It is the position of the National Association of School Nurses that students with chronic health conditions have access to a full-time registered professional school nurse (hereinafter referred to as school nurse). School districts should include school nurse positions in their full-time instructional support personnel to provide health services for all students, including students with chronic health conditions. The school nurse coordinates and conducts assessment, planning, and implementation of individualized health care plans for safe and effective management of students with health conditions during the school day. The school nurse is both the provider of care and the only person qualified to delegate care to an unlicensed care provider as prescribed in state nurse practice laws and regulations and according to Scope and Standards of School Nurse Practice (National Association of School Nurses [NASN] & American Nurses Association [ANA], 2011).
The percentage of children and adolescents in the United States with chronic health conditions (CHC) increased from 1.8% in the 1960s to more than 25% in 2007 (Halfon & Newacheck, 2010). There is some difficulty in measuring prevalence due to the lack of a clear definition of chronic health conditions. CHC include both long-term physical and mental disorders. It is useful to use a non-categorical approach CHC, and for identifying children and adolescents as having special health care needs. These children include those with long-term physical, emotional, behavioral, and developmental disorders that require prescription medications and medical or educational services. They also include disorders that affect a child’s functional status (Forrest, Bevans, Riley, Crespo, & Louis, 2011). The non-categorical approach focuses on needs for service and risk of school failure.
Over the past few decades the number of students with CHC in schools has increased for a variety of reasons. Many students who had been confined to therapeutic settings are now being educated in the local school district in the least restrictive environment. Their right of participation is protected by federal law, including the Rehabilitation Act, Section 504 and the Individuals with Disabilities Educational Act [IDEA] of 2004. As survival rates associated with chronic conditions in infants and children continue to increase and life expectancy increases, the health care and educational service needs of students will increase. Many children with CHC now are able to attend school and succeed due to critical support services, including those provided by school nurses. The school nurse is a key member of the educational team and is the one who is responsible for planning, implementing, and monitoring the health care plans for students with CHC.
DESCRIPTION OF ISSUE
The main issues surrounding health management of students with chronic health conditions in schools are as follows:
Health care services must be provided for students who qualify for services under IDEA or Section 504 to meet requirements of federal laws. The school nurse has an important role in interpreting a student’s health status, in explaining the impairment, and in interpreting medical and other health information in relation to the expanded e standards for eligibility under Section 504 (Zirkel, 2009).
Development of individualized health care plans (IHP) is a nursing responsibility and is based on standards of care that are regulated by State Nurse Practice Acts and cannot be delegated to unlicensed individuals (National Council of State Boards of Nursing [NCSBN], 2005).
Effective and safe management of chronic health conditions is complex, requires careful planning by a school nurse, and may involve delegation of nursing tasks to both licensed and unlicensed assistive personnel (UAP).
A full-time school nurse is essential to achieve quality student health services and to meet student health needs.
Dependable funding is required to ensure quality student health services.
Health care needs of students with chronic health conditions are complex and continuous. School nurses assist many children not served by the health care system and work to create access to health care for students and families. Students who may not have been identified as having a chronic condition prior to school entry are identified by school nurses who then coordinate evaluation and intervention services. School nurses assist students in learning to manage chronic illness, increasing seat time in the classroom, decreasing student absenteeism, resulting in cost savings to the school district and an increase in the overall academic success of the student.
School nurses are responsible and accountable for the assessment of and planning for safe and effective medical management of students with chronic health conditions. These responsibilities cannot be delegated (NCBSN, 2005). Therefore, it is the position of NASN that school districts should provide a full-time school nurse in every school building. NASN recommends school nurse to student ratios based on 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.
Additionally, Healthy People 2020 has included an objective to increase the proportion of schools that have a full-time registered school nurse-to-student of at least 1:750 (USDHHS/CDC, 2010).
A full-time school nurse is essential for oversight of the staffing plan and for informing school administrators of current staffing needs (Peterson & Wolfe, 2006).
Forrest, C. B., Bevans, K. B., Riley, A. W., Crespo, R., & Louis, T. A. (2011).School outcomes for children with special health care needs. Pediatrics, 128, 303 -312.doi: 10.1542/peds.2010-3347
Halfon, N. & Newacheck, P.W. (2010). Evolving notions of childhood chronic illness. JAMA, 303, 665-666.doi: 10.1001/jama.2010.130
Individuals with Disabilities Educational Act (IDEA) of 2004, 20 U.S.C. Sec. 1400 et seq.; 34 C.F.R. Parts 300 et seq. Retrieved from http://www.copyright.gov/legislation/pl108-446.pdf
Rehabilitation Act (Section 504): 29. U.S.C, 794; 20 U.S.C. 1405; 34 C.F.R. Part 104. Retrieved from http://www.access.gpo.gov/nara/cfr/waisidx_07/34cfr104_07.html
National Association of School Nurses (NASN) and American Nurses Association (ANA). (2011). School nursing: Scope and standards of practice. Silver Spring, MD: Author.
National Council of State Boards of Nursing (NCSBN). (2005). Working with others: A position paper. Retrieved from http://www.ncsbn.org/pdfs/Working_with_Others.pdf.
Peterson, B., Wolfe, L. C. (2006). Setting up the school health office. In J. Selekman (Ed.), School nursing: A comprehensive text, (pp.1013-1033). Philadelphia, PA: F.A. Davis Company.
U.S. Department of Health and Human Services (USDHHS).Office of Disease Prevention and Health Promotion (CDC).(2010). Healthy people 2020. Washington, DC: Author. Available at http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=11
Zirkel, P. A. (2009). History and expansion of Section 504 student eligibility: Implications for school nurses. Journal of School Nursing, 25, 256-259. doi: 10.1177/1059840509336930
Acknowledgement of Authors:
Judith Morgitan, MEd, BSN, RN
Margo Bushmiaer, MNSc, RN, NCSN
Marie C. DeSisto, MSM, BSN, NSCN
Carolyn Duff, MS, RN, NCSN
C. Patrice Lambert, MSN, RN, SNC
M. Kathleen Murphy, DNP, RN, FNP-BC
Sharon Roland, BSN, RN
Kendra Selser, MHS, BSN, RN
Leah Wyckoff, MS, BSN, RN
Kelly White, RN, PhD candidate (SME)
Adopted: June 2006
Revised: January 2012 (Formerly titled School Nursing Management of Students with Chronic Health Conditions)
This Position Statement replaces the Issue Brief:
School Nursing Management of Students with Chronic Health Conditions (adopted 2006)