Students with Chronic Health Conditions: The Role of the School Nurse
It is the position of the National Association of School Nurses (NASN) that to optimize student health, safety, and learning, a professional registered school nurse (hereinafter referred to as school nurse) be present all day, every day. The American Academy of Pediatrics’ Council on School Health (2016) highlights the important role school nurses play across a child’s continuum of care and recommends that every school should have at least one nurse. The Every Student Succeeds Act (2015) identifies school nurses as leaders of student chronic disease management in schools. Utilizing the nursing process, the school nurse manages chronic health conditions in the school setting by providing direct care, providing case management, and advocating for students and families to help them access needed resources and support to achieve academic success (CDC, 2017b).
Chronic health conditions include acquired, incurable diseases and other illnesses lasting more than 12 months (U.S. Department of Health and Human Services, 2011). These conditions include long‐term physical, emotional, behavioral, functional and developmental disorders that occur along a continuum from mild to severely disabling (McClanahan & Weismuller, 2015). It is estimated that one in four students in United States schools may have a chronic health condition (Jackson, Vann, Kotch, Pahel, & Lee, 2011; Van Cleave, Gortmaker, & Perrin, 2010). Approximately 6% of those students have multiple chronic conditions leading to challenges with treatment adherence, disease acceptance, lifestyle modification, care coordination, increased exposure to chronic condition risk factors, and difficulties transitioning to adult healthcare settings (Anderson, 2010; Rezaee & Pollock, 2015). Children with chronic conditions are at risk for high absentee rates, low student engagement, dropping-out of school, exposure to bullying, disruptive behaviors, poor grades, and below-average performance on standardized achievement tests (Forrest, Bevans, Riley, Crespo, & Louis, 2011; Bethell et al., 2012). As life expectancy for students with chronic conditions increases, the complexity of the healthcare and educational service needs of students also increases (Martin & Osterman, 2013).
School nurses are responsible for informing educational communities about the impact of the chronic health condition(s) on students’ abilities to engage in their education. These students’ rights of participation and access to school healthcare services are protected by the Rehabilitation Act, Section 504 (1973) and the Individuals with Disabilities Education Improvement Act [IDEIA](2004). It is the responsibility of local school districts to educate students with chronic conditions in the least restrictive environment. The school nurse collaborates with education staff to promote a safe and accommodating school environment for children with chronic health conditions (American Nurses Association & National Association of School Nurses [NASN], 2017; Brook, Hiltz, Kopplin, & Lindeke, 2015).
The special needs of students with chronic health conditions are complex and continuous. The school nurse has a pivotal role in:
- interpreting a student’s health status;
- explaining the health impairment to the school team;
- translating the healthcare provider orders into the school setting by developing Individualized Healthcare Plans;
- providing assessment, direct care, coordination and evaluation of care;
- providing nursing delegation that aligns with state nurse practice acts, rules and regulations; and
- advocating for appropriate accommodations in the educational setting (Leroy, Wallin, & Lee, 2017; McClanahan & Weismuller, 2015; NASN, 2015; Zirkel, Granthom, & Lovato, 2012).
The services of a school nurse support readiness to learn, classroom participation, and academic progress (ANA & NASN, 2017; Bethell et al., 2012; NASN, 2015). Bethell et al., 2012; NASN, 2015). The Whole School, Whole Community, Whole Child Model (WSCC) (ASCD and Centers for Disease Control and Prevention [CDC], 2014) reminds schools and communities that the child, at the center of educational systems, must be healthy, safe, engaged, supported and challenged. The school nurse works to support the constructs of WSCC by coordinating intervention and evaluation services, identifying previously unrecognized symptom patterns and student responses to those patterns, and referring students to the appropriate resources (CDC, 2017a). By assisting students with the management of their chronic conditions, the school nurse contributes to risk reduction, increased classroom seat time, decreased student absenteeism, improved academic success, and cost savings to families and educational and healthcare systems (Forbes, 2014; NASN, 2015; Wang et al., 2014, Michael, Merlo, Basch, Wentzel, & Wechsler, 2015). School nurses decrease chronic absenteeism by assisting families to access health care; by providing condition-related education to parents, students and staff; and by coordinating care between school, family and medical home (Jacobsen, Meeder, & Voskuil, 2016).
School nursing services result in improved health outcomes for students with chronic health conditions (Leroy et al., 2017). The school nurse, working within the constructs of the Framework for 21st Century School Nursing Practice (NASN, 2015) plays a decisive role in mitigating the long-term impact of chronic health conditions on children by coordinating the interests of families, education, healthcare systems, public health, insurance, and community agencies (McClanahan & Weismuller, 2015; Wolfe, 2013). Healthcare providers can utilize the power of school nurses to maintain the health of students who have chronic conditions at the highest level; decrease healthcare costs, unnecessary use of emergency rooms, and hospitalizations; and increase quality of care (Wang et al., 2014). The school nurse collaborates with transition planning teams to facilitate seamless movement of the student through the educational and healthcare settings (Bargeron, Contri, Gibbons, Ruch-Ross, & Sanabria, 2015; NASN, 2014). School nurse care coordination between “schools, parents and health-care providers assists students with chronic health conditions...to optimize health and learning” (Miller, Coffield, Leroy & Wallin, 2016, p. 362). Considering the positive impact school nurses have on health and academic outcomes of students with chronic conditions, school systems should develop processes to include school nurses at the outset of student enrollment and in special education individual education planning.
It is the position of NASN that to optimize student health, safety, and learning, a school nurse be present all day, every day. The school nurse is part of a comprehensive healthcare and education system. The school nurse is well positioned to support the health and academic success of students with chronic health conditions by providing direct care and facilitating the many practice components of care coordination (Bargeron et al., 2015; Brook et al., 2015; NASN 2015). School nurse advocacy helps students and families to access needed resources in support of academic achievement (CDC, 2017). School nurses are leaders who provide care coordination, health education and promotion, quality improvement, and critical thinking skills that benefit schools, families, the healthcare system, and most importantly children with chronic health conditions.
American Academy of Pediatrics, Council on School Health. (2016). Role of the school nurse in providing school health services. Pediatrics,137(6): e20160852. doi:10.1542/peds.2016-0852
American Nurses Association & National Association of School Nurses. (2017). School nursing: Scope and standards of practice (3rd ed.) Silver Spring, MD: Nursebooks.org.
Anderson, G. (2010). Chronic care: Making the case for ongoing care. Princeton, NH: Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf54583.
ASCD & Centers for Disease Control and Prevention. (2014). Whole school, whole community, whole child: A collaborative approach to learning and health. Retrieved from http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdf
Bargeron, J., Contri, D., Gibbons, L. J., Ruch-Ross, H. S., & Sanabria, K. (2015). Transition planning for youth with special healthcare needs in Illinois schools. The Journal of School Nursing, 31(4), 253-260. doi:10.1177/1059840514542130
Bethell, C., Forrest, C., Stumbo, S., Gombojav, N., Carle, A., & Irwin, C. (2012). Factors promoting or potentially impeding school success: Disparities and state variations for children with special healthcare needs. Maternal & Child Health Journal, 16 (Supp 1), S35-S43. doi: 10.1007/s10995-012-0993-z
Brook, H. A., Hiltz, C. M., Kopplin, V. L., & Lindeke, L. L. (2015). Increasing epilepsy awareness in schools: A seizure smart schools project. The Journal of School Nursing, 31(4), 246-252. doi: 10.1177/1059840514563761
Centers for Disease Control and Prevention (CDC). (2017a). Research brief: Addressing the needs of students with chronic health conditions: Strategies for schools. Retrieved from https://www.cdc.gov/healthyschools/chronic_conditions/pdfs/2017_02_15-How-Schools-Can-Students-withCHC_Final_508.pdf
Centers for Disease Control and Prevention (CDC). (2017b). Managing chronic health conditions in schools: The role of the school nurse. Retrieved from https://www.cdc.gov/healthyschools/chronic_conditions/pdfs/2017_02_15-FactSheetRoleOfSchoolNurses_FINAL_508.pdf
Every Student Succeeds Act (ESSA). (2015). Public Law No: 114-95 (12/10/2015) https://www.congress.gov/bill/114th-congress/senate-bill/1177/text
Forbes, T. H. (2014). Making the case for the nurse as the leader of care coordination. Nursing Forum, 49(3), 167-170. doi:10.1111/nuf.12064
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, 12(2), 303 ‐312. doi: 10.1542/peds. 2010‐3347
Individuals with Disabilities Education Improvement Act of 2004, 20 U.S.C. Sec. 1400 et seq.; 34 C.F.R. Parts 300 et seq.
Jackson, S.L., Vann, W.F., Kotch, J.B., Pahel, B.T., & Lee, J.Y. (2011). Impact of poor oral health on children’s school attendance and performance. American Journal of Public Health, 101(10), 1900-1906. doi:10.2105/AJPH.2010.200915
Jacobsen, K, Meeder, L, & Voskuil, V. (2016). Chronic student absenteeism; the critical role of school nurses. NASN School Nurse, 31(3). doi: 10.1177/1942602X16638855
Leroy, Z. C., Wallin, R., & Lee, S. (2017). The role of school health services in addressing the needs of students with chronic health conditions: A systematic review. The Journal of School Nursing, 33(1), 64-72. doi: 10.1177/1059840516678909
Martin, J.A. & Osterman, M.J.K. (2013). Preterm birth- United States, 2006 and 2010. Morbidity and Mortality Weekly Report, 62(03), 136-138. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a22.htm
McClanahan, R., & Weismuller, P. (2015). School nurses and care coordination for children with complex needs: An integrative review. The Journal of School Nursing, 31(1), 34-43. doi: 10.1177/1059840514550484
Michael, S., Merlo, C., Basch, C., Wentzel, K., and Wechsler, H., (2015). Critical connections: Health and academics. Journal of School Health, 85(11), 740-758. doi: 10.1111/josh.12309
Miller, G. F., Coffiled, E., Leroy, Z., Wallin, R. (2016). Prevalence and costs of five chronic conditions in children. The Journal of School Nursing, 32(5), 357-364. doi: 10.1177/1059840516641190
National Association of School Nurses. (2014). Transition planning for students with chronic health conditions (Position Statement). Retrieved from http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/644/Transition-Planning-for-Students-with-Chronic-Health-Conditions-Adopted-January-2014
National Association of School Nurses. (2015). Framework for 21st century school nursing practice. NASN School Nurse, 30(4), 218-231. doi:10.1177/10598405030190020301
Rehabilitation Act (Section 504): 29. U.S.C, 794; 20 U.S.C. 1405; 34 C.F.R. Part 104
Rezaee, M. E., & Pollock, M. (2015). Multiple chronic conditions among outpatient pediatric patients, southeastern Michigan, 2008–2013. Preventing Chronic Disease: Public Health Research, Practice and Policy, 12, 140397. doi: http://dx.doi.org/10.5888/pcd12.140397
U.S. Department of Health and Human Services. (2011). Health, United States, 2010: With special feature on death and dying. Hyattsville, MD: Centers for Disease Control and Prevention, National Center for Health Statistics. https://www.cdc.gov/nchs/data/hus/hus10.pdf
Van Cleave, J., Gortmaker, S.L., Perrin, J.M. (2010). Dynamics of obesity and chronic health conditions among children and youth. JAMA, 303(7): 623-630. doi: 10.1001/jama.2010.104
Wang, L. Y., Vernon-Smiley, M., Gapinski, M., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of school nursing services. JAMA Pediatrics, 168(7), 642-648. doi:10.1001/jamapediatrics.2013.5441
Wolfe, L. C. (2013). The profession of school nursing. In J. Selekman (Ed.), School nursing: A comprehensive text (2nded.) (pp.25-47). Philadelphia, PA: F.A. Davis Company.
Zirkel, P. A., Granthom, M. F., & Lovato, L. (2012). Section 504 and student health problems: The pivotal position of the school nurse. The Journal of School Nursing, 28(6), 423-432. doi: 10.1177/10598405012449358
Acknowledgement of Authors:
Laurie G. Combe, MN, RN, NCSN
Cheryl Mattern, MEd, BSN, CSN
Laurie Fleming, MPH, BS, RN, NCSN
Suzie Killingsworth, DNP, RN-BC, CHES, NCSN
Adopted: June 2006
Revised: January 2012; June 2017
Suggested citation: National Association of School Nurses. (2017). Students with chronic health conditions: The role of the school nurse (Position Statement). Silver Spring, MD: Author.
This position statement replaces the position statement titled Chronic Health Conditions Managed by School Nurses.
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.