School Nursing Practice: Roles and Standards. INSTITUTION National Association of School Nurses, Inc., Scarborough, ME> PUB DATE Jun 93 NOTE 70P

DOCUMENT RESUME

ED 361 612 CG 025 007

AUTHOR Proctor, Susan Tonskemper; And Others TITLE School Nursing Practice: Roles and Standards. INSTITUTION National Association of School Nurses, Inc., Scarborough, ME> PUB DATE Jun 93 NOTE 70p. PUB TYPE Legal/Legislative/Regulatory Materials (090) Guides NonClassroom Use (055)

EDRS PRICE MF01/PC03 Plus Postage. DESCRIPTORS Elementary Secondary Education; *Role Perception; School Health Services; *School Nurses; *Standards

ABSTRACT This document is an application of the American Nurses' Association's (ANA's) "Standards of Clinical Nursing Practice" (1991) to the specialty of school nursing. It identifies specialty standards of practice for the school nurse subsumed under the standards of clinical practice which apply to all nurses. Chapter One focuses on the ANA standards for all clinical nurses. It discusses the relevance of the ANA standards to school nursing practice and presents new models of school health service delivery. Chapter Two looks at standards of school nursing and presents models of school nursing. Education for school nursing practice is examined and the evolution of the school nursing standards is traced. Chapter Three presents the National Association of School Nurses' (NASN) Standards of School Nursing Practice. The 10 standards are categorized under six role concepts: (1) Provider of Client Care (standards of clinical knowledge, nursing process, and clients with sp-ecial health needs);(2) Communicator (standard of communication); (3) Planner and Coordinator of Client Care (standards ofprogram management, collaboration within the school system, and collaboration with community health systems); (4) Client Teacher (standard of health education);(5) Investigator (standard of research); and (6) Role Within the Discipline of Nursing (standard of professional development). (Contains 117 references.) (NB)

*********************************************************************** Reproductions supplied by EDRS are the best that can be made from the original document. *********************************************************************** SCHOOL NURSING PRACTICE

ROLESANDSTANDARDS

Susan Tonskemper Proctor

with SusAN L. LORDI and DONNA SHIPLEY ZAIGER

'sbo

C;) d w

INCIDRPORATED PERMISSION TO REPRODUCE THIS MATERIAL HAS BEEN GRANTED BY U S DEPARTMENT OF EDUCATION CM we 0 Ed., aemnal Resea, and 1,,,P,Overnent EDUCATIONAL RESOURCES INFORMATION LU triClbt CENTER IERICI

. 1 his (Women? has been reproduced as National Association of School Nurses, Inc. received from me person or organization ooginating it

. Minor changes have heen made to 11.11P1One reproduction chtallty TO THE EDUCATIONAL RESOURCES P.O. Box 1300, Scarborough, ME 04074 INFORMATION CENTER (ERICI Points 0 vlew or opinions slated in this dOCu ment dn not necessarily represent official ()FRI po.s.t., in 01 Iedii y 1993

2 BEST COPY IMRE AFFIRMATION

The standards within this document have been accepted and were approved as, The National Association of School Nurses Stan- dards of School Nursing Practice, at a meeting of the Board of Directors, NASN, October 1992.

BEST COPY AVAILABLE PREFACE

This document is an application of the and spirit of the ANA enterprise. Every at-schools. Their work was published as the American Nurses' Association's Standards oftempt was made to retain the essence of the 1981 edition of the Guidelines for a Model Clinical Nursing Practice (1991) to the spe- 1990 Guidelines, which fused eight ANA School Nursing Services Program. cialty of school nursing. The National Asso- Standards of School Nursing Practice (1983) This document, then, identifies specialty ciationof School Nursesparticipated, with two additional standards developed by a standards of practice for the school nurse together with other nursing specialties, in the state school nurse education task force. subsumed under the standards of clinical deliberations leading to the synthesis that is Inherent in this recent version of thepractice which apply to all nurses. Further, the ANA clinical standards paper. Guidelines isthe earlier contribution ofthis book focuses on role synthesis and role Thereafter, using NASN's most recentHelen Weber, RN, of Nebraska, and heractualization. It is the belief of the authors edition of the Guidelines for a Model Schoolcommittee. Ms. Weber served as project co- that the latter cannot occur without the Nursing Services Program (1990), the authorsordinator for the original NASN effort to former. modified the Guidelines to reflect the contentdefine clinical nursing practice within the Susan Proctor Susan Lordi Donna Zaiger

4 1 To THE READER

The use of the second person in Chapter commoninscholarlypublishing,was use of the second person implying "nurse" Three of this work is designed to underscore adopted to achieve the purpose of this under- does not preclude the effective and informed the utility of the concepts discussed herein takingdiscussion of the school nurse roleuse of this document by others interested in for use by the practicing school nurse, par- and the standards of the specialty because school nursing and school health. ticularly the new school nurse. of its facile application and expedient ap- Second-person writing, while not veryproach. But we wish to emphasize that our S.P. Placerville, CA ABOUTTHEAUTHORS

Susan Proctor, R.N., M.P.H. is currently Susan Lordi, R.N., M.S., C.P.N.P. is cur- Donna Zaiger, R.N., B.S., C.S.N. is cur- a professor of community health nursing and rently Consultant, School Health Programs, rently a school nurse and Coordinator, Coordinator, School Nurse Program, Divi- Los Angeles County Office of Education, Los Health Services, North Kansas City School sion of Nursing, California State University, Angeles, CA. Ms. Lordi is past president ofDistrict, Kansas City, MO. Ms. Zaiger is past Sacramento. Ms. Proctor is a doctoral candi- the National Association of School Nurses, achairperson, Standards/Practice Issues Com- date in the Department of Mental Health,member of the Executive Committee of themittee of the National Association of School Community and Administrative Nursing, California School Nurses' Organization, andNurses and a past officer of the Missouri As- School of Nursing, University of California, a past board inember of the California School sociation of School Nurses. Ms. Zaiger repre- San Francisco. She is a past board member of Nurses' Organization. She is an international sented the National Association of School the California School Nurses' Organization. consultant in school nursing practice issues. Nurses at joint meetings of the American Nurses' Associatioq's Committee on Nursing Practice and Guidelines, and the nursing specialties group, the Nursing Organization Li- aisonFederation(N.O.L.F.),inthe development of the A.N.A. Standards of Clinical Nursing Practice.

3 ACKNOWLEDGMENTS

REVIEWERS RECOGNITION The authors gratefully acknowledge the careful and useful critique of draft manuscripts by CynthiaSilkworth,R.N.,M.P.H., the following reviewers: C.S.N.P. is a school nurse for the White Bear Public Schools, White Bear Lake, MN. Ms. PatriciaL. Ackerman, R.N., S.N.P., Sharis Le May, R.N., C.S.N., Montgom- Silkworth is the current chair of the School C.P.N.P., Ph.D., Division of Nursing, Cali- ery Public Schools, Montgomery, AL. Nurse Educators' Caucus, a national consor- fornia Statc University, Sacramento, CA. tium of school nursing educators, whose vi- Shari Lowe, R.N., M.S., P.N.P., Health sion has been inspirational to the authors. Claudia T. Bays, R.N., M.A., M.S., Coordinator, Modesto Unified School Dis- Ms. Silkworth also served as a reviewer. C.H.E.S., Division of Nursing, California trict, Modesto, CA. State University, Sacramento; Arcohe Union School District, Herald, CA. Dana Miller, R.N., M.S.N., C.S.N., Nampa School District, Nampa, ID.

Jo Ellen Bogert, R.N.C., S.N.P., Ed.D., Dallas, TX. Elaine Perrotta, R.N., M.A., Providence APPRECIATION School Department, Providence, RI. The authors wishtothank Priscilla Beverly Bradley, R.N., Ph.D., Coordina- Walton, Ph.D., Consultant, with the Cali- tor, Health Services, San Francisco Unified Sharon L. Peterson, R.N., M.S., Roseville fornia Commission on Teacher School District, San Francisco, CA. City School District, Roseville, CA.; Divi- Credentialing. Dr. Walton provided valuable sion of Nursing, California State University, guidance and direction in the development of Marilyn Y.Burgess,R.N.,M.S.N., Sacramento, CA. state standards of school nurse education S.N.P., University of Wisconsin, Eau Claire, which were used as a template for the Guide- WI, retired. CynthiaSilkworth,R.N.,M.P.H., lines for a Model School Nurse Services Pro- C.S.N.P. gram (NASN, 19901 and the standards Nancy W. Greenberg,R.N.,M.S., statements within this document. C.S.N., Albuquerque Public Schools, Health Lenore K. Zedosky, R.N., M.N., West The authors also wish to thank the mem- and Nursing Services, Albuquerque, NM. Virginia Department of Education, Charles- bers of the school nurse class, 1992-1993, ton, WV. California State University, Sacramento. Beth Gyorgy, B.A., Publications Editor, American Nurses' Association, Washington, DC.

Joyce P. Johnson, R.N., M.A., Curricu- lum Supervisor, School Health Services, New Hampshire Department of Education, Con- cord, NH.

P./ 4 CONTENTS

Preface 1 To the Reader 2 About the Authors 3 Acknowledgments 4 Key Terms 7

Chapter One - ANA Standards of Clinical Nursing Practice 8 ANA Mission 8 Description of the Standards of Clinical Nursing Practice 8 Description of the Standards of Care 8 Description of the Standards of Professional Performance 8 The Relevance of the ANA Standards to School Nursing Practice 8 New Models of School Health Service Delivery 9 The American Nurses' Association Standards of Clinical Nursing Practice 10

Chapter Two - A Framework for School Nursing Practice 11 Toward Standards of School Nursing 11 The Essence of School Nursing 11 Contemporary Models of School Nursing 12 Education for School Nursing Practice 14 The Evolution of the School Nursing Standards 14 Figure 1: Sources of the NASN Standards 15 Role Concepts 16 The Format of the School Nursing Standards 16 -. Figure 2: Relationship of the Standards to Role Concept and to ANA Standards I 7

Chapter Three - Standards of School Nursing Practice 18 The National Association of School Nurses' Standards of School Nursing Practice 19

Role Concept I - Provider of Client Care NASN Standard 1: Clinical Knowledge 19 NASN Standard 2: Nursing Process 23 NASN Standard 3: Clients with Special Health Needs 27

Role Concept II - Communicator NASN Standard 4: Communication 32

5 ____ Role Concept III - Planner and Coordinator of Client Care NASN Standard 5: Program Management 35 NASN Standard 6: Collaboration within the School System 40 NASN Standard 7: Collaboration with Community Health Systems 43

Role Concept IV - Client Teacher NASN Standard 8: Health Education 47

Role Concept V - Investigator NASN Standard 9: Research 51

Role Concept VI - Role Within the Discipline of Nursing NASN Standard 10: Professional Development 54

References 61 Appendix A: Glossary 65 Appendix B: Bibliography 66 KEY TERMS

Definitions of KEY TERMS will assist in us- the focus is on the health state of the unit as a IMPLEMENTATION ing this document. Most definitions arewhole orthereciprocaleffectsof an This may include any or all of these activities: taken directly from the parent document, individual's health state on the other mem- intervening, delegating, coordinating. The Standards of Clinical Nursing Practice (ANA,bers of the unit. When the client is a commu- client, significant others, school personnel, 1991b). Additions or modifications to an nity,thefocusis onpersonaland health care or other community providers ANA definition are indicated by .an under-environmental health and the health risks of may be designated to implement interven- line: example. Deletions are indicated by an population groups. Nursing actions toward tions within the plan of care. underline in brackets: lexamplel. clients may be directed to disease or injury (Adapted from ANA, 1991b) Other definitions of interest are listed in the pi. vention, health promotion, health restora- GLOSSARY in the appendix of this publication,healthmaintenance, or wellness. OUTCOMES tion. (Adapted from ANA, 1991b) Measurable, expected, client-focused goals derived from the diagnoses. ASSESSMENT DIAGNOSIS (Adapted from ANA, 1991b) A systematic, dynamic process by which theA clinical judgment about the client's re- nurse, through interaction with the dient, sponse to actual or potential health condi- PLAN OF CARE significant others, school personnel, health tions or needs. Diagnoses provide the basis An [comprehensive] outline of care or pre- care and other community providers, collects for determination of a plan of care or the di-scribed interventions to be delivered a and analyzes data about the client. Data may rection for program development in order toimplemented to attain expected outcomes. include the following dimensions: physical, achieve expected outcomes. (Adapted from ANA, 1991b) psychological, sociocultural, spiritual, cogni- (Adapted from ANA, 1991b) tive, f unctional abilities, developmental, eco- SCHOOL NURSE nomic, and life-style. EVALUATION A licensed, professional nurse whose practice (Adapted from ANA, 1991b) The process of determining both the client's focuses on the health care needs of clients in progress toward the attainment of expected the large: school community. The school CASE MANAGEMFNT outcomes and the effectiveness of nursing nurse may practice in school-based, school- The coordination, organization, and moni- care. linked, or collaborative school health pro- toring of multiagency, interdisciplinary, or (ANA, 1991b) grams. transdisciplinary services, for the purpose of (Adapted from ANA, 1983) facilitating and ensuring comprehensive, re- HEALTH CARE PROVIDERS sponsive care for the school client with spe- Individuals with special expertise who pro- SIGNIFICANT OTHERS cial health needs, and, for the client's family. vide health care services or assistance to cli- Family members and/or those significant to (Adapted from Merrill, 1985; Wagner, 1987) ents. They may include nurses, physicians, the client. sleutim, dental hygienists, psychologists, (ANA, 1991b) CLIENT counselors, social workers, nutritionists/di- The recipient of nursing actions. When theetitians, and various therapists. Providers also client is an individual, the focus is on the may include service organizations and ven- health state, problems, or needs of a singledors. person. When the client is a family or group, (Adapted from ANA, 1991b) 7 CHAPTER ONE ANA STANDARDS OF CLINICAL NURSING PRACTICE

ANA MISSION The ANA Standards of Clinical Nursingcompetent level of behavior in the profes- In 1989, the American Nurses' Association Practice thus form the basis of accountability sional role.." (ANA, 1991b, p. 3). These convened a task force whose efforts were to for all nurses. Specialty groups develop spe- standards describe attributes that are integral be based on the following charge: cific criteria in addition to these standards,to the role of the nurse regardless of specialty In view of current health care quality assur- which fitrther define expectations for the spe- or practice setting. Indeed, the "Standardof ance activities, define the nature and purpose cific role or area in which they are engaged. Care" could not be maintained without the of standards of practice for nursing and the This book is the product of the application ofconcomitant behaviors includedinthe relationship of quality assurance activities the American Nurses' Association's Standards"Standards of Professional Performance." and standards of practice to specialization in of Clinical Nursing Practice to the specialty ofThese standards address the following enti- nursing practice, credentialing, and implica- school nursing. ties: tions for nursing information systems. (ANA, Quality of Care 1991b, p. v). DESCRIPTION OF THE Performance Appraisal In 1990, in response to this charge, the "STANDARDS OF CARE" Education ANA Task Force became the Standing Com- Standards of Clinical Nursing Practice are Collegiality mittee on Nursing Practice and Guidelines,statements which include "Standardsof Ethics which in collaboration with the nursing spe- Care" and "Standards of Professional Perfor- Collaboration cialty organizations group, N.O.L.F. (Nurs-mance." "Standards of Care' describe a Research ing Organization Liaison Forum), developed competent level of nursing care .. .. (ANA, Resource Utilization standards generic to all nurses engaged in 1991b, p. 2) and encompass the Nursing clinical practice. The National Association ofProcess which is the foundation for the prac- THE RELEVANCE OF THE School Nurses participated in the develop-tice of nursing. The "Standards of Care" are ANA STANDARDS TO ment of the standards as a N.O.L.F. organi- authoritative statements with accompanying SCHOOL NURSING PRACTICE zation, and was represented throughout bymeasurement criteria addressing each of theFor the nurse practicing in school-based, Donna Zaiger, R.N., of Missouri. following entities: school-linked, or collaborative school health Assessment programs, the Standards of Clinical Nursing DESCRIPTION OF THE STANDARDS Diagnosis Practice assume a particular significance. OF CLINICAL NURSING PRACTICE Outcome Identification School nurses work most often in isolation The ANA Standing Committee provides us Planning and rely upon non-nurse administrators for with the following description of a standard : I mplementation evaluation. The "Standards of Care" cannot Standards are authoritative statements by Evaluadon be evaluated by a non-nurse administrator which the nursing profession describes the who does not possess the education and expe- responsibilities for which its practitioners are"The 'Standards of Care' delineate care that rience required for clinical dedsion-making. accountable. Consequently, standards reflect is provided to all clients of nursing services" Conversely, behaviors included in the "Stan- the values and priorities of the profession. (ANA, 1991b. p. 3). dards of Professional Performance" provide Standards provide direction for professional measurable criteria, constructive evaluative nursing practice. Written in measurable DESCRIPTION OF THE "STANDARDS processes in the school setting, which may be terms, standards also define the nursing OF PROFESSIONAL PERFORMANCE" utilized by non-nurse administrators. profession's accountability to the public and " 'Standards of Professional Performance' As outlined in the charge to the Standing the client outcomes for which nurses are re- are authoritative statements with accompa-Committee that developed the Standards, or- sponsible. (ANA, 1991b, p. 1). nying measurement criteria which describe aganized nursing must demonstrate to its pub- 8 11 lics that the quality of nursing care is measur- whenever they undergird the school nursingatric nurse practitioners, family nurse practitio- able and that nursing interventions meet Standard exemplar. The reasurcinent crke-ners, and community health nurseswho iden- quality assurance objectives. This has longria cited within the Standardsof Clinicaltify themselves as school nurses currently been the dilemma of school nursing practice. Nursing Practiceare infused throughout thepractice in the schools and subscribe to theStan- The eternal question begs for an answer: discussions and are applied and expanded dards of Schcl Nursing Practice(ANA, 1983), How do we measure prevention outcomes? additional criteria specific to school nursingalthough their scope of practice differs. The fu- How do we design a data base that qualifies practice. ture may bring other mid-level practitioners and quantifies school nursing actions? The such as adult, obstetric-gynecologic, geron- format of these universal nursing standards NEW MODELS OF SCHOOL HEALTH tological, or psychiatric-mental health nurse contains outcome or measurement criteria SERVICE DELIVERY practitioners into this setting. The Standardsof that include key indicators of nursing prac- As the school nurse role expands to accommo- Clinical Nursing Practiceprovide the common tice and reflect the theoretical framework and date the multiple needs of a more diverse clientdenominator for quality assurance, data bases, current knowledge in the field. Measurement population, so does the vision of "one-stop reimbursement and financing systems, develop- criteria allow qualification and quantification shopping." "One-stop shopping" is a colloquial ment and evaluation of service delivery,and, as of practice, but also change as knowledge term for a collaborative model of the deliveryofappropriate, shared policies, procedures and changes. Measurement criteria differ within health and humanservices within the school set- protocols for these multiple specialties practic- nursing specialty areas. tingto a larger community, a community which ing in schools or sckol-based, school-linked, or Thus, the actual standards statements from includes, but extends beyond, the immediate collaborative programs. theStandards of Clinical Nursing Practiceare school population. School nurses, school nurse presented in their entirety in this publication administrators, school nurse practitioners, pedi- THE AMERICAN NURSES' ASSOCIATION STANDARDSOF CLINICAL NURSING PRACTICE

Measurement criteria for each standard are not included below. See Standards of Clinical Nursing Practice (ANA,1991b) for the full text and discussion of the ANA standards, including themeasurement criteria.

ANA STANDARDS OF CARE ANA STANDARDS OF PROFESSIONAL PERFORMANCE

Standard I: Assessment Standard I: Quality of Care Standard VI: Collaboration THE NURSE COLLECTS CLIENTTHE NURSE SYSTEMATICALLY THE NURSE COLLABORATES WITH HEALTH DATA. EVALUATES THE QUALITY AND EF-THE CLIENT, SIGNIFICANT OTHERS, FECTIVENESS OF NURSING PRAC-AND HEALTH CARE PROVIDERS IN Standard II: Diagnosis TICE. PROVIDING CLIENT CARE. THE NURSE ANALYZES THE ASSESS- MENT IN DETERMINING DIAG- Standard II: Performance Appraisal Standard VII: Research NOSES. THE NURSE EVALUATES HIS/HERTHE NURSE USES RESEARCH FIND- OWN NURSING PRACTICE IN RELA- INGS IN PRACTICE. Standard III: Outcome Identification TION TO PROFESSIONAL PRACTICE THE NURSE IDENTIFIES EXPECTED STANDARDS AND RELEVANT STAT- Standard VIII: Resource Utilization OUTCOMES INDIVIDUALIZED TO UTES AND REGULATIONS. THE NURSE CONSIDERS FACTORS THE CLIENT. RELATED TO SAFETY, EFFECTIVE- Standard III: Education NESS, AND COST IN PLANNING AND Standard IV: Planning THE NURSE ACQUIRES AND MAIN-DELIVERING CLIENT CARE. THE NURSE DEVELOPS A PLAN OF TAINS CURRENT KNOWLEDGE IN CARE THAT PRESCRIBES INTERVEN- NURSING PRACTICE. TIONS TO ATTAIN EXPECTED OUT- COMES. Standard IV: Collegiality THE NURSE CONTRIBUTES TO THE Standard V: Implementation PROFESSIONAL DEVELOPMENT OF THE NURSE IMPLEMENTS THE IN- PEERS, COLLEAGUES, AND OTHERS. TERVENTIONS IDENTIFIED IN THE PLAN OF CARE. Standard V: Ethics THE NURSE'S DECISIONS AND AC- Standard VI: Evaluation TIONS ON BEHALF OF CLIENTS ARE THE NURSE EVALUATES THE DETERMINED IN AN ETHICAL MAN- CLIENT'S PROGRESS TOWARD AT- NER. TAINMENT OF OUTCOMES.

10-- 1 3 CHAPTER Two A FRAMEWORK FOR SCHOOL NURSING PRACTICE

TOWARD STANDARDS School nursing delivers services to smdents groups within its jurisdiction with emphasis OF SCHOOL NURSING of all ages from birth through age 21 and on health promotion, disease prevention, and Chapter One considered the American serves students, families and the school com- health maintenance (APHA, 1981). Public Nurses Association's Standards of Clinicalmunity in regular education, in special edu- health nursing is particularly involved with Nursing Practice. Chapter Two explores some cation, and in other educational arenas. With the health of families, especially mothers and definitional and philosophicalissues ofthe emphasis on children and adolescents,children, and with the health of the commu- school nursing and provides a conceptualschool nursing is considered by many to be anities in which these individuals reside. Such fiamework for the role of the school nurse. specialized area of practice within pediatricfoci and domains are also the purview of the Chapter Three will present ten specialty stan- nursing (Whaley and Wong, 1991). Nursesschool nurse. The role of the Community dards of school nursing practice, each reflec- practicing in both generalized and specialized (public) Health Nurse Specialist working tive of several of the ANA Standards and theirareas of pediatric nursing, such as pediatricwith school-age youth has been articulately accompanying measurement criteria. The tenhome care, pediatric rehabilitation, child and described by Igoe (1987). standards of school nursing practice constitadolescent psychiatric/mental heath roles, as School nursing also shares domains with tute a widely accepted role consensus and pediatric nurse practitioners or adolescentoccupational nursing. The occupational nurse scope of practice for contemporary school health care specialists, have wide areas ofpromotes the health and well-being of the nursing and are referred to as the Nationaltheir scope of practice in common with theoccupational community and is concerned Association of School Nurses (NASN) "Stan- school nurse. with the health of the work environment. dards of School Nursing Practice." School nursing is also a generalist area ofThe school nurse, as the health professional nursing, drawing from a variety of other in the school, promotes the health of the THE ESSENCE OF clinical areas, including adult psychiatric/ school staff and of the school environment. SCHOOL NURSING mental health, emergency, and critical care The school nurse, as a community nurse, School nursing, as a specialty branch of pro- nursing. School nurses working with preg- functions in the school as a community fessional nursing: (1) seeks to prevent ornant and parenting teens share scopes ofhealth professional providing and accessing identify client health or health-related prob- practice with maternity nurses, OB/GYN services for clients, setting professional goals lems [primary and secondary prevention); nurse practitioners, childbirth educators, and for self, and participating in cooperative and (2) intervenes to modify or remediate lactation nurse specialists. school-community health planning (Snyder, these problems [secondary and tertiary pre- Within this document, school nursing is 1991). School nursing has several traits that vention) (NASN, 1988). These purposes arepresenred as a specialized focus within com- collectively differentiate it from nursing prac- accomplished through the provision or facili- munity health nursing. As such, it is com- tice in acute and/or extended care settings: tation of health services and health education munity-based and community-focused, with in, or as part of, the school. In so doing,the school community the center of interest 'CLIENT school nursing contributes directly to the and the recipient of nursing services. SchoolA. School nursing delivers caretothe student's education, as well as to the health of nursing is particularly related to two other individual student as client, particularly the family and the community. In the United community health nursing subspecialties, to the individual "at risk," or considered States, school nurses practice in, or in con- public: health nursing and occupational nurs- vulnerable. junction with, public and private school sys- ing (Stanhope and Lancaster, 1992). Many ofB. Schoolnursingdeliverscaretoa tems of tremendous enrollment variation, the same issues and clients are the concern of "plurality of persons" (Schultz, 1991), to ranging from schools of only a few dozen en- both the public health nurse and the school orto"aggregates" rollees to vast organizational systems of close nurse. Public health nursing directs nursing (Williams,1992),aswellas to to one million studems. actions toward high-risk individuals and individuals. Any of these terms refer to a

11 14 number of individuals sharing a common delivered in the school setting, in homes,be seen as distinct foci. Snyder, in fact, sees characteristic, such as a risk factor, and and in other community arenas. the future of school nursing as one of man- identifiedasatargetgroupfor I.School nursing is independent, often agement, supervision, teaching, and consul- intervention on the basis of necessitating that the nurse organize and tation (Snyder, 1991, p. 52). Within the epidemiologic studies. In school nursing, deliver services without the involvement context of this discussion and this document, populations may be groups of students, of other health care professionals, and inhowever, the role of the school nurse as health parents, or caretakers, school staff or an order and manner determined by educator and as health counselor wal be viewed community members. professional nursing judgment. as integral and essential to the three roles pre- C. School nursing intervenes withthe J.School nursing is collaborative, calling sented and will not be considered as separate. family, as client, in order to mobilize care for jointintervention by thenurse The generalist clinician role, currently for the student as client. together with other school professionalspracticed by most school nurses in the D. School nursing involves working with and staff to facilitate the meeting ofUnited States, is that of a licensed profes- individuals or groups in the community educational and health objectives forsional nurse delivering both health services to facilitate care between the client and clients. (including counseling) and health education, the provider and to bring about changeK. School nursing may involve long-termto school clients and families. In this capac- for the populations that are the foci of goal-setting, planning, and intervention ity, the nursing role and the provision of school nursing practice. for change, necessitating nurse health services are integrated into the basic involvement withclients(students, functioning of the school. This role is one in FOCUS families, staff, and the schoolwhich the nurse is employed directly by the E.School nursing focuses on encouraging community) for months or years. school or the school district, or by another client adaptive responseswhich government entity such as a county office of engender health maintenance, health CONTEMPORARY MODELS OF education or a county health department. As promotion, and the prevention of SCHOOL NURSING such, the nurse is an integral part of the maladaptiveresponses,illness,andAs the school nurse role expands to accom-school day and the school community. The injury. These fociareas much an modate the multiple needs of a more diverse nurse's office is located within the school and emphasis of practice as is illness curingclient population and the changing methods services are provided, typically, during school and health restoration. of delivering and financing of health care, so hours. The nurse knows the faculty members, F.School nursing focuses on the interfacedoes the vision of school nursing as a spe- the school administration, and the families, between the health status of its "plurality cialty. Contemporary school nursing has at and this "insider" position facilitates knowl- of persons," particularly students, and least three diffirent, but frequently overlap-edgeable and appropriate intervention and thelivingenvironment(physical,ping, roles: the generalist clinician role, the referrals. biological, and socio-cultural) (Williams,primary care role, and the management role. The importance of this approach to the 1991). Commonly, two, and occasionally all three, school delivery of health services has grown of these roles are part of the practice of an in- in recent years with the inclusion of more 'SETTING dividual nurse. They are presented here,students in programs serving disabled or dis- G. School nursing delivers care in (a) non-separately, to underscore the complexity andadvantaged students, an increase in the num- health care delivery setting(s). diversity of contemporary school nursing bers of children with acute or chronic health practice. Additionally, many school nurses problems necessitating specialized care and 'CHARACTERISTICS function as health educators or health coun-monitoring, and the emergence or recurrence H. Schoolnursingismobile:careis selors, two roles which, arguably, could alsoof communicable diseases, such as AIDS, -12- hepatitis, and tuberculosis. Nurses partici- achieve the goals of optimal education and Health problems which are less common pate in identifying appropriate educational optimal health, simultaneously. or necessitate further evaluation are identi- placement for children with health needs and The primary care role has evolved sincefied and referrals made to appropriate com- assist schools in developing and implement- the passage of the federal Early and Periodic munityhealthcareproviders. A big ing appropriate policy. Additionally, school Screening, Diagnosisand Treatmentadvantage of the use of primary care in school districts increasingly seek nursing assistance (EPSDT) program in the 1970s, as well assettings is to provide those children with little in serving children and families with special the establishment of nurse practitioner pro- or no health insurance a source of prescrip- health needs, such as those who may be medi- grams in the 1960s. In this capacity, school tive health care. Additionally, those children cally fragile or technologically dependentnurses, as nurse practitioners, practicing un- whose parents or guardians are unable to (Igoe and Speer, 1992). der physician-approved protocols and stan- transport their children for care to commu- As new health care plans emanate from thedardized procedures. diagnose and treat nity providers are not left to languish without federal government, there is a tendency by health problems. As treatment -providers,appropriate intervention. It seems reasonable some to consider the generalist clinician role school districts may be eligible for fiscal reim- to assume that this method of health care de- obsolete. Nothing could be airther from the bursement, either through a particular state'slivery will result in fewer student days lost at truth. Replacement of the generalist clinician Medicaid system, or through a private healthschool and better, more timely referrals to role with a primary care role in which the care insurer. The primary care role for schoolcommunity health care providers. Primary nurse does not hold the "insider" position re- nurses, a part of school health services in health care is described in detail in Chapter sults in loss to the student, family, and the some locales for years, has drawn consider-Three, Standard 7. school. Knowledge of the internal workings able interest since the advent of school-based The management role is one to which of the educational system, of the terminology clinics, school-linked services, and collabora- school nurses have been accustomed. Much used, the programs and curricula offered, and tive, community-based services. of everyday nursing practice is management, of the "pulse" and "rhythm" of the school day "Primary care"is used interchangeablymanagement of screening or health educa- are critical elements in integrating health care with "primary health care" by many authors.tion programs, or case managment for indi- into appropriate education for students. In fact, the two are different. A discussion ofvidualclientsandfamilies.Indeed, School administrators have grown to expect primary care versus primary health care mayundergraduate nursing education curricula that nurses practicing within their educa- be found in Standards 7 and 10. Primary care have included content and practice in leader- tional jurisdictions will be prepared to practicerefers to the first-line provision of health ser- ship and management for nursing students nursing in an educational setting connoting fa- vices, in this case, with the school rather than for at least two decades. miliarity with the functions of the school and a clinic, physician's office, or hospital as the Many staff-level school nurses have re- comfort in being part of educational teamsetting for care delivery. Primary care in the cently transited to a more formalized man- and its faculty. Further, nurses in the general- school provides a mechanism for the child toagement role, however. In districts with more ist clinician role regard the school and thebe assessed and health care management pre- than one nurse, this role is distinct from that community as their venue for practice. These scribed in a setting where the child is alreadyof the Health Services Coordinator, the indi- professionals draw upon appropriate represent. The availability of care on site is par-vidual supervising all nursing personnel (and sources to assist the student and family, butticularly effective for many common acuteoften, other special services personnel), and with a philosophy that espouses accessingand chronic illnesses of childhood and ado- overseeing the school health program, district healtt; for the purpose of fitrthering the educa-lescence. School primary care sources also wide. Rather, in response to new programs tional process. Future roles for nurses as school -perform routine school entrance and athlet- and new funding sources, staff level school primary care providers should seriously con- ics-related physical examinations. nurses are assuming the responsibility for a sider these issues, and identify means to- best

13 1. wider scope of practice, that of managing nursing. Managed care refers to a variety ofNursing preparation at the baccalaureate personnel and services earmarked for a par- health care financing, administrative, and de-level should be the minimal educational ticular purpose. Most function in the role oflivery arrangements, but, most commonly, background for school nurse practice(Snyder, health program coordinator, managing pro-suggests a sNem in which payment to pro- 1991). Recently. school nurse and public grams such as drug and alcohol educauon, viders for health services is prospective or "up health nursing leaders have identified the anti-smoking education, programs which front," transacted before client care is deliv- need for master's level preparation for school identify and assist at-risk students, or others. ered. Such a system compels providers to benursing practice (ACHNE, 1991; S.L. Lordi, Many are also supervising paraprofessionals. more efficient so as not to exceed the dollar personal communication, May 12, 1992). These "categorical programs" often carry amount paid to them: a profit is made if costs Many school nurses are seeking educational with them requisites for fiscal and client out-are less than expected, a loss, if costs exceed programs which will prepare them as nurse come accountability as well. the reimbursement. Additionally, prescribedpractitioners, while others are obtaining cer- School nurses as managers of health orservices must often be pre-approved by a tification as school administrators. A few health-related programs may or may not hold panel of "gatekeepers" as an additional incen- states require that the nurse also be certifi- additional certification from their state astive to cost containment (Hughes, 1993). cated as a teacher as a requisite to becoming a school administrators. Within many states, Schools, as Medicaid-eligible providers, mayschool nurse. It is important that institutions formal management responsibility is assumed well be affected by the coming of managedof higher education appreciate the wisdom of under the scope of practice of the state's care. The implications for schools are not yet preparing nurses for school nursing practice Nurse Practice Act, the state certification re- clear. However, it is reasonable to assumewithin master's degrees programs that sub- quirements for school nurse practice, or both. that school districts would, in wisdom, utilizescribe to a wide scope of practice. Such cur- The National Association of School Nurses,school nurses as case or program managers ricular diversity should consider any state the American Nurses' Association, and the forschool-based managed careservices school nurse certification requirements, the American School Health Association have (Snyder, 1991). need for nurse practitioner preparation, and long recognized the importance of formalized the provision of program management skills health management function by nurses EDUCATION FOR within a conceptual framework of commu- within school districts and have urged both SCHOOL NURSING PRACTICE nity health nursing and primary health care. nurses and school districts to utilize nursingThe comprehensive scope of practice thus far staff in this capacity (NASN, 1981; ANA, described demands appropriate educational THE EVOLUTION OF THE 1983; Snyder, 1991). The Association of preparation to enable nurses to effectively ac- SCHOOL NURSING STANDARDS Community Health Nursing Educators de- tualize their roles and to meet the contempo-The ten NASN standards, presented in scribes as essential, the preparation of com- raryhealthneedsofclieiltsinour Chapter Three, have their genesis in the ,york munity health nurses at the baccalaureate multicultural society (CTC, 1989). Indeed,of two groups of school nurse professionals. level in introductory leadership and manage-"the health of tomorrow's adults may wellThe first was an ANA-sponsored task force ment, and at the master's level in program, depend upon the outcome of their [nurses] which authored the original Standards of personnel,andfinancialmanagementefforts" (Wold, 1981). Many states are mov- School Nursing Practice in 1983. It was com- (ACHNE, 1990; 1991). As health care pro- ing toward recognition of the need for spe- posed of representation from the American fessionals, nurses are ideal candidates to be cialty preparation for nurses who practice inNurses' Association's Division on Commu- health program coordinators. school settings. Indeed, twenty-three of fiftynity Health Nursing Practice, the American The transit to "managed care" proposedstates at present require specialized readiness Nurses' Association's Division of Maternal under federal health care reform plans will for the practice of nursing in the schoolsand Child Health Nursing Practice, the result in a yet unknown impact upon school (Igoe and Speer, 1992; NASN, 19926). American Public Health Association's Public 1 7 14-- Health Nursing Section,the American ANA Standards has recently been developed concepts conceived by the Western Interstate School Health Association, the National As- (Snyder, 1991). Commission on Higher Education sociation of Pediatric Nurse Associates and The remaining two NASN standards were (WICHE, 1985). The content of Chapter Practitioners, the National Association oforiginated by a state task force developing Three was originally published by NASN School Nurses, and the National Association state educational standards for professional (Proctor, 1990) and much of the text is there- of State School Nurse Consultants. Eight ofpreparation as a school nurse (CTC, 1989). fore the same. What is different is the consid- the ten NASN Standards are derived from In addition to writing two new standards,eration of the ANA Standards of Clinical the hallmark document which was a product this group modified the language of the origi- Nursing Practice and their infusion into the of this group (ANA, 1983). An excellent nal eight Standards of School Nursing Practice format of each standard. The following table implementation guide for the original eight(ANA, 1983) and nested the now ten stan- lists the NASN Standards contained in dards within a framework of six nursing role Chapter Three and their original sources..

Figure I SOURCES OF THE NASN STANDARDS: RELATIONSHIP OF STANDARDS TO ORIGINAL SOURCES

NASN STANDARD ORIGINAL SOURCE OF STANDARD

PROVIDER OF CLIENT CARE NASN 1 Adapted from ANA St. I (ANA, 1983) NASN 2 Adapted from ANA St. III NASN 3 CTC St. 22 (CTC, 1989)

COMMUNICATOR NASN 4 CTC St. 29

PLANNER & COORDINATOR OF CLIENT CARE NASN 5 ANA St. II NASN 6 Adapted from ANA St. IV NASN 7 Adapted from ANA St. VII

CLIENT TEACHER NASN 8 Adapted from ANA St. V

INVESTIGATOR NASN 9 Adapted from ANA St. VIII

ROLE WITHIN THE DISCIPLINE OF NURSING NASN 10 Adapted from ANA St. VI

ANA = American Nurses' Association = California Commission on Teacher Credentialing 1 5 1 3 ROLE CONCEPTS PLANNER AND COORDINATOR OF WITHIN THE DISCIPLINE OF NURSING This document will facilitate an understand- CLIENT CARE The standard within this role concept in- ing of school nursing and its role in contem- The three standards making up this role con- cludes issues of role delineation, communica- porary schools. This work employs six overall cept focus on processes that compliment and tion and augmentation. It also examines role concepts taken from The Preparation andextend the delivery of nursing services to in- professional practice issues particular to nurs- Utilizationof New NursingGraduates dividual students and families. These pro- ing in the schools and encourages excellence (WICHE, 1985) and described in the follow- cesses examine larpr contexts of practicein practice through evaluation of nursing ing discussion. The role concepts serve as such as community liaisoning and network- practice and continued professional growth. conceptual umbrellas for the ten specialtying, programming, school interdisciplinary Professional Development - Standard 10 standards of practice around which a nurse collaborations, and political influencing. The THE FORMAT OF THE SCHOOL may define a role and design a school nursing standards within this role concept facilitate NURSING STANDARDS program in(a)school(s)or(a)school the delivery of services through coordination At the beginning of each of the ten school district(s). and management, and further characterize nurse standards in Chapter Three are rwo The six role concepts used as conceptual school nursing as community nursing. Program Management Standard 5 graphics. One is a table, identifying the ANA' frameworks for the school nursing role are: School Collaboration - Standard 6 "Standards of Care" and "Standards of Pro- Community CollaborationStandard 7 fessional Performance" to which the particu- PROVIDER OF CLIENT CARE lar specialty standard under consideration The three standards constituting this role CLIENT TFACHER applies. The reader should recognize that any concept focus largely on the provision of di- The standard subsumed within this role con- given specialty standard reflects all of the "Stan- rect clinical nursing services to students,cept addresses education for health behavior dards of Care" and "Standards of Professional families and/or staff as client. They describe a change with the nurse as educator. The re- Performance. "The table however, identifies body of clinical knowledge fundamental forcipients of health education may be students only those of obvious relevance. The other is school nursing practice and frame the deliv- inthe classroom, students individually, an umbrella. The umbrella symbolizes one of ery of services within a nursing process con- school staff, families, and members of the the six role concepts used as a framework for text. community. Chapter Three. Under each umbrella is (are) Clinical Knowledge - Standard 1 Health Education - Standard 8 Nursing Process - Standard 2 the school nurse standard(s) included in that Clients with Special Health Needs - role concept. INVESTIGATOR Standard 3 The standard within this role concept chal- Within the text of each standard may be lenges school nurses to study phenomenafound: (1) a working definition of the main COMMUNICATOR theme of the standard, such as "Clinical The standard within this role concept pro- within the school setting, and to share the Knowledge" (Standard 1); (2) rationale for motes interpersonal communication as a skill findings with others, both formally and in- the standard; (3) criteria to measure if the applicable to all facets of the school nursing formally. Research - Standard 9 standard has been met; (4) and last, sugges- role and essential for successful community tions for achieving the standard in the work nursing practice. setting. Figure 2 illustrates the format of each Communication - Standard 4 standard as presented in Chapter Three. Figure 2

RELATIONSHIP OF SCHOOL NURSE STANDARDS TO A ROLE CONCEPT AND TO THE ANA STANDARDS OF CLINICAL NURSING PRACTICE.

ANA Standards of Clinical Nursing Practice 1.

Standards of Standards of Care Professional Practice

School Nurse Role Concept, C.g. PROVIDER OF CLIENT CARE

Standard (2)

Standard (1) Standard (3)

Definition Building Toward This Standard

Rationale Measurement Criteria 77 2 0 CHAPTER THREE STANDARDS OF SCHOOL NURSING PRACTICE

ROLE CONCEPT I PROVIDER OF CLIENT CARE

NASN STANDARD 1: NASN STANDARD 2: NASN STANDARD 3: CLINICAL KNOWLEDGE NURSING PROCESS CLIENTS WITH SPECIAL HEALTH The school nurse utilizes a distinct knowl- The school nurse uses a systematic approach NEEDS edge base for decision-making in nursing to problem-solving in nursing practice. The school nurse contributes to the educa- practice. tion of the client with special health needs by assessing the client, planning and providing appropriate nursing care, and evaluating the identified outcomes of care.

ROLE CONCEPT II COMMUNICATOR NASN STANDARD 4: COM MUNI CATION The school nurse uses effective written, verbal, and nonverbal communication skills.

ROLE CONCEPT III PLANNER AND COORDINATOR OF CLIENT CARE

NASN STANDARD 5: NASN STANDARD 6: NASN STANDARD 7: PROGRAM MANAGEMENT COLLABORATION WITHIN THE COLLABORATION WITH COMMUNITY The school nurse establishes and maintains a SCHOOL SYSTEM HEALTH SYSTEMS comprehensive school health program. The school nurse collaborates with other The school nurse collaborates with members school professionals, parents, and caregivers of the community in the delivery of health to meet the health, developmental, and edu-and social services, and utilizes knowledge of cational needs of clients. community health systems and resources to function as a school-community liaison.

ROLE CONCEPT IV ROLE CONCEPT V ROLE CONCEPT VI CLIENT TEACHER INVESTIGATOR ROLE WITHIN THE DISCIPLINE OF NURSING NASN STANDARD 8: NASN STANDARD 9: HEALTH EDUCATION RESEARCH NASN STANDARD 10: The school nurse assists students, families, The school nurse contributes to nursing and PROFESSIONAL DEVELOPMENT and the school community to achieve opti- school health through innovations in practice The school nurse identifies, delineates, and mal levels of wellness through appropriately and participation in research or research-re- clarifies the nursing role, promotes quality of designed and delivered health education. lated activities. care, pursues continued professional enhancement, and demonstrates professional conduct. 21 1 8 NASN STANDARD 1 CLINICAL KNOWLEDGE

Clinical Nursing Clients with Knowledge Process Special Needs

ANA STANDARDS OF CLINICAL NURSING PRACTICE TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE I. Assessment: The nurse collects health data. II. Diagnosis: The nurse analyzes assessment data in determining diagnoses. III. Outcome Identification: The nurse identifies expected outcomes individualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VI. Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

STANDARDS OF PROFESSIONAL PERFORMANCE I. Quality of Care: The nurse systematically evaluates the quality and effectiveness of nursing practice. III. Education: The nurse acquires and maintains current knowledge in Nursing Practice. V. Ethics: The nurse's decisions and actions on behalf of clients are determined in an ethical manner. VIII.Resource Utilization: The nurse considers factors related to safety, effectiveness, and cost in planning and delivering client care.

(ANA, 1991h) 1. THE SCHOOL NURSE UTILIZESA DISTINCT CLINICAL KNOWLEDGE BASEFOR DECISIONMAKING IN NURSING PRACTICE

CENTRAL THEME DEFINITION Developmental Theory chronic physical conditions of childhood Clinical knowledge refers to formally tested Epidemiologic Theory and adolescence. theories from nursing and related disciplines, Family Systems Model* The epidemiology and nursing as well as to the distinct clinical knowledge Goal Attainment Theory' management of child and adolescent and skill required for school nursing practice. Group Theory i nju ries. Hierarchy of Needs Theory Theepidemiology,treatment,and RATIONALE Interpersonal Communication Theory` nursingmanagementof infectious/ School nursing is a specialized area of nursing Management Theory communicable diseases of childhood and which utilizes new knowledge and concepts, Maternal Role Attainment Theory' ado lesce ncf. Th is shall include as well as applying earlier knowledge ac- Parent-Child Interaction Theory' knowledgeofsexuallytransmitted quired from basic nursing preparation, ad- Role Theory diseases, including acquired immune vanced educational programs, and clinical Self Care Deficit Theory* deficiency syndrome. experience. Schoril nurses draw upon a theo- Social Learning Theory The technique of physical assessment, retical foundation in :heir practice and incor- Social Support Theory discerning deviations from normal, with porate both new and prior knowledge and Stress and Coping Theory particular emphasis on the appraisal of skill to make appropriate decisions in the de- Systems Model Theory' vision and hearing, the detection of livery of health care. Systems Theory musculoskeletal conditions, including Wellness-Illness Theory scoliosis, the assessment of the middle MEASUREMENT CRITERIA Nursing Thc, ries (Marriner-Torney, 1989) ear,andthedetectionofdental, To incorporate this standard into a school The aforementioned theories have clear cardiovascular, respiratory, neurological, nursing program, the nurse shall: application for the role concept "Provider of and grow t h or developmental A. Apply theories from nursing and the Client Care," but are also useful in relation to i rregularities. physical, behavioral, public health or social other role concepts presented within this The pharmacology of commonly used sciences to school nursing practice. Theorieschapter. pediatric medications. that have wide-spread application to school B. Have contemporary knowledge of all of Normal pediatric nutritional standards nursing and can be of assistance to the nurse the following clinical areas: andthesignsandsymptomsof in working within, influencing, and under- The physical and psychosocial nutritional deficiency and eating standing the school setting are: developmentofinfants,toddlers, disorders. Adaption Theory* preschoolers, school-aged children, and Emotional and behavioral disorders cf Caring Theory* adolescents. childhood and adolescence, including Change Theory' The pathophysiolog, signs, symptoms, depression and suicide. Community Organization Theory treatment, and nursing management in Learning disorders of childhood and Crisis Theory the school setting of common acute and adolescence, including developmental Cultural Care Theory' delay and attention deficit disorder. 20 Common disordersof speechand Workshops, seminars, conferences spectives and The Journal of Adolescent Health language. These are frequently most helpful to both the Care useful. There are several wellness publi- The etiology of, and nursing role with, neophyte and the experienced school nurse. cations available, one of which is the Berkeley child abuse and neglect. Request placement on the mailing list for Wellness Newsletter. Subscribe to one or two The etiology of, and nursing role with, professional organizations concerned with and ask your district to subscribe to others. the chronically dysfunctional family. school nursing, school health, community Adolescentpregnancy,childbearing,health nursing, etc. so you can receive infor- Nursing textbooks and texts from parenting, and pregnancy-prevention mation about pertinent continuing educa- related disciplines approaches. tion activities. If none are offered, suggest Contemporary nursing textbooks are excel- Childhood and adolescent substance that they be offered. Becoming a member oflent. Visit a college or university bookstore abuse. selected professional organizations automati-and scan shelf selections for new pediatric Poverty and racism and their effects oncally ensures contact with many continuing nursing, community nursing texts, etc. Used child development and child health. education activities. For example, NASN has texts are often available. A Manual of School Domestic and societal violence and theiroffered seed workshops throughout the coun- Health (Lewis and Thomson, 1986) is a most effects on child development and child try over the past several years in areas such as useful reference book, particularly for the be- health. general physical assessment, neuromaturational ginning school nurse. Susan Wold's classic The unique health problems and majorassessment, and the IEP (individualized edu- bock, School Nursing: A Framework fir Prac- practices of American racial, ethnic, andcational program) process. tice, has been reissued in its original form by cultural groups. Sunrise River Press (Wold, 1981). Racial,ethnic. and cultural norms, Articles,research, and programmed beliefs,attitudes,andvalues,with learning in professional journals Classes or courses particular regard to child rearing, health Review professional journals concerned with Enroll in classes or courses when you want a care and sex roles. school nursing, school health, and pediatric more comprehensive picture than can be Environmental health issues in the school and adolescent health care, as well as issuesgained from a seminar or a workshop. Re- setting. related to nursing at large. Particularly help-quest placement on the mailing list for con- ful are the Journal of School Nursing, pub- finuing education or extension courses BUILDING TOWARD lished by the National Association of School offered by local colleges or universities. THIS STANDARD Nurses, The Journal of School Health, pub- After reading the preceding expectations for lished by the American School Health Asso- Certificate or degree programs practice, decide what you need to know and ciation, and the Journal of Pediatric HealthYour school nursing practice will be most fa- how you will acquire the information. School Care, published by the National Associationvorably enhanced by enrollment in degree or nursing builds upon basic knowledge and of Pediatric Nurse Associates and Practitio-certificating programs. Twenty-three states skill. It also necessitates the acquisition ofners. Also of benefit are Public Health Nurs- have academic requirements for state school new knowledge and skill to implement new ing,publishedbyBlackwellScientific nurse certification (NASN, 1992b). When programs successfully and to actualize thePublications, Pediatrics, published by thecombined with degrees (bachelor's, master's role of the school nurse. Ways to review past American Academy of Pediatrics, Pediatricor doctoral), these provide a greater breadth learning or acquire new learning include: Clinics of North America, and publications ofof knowledge and more efficiently educate the Association for the Care of Children'sthe school nurse. Other certification (e.g., Health. If you have a special interest in ado- nurse practitioner, adolescent health care spe- lescents, you may find Family Planning Per- cialist) will expand your knowledge base and

-21- 2 4 scope of practice. As a general rule, advanced education is affirming, consciousness-raising, and confidence-building. If programs are un- available or suffer from a poor reputation, work for their establishment or improvement. Inquire about scholarships and other financial aid if help with funding is needed.

20 -22- NASN STANDARD 2 NURSING PROCESS

Clinical Nursing Clients with Knowledge Process Special Needs

ANA STANDARDS OF CLINICAL NURSING PRACTICE 2 TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE I. Assessment: The nurse collects health data. II. Diagnosis: The nurse analyzes assessment data in determining diagnoses. III. Outcome Identification: The nurse identifies expected outcomes individualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VL Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

STANDARDS OF PROFESSIONAL PERFORMANCE I. Quality of Care: The nurse systematically evaluates the quality and effectiveness of nursing practice. II. Performance Appraisal: The nurse evaluates own nursing practice in relation to professional practice standards and relevant statutes and regulations. Ill. Education: The nurse acquires and maintains current knowledge in Nursing Practice. IV. Collegiality: The nurse contributes to the professional development of peers, colleagues, and others. V. Ethics: The nurse's decisions and actions on behalf of clients are determined in an ethical manner. VI. Collaboration: The nurse collaborates with the client, significant others, and health care providers in providing client care. VII. Research: The nurse uses research findings in practice. VIII.Resource Utilization: The nurse considers factors related to safety, effectiveness, and cost in planning and delivering client care.

(ANA, 1991h) 2G 2,3-- 2. THE SCHOOL NURSE USES A SYSTEMATIC APPROACH TO PROBLEM-SOLVING IN NURSING PRACTICE

CENTRAL THEME DEFINITION A.Assess: the collection and documentation BUILDING TOWARD Nursing Process refers to the thinking process of data/informationaboutorfrom THIS STANDARD that occurs each time the school nurse makes students, families, individuals, health Assessment is the comprehensive, pertinent, any decision and takes any action, no matter care providers, organizations, orand systematic collection of information how small, while serving in a professional ca- communities in a systematic, continuousdocumented in retrievable form. Examples of pacity. The American Nurses Association's manner, using appropriate techniques. data collection would include such activities Standards of Clinical Nursing Practice in- B.Diagnose: the analysis of the assessment as health history-taking; vision, hearing, and cludes both "Standards of Care" and "Stan- data to arrive at (a) conclusion(s) which scoliosisscreening;observingbehavior; dards of Professional Performance." The can be validated by others,is(are) psychosocial assessment; utilization of norm- "Standards of Care" are the actual steps of the documented,and facilitate(s)the referenced tools; school or community needs Nursing Process. Nursing Process is consid- development of*outcomes and a plan of assessments; and administering pretest health ered as a separate standard herein to illustrate care. status assessments for any and all purposes. It that its use may be applied to issues of profes- C.Identify Outcomes: the specification ofwould also include studying descriptions of sional performance as well as of client care. measurable, appropriate, mutually the school nursing role; assessing organiza- Inclusion also underscores the importance of formulated, attainable, and timely goals tion/management plans; and learning about the Nursing Process as a conceptual frame- which are derived from the diagnosi(e)s, administrators or Board of Education mem- work for school nursing as a specialty, and for aredocumented,andprovidefor bers. Data/information may be collected the discipline as a whole. continuity of care. through a variety of methods and from a vari- D.Plan: the prescription of interventions ety of persons and sources (ANA, 1983). Uti- RATIONALE designed to attain outcomes unique to lizing a rapid, succinct method to record your Regardless of the setting, the professional the client which provide for continuity ofdata is essential. nurse goes through a systematic process of as- care. are documented, and are conjoimly Diagnosi(e)s flow(s) from the assessment. sessing a situation, deciding what is occur- created, when appropriate. In the school setting, diagnoses may be nurs- ring, identifying outcomes, deciding what to E.Implement:theexecutionofthe ing or educational, or the recognition and in- do, doing it, and mentally reviewing the suc- interventions prescribed within the plan corporation of medical diagnoses. Diagnoses cess of the entire undertaking. The Nursing of care in a safe, appropriate manner. themselves are conclusions, the result of ana- Process is a logical, problem-solving frame- Interventions are always documented. lyzing data/information. Strategies to assist work and is a generally accepted practice F.Evaluate: the systematic and ongoingyou in diagnosing would include reviewing throughout nursing. appraisal ofclient responsesto the signs, symptoms, and epidemiology of a interventions and to the effectiveness ofsuspected health condition from a reliable MEASUREMENT CRITERIA interventions in relation to outcomes. text or other resource as an aid in making To incorporate this standard into a school Evaluative data are documented and used your diagnosis, or asking a peer or another nursing program, the nurse shall: to revise assessments, diagnoses, professional to validate a conclusion you have outcomes, plans, and interventions. reached. 24-- 27 Nursing diagnoses may have one, two, orgood nutrition, builds self-esteem, reducesAmerican Nurses' Association's "Standards three parts (Carpenito, 1992). The first partsocial isolation, promotes good decision- of Care" (ANA, 1991b) have delineated out- is the diagnostic label, the second part, con-making, facilitates prenatal care, acts as a cli- come identification as an expected standard tributing factors, and the third part, signs andent advocate, provides childbirth and childof care for nurses practicing in all settings. As symptoms. Commonly, school nursing diag-care instruction, and promotes completion ofpart of the nursing process, the nurse would noses have two or three parts. the teen's education. All of these nursing review the diagnosis and determine, together Formulating your conclusions as nursing goals flow directly from the nursing diagnosis with the client or others as appropriate, some diagnoses rather than as medical or educa- and can be mutually identified with the client measurable outcomes. Outcomes are to be: tional diagnoses will help you plan; a well-or others as outcomes. derived from the diagnosis, measurable, real- thought-out nursing diagnosis describes a Haas and colleagues have published an excel- istic for the client's potential and abilities, at- situation as a nursing problem and ddineates lent resource which makes use of school-appro- tainable in relation ta resources available, what you do as a nurse. For example, preg- priate NANDA (North American Nursing designed with a time estimate for attainment, nancy is a medical diagnosis, and "specific DiagnosisAssociation)nursingdiagnoses and written so as to provide direction for learning disability" can be both an educa- (Haas, Kalb, Luehr, Miller, Silkworth, and continuity of care. Identifying and writing tional and a medical diagnosis. A nursing di- Will, 1993). Entitled The School Nurse's Source outcomes is similar to identifying and writing agnosis for a pregnant thirteen-year-old and Book of Individualized Health care Plans, this re- objectives for the IEP and the IHP. IEP/IHP her unborn baby might be: "High risk for al- sourceinterfacesnursingprocess,using objectives may also contain a plan and the tered outcome of pregnancy (diagnostic label) NANDA diagnoses, with IEPs (Individualized particulars of implementation. related to social isolation, insufficient nutri- Educational Plans) and IHPs (Individualized The plan and its implementation are inti- tional intake, and young age (contributingHealthcare Plans) for several dozen studentmately tied to the identification of outcomes factors), as evidenced by inadequate weight health conditions. Shyang-Yun Shiao andand to each other. The plan is the "blueprint" gain and noncompliance with prenatal care" McKaig (1989) have also applied nursing diag- for action, and the implementation, the "do- (signs and symptoms). The nurse arrived at this nosis to nursing practice in the school setting. ing" or the actual action taken. The plan diagnosis following assessment. Other valuable resources for nursing diagnosis must include the who, what, when and While writing all of this down each time is include Nursing Diagnosis: Application to Clini-where: who is to perform the action; what ac- both cumbersome and, frequently, unrealis- cal Practice (Carpenito, 1992) and Classification tion is to be taken; when the action is to oc- tic, doing so initially will help you think of Nursing Diagnoses: Proceedings of the Ninthcur; and where the action is to take place, if more broadly. In the preceding nursing diag- Confirence (NANDA, 1991). appropriate. IEP/IHP objectives written at a nosis, we know the teenager is not only preg- In addition to nursing diagnoses, nursestaffing meeting contain all of these compo- nant, but has little or no support frompractitioners working in the school setting nents and are an educational plan for the stu- significant others, perhaps her family. Wemake medical diagnoses. The CWO kinds ofdent under consideration. Objectives are know also that the fetus is at risk because ofdiagnoses may be closely related but also have always written behaviorally, with student be- inadequate nutrition. The teen's young age parallel yet separate outcomes, plans, and in- haviors as the focus of the objectives. Further may contribute to problems in accessing pre- terventions. Most nurse practitioners employdiscussion of IEP/IHP objectives may be natal care. poor decision-making, or to physi- both cognitive processes simultaneously and found in Standard 3. cal problems of pregnancy, labor and/or expand their plan of care to accommodate inter- delivery. Immediately evident, as well, is the ventions from both disciplinary perspectives. The nursing plan of care may extend benursing role, in which the nurse not only Outcome identification as a step in theyond the educational plan and prescribe monitors blood pressure, weight, and en- Nursing Process has not consistently been in- nursing interventions which do not have di- courages regular prenatal visits, but promotescluded in the literature until recently. The rect bearing on the education of the student, but are seen as essential for the optimal func-care which would not be part of the IEPhave been done differently? Where were you tioning of the student in the school setting. A might be "to refer the student's family forsuccessful? Were the plan and implementa- taxonomy of nursing interventions is nowfamily counseling." Additionally, a nursing tion realistic? Examples of evaluation include available and can be utilized by the school plan of care may be written from the perspec- assessing whether or not a referral to a par- nurse. The interventions, identified in Nurs-tive of the nurse and need not have the stu- ticular child protection advocate was effec- ing InterventionsClassifications(N.I.C.)dent as the active subject in all the prescribed tive; determining whether your decision to (Bulechek and McCloskey, 1992), "are at the behaviors. send a child back to class was correct; con- conceptual level and require a series of ac- In order to implement the plan of care, including you need more information regard- tions or activities to carry them out. Nursing terventions are employed. Plans and imple-ing a particular client situation (additional interventions include nurse-initiated inter- mentations are used for everything one does data collection); and deciding whether a plan ventions or...[administrator] - (substitution in school nursing, not just student and familyand/or its implementation should be altered. for physician) initiated interventions" (p.issues. For example, negotiating for more The employment of evaluation in relation XVII). Such activities or actions would nottiursing time within a school district necessi- to "Provider of Client Care" (WICHE, necessarily be included as part of the IEP, buttates a plan, followed by implementation of 1985) has been the focus of this discussion. would be part of a nursing plan of care for athat plan. Evaluation is also an integral part of the five student or his family, sometimes referred to Evaluation is made easy by the accurate remaining role concepts, particularly "Plan- in the school setting as the IHP (Individual-delineation and documentation of outcomes. ner and Coordinator of Client Care," "Client ized Healthcare Plan) (Haas et al., 1993). An Have your outcomes been met? On time? Teacher," and "Role Within the Discipline of example of an item within the nursing plan ofWhere did the process fall apart? What could Nursing."

29 26-- NASN STANDARD 3 CLIENTS WITH SPECIAL HEALTH NEEDS

Clinical Nursing Clients with Knowledge Process Special Needs

ANA STANDARDS OF CLINICAL NURSING PRACTICE 3 TO WHICH THIS SCHOOL NURS7NG STANDARD PARTICULARLY APPLIES

STANDARDS OF PROFESSIONAL PERFORMANCE

1. Qualit, of Care: The nurse systematically evaluates the quality and effectiveness of nursing practice. III. Education: The nurse acquires and maintains current knowledge in Nursing Practice. V. Ethics: The nurse's decisions and actions on behalf of clients are determined in an ethical manner. VIII.Resource Utilization: The nurse considers factors related to safety, effectiveness, and cost in planning and delivering client care.

(ANA, 1991h)

-2 7-- 3. THE SCHOOL NURSE CONTRIBUTES TO THE EDUCATION OF THE CLIENT WITH SPECIAL HEALTH NEEDS BY ASSESSING THE CLIENT, PLANNING AND PROVIDING APPROPRIATE NURSING CARE, AND EVALUATING THE IDENTIFIED OUTCOMES OF CARE

CENTRAL THEME DEFINITION programs serving the emotionally disturbed. ' by Congress in 1990, and in the process, Special health needs refer to the health needs New immigrants arrive in the United States was renumbered PL 101-476, and of students enrolled in Special Education with previously undiagnosed, and therefore retitledIndividualsWith Disabilities programs, and to the health needs of students unmet, health needs. All of these changing Education Act,or IDEA (Winger, 1993). with chronic health problems who may not societal and demographic patterns combine Both PL 94-142 (PL 101-476) and PL be in Special Education. It includes children to forge a more complex and comprehensive 99-457, Education of the Handicapped aged birth through 21. The term does not re- role for the nurse. As a matter of emphasis, a Amendments, 1986, constitute federal fer to episodic or acute health needs as identi- separate Standard was devoted to this issue legislation with significance to school fied within Standard 1. rather than subsuming it under either Stan- nursing. The former established the right dards 1or 2. Conceptually, it is important to a free, appropriate education and RATIONALE the reader recognize that the content of Stan- related services for handicapped children, There has been a steady increase in the num- dard 3 is inherent in Standards 1 and 2 and adolescents, and young adults through bers of students in Special Education or with has been separated here only because of its the 21st year of life. The latter established chronic health conditions in recent years. Lo- increasing significance for education and for a state-by-state planning process for the cal school districts are increasingly successful school nursing. provision of a community-based, family- in communicating the availability of pro- centered case management and service grams to the comimmity, and in promodng MEASUREMENT CRITERIA systemforat-riskand handicapped early identification of potentially eligible stu- To incorporate this standard into a school children, birth to five years (Woodruff dents in need of Special Education services by nursing program, the nurse shall: and McGonigel, 1988). teachers, parents and/or care givers. Neona- A. Have contemporary knowledge of all of "Related services" is a key term in PL tology is saving infants who one or two de- the following: 94-142 for schoul nurses; the "related cades ago would not have survived. Some of Common chronicanddisabling services"provision authorizes school these children may manifest mild to severe conditions of childhood and the nursing health services, including school nursing. disability as they mature. Substance use and role therein. Early intervention services authorized by abuse during pregnancy have increased the National, state and local laws governing PL 99-457 differ from state to state as a numbers of drug-exposed infants born with SpecialEducationstudents,Special result of the flexibility allowed in the congenital anomalies and/or subsequent de- Educationprograms,chronicallyill state planning process. velopmental problems. The escalating rate of students, and the rights of the disabled. Also of significance is Section 504 of domestic violence has contributed to the Public Law (PL) 94-142, Education of All the Vocational Rehabilitation Act of 1973 larger numbers of students qualifying for Handicapped Act, 1975, was reauthorized (PL 93-112). This statute deals with 28 3 access issues, and is commonly utilized by A health and physical assessment including necessary, and supervise others where parents and child advocates seeking school vision, hearing, nutritional, and develop- permitted by local or state law and state health services for chronically ill students mental appraisals. nurse practice acts. who do not qualifr for special education Observation in the classroom and on theN. Participate in the development of the and related services under IDEA (PL 101- playground or school area. individualized family service plan (IFSP) 476) (S.L. Lordi, personal communication, Elicitation of supporting medical data as when working with infants and toddlers. Sept. 2, 1992). available. The Americans with Disabilities Act of Review of all health records. BUILDING TOWARD 1990 (42 USC, 12-116, CFR Part 1630) 'Communication with health care THIS STANDARD outlines protective and antidiscriminatory providers. This role for nursing has expanded greatly in provisionswhichrelatetomultiple C.Attend team meetings, present findings,recent years. For many nurses, working with concerns in both the public and private nursing diagnoses and recommendations, Special Education students is a full-time pur- sector. This act refers to personnel issues and participate in the writing of IEP orsuit; for others, a significant portion of their and to students outside of those concerns other objectives (MDT, IDT, TDT) as practice. covered by the IDEA (Winget, 1993). necessary. Utilizing current pediatric nursing or D.Conduct appropriateassessments prep- medical texts may be of great assistance in re- Significant judicial decisions dealing with aratorytoperiodicIEPand IHPviewing disabling conditions and chronic ill- individual students and necessary school reevaluation. nesses,particularlytexts which contain health services either within or apart from E.Develop and implement nursing plan ofsections on genetic diseases. The range of Special Education. care/IHP (individualized healthcare plan) conditions among students in your school(s) School district policy and procedure for each student, as needed. may vary from mildly disabling conditions to regarding Special Education students and F.Monitor ongoing health status of students. medically fragile states. Some study regarding programs, and chronically ill students. G.Act as a parent advocate before, during, and an update of nursing care procedures may be The existence and nature of local following the team meeting. in order if it has been some time since you programs for the education of the disabled H.Act as a rise manager and advocate for the have cared for persons with specific or unique child. infant, child, or adolescent with special conditions. The legal expectation emanating The role of thenurseinSpecial health needs. from your nursing license assumes you have Education. 1. Facilitate normalization of the student'sadequate knowledge and skill regarding the The role of the nurse with the chronically educational experience. client conditions with which you deal. ill and disabled child. J.Educate teachers and other staff as to the State, county, or district school nurse asso- Therolesofmembersofthe natureandeducationalrelevanceofciations can supply role descriptions of individualized educational program (IEP), disabling conditions. school nurse practice within Special Educa- multidisciplinary(MDT), interdisciplinaryK. Educate parents of students regarding the tion and with the chronically ill child. Na- (IDT), or transdisciplinaty (TDT) teanis. school policy, procedures, and parental roletional and state documents, policies, and The effect of chronic illness or disability of in Special Education. position papers have been developed address- childhood on the student and family. L.Educate parents of students with chronic ing the role of the nurse in Special Education. B. Conduct full nursing appraisals of each illnessregardingschoolpolicyand Some notable examples include Resolution student with special health needs including: procedures related to their child and his or and Polity Statements (NASN, 1992a), and A health and developmentalhistory, her condition. School Nurses Working with Handicapped preferably in the student's home. M. Perform skillednursing procedures as Children (ANA, 1980b). 29 32 Clients who enrollincontemporary available; inquire within a local nursingnursing personnel or Special Education per- schools may be technologically dependent. school, your state or local school nurse asso-sonnel within your district, county, or state, At the current rate of new developments in ciation, or a hospital. A national resource of including other school nurses. biomedical engineering and technology, only interest is Guidelines and Delineation of Roles Nursing appraisals prior to the IEP may nurses who have very recent acute care nurs-and Responsibilities for the Safe Delivery ofbe more or less comprehensive, depending ing experience, especially ICU or PICU expe-Specialized Health Care in the School Settingupon the existence of previous assessments rience, or those experienced in pediatric (AFT, CEC, NASN, and NEA, 1990). and on the nature of the pupil's educational rehabilitative nursing, will be familiar with School nursing, school health, education, disability. The nursing assessment should ad- the new apparatus. It is not reasonable to ex- or Special Education journals may have ar-dress all components contained in Standard pect a nurse who has not practiced recently in ticles dealing with aspects of Special Educa- 3, Objective B. A strategic part of the nursing the acute setting to be familiar with all thetionlaw.Designatedstateagenciesassessment is the health and developmental new engineering developments. Further, responsible for Special Education fundinghistory, which elicits not only significant his- technology varies from hospital to hospital, may carry copies of both state and federal law tory and evaluates milestones, but allowsthe even within the same community. A more and offer other publications in the area ofnurse an opportunity to interact with the par- appropriate role lies in familiarizing yourselfSpecial Education. County agencies or localents or guardians, preferably in the home, with the technology as it arrives with variousschool districts should be queried for any and and begins the development of a nurse-par- students. all relevant literature governing local law and ent relationship leading to a parent advocacy For more common technical skills anddistrict policy. Information regarding prece- role for the nurse. technologies, pediatric techniques or general dent-setting court cases of importance to the The 1EP or other team meeting itself should nursing procedures texts will help in a re-mirse may be available from your local or be attended by the nurse who has conducted the freshment of skilled nursing procedures, such stote Special Education unit. The school nursing assessment. In some instances, the nurse as tracheostomy care. Clinical nurse special- nurse associationnational, state or local participates in all starlings, in other instances, in ists in medical centers, nursing schools, ormay be of assistance here as well. Nenvorkingstaffings for only those students with health or hospitals may also be approached for consul- with school nurses who work with the se-health-related problems. The nurse should be tation or provision of continuing education verely handicapped is also recommended. notified of all pending IEP or other team meet- classes which review skilled nursing proce- Learning the functions of the team mem- ings in sufficient time to conduct the nursing dures and provide opportunities to practice bers (IEP, MDT, 1DT, or TDT) is a useful appraisal. The notification process varies from these skills. Parents are often eager to teach exercise. Interview the other team members district to district and state to state. Except in in- school personnel the intricacies of a special- and ask about their roles, the tests they per- stances where the nursing data are notsignifi- ized procedure needed to care for their child form, the purpose of the tests, and something cant to the outcome of the team decision, the during school hours. Parents should be active about what the scoring means. Ask how each nurse must participate in the deliberations as a participants in the development of the 1HP of them perceives the nurse's role and share full-functioning professional and write IEP ob- and their input sought and heeded. However, your role with them. Clarify and understand jectives as indicated. This role should not be re- as a general rule, it is better to receive instruc- each other's respective functions, as each situ- linquished, since nursing assessment may be tion from nurses rather than physicians or ation permits. critical to the outcome of the placement deci- parents. The performance of such skills is Much has been written concerning the im- sion. NASN's HADHAS Syllabus (1982) pre- nursing care and nurses will be more familiarpact of the disabled child on the family. sents formats for writing IEP objectives. with the practices and more skilled in per- Visit a university or college library or locate The IEP or other objectives frequently are forming them. Print and video resources de-. books or periodicals dealing with this impor- part or the overall nursing care plan or the signedfor self-pacedlearningarealso tant subject area. Talk with knowledgeable nursing plan of care (the terminology used -30- by the American Nurses' Association in the involved in the development of the Individu- child and the family receive a variety of ser- Standards of Clinical NursingPractice, alized Family Service Plan (IFSP) rather than vices. Indeed, federal legislation requires case 1991b). In some school districts, the nursingthe IEP (McCarty-Marple, 1991). Find other management (McCarty-Marple, 199 I).The plan of care is referred to as the Individual- nurses who are in infant programs and de- school nurse, as case manager, facilitates con- ized Health Plan, or the 1HP. Care plans pro- velop support sections within state school tinuity of care by assisting the parent or care vide a framework for ongoing monitoringnurse associations to provide you with the giver in accessing services needed by the child and nursing involvement whether or not theknowledge needed for assessment and inter- with special health needs. There appears to be student is formally the recipient of Specialvention with the very young child. Helpful a move in hospital nursing toward nurse- Education services (Gregory, 1991). Indeed, references include Nursing Standards for Earlymanaged care. In this model, the nurse coor- many nurses develop care plans for students Intervention Services for Children and Families dinatesallcareprovidedthepatient with complex needs simply because it is good at Risk (CNA, 1990) and Woodruff and regardless of the discipline of the provider. By nursing practice. The School Nurse's Source McGonigers chapter in Early Childhood Spe- the year 2000, most hospital patients (and Book of Individualized Health Care Planscial Education: Birth to Three (1988). community clients) will be the chronically (Haas et al., 1993) is an excellent compen- Nursing role also extends to periodic re-and/or degeneratively ill. Such patients are dium of nursing plans of care using nursing evaluations as defined by federal, state and/or not the ideal purview of modern medicine, diagnoses, and a nursing process approach, local policy and guidelines. Reevaluations trained to utilize high technology in the iden- and covering a variety of chronic and acute vary from case to case and may extend from tification and remediation of acute disease conditions. cursory reappraisals of student placement to (Gamble, 1989). It seems that the care and In the event you are working with very comprehensive, multidisciplinary reassess- management of the client with chronic illness young children and their families, your role ments. and disability could become the domain of will be somewhat different. For example, as Finally, the complex needs of many stu- nursing in the community/school setting as part of the transdisciplinary team, you will bedents in special education necessitate that the well.

34 -31- NASN STANDARD 4 COMMUNICATION

Communication

ANA STANDARDS OF CLINICAL NURSING PRACTICE 4 TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE I. Assessment: The nurse collects health data. II. Diagnosis: The nurse analyzes assessment data in determining diagnoses. III. Outcome Identification: The nurse identifies expected outcomes iniiividualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VI. Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

STANDARDS OF PROFESSIONAL PERFORMANCE II. Performance Appraisal: The nurse evaluates own nursing practice in relation to professional practice standards and relevant statutes and regulations. III. Education: The nurse acquires and maintains currem knowledge in Nursing Practice. IV. Collegiality: The nurse contributes to the professional development of peers, colleagues, and others. V. Ethics: The nurse's decisions and actions on behalf of clients are determined in an ethical manner. VI. Collaboration: The nurse collaborates with the client, significant others, and health care providers in providing client care.

(ANA, 1991h) 4. THE SCHOOL NURSE USES EFFECTIVE WRITTEN, VERBAL, AND NONVERBAL COMMUNICATION SKILLS

CENTRAL THEME DEFINITION pose of emphasis. Conceptually, the readerrecording, storage, and retrieval of health Communication refersto interpersonal com-should recognize that communication is in- data. Outcome data will continue to be im- munication whether verbal, nonverbal, orherent within all the Standards contained inportant in communicating the results of graphic. It refers to the ability to understand this document. nurse activities to decision-makers. Many one's self as well as to understand and com- school nurse recording systems are cumber- municate with others both within and out- MEASUREMENT CRITERIA some and unnecessarily time consuming. side of the organizational structure. To incorporate this standard into a school Others are sparse to the point of imprudence. nursing program, the school nurse shall: Recording needs to reflect safe and account- RATIONALE A. Employ effective expressive and receptive able nursing practice and consider possible Nursing practice in any setting is intricately verbal skills, reflective of both articulateconflicts between education law and nursing linked to style, purpose, and content of com- speech and good listening ability. practice (Schwab, 1991). Some districts have munication. Nursing cannot occur without B. Write clearly, cogently, and conciselyemployed the use of computers to store data effective communication. Good communica- using correct grammar and spelling. for easy retrieval. Investigate such possibili- tion demonstrates caring, competence, and C. Utilize a system of easy data storage, ties in your own setting and ask other school consideration. It is the heart of community retrieval, and analysis. nurses how they deal with the important is- nursing, which focuses as much on theD. Employ formal counseling techniquessue of d&umentation and recording (Mehl psychosocial aspects of client needs as ir does and crisis-interventionstrategiesfor and Whisenant, 1990; 1992). Do not over- on the physical. The nurse uses effective individuals and groups. look the possibility of devising your own "in- communication as a therapeutic tool, as a E.Demonstrate sensitivity to the values offormation system" whether electronic or not. strategy for change, as a vehicle to transmit students, families, and staff. Consult acquaintances in business for ideas vital information to significant others, and as F.Clarify professional and personal values on how best to manage the information flow a mechanism for legal documentation. The in preparation for school nursing practiceand processing. Local colleges or universities effectiveness of the school nurse's communi- and periodically reevaluate these values. may have communications departments that cation can determine the nurse's success in G. Utilize communication as apositive would be willing to take on your situation as the practice setting. Nurses who are effective strategy to achieve nursing goals. a project for a graduate student. communicators will quite likely be successful H. Share perspectiveswithschoolnurse The storage and retrieval of confidential in school nursing practice. This implies sensi- colleagues through professional data, likewise, is an important consideration. tivity to other's viewpoints, good listening publications. Nurses should be keeping confidential entries ability, and the capacity to argue cogently I. Ickitify and utilize one's own interpersonal apart from regular health records. The possi- and diplomatically for students, families, or strengths. bility of court subpoena in cases of abuse, ne- oneself. Good communication is as impor- glect,or other sensitiveareas demands tant as psychomotor clinical skill. BUILDING TOWARD documentation of nursing assessments and The quality of the nurse's communication THIS STANDARD actions with dates, times, and particulars. is of such importance that it also has been It is essential that the nurse carefully evaluate Such notations nor only provide an accurate singled out from other Standards for the pur- the method used by the schod system for the record, but protect against memory lapses.

33-- 3G Confidential data may be kept in a locationporary texts, in the area of either psychiatriccommunication. Reacquaint yourself with of the nurse's choosing and are not available nursing or communication, are excellent.multicultural norms, practices, beliefs and for any inappropriate party to view. TheVisiting a college or university bookstore may values so your communication with students Buckley Amendment (Cohn, 1988; Oda and be helpful. and families from cultural groups other than Quick, 1977; Wold, 1981) allows parents or How is your writing? Many communities your own will be maximally effective. guardians access to official school files butsponsor writing workshops to assist you in Last, work to build meaningful relation- does not extend to confidential notes the pru- this regard. Use a computer with a spell check ships. Relationships are built through open dent nurse should keep in the interest of stu- if spelling is a problem, or ask a colleague tocommunication and on a foundation of trust dent health and well-being and for theproof materials for you before they are sent and confidence. They do not happen over- protection of one's nursing license (Schwab,out. Good spelling, grammar, construction night. Relationships will be your biggest ally 1988). Consult your state school nurse asso- and syntax reflect favorably upon you as a in achieving your goals. Nurses who have ciation or your state nurse licensure board for professional and may enhance your ability to more than one practice site are particularly an interpretation of laws in your own state.accomplish what you have in mind. challenged with regard to the establishment Implement policies for the storage of sensi- Writing is a good way to share your in-of effective relationships. Changing nursing tive data in your own school setting (Schwab,sights, concerns, or innovations in practice. assignments annually makes the practice of 1991). Prior to writing, outline your thoughts toschool nursing difficult. It often takes years Assess your own communication ability.preserve the essence of your ideas while to build trusting relationships with clients, How do others respond to you? Are you cred- awaiting the opportunity to fully developfamilies, faculty, staff, and administrators. ible? Do you come on too strongly? Notyour ideas. Submit your writing to local Frequent changes in assignment render the strongly enough? Do you have adequate school nurse or education newsletters, state nurse impotent in terms of effecting long- counseling and crisis intervention skills?publications, or national journals. Both Theterm change, and are antithetical to the disci- There are a variety of ways to help yourself inJournal of School Nursing and The Journal ofpline of nursing as a helping profession. Such this area. Classes or courses in counseling School Health are pleased to receive manu-thinking reduces the school nursing role to theory and technique with opportunity toscripts written by nurses in school settings.one of task rather than process. It is impor- practice will help you not only in your nurs- Writing for publication is a way to build thetant that you communicate this aspect of ing practice but also in other aspects of yourbody of knowledge that is school nursing. your role to school district personnel. Work life. Public speaking and assertiveness train- Examine your own values both personally to build collegial, supportive professional re- ing classes can help you overcome shyness and professionally and assure yourself thatlationships both inside and outside the and reticence and build self-esteem. Contem- these values are not negatively affecting yourschool setting. NASN STANDARD 5 PROGRAM MANAGEMENT

Program Collaboration within Collaboration with Management the School System Community Health Systems

ANA STANDARDS OF CLINICAL NURSING PRACTICE TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF PROFESSIONAL PERFORMANCE I. Quality of Care: The nurse systematically evaluates the quality and efffiiveness of nursing practice. III. Education: The nurse acquires and maintains current knowledge in Nursing Practice. VI. Collaboration: The nurce collaborates with the client, significant others, and health care providers in providing client care. VIII.Resource Utilization: The nurse considers factors related to safety, effectiveness, and cost in planning and delivering client care.

(ANA, 1991h) 35 5. THE SCHOOL NURSE ESTABLISHES AND MAINTAINS A COMPREHENSIVE SCHOOL HEALTH PROGRAM

CENTRAL THEME DEFINITION commonly utilized in public agencies. The all students receiving services from the program. Management refers to a range of activities. It necessity of assigning nursing responsibilityThe nurse in the program coordinator role, with includes: (1) the development, coordination to others, and the need to develop healthresponsibility for managing one or more pro- and evaluation of programs and activitiespolicy and procedure, have likewise ex- grams, is likewise expected to demonstrate pecu- concerned with client health; (2) the develop- panded the program management compo- niary and outcome accountability. ment and-implementation of policy and pro- nent of practice. Program management includes the man- cedure concerned with client health; (3) the Community nursing involves service toagement of personnel, as well as involvement acquisition and management of funds neces- populationsoraggregates" (targeted in the formulation of policy (Snyder, 1991). sary to implement client health activities and groups), as well as to individuals. Service to Increasingly, schools are becoming complex programs; and (4) the supervision and evalu- populations requires a program approach. care centers, responsible for the health care of ation of allied health personnel. Within thisEstablishing a vision screening program, asstudents with special health needs. The care standard, client may be the student, family, population-focused nursing, involves nursing of these students is assigned to persons other faculty, staff, or the community. "When the skill in program planning/execution in order than the nurse, and nurses are supervising client is community, the focus is on personal to provide for the delivery of services to thesuch individuals in the care of special-needs and environmental and the health risks ofparticular subgroup. Screening programs are children. Additionally, nurses coordinate population groups" (ANA, 199 lb, p. 7). The implemented as a consequence of the detec- health or health-related programs in which nursing role in case management with the in- tion of a high incidence of a particular condi- others are players. Further, program-level individual student or family is discussed within tion or disability among the members of a volvement suggests the need for the nurse to Standards 3, 6 and 7 and is not included incertain population. be a contributor to the development of this discussion. There are other reasons why program man- school health policy. In a litigious era, policy agement skills are important to school nurs- assumes an ever greater role in the adminis- RATIONALE ing. Legislative intent determines publictration of a school district. Nursing in public health settings may neces- policy which, in turn, drives funding streams. Finally, the dawning of a "managed care" sitate engagement in program-level skills, Public agency funding isfrequently ear-era in public health services financing will such as program planning, development, and marked for a specific purpose so that a given evoke the need for management of health evaluation. Likewise, contemporary schoolschool district will have several pools ofdollars and health services. While the effect nursing requires such a scope of involvement, money from which to draw. Many of theseof managed care upon the public schools is and the school nursing literature has, for are restricted to particular aims, i.e., Special far from clear, nurses, as health program co- some time, recognized this dimension ofEducation, or Migrant Education. Nursingordinators and managers, must be cognizant practice and responded accordingly (ANA,involvement within a particular categorical of the impact of managed care on the health 1983; "By the year," 1993; Igoe, 1980; program carries with it fiscal and outcomeof the client, and of potential threats to the NASN, 1988; Wold, 1981). Program man- incumbency: nursing time purchased by acharacter of the school health program. agement, as a dimension of school nursingparticular program with a restricted funding practice, is a product of the nature of com-source requires the nurse who is part of the munity nursing and the atuding mechanisms program to account for nursing outcomes for

36 rt) MEASUREMENT CRITERIA fion, and other management skills are re- book forged new conceptual dimensions for To incorporate this program into a school quired to meet the objectives in the preceding school nursing in the 1980s. nursing program, the nurse shall: sect;jn. Prior educational preparation and/or Needs assessments may involve reviewing A. Conduct school health needs assessments experience with these skills will be of signifi-.health records or health problem lists in order to identify current health problems and cant advantage in school nursing. to identify commonly occurring health con- identifr the need for new programs. Management courses may be of assistance: cerns and documenting their frequency, de- B. Demonstrate knowledge of existing orsuch skills are taught within many disci-scribing their urgency, or both. They may potential school health programs, the plines, including nursing, education, public also involve surveying other staff, particularly sources of funds for each, district policy health, and business. Management skillsnurses, or parents concerning their percep- related to each, and local, state, and workshops for nurses are offered periodically tion of frequently occurring or urgent health federal law governing each. in many communities. Consult with ad-needs. Health needs should be interpreted C. Develop and implement needed health vanced nursing practice colleagues and/orbroadlytoinclude bothphysicaland programs using a program planning nursing faculty in your area to assist you inpsychosocial health concerns. To limit a process. this regard. school health needs assessment to physical D. Coordinateand manageongoing Texts may also be useful. Contemporary health problems would negate the urgency of nursing, health, or health educationcommunity health nursing texts provide in-such concerns as child neglect intervention, programs and their personnel. formation from both a nursing and a com-adolescent pregnancy prevention and self-es- E.Evaluate ongoing health programs as to munity perspective. Community nursingteem issues. Needs assessments can provide outcomes and communicate findings to texts typically will have chapters or sectionsthe statistical basis for deleting less effective administratorsandtheBoardofspeaking to program planning and evalua-programs and establishing new programs, or Education. tion, needs assessment, nursing management, serve as an impetus for seeking new fimding. F.Develop and implement health policiesepidemiology concepts, public funding of State or national publications are available and procedures in collaboration with health services, health policy, and the politi- to assist the nurse or the school district in the school administration and the Board ofcal process (Stanhope and Lancaster, 1992). inauguration of new programs. An example Education. A useful resource which addresses many ofof a new program implemented recently in G. Pursue alternate or supplemental fundingthe issues discussed within this standard is many school districts is the school-based sourcesforhealthorhealth-related School Health: Helping Children Learn, a pub- health clinic, a model of primary care within programs, as necessary. lication of the National School Boards Asso- the school. School-based clinics can involve H. Participate in budgeting for nursing andciation (NSBA, 1991). Susan Wold's Schoolthe school nurse as generalist clinician, pri- health services as necessary. Nursing A Framework for Practice (1981) is mary care provider, or program manager (see I.Orient, supervise, and evaluate health the most sophisticated publication thus far"Contemporary Models of School Nursing," assistants, aides, and others involved in produced with regard to school nursing. This Chapter 2). Much has been written on the health services delivery. book (recently reissued by a new publisher) role of the nurse practitioner in primary care.

1.Develop (as needed) and/or participate in contains a clearly developed chapter on man- Publications arc available regarding models a school health advisory committee. agement, which includes concepts related to of primary care in the school, notably, a joint program planning and evaluation, budget-statement by national school nurse groups, BUILDING TOWARD ing, needs assessment, and principles under- pubhshed by the American School Health THIS STANDARD lyingthedevelopmentofscreeningAssociation (ASHA, 1988). The role of the Program planning, needs assessment, policyprograms. Together with the Standards ofnurse petitioner is further discussed within development, budgeting, supervision, delega- School Nursing Practice (ANA, 1983), Wold's

-3 7- 4 0 Standard 10, and primary care versus primary tional units or state school nurse associations agement; family life and sex education; sexu- health care, within both Standards 7 and 10. publish compendiums of law covering school ally transmitted disease (STD) education (in- Currently, we are in an era of emerging nursing and school health issues and pro-cluding HIV); and the provision of skilled state and national legislation which desig- grams. nursing procedures to chronically ill, medi- nates schools as the cornerstone for the col- Keep yourself apprised of legislative trends, cally fragile, or technologically dependent laborative delivery of health and human whether or not new legislation carries funding. children (Snyder, 1991). services to children and families. Models Legislative trends result in policy trends which New programs are almost always imple- have been proffered by a variety of organiza- in turn ultimately affect programs and profes- mented to meet unmet health needs and/or dons and foundations (ANA, 1991a; APWA, sional roles. Recognizing the impact of public to take advantage of available moneys. Fund- CLSP, CCSSO. and ECS, 1992; "By the policy, legislation, and regulations upon the ing available for resulting new programs is year," 1993; CDE, 1990; Carnegie Council, school health program at all governmental levels commonly awarded competitively through a 1989; Melaville and Blank, 1991; NCC, is cridcal. Currently, public policy, as expressed grant-winning process. Ability in grant writ- 1991; NCRSC1AH, 1990; Packard Founda- in America 2000: An Education Strateg(USDE, ing is an important skill for the nurse to pos- tion, 1992). Inquire within your district as to 1991) andHealthy People 2000 (USDHHS, sess. Grant-writing workshops are widely the availability of some of these publications, PHS, 1991), reflects a less categorical approach offered through private corporations, univer- or attempt to find them elsewhere. to fimding than cited here. However, commin- sities, and colleges. The source of money for health programs gling of categorical funding is not yet a reality. Another contemporary role for school within schools may be federal, state, or local Examine district policies related to exist- nursing is the coordination of individual public dollars. Occasionally, private funds ing health programs and functions so you be- programs and the School Health Program as may be involved as well. You should have come familiar with them. Further, evaluate a whole. The School Health Program is made knowledge of all school programs which in- district health policies for appropriatenessup of multiple programs or activities, all of clude fiscal allocations for health, or pre- and comprehensiveness, and move to modify which must be coordinated with each other scribe health services, especially those which policy or draft new policy as you see the need. and with ongoing school operations.The are operational in your school setting and are Policy development in school nursing is not Implementation Guide for the Standards of funded in your state or community. School difficult except when sensitive subjects are School Nursing Practice (Snyder, 1991)pre- administrators are not always aware of these undertaken. The nurse should take the lead sents a framework for establishing a compre- resources; further, obtaining this information in the development or modification of health hensive school health program, including is not always easy. You may also be uncertain policy. A draft should be prepared for appro- philosophy, purposes, and goals (p. 6). as to the eligibility of your school setting for a priate decision-makers with supporting ratio- Program planning and evaluation involve given program. State or local school nurse as- nale, and a nurse should be present at the designing objectives or goals for an activity sociations can be helpful here, as can your Board of Education meeting to answer any (such as screening); identifying dates, times, state NASN representative. Belonging to questions. Generally, school districts without places, resources, and needed personnel; edu- NASN will keep you up to date about federal health policies place both their employee',cational and community organization activi- funding trends in school health through their and their students at greater legal risk than ties; ithplementing all of these, utilizing publications,Journal of School Nursingand those with policies. Areas of nursing practice economy of scale (the most cost-effective); theNASNewsletter. where policy is frequently written include and measuring the outcomes. Looking at You should also be familiar with legal stat- medication administration;firstaid and outcomes and noting whether or not goals/ utes governing all categorical programs per- emergency care protocols; communicable objectives were met is the goal of evaluation. taining to the school nurse role, whether they disease cotttrol, including immunization ad- This information is then readily available to be federal, state, or local. Some state educa- ministration; child abuse and neglect man- decision-makers, usually boards of education, 41 who make funding decisions based on sub- nor your supervision is direct (on-site) or in- Last, coordination ability requires skill not stantive data. Program planning and evalua- direct. only in program coordination but also in tion may be used for ongoing nursing A note of caution regarding the use oftime management. The demands on nursing programs or for new programs. The duration health paraprofessionals in the school setting: time are often excessive, and good organiza- of a program may be short, culminating in aprudent judgment must not be compromisedtional and time management skills are essen- few weeks, more lengthy, spanning one or through relinquishment of what is distinctly tial. If you are naturally organized, you will more years, or ongoing. nursing practice, or by assignment of func- find the flow of your professional life easier. Relared to program planning is budgeting. don to individuals who cannot legally per-Talk with other school nurses for time man- Health budgeting is an activity in which form or are not qualified to perform such agement or organizational hints. SNOW, the school nurses are increasingly involved, in function. Such assignment by a nurse or a School Nurse Organization of Washington, part, owing to the complex nature of school school district constitutes a violation of thehas developed a useful calendar for organiz- finance. Ask to see samples of nursing and nurse practice act or other legal statutes. Ob-ing and managing the school nursing year health services budgets from other school sys- tain a copy of the nurse practice act in yourwhich is published by NASN. Analyze your tems. Nurses working alone or in small state and seek interpretation of the statute, ifdays, your priorities, and keep track of how school districts may be expected to generate necessary. you spend your time. What can be done dif- nursing budgets annually and will have a par- If your school district does not have aferently? Whom can you get to help? What dcular need for some knowledge of budget- school himIth advisory committee, form one. must be done? Must it be done by you? How ing. Larger school districts utilize a nursingThe constituency should consist of persons do you handle paper? Can it be streamlined? supervisor or other individual, often a non- both within and outside of the school setting. What can be changed? Still, even the best nurse, to develop the budget for nursing and The more involved the committee with thetime management and organizational skills health services. business of school health, the greater the willnot compensate for an unrealistic Differentiate your role and that of health commitment of the members. School healthworkload. If you assess your situation and aides or health assistants. Discuss roles and advisory committees can assist in a variety of find you are working as efficiently as possible, responsibilities with those you supervise in ways. They can act as sounding boards foryet are unable to meet the demands of the the delivery of nursing and nursing-related you or for other health personnel in the ini- position, it is time to ask for more nursing services. Clarification of role will avoid mis- tiation of new ideas; review health curricu- time. understandings and maximize everyone's ef-lum; provide suggestions and direction for fectiveness. NASN has a policy/resolution program development, implementadon, or statement related to the use of health aides evaluation; assist in needs assessments; and (NASN, 1992a). Participate in the identifica-offer needed assistance and nonvested sup- tion of qualifications, and in the develop- port in times of fiscal constraint. Many of the ment of position descriptions, for healthcategorical programs fundedfor school paraprofessionals. Orient, supervise, and health issues call for input from an advisory evaluate the performance of these persons. committee. Rather than forming several advi- State school nurse associations may have sory committees, develop one larger commit- written materials or resources to assist you in tee or consolidate existing committees into the supervision of aides, assistants or parapro- one group, with subcommittees addressing fessionals. Your style of supervision will differ categorical program requirements or special depending upon the nature of the activity issues. performed by your assistant, and whether or

39-- 4 11 NASN STANDARD 6 COLLABORATION WITHIN THE SCHOOL SYSTEM

PLANNER AND COORDINATOR OF CLIENT CARE

Program Collaboration within Collaboration with Management the School System Community Health Systems

ANA STANDARDS OF CLINICAL NURSING PRACTICE TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE I. Assessment: The nurse collects health data.

11. Diagnosis: The nurse analyzes assessment data in determining diagnoses. III. Outcome Identification: The nurse identifies expected outcomes individualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VI. Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

STANDARDS OF PROFESSIONAL PERFORMANCE I. Quality of Care: The nurse systematically evaluates the quality and effectiveness of nursing practice. V. Ethics: The nurse's decisions and actions on behalf of clients are determined in an ethical manner. VI. Collaboration: The nurse collaborates with the client, significant others, and health care providers in providing client care.

(ANA, 1991h)

-40- 43 6. THE SCHOOL NURSE COLLABORATES WITH OTHER SCHOOL PROFESSIONALS, PARENTS, AND CARE GIVERS TO MEET THE HEALTH, DEVELOPMENTAL, AND EDUCATIONAL NEEDS OF CLIENTS

CENTRAL THEME DEFINITION B. Demonstrate knowledge of the roles of BUILDING TOWARD Collaboration within the school systemrefers to other school professionals and adjunct THIS STANDARD the cooperative and collaborative effortsby personnel, anddelineaterolesand As a health professional working within a thenurse, together with other school person- responsibilities as necessary. non-health care delivery setting, the purposes nel, parents and care givers, to achieve educa- C. Collaborate with parents or care giversand mission of the organization may be dif- tional and health objectives forstudents and regarding client self care. ferent from that to which you are accus- families.The nurse's collaboration with theD. Dialoguewith parents/caregivers tomed. Access the school's philosophy or community is described within Standard 7. regarding ongoing care for clients. mission statement. This will facilitate an un- E.Utilize the expertise of other school derstanding of how the organization sees it- RATIONALE personnel conjointly to meet studentself and how it views nursing and health Many student problems are of sufficient health, developmental, and educational services within-the context of education. In- complexity to require the professional inter- needs. quire about all the curricular offerings within vention of several disciplines working to- F.Functionasaclientcasemanagerthe school setting. Which texts are used and gether, within the school as a team, to best collaborating with school personnel. why? Is there a comprehensive curricular facilitate student and family outcomes. Fur- G. Develop interdisciplinary and plan? How does your school setting interface ther, parents and care givers are important transdisciplinary care plans to facilitatewith other systems, such as neighboring el- membersoftheschoolteam.Many cohesive interventions for student andementary, junior high, or high school dis- psychosocial health concerns as well as Spe- family. tricts? What are expected student cial Education issues can most effectively, orH. Act as an advocate for student and family achievement standards and how are they in some cases, canonlybe minimized or alle- in interdisciplinary collaboration. measured? What are graduation require- viated through a systematic team approach I.Functionas school-home liaisonin ments? utilizing the skills of several professional dis- student/family health concerns. Familiarize yourself with the roles of oth- ciplines and the family working in concert. 1. Make home visits, as necessary, to further ers in the school setting, both professional data collection, planning, implementation and adjunct personnel. Interview them or re- M EAS U REM ENT CRITERIA and/or evaluation for client care. view their position descriptions. Take every To incorporate this standard into a schoolK. Inform administrators and the Board ofopportunity to get to know members of the nursing program, the nurse shall: Educationofcollaborativeplansas staff by attending staff meetings, sharing A. Demonstrate knowledge of the necessary. lunch periods, or seizing other opportunities philosophy and/or mission of the school L.Utilize parent-teacher groups to further to collaborate and provide them with counsel district,the kind and nature ofits nursing goals. regarding student health concerns. Occa- curricular and extracurricular activities, sional role conflict will occur, since the nurs- and its programs and special services. 41 4Li ing role often overlaps, appropriately, with have functioned as public health nurses will family. Home visiting is almost always the the domains of other professionals. Entirely be particularly comfortable with the role ofnurse's purview and has been a traditional role separate and noncontiguous role functionscase manager. Nurses who have experiencefor community nursing since the early 1900s almost never exist within organizationalwith managed care in the hospital or other (Loveland-Cherry, 1992). "Home visits give structures where the agency's mission is a settings may also find some familiar ground. a more accurate assessment.... [and] provide united one, as it is in a school setting. When With complex student and family prob-opportunities to observe the home environ- such predictable role confusion arises, seek to lems, it is wise to develop interdisciplinaryment and to identify barriers and (emphasis identify a mutually acceptable compromise and transdisciplinary care plans. The writtenadded) supports for reaching.. .health pro- with the individual(s) involved. Role articu- IEP is a form of an interdisciplinary care plan motion goals.... Meeting the family on its lation with members of the same discipline within the Special Education structure. Apart home ground also may contribute to the

may differ from school to school as profes-from Special Education, however, there are family's sense of control..." (Loveland- sionals within the same discipline may inter- student needs which benefit from the col- Cherry, p. 474). pret their roles differently. laborative efforts of several disciplinary per- Complex student issues frequently necessi- Many students have needs of such com-spectives. In these instances, utilize your tate a need for informing administrators. Ei- plexity that collaboration with parents orgeneric nursing care-planning knowledge thersingularprofessionaleffortsor care givers is indicated in addition to collabo- and apply the same model to devise an IHP (a interdisciplinary collaborative efforts should ration with school personnel. Parents/care plan of care) which will identify problems, be shared with administrators and boards of givers are a valuable source of information propose interventions, identify participants, education as necessary. and should be consulted regarding client timelines, and expected outcomes, and estab- Finally, acquaint yourself with parent ac- needs and self-care abilities. lish a time to meet again to evaluate thetion groups or with the parent-teacher orga- The very complexity and multidisciplinary progress of the plan. In thinking through in-nization. These groups can often be of nature of many clients' disabilities demand terventions for clients, assume the advocacyassistance to you in your efforts to develop that the school assume the role of client man- role for the student or family, or both. programs for students. agement. The nurse as case manager coordi- Utilize your skills in family assessment and nates and facilitates client services bothinterviewing, and to meet the parts of the within and outside the school. Nurses who care plan which call for involvement with the NASN STANDARD 7 COLLABORATION WITH COMMUNITY HEALTH SYSTEMS

PIANNER AND COORDINATOR OF CLIENT CARE

Program Collaboration within Collaboration with Management the School System Community Health Systems

ANA STANDARDS OF CLINICAL NURSING PRACTICE 7 TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE I. Assessment: The nurse collects health data.

11. Diagnosis: The nurse analyzes assessment data in determining diagnoses. Ill. Outcome Identification: The nurse identifies expected outcomes individualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VI. Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

(ANA, 1991 b)

43 4 7. THE SCHOOL NURSE COLLABORATES WITH MEMBERS OF THE COMMUNITY IN THE DELIVERY OF HEALTH AND SOCIAL SERVICES, AND UTILIZES KNOWLEDGE OF COMMUNITY HEALTH SYSTEMS AND RESOURCES TO FUNCTION AS A SCHOOL-COMMUNITY LIAISON

CENTRAL THEME DEFINITION your school system utilizes social work ser- C.Identify absent or deficient community Collaboration with community health systems vices, such professionals are also skilled and resources,andmovetoestablish refers to the role of the school nurse in inter-knowledgeable regarding community re- community services or programs to fill agency networking as a community health sources. these gaps through joint professional or professional. Collaboration is a product of Many client health concerns cannot be ef- political action. school-community cooperation and results in fectively handled by the nurse alone. Corn- D.Communicateand networkwith identification and optimal utilization of community agencies and resources may assist the community health providers regarding munity resources to benefit the client. nurse and the school team in achieving posi- client interventions, new community tive ends for students and families, or may developments, and ongoing school- WHY IS THIS IMPORTANT FOR assume the primary responsibility for inter- community agency cooperation. SCHOOL NURSING? vention with the student and family. Such E.Functionasaclientcasemanager School nursing is community nursing. Incomplex arrangements require communica- collaborating with community providers. Chapter Two of this document, the charac- tion within the school, and coordination F.Encourage the development of teristics of school nursing were noted. These among and between the agencies, and with interagencycareplanstofacilitate characteristics are harmonious with roles ofthe student and family. cohesive intervention with clients. the community nurses, especially public G.Make joint interdisciplinary or healthnurses andoccupationalnurses MEASUREMENT CRITERIA interagency home visits as necessary. (Stanhope and Lancaster, 1992). The school To incorporate this standard into a school H.Participate in community health nurse is a logical professional within the nursing program, the nurse shall: activitiesasanindividualorasa school system to interface with the commu- A. Conceptualize the nursing role in the representative of the school. nity health agencies and services. Knowledge school setting as an integral part of the I. Conduct communityhealthneeds of community health resources, skill in col- community. assessments. as necessary.

laborating w1zh many agencies, experience B. Identify community agencies as resources 1. Educate school perscnnel as to the role of with multi-problem families, and expertise in forclientsandevaluateeachfor the school nurse in the community. family assessment and home visiting, point to appropriateness,eligibility criteria. K.Evaluate the potential for the this function as a natural and expected role existenceofwaitinglists,costs, establishment of family health centers for the nurse. The school nurse promotes pri- accmibility, and consideration shown to based in, or linked to, the schools. mary, secondary, and tertiary prevention. If clients. 4 4 4 7 BUILDING TOWARD sources so you will make only the best, most advocacy, assessment, planning, and moni- THIS STANDARD appropriate referrals. Often, there are com- toring. Nurses in other settings are struggling The most effective school nurses see them- munity resource directories available which co achieve these aims, which may collide with selves as community health professionals. list each agency and its programs. thegoalsofcostcontainmentand They have a vision of their role as mobile, as As you identify services or resources which gatekeeping. Definitions of case management one of liaisoning, interacting, and cooperat- are absent in your community, reflect ondiffer by discipline and funding source. It is ing with other community professionals to how the void might be filled. For example, ifwise for the school nurse to ascertain how bring about maximum health and health care there are no dentists in your community pro- agencies in the community define case man- for the clients they serve. They do not limitviding care to children on Medicaid, couldagement prior to embarking upon coopera- themselves to service delivery solely within you or the local school nurse association write tive and collaborative agreements. the school setting, but see the surrounding a letter to the dental society? If the children's Successful multiagency involvement in community as a menu of services, programs, protective services network in your commu-complex family health issues can be facili- and people which they can access to serve sm- nity is overworked and underfunded, whattated by the use of an interagency care plan. dents better. Community nursing is therefore can be done about it? A joint appeal to a state Each agency professional assumes a role fol- not only a skill but a mentality. It is nursing or a federal elected official by a group of lowing the identification of problems and the without walls. Creating this mindset for school nurses, social workers, teachers, coun-proposal of interventions. This approach fa- yourself is useful. Your car, the telephone, selors and public health nurses may be effec- cilitates coordination, does not confuse the and perhaps even local road maps, are tools tive. family, avoids unnecessary duplication of ser- you utilize within your role as a school nurse One of the most important aspects of yourvices and, most importantly, allows profes- to access the community and the families ofrole is to know key community providers.sionals working with clients with complex students in your school setting. Secure the name of an individual within fre- needs to share their perspectives and stream- It is essential that you know the local com- quently used resources and agencies andline their efforts. Interagency home visits are munity agencies and resources thoroughly, maintain contact with that individual. Per- also a technique. The school iurse can make both public and private. Visit those fre- sons particularly important to know are thejoint visits with a children's protective service quented by clients in your school setting and local public health nurse, physicians (espe- worker, with a public health nurse, or with a evaluate each. How does the agency or re- cially pediatricians and famil)' practitioners),school professional. source treat clients? How much do they dentists, eye professionals, a children's pro- Some school nurses participate in commu- charge and do they have a sliding scale? Are tective service professional, and probation of- nity health activities, either as professional the professionals and staff providing services ficers. You may also be able to identify representatives of the school, or as private competent and courteous? How easy is the individuals within the following services: citizens. Such involvement can lead to oppor- facility to reach? Is there a waiting list? What adolescent clinics, drug and alcohol treat- tunities for program presentation or inaugu- will the agency or resource expect from the mentcenters,mentalhealthfacilities, ration within schools, or to strategic political client? Is the agency or service ethical? Allwomen's shelters, homeless shelters, EMT networking. Such involvement can further these questions are important: there is noth- units, and hospital emergency rooms. expand the nurse's knowledge of the commu- ing more discouraging for a nurse than to Case management is not a new process for nity. work to motivate a family or a student to seek the nurse in a school/community health prac- Another mechanism for understanding the help in the community only to have thetice. What is new are the myriad definitions community isto conduct a community agency be nonaccepting, too expensive, re- of case management in the literature (Brault health needs assessment, which can be lim- quire a lengthy wait, or to have discontinuedand Kissinger, 1991). School nurses perceive ited to the area immediately surrounding the services. Check out all your community re- case management as coordination of services, nurse's school site(s) or may extend to the larger community. A simple community families as well. Be open to the possibility ofprimary care versus primary health care may health needs assessment can be done by an- using school sites for the establishment ofbe found in Chapter Two, "Contemporary swering several questions: What is the general family health centers utilizing primary care Models of School Nursing," and within Stan- level of health in the community? What are professionals collaboratively with school and dard 10. Family health centers are also fur- the common health problems? What is thecommunity health professionals to bring ser-ther discussed in Standard 10. Expanding level of income? What is the level of employ-vices to families in need. Igoe and Giordano School Health Services to Serve Families in the ment? 'What are the health resources available (1992) have developed a conceptual guide for 2Ist Century, while not referencing the to the community? What is the neighbor- such an enterprise, entitled Expanding SchoolWHO work, subscribes and aspires to many hood or countryside like? Drive through the Health Services to Serve Families in the 21stof the principles of primary health care (Igoe neighborhoods or the countryside around Century. An important conceptualization ofand Giordano, 1992). your school settings and do a "windshield such a center is that it go beyond primary care survey." What kinds of businessesare delivery and embody principles of commu- present? What is the transportation system nity-oriented primary health care, a broader, like? Having an idea of the health of the com- more grass-roots concept espoused by the munity will tell you much about the health of Ahna-Ata declaration, the report of the Inter- the students in your school settings. national Conference on Primary Health Care Utilizing your school health advisoryheld in the USSR, September 1978 (WHO committee is an effective way to involveand UNCF, 1978). community providers in the business of Primary care is different from primary school health and to further expand a com- health care. Primary care is largely regarded munity needs assessment. Community mem- as the first-line provision of health services bers can assist you in planning by identifyingand is often rendered in community clinics, and filling service gaps. physicians' offices, or health department fa- Occasionally, administrators or boards ofcilities. Access and availability are key land- education are not aware that the community marks of primary care services. Primary nurse function is an expected area of school health care involves not only access, availabil- nurse practice. Their view of nursing may beity, and service delivery, but community par- as an emergency care or illness-management ticipation, remediation of the causes of person, since they are legitimately concerned health inequities (e.g., poverty, unemploy- about liability. They may also have a "hospi-ment) and a subscription to the right of all tal" view of nursing which tends to focus citizens to health care. Universal distribution more on technical procedure and less on pro- of essential services with emphasis on vulner- cess. It may be necessary for the nurse to ex- able (high-risk) groups is a principle of pri- plain the importance and significance ofmary health care which differentiates it from client and community outreach as a neces- primary care. Primary health care embodies sary part of the nursing role. not only principles of good primary care but Last, the nursing role as a connunityalso principles of good public health and is health nursing professional may involve ex-currently practiced in the United States by panding school health services to meet not public health nurses, school nurses, and other only the health care needs of students but ofpublic health professionals. A discussion of 4 -46-- NASN STANDARD 8 HEALTH EDUCATION

Health Education

, ANA STANDARDS OF CLINICAL NURSING PRACTICE 8 TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE _ I. Assessment: The nurse collects health data. II. Diagnosis: The nurse analyzes assessment data in determining diagnoses. III. Outcome Identification: The nurse identifies expected outcomes individualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VI. Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

STANDARDS OF PROFESSIONAL PERFORMANCE III. Education: The nurse acquires and maimains current knowledge in Nursing Practice. IV. Collegiality: The nurse contributes to the professional development of peers, colleagues, and others. V. Ethics: The nurse's decisions and actions on behalf of clients are determined in an ethical manner.

(ANA, 199 1 11)

5 -4 7- 8. THE SCHOOL NURSE ASSISTS STUDENTS, FAMILIES AND THESCHOOL COMMUNITY TO ACHIEVE OPTIMAL LEVELS OF WELLNESS THROUGH APPROPRIATELY DESIGNED AND DELIVERED HEALTH EDUCATION

CENTRAL THEME DEFINITION more likely to be retained by the student F.Evaluate health curricula, health Health educationrefers to activitiesby thethroughout a lifetime, particularly if rein- instructionalmaterials,andhealth nurse with students, families, groups, and the forced. The influencing of this population in education activities. school community which facilitate mainte- positive ways has implications for the health G. Encourage the selection or purchase of nance of, or positive change in, health atti- -of the nation. The school, second only to the health education materials for classroom tudes, values, beliefs or behavior. Health home, is the desired setting for the formation or library. education is not limited to formal health in- of favorable health values and behaviors. H. Act as a resource person to school staff struction, and includes nurse interactions The content of this Standard might be regarding health education and health which maintain health, prevent disability,subsumed within Standards 1, 2, and 5. The education materials. and promote client well-being. reader should note that the subject has been I.Promotetheintegrationofhealth made a separate Standard for emphasis. concepts withintheregular school WHY IS THIS IMPORTANT FOR curriculum. SCHOOL NURSING? MEASUREMENT CRIT ERIA J.Furthertheapplicationofhealth The school nurse, as a community nurse, is To incorporate this standard into a school promotive principles within all areas of engaged in a practice that focuses on strate- nursing program, the nurse shall: school life (e.g., food service, custodial, gies which promote adaptive responses re-A. Participate in the assessment of health etc.). sulting in health maintenance and education and health instruction needs K.Act as an advocate for the employment of promotion, and illness, disability and malad- for the school community. certified health education teachers in the aptation prevention. Preventing negativeB. Provide formal health instruction widiin public schools. health outcomes, as well as maintaining and the classroom based on sound learning Educate staff regarding student health promoting health through education, in- theory,asappropriatetostudent concerns. volves the influencing of values and beliefs developmental level. M. Educate staff regarding their own health. which in turn manifest themselves in appro-C. Provide individual health teaching andN. Promote student and staff self care. priate health behavior. The nurse, as the counseling for and with students. 0. Educate parents regarding student health health professional in the school, is in a stra- D. Conduct group meetings for students, concerns and parenting techniques. tegic position to facilitate health behavior staff, and parents regarding particular P.Promote student, staff, and school safety maintenance or change. Children's health health concerns. through health education. values and attitudes are in the process of be- E.Participate in the design and development ing formed. Health values (such as the im- of health curriculum utilizing the Healdo, portance of good nutrition and exercise), if People 2000 health objectives (USDHHS, developed during the formative years, are PHS, 1991) as a guide. BUILDING TOWARD In order for the nurse to become skilled as After curriculum is presented in the class- THIS STANDARD a classroom teacher and in curriculum devel- room or group setting, learning must be An important role for the school nurse in the opment, additional formal education is re-evaluated. Another role, therefore, is the school setting is classroom instruction in quired. Some states require school nurses to evaluation of the health education activity it- health. Health instruction in the school set- become certificated as teachers. Other statesself. Frequently such evaluation takes the ting is often neglected and, when done, may require course work in teaching methods, form of a pre-test or a post-test. Skill develop- not be consistently well taught or conceptual- curriculum, or health education. Seek outment in making wise health decisions might ized. The reasons for this are several. One ofsuch courses, especially those which provide also be employed to appraise health instruc- the most likely explanations is that classroom knowledge and skill in curriculumand tion endeavors. Regardless of the methodol- teachers feel overburdened by the many de- methods. ogy, however, some evaluative measure is mands on their teaching day. Additionally, Prior to the initiation of any classroom or essential to assessing the effectiveness of the classroom teachers who are not school health other school health instruction, it is impor-particular health education program under educators are not always well prepared to tant to determine what are the learning needs consideration. Ultimately, behavior mainte- teach health education content. Health in-of the school community under consider- nance, or change, as appropriate, is the goal struction, therefore, may be an area of unfa-ation. A needs assessment should be con- of health instruction. miliarity or of little interest to the teacher. ducted to determine what individuals or Nurses engaged in direct care have both Further, it is a curricular piece where out- groups within the school community need or the obligation and the opportunity to pro- comes may not be measured by school sys- desire to learn. The U.S. Department ofvide health teaching to assist the client in de- tems or state education agencies. The result, Health and Human Services' publicationcision-making and to promote self care. The too often, is less than optimally designed orHealthy People 2000 delineates nationalnurse should take advantage of each teach- delivered health instruction. health promotion and disease prevention ob- able moment in one-to-one contact with the Nurses, on the other hand, are health pro- jectives for the U.S. population for the yearclient. fessionals with an intrinsic commitment to2000, and is an essential reference for the Other roles for the nurse in health educa- health promotion and maintenance. Further, nurse and the school to utilize in assessing tion involve the selection and evaluation of nurses have expansive health knowledge curriculum needs and in curriculum develop- health education materials, including health when compared to classroom teachers who ment (USDHHS, PHS, 1991). Additionally, curricula, and the provision of nursing exper- are not school health educators, and are,becoming familiar with America 2000: An tise as a health education resource person for therefore, more qualified content experts. Education Strateg, a similar document for staff members. Additionally, nurses often have more prepa- education, will be of assistance ih curriculum Promoting the incorporation of health ration than teachers in child development, development endeavors (USDE, 1991). content within the regular school curricula which is necessary for constructing develop- Knowledge in the building of curriculum can be a creative and imaginative challenge for mentally appropriate teaching units. Nurses, is used by nurses in the development of drug, the nurse. Physics concepts related to pressure however, may have little or no preparation in alcohol, family life, AIDS (and other STDs), and lumens of tubes can be understood through the development of curricula, in writing lesson child care, prenatal, self-esteem, and other lessons on hypertension and the principles un- plans, in delivering instructional material to curricula currently being offered within derlying good circulation. History lessons dis- children, and in the management of a class. many school settings. Access Healthy Peoplecussing the early Pilgrims and their sail across Teachers are prime resources in this regard. 2000 and align your health education effortsthe Atlantic have incorporated concepts re- No one knows better how fifth graders think with national priorities (USDHHS, PHS, lated to communicable disease, and the rela- and behave, and how they best learn, for ex- 1991). tionship between food storage/preservation ample, than an experienced fifth grade teacher. and disease (Hardin, 1974).

4 9-- 5 2 The school district that enjoys the services nesses and disabilities, the nurse will be con- ness. It is an expected role of the nurse to take of a certified health education teacher is in- sulted for explanation, reassurance, and di-a lead in this area. Staff and older students deed fortunate. Such individuals augment rection. It is imperative that contemporary can be instructed in cardio-pulmonary resus- the regular curriculum in imaginative ways school nurses have current pediatric health citation as well as disaster preparedness and and bring with them a strong .1mmitment tocare knowledge. As mentioned within Stan- emergency evacuation procedures. Every the instruction of health contein the school dard 1, update your library and involve yourschool setting should have at least one employee setting. Whenever possible, the nurse should self in home study to assure the accuracy ofcurrent in CPR and first aid who is on the pre- promote and facilitate the employment andyour knowledge of the pathophysiology ofmises at all times. utilization of health education teachers. Pro- pediatric conditions and to ensure that you Finally, parents need to know more about fessional responsibility to the health of thehave a good understanding of the nursingstudent health concerns, both the specific whole child demands nothing less. role in varying conditions. Again, consulta- existing problems of their own children, and The most effective health education with tion may be sought from hospitals or schools the importance of early recognition of poten- teachers, parents, and staff is that in which of nursing. tial health concerns. Specifically, parents may the approach to information exchange is mu- As an example of the nursing role as client benefit from opportunities to learn more tual and collaborative. There are instances, teacher, teachers, staff, and parents can beabout such topics as substance abuse, child nonetheless, where nursing knowledge is es- the recipients of nurse in-service related toabuse, and accident prevention. Parents may pecially helpful to other professionals andtheir own health, and encouraged to engage alsowelcomepositiveapproachesto parents. Teachers and other staff frequentlyin self care. Additionally, clients can beparenting, which can be incorporated into need assistance in understanding student helped to improve the safety of the school set- nurse family life presentations or provided health problems and concerns. As studentsting through periodic education. Related to separately. come to school with a myriad of chronic ill- safety is emergency care and first aid readi- NASN STANDARD 9 RESEARCH

Research

ANA STANDARDS OF CLINICAL NURSING ?RACTICE TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE I. Assessment: The nurse collects health data. II. Diagnosis: The nurse analyzes assessment d.= in determining diagnnses. III. Outcome Identification: The nurse identifies expected outcomes individualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VI Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

STANDARDS OF PROFESSIONAL PERFORMANCE V. Ethics: The nurse's decisions and actions on behalf of clients are determined in an ethical manner. VII. Research: The nurse uses research findings in practice.

(ANA, 1991b) 9. THE SCHOOL NURSE CONTRIBUTESTO NURSING AND SCHOOL HEALTH THROUGH INNOVATIONS IN PRACTICE AND PARTICIPATIONIN RESEARCH OR RESEARCH-RELATED ACTIVITIES

CENTRAL THEME DEFINITION whether the directions chosen are correct and C. Compile results of needs assessments, Research refers to the conduction of statisti- provides accountability for much profes- surveys, pre and post tests, and program cally based studies, including surveys, assess- sional energy output by measuring outcomes. evaluations, and share with other school ments, and evaluations which may or may Further, it is unnecessary for nurses as a pro- nurses, school administrators, boards of not utilize inferential statistics; to qualitative fessional group to rely on research done by education, and others whose efforts research studies; and to the utilization of re- others. Reviews of nursing and school health benefit the school community. search findings in practice. journals elucidate many research studies done D. Comply with existing school district within the domain of school nursing but con- policyregardingthe conducting of RATIONALE ducted by other professionals. The number research. Schoolnursesareamongthemost of school nurses doing research and publish- E. Use federal guidelines for the protection advantaged of all nurses, because their work ing their results is increasing, however. This of human subjectsinallsurveys, setting is a natural place in which to study is encouraging, and is undoubtedly reflective assessments,evaluations,andother health problems, measure the effectiveness ofof a growing exposure co statistics and re- research. programs, and contribute to a growing bodysearch courses as part of baccalaureate or F.Apply the results of research findings to of knowledge about nursing. The nature of master's degree programs. Doing research thedevelopmentofpoliciesand school nursing, as also community nursing, within the discipline strengthens all of nurs- procedures in theinstitution,to lends itself nicely to measurement: sinceing by building a body of school nursing guidelinesforclientcare,program school nurses work with populations or tar- knowkdge, which school nurses can share. It development, professional development, get groups, programs (e.g., screening or health also increases nursing's credibility in the and to staffing and institutional issues. education programs) are devised to deliverworld of education. G. Collaboratewithresearchersfrom nursing services to these groups. An expected outf.ide the educational system whose result of program implementation is evalua- MEASUREMENT CRITERIA research aims have a legitimate health or tion. School nurses also conduct school health To incorporate this standard into a school educational purpose. needs assessments. Both program evaluation nursing program, the nurse shall: and needs assessments, as well as other school A.Identify issues of concern, patterns of BUILDING TOWARD nursing activities, are forms of research. health/illness, function/disability, recurring THIS STANDARD There has been a clarion call for more re- signs and symptoms, utilization patterns, or Many nurses may find the notion of conduct- search, for "clinical investigation" (Chauvin, other phenomena as potential research ing research to be intimidating. Research is 1991) by school nurses. Being able to mea- questions. seen as something remote, abstruse, and not a sureactivitiesisexceedinglyimportantB. Collect data in the school setting and part of "real" nursing. Yet these same profes- within school nursing. It tells the nurse relate the data to client health problems. sionals would agree that pre- and post-tests are important when implementing a healththis area. Recommended texts are listed in was discussed under Standard 5, Program education program, or that a needs assess- the Bibliography in the appendix of this pub- Management. Databases are valuable in ment is appropriate as part of establishing the lication. If you plan to do fairly sophisticated school nursing beyond the level of schools or need for school-based clinic services. Thestatistics as part of your study, statistical pro- districts. Encourage your state school nurse problem may be, in part, that school nurses grams designed for computer use will do yourorganization to develop a database about the need to expand their vision of whv is re- stafistics for you. school nurses in your state using information search to include the more commonplace ac- Identify individuals who have research garnered through membership applications, tivities of everyday school nursinglife. skills. Master's or doctorally prepared nurses renewal notices, etc. This database could Examples include needs assessments, parent or others in your school district can assist you contain information about school nurses in or teacher surveys, program evaluation, or with the research design. Nearby universitiesthe state who are members, the numbers of the generating and compiling of statisticsor colleges may have faculty who could be part-time or hill-time nurses, the number of and statistical documents for end-of-the- approached for assistance or who might likeschools served by each nurse, the size of the year reports. All of these activities are descrip- to do a study with you. Statisticians at theseschool district, the educational levels of the tive research. institutions may give you guidance as to theschool nurses in the state, the level of service Additionally, school nurses confront prac-kind of statistics you will need, or they may (i.e., elementary, secondary, preschool, Spe- tice situations daily which lead to asking do the actual computations for you. Severalcial Education, etc.), and salaries, benefits, questions of themselves or of others. This nurses within z district or a community may and other information which the association Standard encourages the nurse to attempt towish to cooperate in conducting a research collects. A database might also assist in iden- answer some of those questions or to seek out study. Be sure to adhere to federal guidelines tifying similar information concerning non- others who have the resources or abilities to for the protection of human subjects when- members. do so. Should questions arise to which you ever applicable (Code of Fed. Reg., 1986). don't know the answers, or if a survey or an None of this precludes the return to school evaluation you have done answers some ques- to acquire your own research skills. Most tions but asks still bigger ones, iocate some master's programs have the option of a thesis, help in order to design a more sophisticatedwhich will allow you to learn research skills study. If you sense you are witnessing a and statistics in order to conduct a study and change in some aspect of school nursing, thewrite the thesis. Qualitative research is an ex- school health program or client care issues, citing new frontier for school nursing. Quali- would it be worthwhile to verify your suspi- tativeresearchinvolvesanonstatistical cion in some way? Asking a question or a- approach to understanding problems and an- pressing a concern is the beginning of a swering research questions. Seize the oppor- research study. tunity to pursue master's study ifitis Begin by accessing resources available topresented to you. You will not only gain valu- you for your own study or use. Look at aable information, but, just as important, you good nursing research text to give yourself an will come out of the educational program idea of where you are going and what needs feeling more competent and better equipped to be done. Reviewing a research text also as- to conduct research. sists in developing a mindset for research; re- Whether or not you conduct research stud- viewing epidemiology texts or chapters is a ies, developing a database is important so also a good way to expand your thinking in that you can generate statistics. This subject

-5 3-56 NASN STANDARD 10 PROFESSIONAL DEVELOPMENT

ROLE WITHIN THE DISCIPLINE OF NURSING

Professional Development

ANA STANDARDS OF CLINICAL NURSING PRACTICE 10 TO WHICH THIS SCHOOL NURSING STANDARD PARTICULARLY APPLIES

STANDARDS OF CARE I. Assessment: The nurse collects health data. II, Diagnosis: The nurse analyzes assessment data in determining diagnoses. III. Outcome Identification: The nurse identifies expected outcomes individualized to the client. IV. Planning: The nurse develops a plan of care that prescribes interventions to attain expected outcomes. V. Implementation: The nurse implements the interventions identified in the plan of care. VI. Evaluation: The nurse evaluates the client's progress toward attainment of outcomes.

(ANA, 1991b)

54 5 7 10. THE SCHOOL NURSE IDENTIFIES, DELINEATES AND CLARIFIES THE NURSING ROLE, PROMOTES QUALITY OF CARE, PURSUES CONTINUED PROFESSIONAL ENHANCEMENT, AND DEMONSTRATES PROFESSIONAL CONDUCT

CENTRAL THEME DEFINITION sue in school nursing as important as thor- are therefore ever-present dangers; thus, the Professional development refers to the process oughly apprehending the nature and poten-necessity for involvement in professional of role-taking, role-implementation, and role tial of the nursing role in the school setting. school nurse organizations and for continu- enhancement by the school nurse. It includes The nurse in the schools must be cognizanting education becomes most important. The preparation for the role; its delineation, clari- of the relationship of nursing to the educationalcognitive stimulation, networking, and colle- fication, and actualization; the legal, ethical, system and must be able to articulate the mis-giality provided by involvement in profes- and political parameters of practice; and ele-sion of nursing within the context of educa-sionalschoolnurseorganizationsare ments of professionalism, particularly, pro- don. At the same time, schools hire nursesimportant sources of professional support motion of quality practice, evaluation of because they are nurses and not edq.ators, al-and rejuvenation for any school nurse. nursing practice, continuing education, pro- though a few states do require nurses to be Because a school nurse is often the only fessional relationships, and professional com- certificated as teachers, as well. Retaining ahealth care professional in the school setting, portment. nursing identity in a non-health care setting, evaluation of nursing practice may be done while at the same time expanding a vision ofby persons with limited knowledge about the RATIONALE healthtoencompassoptimalwellness true nature of nursing. In order to secure a School nursing practice necessitates a clear, through optimal education, is a challenge. more accurate picture of one's practice, confident understanding of school nurse role. It behooves the nurse to examine what areevaluation by another school nurse, or by That is, a deep, unequivocal, self-assuredprofessionally agreed upon definitions ofoneself, is most important. Certain levels of view of what is expected, what is possible,school nursing practice, to identify one's own accountability and responsibility must be and what national organizations have defined philosophy (statement of beliefs) aboutmaintained despite the absence of other nurs- as reasonable and common practice for schoolnursing, and to understand the ing professionals. school nursing. Without this vision, theschool's position in relation to the health nurse experiences considerable role confusion needs of its students. Such clarity and confi- MEASUREMENT CRITERIA and is vulnerable to assuming role function dence will enhance the nurse's ability to co- To incorporate this standard into a school assigned by non-nurses, or to underestimat-gently communicate nursing role to members nursing program, the nurse shall: ing the potentialities and the full, rich re- of the school district, and expand the school'sA. Identifyaclear,confidentrolefor wards of practice. Such misplacedrole vision of the nursing role. nursing based on national standards of conceptualization can lead to years of misdi- School nurses practice alone even if they practice,national,stateandlocal rected nursing energy and neglect of criticalare part of a school system employing morc descriptions of school nursing, and a client health problems. There is no single is- than one nurse. Obsolescence and isolation personal philosophy of school nursing. 55 5 0 B.Clarify personal values in preparation for BUILDING TOWARD Decide, then, on what you believe school school nursing practice. THIS STANDARD nursing to be. Beliefs about school nursing C. Participateintheplanning/design/ The most important thing you can do forconstitute a personal philosophy. A philoso- organization and location of the nurse's yourself is to arrive at a comfortable, confi- phy is based on your values, your view of office or clinic as possible. dent attitude with respect to your role. Begin nursing, clients and health. What is nursing D. Utilize opportunities to communicate,with state or national publications which to you? What is school nursing to you? Some- clarify, and implement a defined role for provide definitions of role and function. The times, reviewing the early history of nursing nursing. National Association of School Nurses and theand school nursing helps us reconnect with E. Market school nursing to administrators, American School Health Asseciation have more our reasons for choosing nursing initially. boards of education, staff, and parents. clearly defined school nurse role and function Susan Wold's book, School Nursing: A Frame- F.Project nursing program and staffing than have other organizations. Read and digest work for Practice (1981), describes the his- needs to decision-makers. NASN and ASHA publications as well as rel- tory of school nursing in the United States G. Demonstrate sensitivity to the politicsevant publications of the American SchoolandEurope.TheAmericanNurses' and organizational structure of the school Healih Association; the American Nurses' Association's Nursing: A Social Policy State- setting. Association, Division of Community Health ment is a provocative look at the nature of H. Develop position descriptions to guide the Nursing; the National Education Associa- contemporary nursing (ANA, 1980a). Con- hiring, practice, and evaluation of nurses. tion; the American Federation of Teachurs; tinue to clarify your values. What is your po- I.Utilize instruments to evaluatethe National Association of Pediatric Nurse sitionwithregardtosexuallyactive performance which appraise quality inAssociates and Practitioners; the American adolescents? Abortion? Sex education? Rac- nursing practice rather than effectiveness Public Health Association, Public Health ism? Why should the school have a role in of programs. Nursing Section; and the National Associa- health care? In primary care? In primary J.Conduct self evaluation, promote nurse tion of State School Nurse Consultants. The health care? What role should the school and peer evaluation, and participate in the more you read, the more you will see the same society play with the new immigrants? What evaluation of self by others. themes reappear. Reiteration of themes is sig-does health mean to you? Is it a right? Who is K. Demonstrate knowledge of the legal nificant, because it means several professionalsentitled to health care? What role should the aspects of school nursing practice. representing various school nursing, nursing or federal government play, if any, in health care L.Practice school nursing with a school health organizations have separately, and for children? Are we at a crisis point in the de- consciousnessof communitynursing at different times, identified the same concepts livery of health care for children as Oda ethics. as significant for practice. Many long, thought- (1989) suggests, and what will it take to in- M. Maintainprofessionalresponsibility, ful hours went into the products of thesefluence political decision-makers toward a accountability, and behavior. groups, and they will not only be of assistance to national health policy? It is not necessary to N. Participate in school nurse professional you, but also to your school administration who alter your values. Rather, what is important is activities at local, state, and national may have questions or be uncertain about as- knowing what your values are. levels. pects of your practice. Revic-Ning local school Fundamental to conceptualizing your phi- 0. Pursue continued professional growth nurse position statements can assist you, as losophy is the need to consider whether the and development through education andwell. Other school nurses can offer insightful school should be involved in primary care, national certification. perspectives on role. Select potential schoolprimary health care, or both. Primary care P. Shareprofessionalperspectives with nurse mentors carefully, however. Talk with refers to first-line medical and health care, school nurse colleagues through those who are admired, imaginative, :-ind controlled by the providers, but community- professional publications. whose practice you would like to emulate. based and frequently accessible. Primary care 5 6 5) services do not ,uarantee essential services tolosophy. They strive for universal access and which will enhance your practice and the everyone nor do they necessarily offer services affordability, espouse empowerment of the mission of your program(s) by reducing your at affordable costs to those without health in- client, target those at risk for health prob- stress and promoting collegiality and collabo- surance. They do, however, frequently pro- lems--particularly preventable health prob- ration. vide services beyond the level of what is an lemsand promote remediation of social In this tight fiscal time, physical space is "essential" level of care through referral and aand economic concerns. sometimes an issue for school nurses. If space systematic use of third-party insurers to cover The location and utilization of your work is inadequate in your setting, negotiate for a cost. Primary care services may not focus asspace is important to consider. Organizemove to a different location, or, minimally, much on prevention and promotion as they your space to be as functional as possible. for an improvement in the space currently al- do on curing and restoring, but will employ The arrangement of the nurse's office orlotted to you. Having adequate space is criti- all the best technologies in the process of cur- clinic is a reflection of your philosophy. If acal to your providing the services you are ing and restoring. larger "suite" is available to you, plan the uti- hired to provide. Physical space is also power. Primary health care, by contrast, refers to lization, function and decor to the best ad- Power, in the positive sense, is important for an array of essential services, those which thevantage. Ask to participate in the design ofschool nurses to cultivate. The way you are client cannot do without for a healthy life. the nurse's office or clinic for new schoolsseen by others will have much to do with These services are to be provided to every citi- under construction. Decide what you willyour effectiveness and the effectiveness of zen, regardless of degree of health risk, and at call your place of professional activity. Will it your program(s) in the school setting (Bays, a reasonable cost. Primary health care does be the nurse's office, the health office, the 1991). A perception of yourself as an equal not necessarily go beyond a guarantee of es- clinicor other? If you see nursing in this professional entitled to space and other pro- sential services, but does commit to access, setting as associated with the curative and re- fessional courtesies is vital to your success. equity, and affordability, with particular em-storative functions of care, "health," or Communicating and clarifying your role phasis on "vulnerable populations" (Meleis, "clinic," may be a more appropriate term for to others is an ongoing endeavor. School per- 1993). Primary health care services are both your space. On the other hand, nursing may sonnel have somewhat stereotypical views of curative and restorative, as well as preventivebe viewed as a discipline which assists the cli- nursing generated by media and notions of and promotive (WHO and UNCF, 1978). ent to achieve optimal levels of health encom- hospital nursing. Both the presentation of A key feature of primary health care is that passing not only curing and restoration, butyour education and your attire should be governments (i.e., schools) are involved and health and wellness promotion. "Nurse," considered here. Initially, staff may not know committed to the health of the population.then, might be seen as compatible withyour educational background. Introduce Further, the system which delivers primary"health" and helping and not solely associ- yourself and make it known to the staff what health care is integral to the entire health careated with illness or pathology. you can do. Use the initials "R.N." whenever system of the country. Ideally, co isumers are The location of your space is also impor- possible. Such a designation is widely recog- involved in the planning and delivery of care. tant. Is your work space situated so as tonized by members of the public and, further, Primary health care subscribes to a philoso- maximize collaborative efforts with others in will dispel discussions about whether or not phy which aims to alter major sociopolitical the school? Are you conveniently located to you are a "real" nurse. There is nothing pre- barriers to achieving and maintaining health, promote ease of communication with othersumptuous or egotistical about identifying such as poverty or unemployment. It would significant constituencies, such as adminis- yourself as a Registered Nurse. You have seem clear that most school nurses have been trators, other clinic personnel, or significantworked hard for the license associated with practicing primary health care for years.school support staff? Do students have easy the title, and its use will enhance your efforts Those who are nurse practitioners practice access to your setting? Working toward these to be acknowledged and respected within the primary care with a primary health care phi-ends will result in physical space alterationsschool setting. Simdarly, the use ofR.N."

-5 7- 60 should be not be avoided because of multiplereference to the nurse practitioner is madefamilies, in the diversity of cultural groups levels of basic nursing preparation in thewithin Standards 1 and 5.) The nurse whoserved, in the number and nature of special United States, or because of your educational also functions as a nurse practitioner will programs within each school site, in the achievements beyond your initial nursing prompt the school district to readjust the way number of school sites served, and in the dis- education. Your basic license is that of a in which it views its mission. Studies havetance among and between schools all affect nurse, and you should identify yourself asshown that nurse practitioners who do not the amount of nursing time allocated to each such. If you are proud of it, others will be as prepare the school for a change in role aresite or to each program (Snyder, 1991). well. Additional certifications or degrees unsuccessful in operationalizing newly ac- Nursing assignments that allow the nurse to should be used, as you choose, in order to ex- quired skills. Districts must be prepared fordo only the very minimal in care delivery to pand further understanding of your role. A the necessity of assuming greater liability andpupils, families and staff, fragment the mini- name tag is a consideration as well. in cooperating with community physicians inmal service delivered, undermine the ability Some school nurses feel that the use of a the generation of standing orders. Both of the nurse to build the relationships so es- "lab" coat enhances their credibility and im- NAPNAP and NASN can assist the newsential for effectively serving in the school mediately identifies them as a health profes- school nurse practitioner in strategies to opti-setting, and demoralize the nurse as a professional. Others feel that anything ocher than mize role. Reading relevant position state- sional. street attire creates a barrier between them- ments developed by both these organizations One of the more significant aspects of selves and students. You may wish to try it as well as Recommendations fir Delivery of Com-school nursing practice is communicating both ways and assess the reaction. prehensive Primary Health Care to Children andyour role and function to boards of educa- Other ways to communicate your role and Youth in the School Setting (ASHA, 1988) will tion. Making a presentation to your Board of to enhance your visibility are to write a sec- facilitate clarification and direction. Telephone Education requires forethought, planning, tion for the school's parent newsletter, and to or write other nurses who are school or pediatric and political acumen. School district boards attend back-to-school night or open house. nurse practitioners in the school setting or who of education are usually elected officials who Volunteer for committee or school activities have been involved in the delivery of primaryare barraged with requests for funding. The such as fund-raisers, etc. Visibility is impor- care for practical advice. most compelling and substantive arguments tant for understanding, for your image, and Any successful school nurse will have a fin- have the most chance for success. Parents, for developing a sense of belonging. Developger on the political pulse of the school and pupils or staff can be asked to argue on behalf a mentality which says that you are as much a will be sensitive to the politics of the schoolof nursing and school-based health care pro- part of the school as anyone else. Then set out setting. Bringing about change is a tactful,grams. Presentations should focus on the to become part of the school and to imple- deliberate, planned process which strategizes needs of students and families 2nd avoid the ment the role you have defined for yourself. and achieves goals over time through rela-appearance of self-service. Your presentation School nurses who are also nurse practitio- tionships and political acumen. Such skill is may be limited to a very few minutes. Re- ners are becoming increasingly significant in useful in projecting nursing/health program member that concrete facts are the most per- the delivery of primary care and primaryand staff needs to appropriate administrators suasive inbackingupphi losophical health care to students whose access to health and in alerting them to emerging health arguments. Within school districts, there are care is limited or nonexistent (Igoe and Sil- trends and patterns. Nursing staffing should differing administrative procedures for ac- ver, 1984). These professionals divide their be based on student and program need rathercessing boards of education. Some school dis- time between the generalist clinician func-than on enrollment numbers. That is to say, tricts may have very informal systems, while tion and the primary care function of schoolvariations in socioeconomic level, in theothers require consent, or presentation by nurse practice (see "Contemporary Models ofnumber of students with special needs, in the someone other than the nurse. School Nursing," Chaptcr 2). (Additional number and complexity of multiproblem 5 8-- 61 Clarity of role function will be of benefit to may be appraised by a non-nurse, clinicalics. A comprehensive community health you in the development of position descrip- knowledge, nursing diagnosis, judgment, ac- nursing text will have a chapter applying eth- tions and vacancy announcements. Again,don and intervention can only be appropri- ics to community nursing. Other ethics re- professional association standard. and roleately evaluated by another nurse. Thesources could also be consulted. Ethics in definitions can be utilized to write an im-American School Health Association hascommunity nursing is different from ethics proved position description for your schoolauthored a guide to assist the non-nurse ad-within hospital nursing because community setting. NASN, ASHA, and some state school ministrator to evaluate nursing performance nursing deals with populations as much as nurse groups have position descriptions for in instances where itis necessary (ASHA,with individuals. The good of the group and the traditional clinician role (including the 1987). the larger community is considered in addi- management function), and the primary care In these increasingly complex times, school don to the good of the individual. The nurse (nurse practitioner ). role (CSNO, 1990; nurses should access all legal statutes which might also consider the establishment of eth- CSNO, 1991; NASN, 1992a; Snyder, 1991).affect practice. These would include federal ics committees in school districts, as hospitals A well-written position description can law in relation to categorical programs, par- have done. On the occasion when difficult serve as a performance evaluation instru- dcularly Special Education and Chapter 1, decisions arise, the ethics committee could ment. School nurse performance evaluationstate law governing nursing practice, state convene. This approach is sounder than relin- should focus on the quality of the nursinghealth and safety regulations, education quishing ethical decision-making to a single in- performed by the individual. Evaluation lim- codes, and any local codes which may apply. dividual. Care must be taken by all concerned to ited to whether or not a nurse makes referrals, Particularly important for the nurse is knowl- sift out kgal issues from ethical concerns and to conducts screenings, or performs physical as- edge of the state nurse practice act. There deal with both accordingly. In the final analysis, sessments only indirectly measures quality ofmay be conflict between what is prescribed it is most appropriate for the nurse to be in- performance. Evaluation instruments shouldby the nurse practice act and what is required volved in this arena, since many potential ethical reflecthow wella nurse performs nursingwithin state education statutes. dilemmas for schools involve pupils with physi- function rather than whether or not a func- Side by side with legal aspects of practice cal or emotional health concerns. tion was achieved. are ethical considerations. Ethics is a branch Professional responsibility involves account: An Evaluation Guide for School Nursing of philosophy which looks at moral issues ability for nursing actions and a willingness to Practice Designed for Self and Peer Review and principles guiding human action and take risks. School nurses should seriously con- (NASN, 1985) is an excellent instrumentseeks to resolve rather than solve dilemmas. sider carrying their own professional liability in- based on the earlierStandards of School Nurs- Ethics may involve the application of prin- surance inaddition toliabilityinsurance ing Practice(ANA, 1983). Nurses are encour-ciples such as Justice. The professional must provided by the employer. The employer may aged to utilize it in nursing performance do what is right according to a "Code of Eth- have liability insurance but not necessarily of a evaluations alone, or in combination with ics" for the discipline. In the case of school nature to cover the nuances of nursing practice. other evaluative procedures. Nurses should nursing, these guidelines are theCode of Eth- Membership in NASN and/or NAPNAP pro- evaluate themselves on an ongoing basis. ics with Interpretive Statements fir the Schoolvides access to professional liability insurance. When the school requires formal evaluation, Nurse(NASN, 1990) and theCode for Nurses Responsibility involves meeting deadlines, fol- a nurse peer may conduct the evaluation if no with Interpretive Statements(ANA, 1985). In lowing through with professional commit- nurse supervisor is available, or to supple- other instances, ethical dilemmas may not ments, and performing one's role competently ment a non-nurse supervisor evaluation. Fre- have right or wrong absolutes. Rather, they and conscientiously. Professionalism is also de- quently, nurses are evaluated by non-nurses. involve conflict arising out of oppositional meanor and image. Dress and appearance While some aspects of employee performancestances based on strongly held values. Resolu- should be in keeping with what is acceptable are generic to many service disciplines and don should be based on a knowledge of eth- in your work setting (Bays, 1991). -5 Parr of professional responsibility is contri- One measure of professionalism is national century of human history. These papers, bution to the discipline through participa- certification as a school nurse or school nurse written by nurses within nursing specialties, tion in professional school nurse and other practitioner. Certification validates your cur-are available from the ANA. Igoe and professional organizations. Join your state rency in the field. School nurse certification Giordano (1992) co-authored the paper for school nurse association and become an ac-is currently offered through the Nationalschool nursing. Their penetrating look at the tive member. Join one or more national orga- Board for Certification of School Nurses, health needs of students and families, entitled nizations and endeavor to attend their annualoriginated by the National Association ofExpanding School Health Services to Serve meetings. Membership in school nurse asso- School Nurses, and the American Nurses' As- Families in the Twenty-First Century,is ciations is valuable for your "mental health" sociation Credentialing Center, also inde- "must" reading for the new as well as the ex- and reduces the professional isolation which pendent of its parent organization, the perienced school nurse. Their premise is the school nurses, in all roles, often experience. American Nurses' Association. use of schools as either school-based or You might also consider activity in your local Finally, it is usefill to consider from time to school-linked centers to provide primary care school nurse unit or collective bargainingtime where the future is taking us, or, putto families (also discussed in Standard 7). unit. Professionalism is also keeping yourselfanother way, where we will take the future.This concept would seem to be optimally ef- current with developments in the field and, These are tumultuous times as regards public fective if community health professionals in general, continuing to advance your edu- funding for health, education, and social ser- with public health views and visions function cation as a lifelong professional commitment. vices. The American Nurses' Association has as, or cooperate with, primary care personnel You owe it to yourself to keep your mind and developed a series of "white papers" examin- in the delivery of services to families. spirit invigorated with professional growthing the health care needs of individuals and and development activities. families as we prepare to enter yet another REFERENCES

American Federation of Teachers, Council for Exceptional Children, American School Health Association (1988). Recommendations fir de- National Association of School Nurses, & National Education livery ofcomprehensive primary health care to children and youth in Association (AFT, CEC, NASN, & NEA) (1990). Guidelines the school setting. Kent, OH: American School Health Associa- and delineation of roles and responsibilities for the safe deliveg of tion. specialized health care in the school setting. Reston, VA: Council for Exceptional Children. Association of Community Health Nursing Educators (ACHNE) (1990). Essentials of Baccalaureate nursing education fir entry level American Nurses' Association (ANA) (1980a). Nursing: A social policy practice in community health nutsing. Lexington, KY: Association statement. Kearneysville, WV: American Nurses' Publishing. of Community Health Nursing Educators.

American Nurses' Association (1980b). Statement on school nursesAssociation of Community Health Nursing Educators (1991). Essen- working with handicapped children. Kearneysville, WV: Ameri- tials of Master's level community health nursing education fir ad- can Nurses' Publishing. vanced practice. Lexington, KY: Association of Community Health Nursing Educators. American Nurses' Association (1983). Standards of school nursing practice. Kearneysville, NM American Nurses' Publishing. Bays, C.T. (1991). The school nursc: Enhancing professional recognition. Journal of School Nursing 7(3), 18-24. American Nurses' Association (1985). Code fir nurses with interpretive statements. Kearneysville, WV: American Nurses' Publishing. Brault, G.L. & Kissinger, L.D. (1991). Case management: Ambigu- ous at best. Journal of Pediatric Health Care, 5(4), 179-182. American Nurses' Association (1991a). Nursing's agenda for health care reform. Kearneysville, WV: American Nurses' Publishing. Bulechek, G.M., & McCloskey, J.C.(1992). Nursing interventions classifications (N.I.C.). St. Louis, MO: Mosby Publishing Co. American Nurses' Association (1991b). Standards of clinical nursing practice. Kearneysville, WV: American Nurses' Publishing. By the year 2000 (1993). Sacramento, CA: California School Nurses Organization. American Public Health Association, Public Health Nursing Section (APHA) (1981). The definition and role of public health nursing in California Department of Education ,(CDE) (1990). Not schools alone. the delivery of health care. Washington, D.C.: American Public Sacramento, CA: California State Department of Education. Health Association. California Nurses Association (CNA) (1990). Nursing standards for American Public Welfare Association, Center for Law and Social early intervention services for children and families at risk. San Policy, Council of Chief State School Officers & Education Francisco, CA: California Nurses Association. Commission of the States (APWA, CLSP, CCSSO, & ECS) (1992). Confidentiality and collaboration: Information sharing in California School Nurses Organization (CSNO) (1990). Guidelines interagency efforts. Denver, CO: Education Commission of the for the recruitment and employment of the school nurse. Sacra- States. memo, CA: California School Nurses Organization.

American School Hcalth Association (ASHA) (1987). EvaluatingCalifornia School Nurses Organization (CSNO) (1991). Job descrip- school nursing practice: A guide for administrators. Kent, OH: tions. Sacramento, CA: California School Nurses Organization. American School Health Association. -61-64 Carnegie Council on Adolescent Development, Carnegie Corpora- Hughes, D. (1993, Winter). Managed care and Medi-Cal issues and tion of New York (1989). Turning points: Preparing American concerns. Public Health Watch, pp. 5-6. California Public Health youth fir the 2Ist century. The report of the task firce on education Association, North. of young adolescents. Washington, D.C.: Carnegie Council on Adolescent Development. Igoe, J.B. (1980). Changing patterns in school health and school nursing. Nursing Outlook, 28 (8), 486-492. Carpenito, L.J. (1992). Nursing diagnosis: Application to clinical practice. Philadelphia, PA: J.B. Lippincott Co.. Igoe, J.B. (1987). The role of the community health nursing specialist working with school age youth. Unpublished paper, University of Chauvin, V.G. (1991). Clinical investigation: A vital part of school Colorado Health Sciences Center, School of Nursing. Denver, nurse practice. School Health Watch, 3 (2), 3-5. CO. (pp. 132-152).

Code of Federal Regulations, Title 45, Section 46 (1986). Protection Igoe, J.B, & Giordano, B.P.(1992). Expanding school health services to of human subjects. (USDHHS publication, June 3). serve families in the 21 st century . Washington, D.C.: American Nurses Publishing. Cohn, S.D. (1988). Legal issues in school nursing practice. School Nurse, 4 (1), 9-12. Igoe, J.B., & Silver, H.K. (1984). Improving health care in the school setting. Nurse Practitioner, Sept./Oct., 7-9. Commission on Teacher Credentialing (CTC) (1989). Standards of program quality and effectiveness fir developing and evaluating pro- Igoe, J.B., & Speer, S.E. (1992). The community health nurse in the grams of professional school nurse preparation in Califirnia. Sacra- schools. In M. Stanhope & J. Lancaster (Eds.), Community mento, CA: State of California, Commission on Teacher health nursing: Process and practice for promoting health (pp. 707- Credentialing. 730). St. Louis, MO: Mosby-Year Book, Inc.

Gamble, S.W. (1989, May). Management on the defensive: Working Lewis, K.D., & Thomson, H.B. (1986). Manual of School Health. successfully within a changing power structure. Paper presented at Menlo Park, CA: Addison-Wesley Publishing Co. the 26th International Hospital Federation Congress, The Hague, Netherlands. Loveland-Cherry, C.J. (1992). Issues in family health promotion. In M. Stanhope & J. Lancaster (Eds.), Community health nursing: Gregory, E. (1991). Nursing practice management. Journal of School Process and practice for promoting health (pp. 470-483). St. Louis, Nursing 7 (3), 26-27. MO: Mosby-Year Book, Inc.

Haas, M., Gerber, M.J.V., Kalb, K.M., Luehr, R.E., Miller, W.R., Marriner-Tomey, A. (1989). Nursing theorists and their work. St. Silkworth, C.K. and Will, S.I.S. (1993). The school nurse's source Louis, MO: C.V. Mosby Co. book of individualized healthcare plans. North Branch, MN: Sun- rise River Press. McCarty-Marple, M. (1991). P.L. 99-457 and case management in school nursing. Califirnia School Nurse, Fall, 22-25. Hardin, A. (1974, January). Integrating health into the curriculum. Unpublished manuscript as parL of a course, Santa Rosa Junior College, Santa Rosa, CA. 6 2 6 Mehl, R., & Whisenant, J. (1990, June). Computer use in the schoolNational Association of School Nurses (1985). An evaluation guide fir health office. Paper presented at the annual meeting of the Na- school nursing practice designed for self and peer review. tional Association of School Nurses, New Orleans, LA. Also on Scarborough, ME: National Association of School Nurses, Inc. audiocassette: (Cassette recording No. 5-71). Scarborough, ME: National Association of School Nurses, Inc. National Association of School Nurses (1988). Philosophy of school health services and school nursing. Scarborough, ME: National As- Mehl, R., and Whisenant, J. (1992, June). Computer use in the health sociation of School Nurses Inc. office. Paper presented at the annual meeting of the National As- sociation of School Nurses, Philadelphia, PA. Also on audiocas- National Association of School Nurses (1990). Code of ethics with in- sette: (Cassette recording No. 8). Scarborough, ME: National terpretive statements for the school nurse. Scarborough, ME: Na- Association of School Nurses, Inc. tional Association of School Nurses, Inc.

Melaville, A., & Blank, M.J. (1991). What it takes: Structuring inter- National Association of School Nurses (1992a). Resolutions and polity agency partnerships to connect children and families with compre- statements. Scarborough, ME: National Association of School hensive health services. Washington, D.C.: Education and Nurses, Inc. Human Services Consortium. National Association of School Nurses (1992b). [Survey of states: Meleis, A.I. (1993, January). Primary health care: An international and Educational preparation]. Unpublished data. national agenda. Unpublished paper presented as part of primary health care seminars, Primary care: Myths and realities. University National Commission on Children (NCC) (1991). Beyond rhetoric: A of California, San Francisco School of Nursing, San Francisco, new American agenda for children and families. Washington, CA. D.C.: U.S. Government Printing Office.

Merrill, J. (1985). Defining case management. Business and Health, 2 National Commission on the Role of the School and the Community (4). 6-7. in Improving Adolescent Health (NCRSCIAH) (1990). Code blue: Uniting fir a healthier youth. Alexandria, VA: National As- North American Nursing Diagnosis Association (NANDA) (1991). sociation of State Boards of Education. Classification of nursing diagnosis: Proceedings of the ninth conference (R.M. Caroll-Johnson, Ed.).Philadelphia, PA: J.B. National School Boards Association (NSBA) (1991). School health: Lippincott Co. Helping children learn. Alexandria, VA: Nationai School Boards Association. National Association of School Nurses (NASN) (1981). Guidelines for a model school nurse services program. Scarborough, ME: Na- Oda, D.S. (1989). The imperative of a national health strategy: Is tional Association of School Nurses, Inc. there a political will? Nursing Outlook, 37 (5), 206-208.

National Association of School Nurses (1982). Health and develop-Oda, D.S. & Quick, M.J. (1977). School health records and the new mental history and assessment (HADHAS) syllabus. Scarborough, accessibility law. Journal of School Health, 47 (4), 212-216. ME: National Association of School Nurses, Inc.

6 3 6 G Packard Foundation, David & Lucile, Center for the Future of Chil- Wagner, D. (1987). Client case management. Caring, 6(2), 12-13. dren (Eds.). (1992). School linked services [Entire issue]. The Future of Children, 2 (1). Western Interstate Commission on Higher Education (WICHE) (1985). The preparation and utiliz.ation of new nursing graduates. Boulder, Proctor, S.T. (1990). Guidelines fir a model school nurse services program. CO: Western Interstate Commission on Higher Education. Scarborough, ME National Association of School Nurses, Inc. Whaley, L.F., & Wong D.L. (1991). Nursing care of infants and chil- Schultz, P.R. (1991, July). Analyses of existing data in primary health dren. St. Louis, MO: Mosby-Year Book. care research. Unpublished paper presented at primary health care seminar. University of California, San Francisco School ofWilliams, C.A. (1991). National health policy: Preparing students Nursing, San Francisco, CA. and faculty for community health nursing in the year 2000. In T.R. Misener & M.J. Hickman (Eds.), 1991 papers: State of the Schwab, N. (1988, February). Liability issues in school nursing practice. art in community health nursing education, research, and practice Paper presented at the annual meeting of the California School (pp. 4-8). Lexington, KY: Association of Community Health Nurses Organization, La Jolla, CA. Nursing Educators.

Schwab, N. (1991). Guidelines for documentation for school nursing. Williams, C.A. (1992). Community-based population-focused prac- Scarborough, ME: National Association of School Nurses, Inc. tice: The foundation of specialization in public health nursing. In M. Stanhope & J. Lancaster (Eds.), Community health nurs- Shyang-Yun Shiao, P. & McKaig, C. (1989). Categorizing school ing: Process and practice for promoting health (pp. 244-252). St. health office visits by nursing diagnoses. School Nurse, 5 (3). 18- Louis, MO: Mosby-Year Book, Inc. 20. Winget, P. (1993). ADA, IDEA expand opportunities and inclusion. Snyder, A.A. (Ed.). (1991). Implementation guide fir the standards of The Special Edge, 7(4), pp. 1,10. Resources in Special Education school nursing practice. Kern, OH; American School Health Asso- (RISE), Calif. Department of Education and Calif. State Univer- ciation. sity, Sacramento.

Stanhope, M. & Lancaster, J. (1992). Community health nursing: Pro- Wold, S.J. (1981). School nursing: A framework for practice. North cess and practice fir promoting health. St. Louis, MO: C.V. Mosby Branch, MN: Sunrise River Press. Co. Woodruff, G., & McGonigel, M.J. (1988). Early intervention team United States Department of Education (USDE) (1991). America approaches: The transdisciplinary model. In J.B. Jordan, J.J. 2000: An education strategy (DE Publication No. ED 0591-13). Gallagher. P. Hutinger, & M.B. Karnes (Eds.), Early childhood Washington, D.C.: U.S. Government Printing Office. special education: Birth to three (pp. 163-181). Reston, VA: Council for Exceptional Children. United States Department of Health and Human Services, Public Health Service (USDHHS, PHS) (1991). Healthy people 2000:World Health Organization & the United Nations Children's Fund National health promotion and disease prevention objectives (WHO & UNCF) (1978). Primary health care: Report of the in- (DHHS Publication No. (PHS) 91-50213). ternational conference on primary health care, Alma-Ata, USSR. Geneva, Switzerland: World Health Organization. 6 4-- 6" APPENDIX A GLOSSARY

CERTIFIED SCHOOL NURSE(CSN) LEVELS OF PREVENTION STANDARDS OF CARE The registered trademark of the National Primary: Health promotion and specific pro- Authoritative statements that describe a com- Board for the Certification of School Nurses. tection. petent level of clinical nursing practice dem- Secondary: Early diagnosis and prompt inter- onstrated through assessment, diagnosis, CONTINUITY OF CARE vention to limit disabilities. outcome identification, planning, implemen- An interdisciplinary process that includes cli-Tertiary: Rehabilitation activities (ANA, tation, and evaluation (ANA, 1991b). ents and significant others in the develop- 1983). ment of a coordinated plan of care (ANA, STANDARDS OF PROFESSIONAL PER- 1991b). N URSING FORMANCE The diagnosis and treatment of human re-Authoritative statements that describe a com- CRITERIA sponses to actual or potential health prob- petent level of behavior in the professional Relevant, measurable indicators of the stan- lems (ANA, 1980a). role, including activities related to quality of dards of clinical nursing practice (ANA, care, performance appraisal, education, colle-- 1991b). REGISTERED NURSE CERTIFIED giality, ethics, collaboration, research, and re- (R.N.C.) source utilization (ANA, 1991b). HEALTH EDUCATION The certification trademark of the American A process which seeks to improve the quality Nurses' Association. Certification is con-TRANSDISCIPLINARY TEAM of life by helping people establish patterns offerred by the ANA credentialing center. A unit composed of professionals from vari- living based on knowledge, attitudes, values, ous disciplines who, with the parent and care and practices that will enhance optimal SPECIALTY STANDARD giver as a full partner, conduct comprehen- health and delay the onset of disease. An authoritative statement enunciated and sive developmental assessments together; de- promulgated by those within the professional velop service plans based on family priorities, I.E.P. specialty by which the quality of practice, ser-needs, and resources; and who assume re- Individualized Educational Program vice, or education can be judged (Adapted sponsibility for how the primary service pro- from ANA, 1991b) vider implements the plan. Transdisciplinary I.F.S.P. teams make a commitment to teach, learn, Individualized Family Service Plan STANDARD and work together across discipline bound- An authoritative statement enunciated and aries(AdaptedfromWoodruffand I.H.P. promulgated by the profession by which the McGonigel, 1988). Individualized Healthcare Plan or Individu-quality of practice, service, or education can alized Health Plan be judged (ANA, 1991b).

INTERDISCIPLINARY TEAM STANDARDS OF NURSING PRACTICE A functioning unit composed of individualsAuthoritative statements that describe a com- with varied and specialized training and ex- petent level of care or performance common pertise who coordinate their activities to pro- to the profession of nursing by which the vide services to and solve specific problems quality of nursing practice can be judged. with clients (Adapted from ANA, 1983). Standards of clinical nursing practice include both standards of care and standards of professional performance (ANA, 1991b). APPENDIX B BIBLIOGRAPHY

American Academy of Pediatrics (l981). School health: A guide for Friedman, G.D. (1987). Primer of epidemiolog New York, NY: health profissionals. Evanston, IL: American Academy of Pediat- McGraw-Hill Book Co. rics. Friedman, M.M. (1992). Family nursing: Theory and practice. American Academy of Pediatrics (current edition). The red book. Elk Norwalk, CT: Appleton & Lange. Grove Village, IL: American Academy of Pediatrics. Guttmacher, A., Institute (1989). Risk and responsibility: Teaching sex American Red Cross (current edition). American Red Cross standard first education in America's schools today. New York, NY: Alan aid and penonal safil. Garden City, NY: Doubleday & Co., Inc. Guttmacher Institute.

Bates, B. (1991). A pocket guide to physical examination and history tak- Lookingbill, D., & Marks, J. (1986). Principles of dermatolog. Phila- ing. Philadelphia, PA: J.B. Lippincott Co. delphia, PA: W.B. Saunders.

Bates, J.D. (1990). Writing with precision: How to write so that you Lynch, A. (1982). Redesigning school health services. New York, NY: cannot possibly be misunderstood. Reston, VA: Acropolis Books. Human Science Press.

Bays, C.T. (1984). An elementary school health fair planning guide. Martin, K.S., & Sheet, N.J. (1992). The Omaha system: Applications Sacramento, CA: Author. for community health nursing. Chap. 11: Use in school health settings (pp. 228-240). Philadelphia, PA: W.B. Saunders. Behrman, R.E., & Kliegman, R. (1990). Nelson: Essentials of pediatrics. Philadelphia, PA: W.B. Saunders. Mutd, M., Sterling, H.M., & Spalding, N.V. (1978). Quick neurological screening test. San Rafael, CA: Academic Therapy Publica- Benenson, A. (1990). Controi of communicable disease in man. Wash- tions. ington, D.C.: Affierkan Public Health Association. Newton, J. (1984). School health handbook. Englewood Cliffs, NJ: Benjamin, A. (latest). The helping interview. Bouon, MA: Houghton- Prentice-Hall, Inc. Mifflin Co. Nieswiadomy, R.M. (1993). Foundations of nursing research. Bleck, E.E., & Nogel, D.A. (1982). Physically handicapped children. A Norwalk, CT: Appleton & Lange. medical atlas for teachers. New York, NY: Grime & Stratton. Olivas, G.S., Armanasco, V.D.T., Erickson, J.R., & Harter, S. Bomar, P.J. (1989). Nurses and family health promotion: Concepts, as- (1989). Case management: A bottom-line ca 'livery model. sessment, and interventionc. Philadelphia. PA: W.B. Saunders. Journal of Nursing Administration, 19 (12), 12-17.

Butraravoli, P.M., & Stair, T.C. (1985). Common simple emergencies. Palfrey, J.. Hayne, M., & Nrrer. S. (1988). Children in educational Bowie, MD: Brady Communications Co., Inc. settings assisted by medical technolog: Guidelines for care. Boston, MA: Project School Care, The Children's Hospital. Combs, j.A., & R., S.C. (1990). Creating a healing environment: Nurse case managers address pregnant teenagers' needs--physical, Polit, D.F., & Hungler, B.P. (1987). Nursing research: Principles and emotional, and spiritual. Health Progress, May, 38-41. methods. Philadelphia, PA: J.B. Lippincott Co. 66 Schmitt, B.D. (1980). Pediatric telephone advice. Boston, MA: Little, Thomas, C.L. (Ed.). (1989 or latest) Taber's ryckpedic medical dictio- Brown, & Co. nary. Philadelphia, PA: F.A. Davis Co.

Scott, S.M. (1990). The white cap faces a new challenge: ExploringTrucano, L. (1985). Students speak. Seattle, WA: Comprehensive the changing role of the rehabilitation nurse specialist. Journal of Health Education Foundation. Rehabilitation, Jan., Feb., March. 15-16. Valanis, B. (1992). Epidemiology in nursing and health care. Norwalk, Seller, R.H. (1993). Differential diagnosis of common complaints. CT: Appleton & Lange. Philadelphia, PA: W.B. Saunders. Wallace, H.M., Patrick, K., Parcel, G. & Igoe, J.B. (Eds.) (1992). Silver, H.K., Kempe, C.H., Bruyn, N.B., & Fulgineui, V.A. (1990). Principks and practices of student health, Vols. 1, 2, & 3. Oak- Handbook of pediatrics. Norwalk, CT: Appleton & Lange. land, CA: Third Party Publishing.

Spradley, B.W. (1991). Readings in community health nursing. Phila-Whitman, N., Graham, B., Gleit, C., & Boyd, M. (1992). Teaching delphia, PA: J.B. Lippincott Co. in nursing practice: A profissional model. Norwalk, CT: Appleton & Lange. Strauss, A., & Corbin, J. (1992). Basics of qualitative research. Newbury Park, CA: Sage Publications. Wilson, H. (latest). Introduction to nursing research. Menlo Park, CA: Addison-Wesley Co. Swanson, J.M., & Albrecht, M. (1993). Community health nursing: Promoting the health of aggregates. Philadelphia, PA: W.B. Woods, N.F., & Catanzaro, M. (1988). Nursing research: Theory and Saunders. practice. St. Louis, MO: The C.V. Mosby Co.

67t)