As I was reflecting on this topic, I had a few things come to mind that I think as a "school nursing innovation" might be interesting to explore. I can visualize future research (by someone, not me) who could somehow meld them together to come up with an advanced acuity system in school health.
- First, there has been the push for all registered nurses to apply for having an NPI (National Provider Identifier) Number. This idea has been being pushed by the American Nurses Association (ANA) for a number of years now. In 2022, ANA approved a position statement on NPIs - click here.
There has been the concern for decades about the profession of nursing being placed into the "room and board" in healthcare facilities, which diminishes our value and the recognition of "value-based care". If you 'google' you will find publications about this topic. By documenting the ICD-10-CM codes that are used for Medicare/Medicaid billing, our nursing care in terms of symptoms and time can be determined. I will share that I was a hospital-based case manager (CM) at one point in time, so you might ask about children with commercial insurance, that we wouldn't bill for in the school setting, these companies do also generally follow the guidelines that the Centers for Medicare and Medicaid (CMS) do when it comes to documenting for billing to them. There are some exceptions, but overall they want CMs to use the same format.
As school nurses, we should generally be familiar with the understanding of why having an NPI number is important as the "Medicaid in Schools" programs, whether your school bills only for students with IEPs or has the expansion to bill for all students who have Medicaid as long as parents consent, provides a 'value' to our nursing care. How your state and district calculate this might be a bit different, but this also give insight to the "skilled" and unskilled nursing care that students need that be one aspect of formulating a school nursing acuity scale. The recognition and understanding of our 'value' in the monetary sense as well as actual care are important to include.
This just FYI - In past conversations with some nurse researchers, who focus on school health, they feel we should also have a UNI (Unique Nurse Identifier) that the National Council of State Boards of Nursing (NCSBN) promotes, but I don't see any correlation to our value. This would just be about a national database of nurses. You can 'google' more about this on your own.
- Second, Precision Nursing Care (PNC). Now, I do not know all there is to know about Precision Health (PH) and PNC but I do know that the recognition that standardizations and understanding PH would be extremely important to integrate in the determination of acuities. This aspect of PNC would bring into the acuity scale the importance of integrating holistic care needs that we know are a part of our NASN School Nursing Practice Framework's Principle of "Care Coordination" and might integrate aspects of the other principles (click here).
As mentioned, I do not know a lot about PH and PNC, but can see this would be an important consideration for a school nursing acuity scale. Here is a publication, just to give you a bit of flavor about PH and PNC, but surely you can 'google' more:
Fangonil-Gagalang, E., Schultz, M.A., Huryk, L.A., Payne, P.A., Schoenbaum, A.E., Velez, K., & Wilson, M.L. (2024). Exploring the Capacity of Practicing Registered Nurses for Precision Health. The Online Journal of Issues in Nursing, 30(1). https://ojin.nursingworld.org/table-of-contents/volume-30-2025/number-1-january-2025/articles-on-previously-published-topics/exploring-the-capacity-of-practicing-registered-nurses-for-precision-health/.
- Third, the integration of information technology (IT) and school nurses, who have strong nursing informatics skills to create tools that make sense for us. So many times, non-'end-users' create products for groups that they have no clue about how the IT would integrate into the flow of their workday or when there would be need to document this important information in an acuity scale.
There would need to be the understanding that nursing care is not always static. Flexibility to recognize that even on a day-to-day basis, the care given to "x" student might look totally different the next day based on impacts to their health that would also adjust their acuity level. In schools, we do not generally see the same levels of fluctuation, but it could happen. By understanding these important aspects "staffing" requirements might not be stagnant. I am speculating, but probably a part of the reason why NASN created the updated position statement in 2020, that notes:
"Using ratio of nurse to student alone is not evidence-based or appropriate". (click here to read)
There are many who strictly promote ratios, but there does need to be more thought and consideration for some of the information that NASN has in this position statement. Be sure you read this position statement. I know there are a few states that even have ratios in their laws, there should really be a rethink to this.
Also, by the way for those of you who have the National Education Association as your national-level union, the NEA Nurses in Schools Caucus had NEA update their legislative programs to reflect this a couple years ago. (see image)
Again, as this topic came up and for others, many times, my brain goes into "potential solutions mode" and I have to share my thoughts. I know to get to the level of a 'national' acuity system might never happen, but at state levels there might be opportunities or even more local or county pilots that can be considered. There are already some standardized components, like the CMS ICD coding system in place that speaks directly to the nursing care that is given. Yes, this might lead to more documentation, but if the data from this is used correctly for staffing and even to obtain Medicaid dollars for schools, it might well be worth it. So, I leave my thoughts on the table for all of you amazing, knowledgeable school nurse thought leaders and researchers to consider.