School-Sponsored Before, After and Extended School Year Programs: The Role of the School Nurse
It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse) has the educational and clinical background to coordinate the necessary school health services to provide students with the same health, nutrition, and safety needs while attending school-sponsored before, after, and extended school year programs as the students receive during the traditional school day/year. In 2010, the White House Task Force on Obesity called for an increase in access to safe supervised physical activities beyond the school day (White House Task Force on Childhood Obesity Report to the President, 2010); and, as these programs have expanded, the necessity for providing quality, effective healthcare services during these hours has developed. As the expert in school health services delivery models of health care, the school nurse is an essential facilitator for student access to these programs. The school nurse plays a vital role in preparing the school-sponsored before and after school and extended school year program personnel with the necessary resources to respond to a health emergency.
Each afternoon throughout the United States, 15 million children -- more than a quarter of our child population - are alone and unsupervised after school (Afterschool Alliance, 2009). Research continues to support the premise that students who receive adult supervision and additional learning opportunities outside of the traditional school day show improved academic achievement, are less likely to engage in unhealthy behaviors, and have a better attitude toward school (Centers for Disease Control and Prevention [CDC], 2009). Students continue to have the same health, nutrition, and safety needs when enrolled in school programs that occur beyond the traditional school day. School-sponsored extended school year programs and before and after school programs that are a part of the school system should, at a minimum, engage the school nurse to act in an advisory capacity to address these student needs (Afterschool Alliance, n.d.).
On-site, school-sponsored before and after school programs, as well as extended school year programs, are on the increase in school districts across the United States primarily due to funding from federal, state, and local monies. No Child Left Behind mandated before, after, and summer school programs for students in low performing schools starting in 2002, and currently over 1.6 million students across the United States benefit from these programs (Afterschool Alliance, 2013.) Programs are offered to all students, including students receiving special education services and those with identified health conditions. School nurses will likely have such programs in their local school districts. The Scope and Standards of Practice for School Nurses (American Nurses Association [ANA]/National Association of School Nurses [NASN], 2011) promotes a safe and healthy environment; therefore, the school nurse should function as both a resource and an advocate for health-related issues in the school setting, including school-sponsored before, after, and extended school year programs. The staff planning and providing these school-sponsored programs will need consultation on various medical concerns, including response to health-related emergencies, disaster preparedness, first aid, CPR, recognition of signs and symptoms of child abuse and neglect, and procedures for protecting against blood borne pathogens. The school nurse should be engaged by program leaders to provide this consultation. Students with special healthcare needs may require nursing services beyond the regular school day; and supplies, staff, and nursing services for providing these additional services should be considered.
In on-site, school-sponsored extended school year and before and after school programs, the school nurse may explore the use of delegation to provide effective healthcare services, if allowable, according to the State Nurse Practice Act. Delegation is defined as the assignment of the performance of a nursing activity to a non-nurse. Accountability remains with the registered nurse. State laws and regulations must be followed and standards of school nursing practice must be upheld (ANA & NASN, 2011). The implications of appropriate delegation of nursing tasks for school nurses center around four major themes: development of school policies, competence in the five rights of delegation, education, and relationship building (Resha, 2010).
When engaged by school-sponsored extended school year and before and after school program leaders, the school nurse can provide expertise on a variety of issues faced by school staff, including but not limited to:
The school nurse should ensure emergency response plans are in place to address health-related events that could occur either at school or during school-related activities in the school setting, including before, after, and extended school year programs. Emergency preparedness must be a priority every day. When the school nurse is not available at the school, the school nurse often remains responsible for training and developing plans for use by others serving the school (Cosby, Miller, & Youngman, 2013). Successful integration of students who are dependent on medical technology requires a coordinated effort among the school nurse, educational staff, primary care physician, family, and -- when appropriate -- the student (Raymond, 2009).
School nurses are the healthcare experts in their buildings and should be engaged with program leaders to take an active role in this process outside the school day as well as during the more traditional school day. When involved with on-site, school-sponsored before, after, and extended school year programs, the school nurse will advance the academic achievement of participating students by promoting the health and safety aspects of these programs. It is imperative, therefore, that the school nurse is an active participant in providing guidance to school-sponsored program staff so they can intervene with actual and potential health problems experienced by the students in attendance. In order to achieve this, the school nurse should recommend any necessary budgetary resources needed to ensure supplies, staff, and programs are made available for the safe delivery of health care, including delegating nursing-related tasks as directed by their state nurse practice act and – when agreed upon – providing direct nursing services.
Afterschool Alliance. (2013). The afterschool hours in America. Retrieved from http://afterschoolalliance.org/Afterschool_Outcomes_2013.pdf
Afterschool Alliance. (2009). America after 3PM: Key findings. Retrieved from http://www.afterschoolalliance.org/documents/AA3PM_Key_Findings_2009.pdf
Afterschool Alliance. (2013). Afterschool programs keep kids safe, engage kids in learning and help working families. Retrieved from http://www.afterschoolalliance.org/National_fact_sheet_04_03_13.pdf
American Nurses Association (ANA) and National Association of School Nurses (NASN). (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursebooks.org.
Centers for Disease Control and Prevention (CDC). (2009). School connectedness: Strategies for increasing protective factors among youth. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/healthyyouth/adolescenthealth/pdf/connectedness.pdf
Cosby, M.F., Miller, N.B., & Youngman, K. (2013). Acute measures for emergent problems. In J. Selekman (Ed.), School nursing: A comprehensive text (2nd ed., pp. 516-577). Philadelphia, PA: F.A. Davis.
Raymond, J. A. (2009). The integration of children dependent on medical technology into public schools. The Journal of School Nursing, 25(3), 186-193. doi: 10.1177/1059840509335407
Resha, C. (2010). Delegation in the school setting: Is it a safe practice? OJIN: The Online Journal of Issues in Nursing, 15(2). doi: 10.3912/OJIN.Vol15No02Man05
White House Task Force on Childhood Obesity Report to the President. (2010). Solving the problem of childhood obesity within a generation. Retrieved from http://www.letsmove.gov/sites/letsmove.gov/files/TaskForce_on_Childhood_Obesity_May2010_FullReport.pdf
Acknowledgment of Authors:
Elizabeth Clark, MSN, RN, NCSN
Sue Ann Buswell, MSN, RN, NCSN
Judith Morgitan, MEd, BSN, RN
Linda Compton, MS, RN
Georgene Westendorf, MPH, BSN, NCSN, CHES
Elizabeth Chau, SRN, RN
2012 Issue Brief Authors:
Barbara Yow, MEd, BSN, RN, NCSN
Cynthia Hiltz, MS, RN, LSN, NCSN
Lynn Rochkes, MS, BSN, RN, NCSN
Connie Board, BSN, RN, NCSN
Adopted: January 2014
This document replaces the Issue Brief Care in Extended School Year Before and After School Programs and the Responsibilities of the School Nurse. A School Nurse All Day, Every Day (Adopted June 2003; Revised June 2012).
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.