It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse), in collaboration with the student, family and healthcare providers, shall meet nursing regulatory requirements and professional standards by writing an Individualized Healthcare Plan (IHP) for students whose healthcare needs affect or have the potential to affect safe and optimal school attendance and academic performance. Health conditions can be “complex and unfamiliar to school staff, and the children’s requirement for nursing can be frequent and sometimes emergent, therefore, accurate and adequate documentation of their chronic medical conditions and individual needs is critical” (Lyon, 2012, p. 288). Development of IHPs is a nursing responsibility, based on standards of care regulated by state nurse practice acts and cannot be delegated to unlicensed individuals (National Council of State Boards of Nursing [NCSBN], 2005). It is the responsibility of the school nurse to implement and evaluate the IHP at least yearly and as changes in health status occur to determine the need for revision and evidence of desired student outcomes.
The IHP is a written document based on the nursing process. Since emerging in the 1970s, the nursing process is the cornerstone of nursing practice, using a scientific approach in the identification and solution of health problems in nursing practice (Hermann, 2005). The American Nurses Association (ANA) and NASN define the nursing process as a “circular, continuous and dynamic critical-thinking process comprised of six steps and that is client-centered, interpersonal, collaborative, and universally applicable” (American Nurses Association [ANA] & NASN, 2011, p. 76). Documentation of these steps for individual students who have healthcare issues results in the development of an IHP, a variation of the nursing care plan.
Development of the IHP by the school nurse provides a framework for meeting clinical and administrative needs:
Demonstrates Standard of School Nursing Practice
Development and implementation of the IHP is documentation of professional performance in accordance with standards of school nursing practice, the professional expectations that guide the practice of school nursing (ANA & NASN, 2011). The Standards of School Nursing Practice are “authoritative statements of the duties that school nurses, regardless of role, population, or specialty within school nursing are expected to competently perform” (ANA & NASN 2011, p. 4). These standards “describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process” (ANA & NASN, 2011, p. 12).
Documents the Nursing Process
Creation of the IHP incorporates and documents the nursing process in student care in accordance with state nurse practice acts. The nursing process provides a framework for the nurse’s responsibility and accountability. “The RN may delegate components of care but does not delegate the nursing process itself. The practice pervasive functions of assessment, planning, evaluation and nursing judgment cannot be delegated” (ANA & NCSBN, 2005).
School Nursing: Scope and Standards of Practice (ANA & NASN, 2011) outlines how implementation of each step of the nursing process strengthens and facilitates educational outcomes for students. These steps parallel components of a well-written IHP.
Standard 1. Assessment: The school nurse collects comprehensive data pertinent to the healthcare consumer’s health and/or situation.
Standard 2. Nursing Diagnosis: The school nurse analyzes the assessment data to determine the diagnoses or issues.
Standard 3. Outcome identification: The school nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
Standard 4. Planning: The school nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.
Standard 5. Implementation: The school nurse implements the identified plan.
Standard 6. Evaluation: The school nurse evaluates progress toward attainment of outcomes.
Provides Legal Documentation
A school nurse plans safe care for students and demonstrates an appropriate standard of professional care when the IHP is used as the foundation for students’ health interventions. “Judicious use of the IHP as a vehicle to ensure safe nursing services and continuity of care for students with special (health) needs is a standard of care against which a school nurse’s conduct can be judged in a legal proceeding” (Hootman, Schwab, Gelfman, Gregory, & Pohlman, 2005, p. 190). Along with applicable laws including state nurse practice acts, expert testimony, organizational policies and procedures, the standard of care is a significant factor used by courts in professional liability cases (Pohlman, 2005).
Clarifies Clinical Practice
The IHP’s clinical purposes include: clarifying and consolidating meaningful health information; establishing the priority set of nursing diagnoses for a student; providing communication to direct the nursing care of a student; documenting nursing practice; ensuring consistency and continuity of care as students move within and outside school districts; directing specific interventions; identifying (safe and appropriate) delegation of care; and providing methods to review and evaluate nursing goals and student outcomes (Hermann, 2005). The IHP is the document that combines all of the student’s healthcare needs into one document for management in the school setting (Zimmerman, 2013).
To offer additional clarification for the clinical practice in the IHP, NASN supports the use of standardized nursing languages to provide a common database in IHP development. North American Nursing Diagnosis Association-International (NANDA), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) are most applicable to school nurse practice (Denehy, 2010; NASN, (2012).
Provides Administrative Information
The IHP serves administrative purposes, which include: defining the focus of nursing; validating the nurse’s position in the school; facilitating management of health conditions to optimize learning; differentiating accountability of nurse from others in the school; providing criteria for reviewing and evaluating care (quality assurance); providing data for statistical reports, research, third-party reimbursement and legal evidence; and creating a safer process for delegation of care in the school setting (Herrmann, 2005).
Becomes the Foundation for Health Portion of Other Educational Plans and Emergency Plans
The IHP provides the health information and activities that can be incorporated into the health portion of other school -educational plans to foster student academic success and to meet state and federal laws and regulations. These include the Individualized Education Plan (IEP) in accordance with the Individuals with Disabilities Education Improvement Act (P.L. 108-446, 2004), and a 504/ADA plan in accordance with Section 504 of the Rehabilitation Act (P.L. 102-569, 1992) and the Americans with Disabilities Act (P.L. 110-325, 2008).
The student Emergency Plan (Emergency Care Plan or Emergency Action Plan) is developed based on the IHP, and is written in clear action steps and provided to school staff to assist them in responding to a health crisis (Zimmerman, 2013).
It is the professional responsibility of the school nurse to create the IHP, using the nursing process, in response to the health needs of the student, whether chronic or acute. Development, documentation and implementation of an IHP by the school nurse promotes sound planning, coordination, continuity and evaluation of care, thereby enabling the student to access educational programs, to prevent the development of serious and life-threatening complications and emergencies, and to prolong life.
American Nurses Association & National Association of School Nurses. (2011). School nursing: Scope and Standards of practice (2nd ed.). Silver Spring MD: Nursesbooks.org.
American Nurses Association & National Council of State Boards of Nursing. (2005). Joint statement on delegation. Retrieved from https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf
Americans with Disabilities Act of 1990 as Amended (2008). Publ Law 110-325.
Denehy, J. (2010). Using nursing languages in school nursing practice (2nd ed.). Silver Spring, MD: National Association of School Nurses.
Hermann, D. (2005). Individualized healthcare plans. In Silkworth, C. Arnold, M., Harrigan, J., Zaiger, D. (Eds.), Individualized healthcare plans for the school nurse: Concepts, framework, issues and applications for school nursing practice (pp. 1-4). North Branch, MN : Sunrise River Press.
Hootman, J., N.C. Schwab, Gelfman, M.H.B., Gregory, E.K. & Pohlman, K. J. (2005). School nursing practice: Clinical performance issues. In Schwab, N. C., & Gelfman, M.H.B. (Eds.), Legal issues in school health services (pp. 167-230). North Branch, MN: Sunrise River Press.
Individuals with Disabilities Education Act. (2004). 20 U.S.C. 1400, § 602 (26) [Definitions]. Code Federal Regulations (CFR), part 300.
Lyon, L. (2012). School assessment form for students with special health care needs . NASN School Nurse, 27 (6), 288. DOI: 10.1177/1942602X12446752
National Association of School Nurses (NASN). (2012). Position Statement: Standardized nursing languages. Retrieved from Http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/48/Standardized-Nursing-Languages-Revised-June-2012
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
Pohlman, K. J. (2005). Legal framework and financial accountability for school nursing practice. In Schwab, N. C. , & Gelfman, M.H.B. (Eds.), Legal issues in school health services (pp. 95-121). North Branch, MN: Sunrise River Press.
Section 504 of Rehabilitation Act of 1973 (P.L. 102-569. 199229 U.S.C.A – 794; 34 C.F. R., Part 104). U.S. Department of Labor.
Zimmerman, B. (2013). Student health and education plans. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed., pp. 284-314). Philadelphia, PA: FA Davis Company.
Acknowledgement of Authors:
Janet Bryner, BSN, RN, NCSN
Sue A. Buswell, MSN, RN, NCSN
Bernadette Moran McDowell, MEd, BSN, RN
Georgene Westendorf, MPH, BSN, RN, NCSN, CHES
Susan Will, MPH, BS, RN, NCSN, FNASN
Adopted: June 1998
Revised: November 2003, March 2008, June 2008, June 2013