic health conditions are complex, and increasingly those students are attending school. In 1998, Newacheck, et al. estimated, based on the 1994 National Health Interview Survey, that in the United States, 18% of children under the age of 18 years 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). As the numbers of students with chronic health conditions increases, more school nurses are needed to provide health care services during the school day.
The ratio of professional school nurses to students exceeds 1:3000 in many school districts (Praeger, Zickler, & Mosca, 2002). Only one state, Delaware, mandates the employment of a school nurse for every school. In schools where there is not a full-time licensed professional school nurse, disease management is left to either a part-time school nurse, or to UAP, who may be trained to carry out certain procedures or administer certain medications, but who do not have the knowledge or skills to make judgments in regard to side effects of medication or to prevention of, or action in, an emergency.
Individualized health care planning, a professional school nursing function that cannot be delegated (National Council State Boards of Nursing, 2005), is necessary for the successful management of students with chronic health conditions to enable them to fully access their educational programs, to prevent the development of serious and life-threatening complications and emergencies, and to prolong life. The registered professional school nurse is responsible and accountable for creating the individualized health care plan (IHP), for management of activities of the plan and for the outcomes of the plan, even when implementation of the plan requires delegation to UAP.
CONCLUSION
Licensed 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 (National Council of State Boards of Nursing, 2005). 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,
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, 2004).
References/Resources
Cedar Rapids Community School District v. Garrett F, 119 S.CT. 992, 29 IDELR 966 (U.S. 1999). Retrieved February 7, 2006 from http://supct.law.cornell.edu/supct/html/96-1793.ZS.html.
Gelfman, M. H. B. and Schwab, N. (2001). Discrimination in School: § 504, ADA, and Title IX. In N. C. Schwab, & M. H. B. Gelfman (Eds.), Legal issues in school health services: A resource for school administrators, school attorneys and school nurses (pp.335-371). North Branch, MN: Sunrise River Press.
National Association of School Nurses. (2004). Position statement: Caseload assignments. Retrieved February 21, 2006, from http://www.nasn.org/Default.aspx?tabis=209.
National Association of School Nurses. (2006). Issue brief: School nursing management of students with chronic health conditions. Scarborough, ME: Author.
National Council of State Boards of Nursing. (2005). Working with others: A position paper. Retrieved January 10, 2005, from http://www.ncsbn.org/pdfs/Working_with_Others.pdf.
Newacheck, P. W., Strickland, B., Shonkoff, J. P., Perrin, J. M., McPherson, P. A., McManus, M., Lauver, C., Fox, H., and Arango, P. (1998). An epidemiologic profile of children with special health care needs. Pediatrics, 102, 117-123. Retrieved February 9, 2006, from http://www.pediatrics.org/cgi/content/full/102/1/117
Praeger, S., Zickler, C., & Mosca, N. W. (2002). Care of students with special needs in schools: Application of professional school nursing practice standards. Scarborough, ME: National Association of School Nurses.
Schwab, N. C., Gelfman, M. H. B., & Cohn S. D. (2001). Fundamentals of U.S. law. In N. C. Schwab & M. H. B. Gelfman (Eds.), Legal issues in school health services: A resource for school administrators, school attorneys and school nurses (pp.55-79). North Branch, MN: Sunrise River Press.
Schwab, N. C., Gelfman, M. H. B., & Cohn S. D. (2001). In N. C. Schwab & M. H. B. Gelfman (Eds.), Legal issues in school health services: A resource for school administrators, school attorneys and school nurses (p.609, Glossary). North Branch, MN: Sunrise River Press.
Adopted: June 2006