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Ethical Issues in School Nursing

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Teresa A. Savage, PhD, RN


School nurses are a unique group. They may be responsible for hundreds of students; some may have over 1000 students in their charge. They must have a breadth of knowledge to assess, treat, or refer for common pediatric illness and injuries, as well as ability to manage health emergencies and disasters. In addition, they must navigate rules, policies, and regulations that apply to their educational setting, and adhere to their state Nurse Practice Act. Overall goals for school nurses address student health, safety, and learning. In this quest, they may encounter myriad ethical issues. Rarely does literature include specific ethical issues faced by school nurses. This article addresses this gap by offering a brief review of the literature, and discussion about ethical concepts in the context of school nursing, ethical decision-making, and other relevant concepts such as moral distress, moral courage. Also included are recommendations and resources for school nurses.

Citation: Savage, T.A., (September 30, 2017) "Ethical Issues in School Nursing" OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 3, Manuscript 4.

DOI: 10.3912/OJIN.Vol22No03Man04

Key Words: school nursing, school nurse, ethics, ethical decision-making, advocacy, moral distress, moral courage, social justice

...a notable difference for school nurses is that they live in two worlds: education and nursing. “Grit is the ability to continue on after failing with no loss of enthusiasm” (Mattey, 2017, p. 79). This quote was taken from Mattey’s article about school nurse grit. She aptly captured the perseverance and tenacity of the school nurses described in the article, who likely represent those in the field of school nursing. School nurses seek to “improve the students’ health, safety, and abilities to learn” (National Association of School Nurses [NASN], 2015, p. 290). Each nursing specialty claims a “uniqueness” to their practice. However, a notable difference for school nurses is that they live in two worlds: education and nursing. In some states, nurses need to become certified as educators to work in the school system. nurses often navigate ethical and legal complexities. In addition to familiarity with state Nurse Practice Act, school nurses must also be aware of federal, state, local, and institutional rules, policies, regulations, and laws that apply to educational settings. This duality can lead to ethical problems, and school nurses often navigate ethical and legal complexities. To work through ethical issues school nurses might face, they must be aware of legal boundaries that may have a bearing on ethical issues. Legal issues are beyond the scope of this discussion, but nurses must always be aware of the relationship between ethical and legal issues.

As to school nurse grit, school nurses often face challenges with non-nurse administrators related to role clarification, accountability, and scope of practice. Because of their wide scope of knowledge, skills, and responsibilities, they can easily become overwhelmed in a large school system, or perhaps in striving to meet the needs of medically complex students. School nurses may also be expected to accept non-nurse responsibilities, or to delegate nursing tasks to unlicensed assistive personnel. While ethical concerns are often addressed in the literature, less so are specific ethical issues faced by school nurses. This article addresses this gap by offering a brief review of the literature, and discussion about ethical concepts in the context of school nursing, ethical decision-making, and other relevant concepts such as moral distress and moral courage. Also included are recommendations and resources for school nurses.

Review of Literature

To reflect the dual context of the school nurse role, both a healthcare and an education database were considered in the review of literature. PubMed OVID and the Education Resources Information Center (ERIC) were searched using the terms “school nurse” and “ethics. The total search yielded 21 articles published since 2003.

Primary reasons for moral distress were inability to deliver necessary services to students with chronic illnesses, and not enough time and resources to provide care. These articles included two research projects, one a phenomenological study exploring ethical issues experienced by six school nurses (Solum & Schaffer, 2003) and the other, a mixed methods study that explored moral distress in school nurses (Powell, Engelke, & Swanson, 2017). Solum and Schaffer (2003) did interviews with six school nurses (2 rural, 2 suburban, 2 urban) recruited from their state school nurse association. The interviews revealed that these nurses did not use ethical decision-making models or frameworks, but used “contemplation, intuition, and seeking advice” (p. 335). Ethical issues they confronted were related to conflicts with administrators and/or parents, delegation of nursing tasks, confidentiality, resuscitation policy, and mandatory reporting. The authors recommended school nurses learn more about ethical decision-making models.

Powell et al. (2017) conducted a study to explore moral distress in school nurses. Using the Moral Distress Thermometer (MDT) and an investigator-developed survey of moral dilemmas, the research team conducted face-to-face interviews with 264 school nurses who represented 619 public schools. Data were collected from nurses who attended regional or district school nurse meetings across North Carolina. Nearly half of the nurses (49.6 %) reported their level of moral distress at >4-6, or “greater than uncomfortable to distressing.” Primary reasons for moral distress were inability to deliver necessary services to students with chronic illnesses, and not enough time and resources to provide care. Moral distress was higher in school nurses with larger caseloads; investigators set the upper limit of 900, but some nurses reported caseloads up to 3000-4000 students. The investigators recommended that school nurses and school administrators recognize the presence of moral distress. Powell et al. (2017) also suggested offering group debriefing sessions, instituting a culture of care, and adopting interventions such as professional development and support to increase nurse resilience. Their conclusion supported the NASN position statement (2015) regarding school nurse workload.

Moral distress was higher in school nurses with larger caseloads... A number of articles suggested that school nurses should advocate for a wide variety of issues, such as consent and confidentiality (Dickey, Kiefner, & Beidler, 2002); do not attempt resuscitation (DNAR) policies in schools (White, 2005); Human Papillomavirus Vaccine (HPV) vaccine for girls (Bennet, 2008); policy development for delegation (Spriggle, 2009); education about reproductive and gender health (Cowell, 2010); banning corporal punishment, including use of restraints and seclusion (Mohr, LeBel, O’Halloran, & Preustch, 2010); management of food allergies (Behrmann, 2010); meeting and maintaining standards (Davis-Alldritt, 2012); using the NASN Code of Ethics to resolve ethical issues (Wolfe, 2013); cultural competence (Carr & Knutson, 2015); and collecting accurate, precise data (Bergren et al., 2017). The remaining articles discussed issues in the United Kingdom and Sweden, or were tangentially relevant to ethics.

Since the Solum and Schaffer (2003) study, there has not been another study that explored ethical issues in school nursing practice. However, clinical articles identified many issues that school nurses face and most make recommendations for individual or collective action by school nurses. Solum and Schaffer (2003) suggested nurses become familiar with and use ethical decision-making models, while Wolfe (2013) suggested using the NASN Code of Ethics (2016b) as a guiding framework. A brief review of selected ethical concepts in the context of school nursing, including ethical decision-making models and the use of the NASN Code of Ethics (2016b), follows in the next sections.

Ethical Concepts in the Context of School Nursing

School nurses... have recently also crafted a specific code of ethics... During their nursing education, students internalize the values and ethics of the profession, and subsequently, as the registered nurse (RN) specializes, the values and ethics specific to the selected specialty. Nurses pledge to follow the code of ethics of the nursing profession, which is a social contract with the public. School nurses, as an association, adopted the American Nurses Association (ANA, 2015) Code of Ethics for Nurses, and have recently also crafted a specific code of ethics for school nurses (NASN, 2016b).

School nurses strive to uphold the provisions of both codes. Referring to the codes, however, does not always clearly show how one should act in a particular situation. Wolfe (2013) gives examples of three scenarios where the NASN Code (2016b) could be used for guidance, 1) a child with a skin disorder who should use a computer but the school doesn’t have funds for it; 2) a new school nurse with extensive obstetrical experience who is asked to be available at a basketball game to treat any injuries; and 3) a nurse invited to participate in research with a local hospital. For each scenario, Wolfe (2013) identifies the relevant Code and/or Interpretive statement from the NASN Code (2016b).

Before exploring ethical decision-making, a brief review of ethical theories and principles might be helpful. Below is introductory information related to two ethical theories and four common ethical principles presented in the context of school nursing. Names and scenarios are fictional and created to provide examples.

Ethical Theories
Bioethics has only been a “field” since the early 1950s (Jonsen, 1998). When technology started pushing the boundaries of human existence, healthcare providers turned to theologians and philosophers for advice and wisdom. The use of mechanical ventilators and hemodialysis were two of the earliest technological advances that posed ethical dilemmas and raised questions about “playing God,” equity, and quality of life. Beauchamp and Childress (1978) authored one of the first books that provided a “systematic analysis of the principles that should govern a wide range of decisions affecting biomedicine” (p. xiii). They identified ethical theories and ethical principles that should guide ethical practice realm of healthcare. Two of the most common theories are briefly discussed here.

Utilitarianism is an approach to guide decision-making noting consequences of an action as the most important aspect... Utilitarianism. Utilitarianism is an approach to guide decision-making noting consequences of an action as the most important aspect; hence, it is also called “consequentialism” (Nelson, 2007, pp. 4-6). In the mid-18th century, English philosopher Jeremy Bentham introduced the concept of utilitarianism in terms of the greatest happiness for the greatest number, as a way to determine what is right or wrong (Nelson, 2007). The theory was later refined by one of his students, John Stuart Mill, who wrote “...the Greatest Happiness Principle, holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reserves of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure” (Mill, 1863, pp. 9-10).

An example of a utilitarian approach to a school related decision might be the choice of whether or not to fund a school arts program, rather than a program for gifted students. With limited resources, more children would have exposure to the arts program than a program for the few children who qualify as “gifted.” A school nurse makes a utilitarian decision if she decides to spend her time doing screenings and education on an important health topic for many students, rather than devoting time to a few students with a less common health condition, like reflex sympathetic dystrophy. Often she cannot do both, so she must choose who will get her time and attention at the moment.

A deontological approach does not focus on consequences, but whether the act, in and of itself, is good or not Deontology. A deontological approach does not focus on consequences, but whether the act, in and of itself, is good or not (Nelson, 2007). The German philosopher Immanuel Kant (1780/2008) believed that actions were more important than consequences. In this perspective, morality is based on rules, and acts should follow rules. Two examples in Table 1 below illustrate this approach from a school nursing perspective.

Table 1. Examples of Deontological Approach

Example 1 considers a violation of school policy.

Angela, a 10th grader, has experienced migraine headaches. Recently her mother gave Angela one of her tranquilizers (alprazolam; Xanax™) at the onset of the migraine, and it has helped to prevent the headache from worsening. Angela brought two pills with her to school in a small plastic bag, kept in her purse. When she began to experience the onset of a migraine headache, she took one of the pills. A teacher observed this, and based on the “Zero Tolerance” policy of the school, the teacher escorted Angela to the principal. Angela was suspended from school. The “act” of possessing and taking a medication that had not been approved through the proper channels violated a policy. The consequences of Angela’s action, taking the alprazolam, resulted in thwarting the onset of a migraine headache, which brought about a “good” outcome. But the “act” of possessing and taking the medication violated policy. A deontologist, focusing on the act, would support the decision to suspend Angela rather than looking at the consequences of her act.

Example 2 describes the school nurse’s dilemma related to mandatory reporting for suspected child abuse or neglect.

Madison is a 15 year old girl with myelomeningocele and an intellectual disability. The school nurse is called to the classroom because Madison is having a seizure. After the seizure Madison is stable, so the nurse takes her to the nurse’s office and asks if she has been taking her medication as prescribed. Madison said she ran out of medication 3 or 4 days ago. The nurse contacts the mother to inform her about today’s episode; the mother replies that she believes it is Madison’s responsibility to take her medication and to inform her when refills are needed. She thinks it is a good lesson for Madison if she has a seizure because she forgets to take her medicine. The mother admits that she does not always remember to refill the prescription, so sometimes Madison can go “a few days” without medication. But she blames Madison for not reminding her, “After all, she’s the one with the epilepsy,” the mother said. The nurse suggests that the mother contact Madison’s physician to arrange a visit in the physician’s office or emergency department (ED) today.

The nurse also notices that Madison has a strong odor of urine and asked when she last performed clean intermittent catheterization (CIC). Madison said that her mother stopped getting catheters and told Madison to use the credé maneuver (i.e., manual pressure on the abdomen over the bladder) to empty her bladder and wear diapers. The school nurse is aware of the plan for Madison to perform CIC every four hours, and Madison has demonstrated her ability to perform CIC correctly.

Based on Madison’s report that she has not had medication for 3-4 days and that her mother has not provided the necessary supplies for CIC, the nurse believes she is mandated to report suspected neglect. The nurse intends to work with the mother and Madison to strategize on how to ensure that Madison gets her medication as prescribed and returns to performing CIC, but she believes she must report this situation to appropriate child welfare authorities. Regardless of the consequences (although the nurse hopes the result of reporting will be beneficial for Madison), the nurse is compelled to report the situation to child welfare authorities. From a deontological perspective, regardless of the consequences, the “act” of reporting must be done.

Examples in table fictional and created to provide examples.

In sum, utilitarianism is often used when making resource allocation decisions. Deontological approaches are considered when formulating policies or rules. These examples were written in a way to illustrate the application of these approaches; it is likely the school nurse would follow the rules, but may also pay attention to both the “acts” of the moral agent (nurse) as well as the consequences. Often, as mentioned by Solum and Schaffer (2003), nurses may not easily and clearly identify the ethical aspect of a particular situation. In order to do this, it may be helpful to think of the ethical principles that may be in play in any situation.

Ethical Principles
Beauchamp and Childress (1978) identified four biomedical principles: autonomy, beneficence, nonmaleficence, and justice. The principles encapsulated in an abbreviated way the spirit of the ethical intention. Beauchamp and Childress’ (2013) book, now in its 7th edition, is a resource for an in-depth discussion of the ethical principles.

Autonomy. Autonomy means self-rule. As healthcare providers, especially in Western medicine, a person’s right to make his or her own decisions is respected and honored. Healthcare providers have an obligation to provide information in understandable language, with enough detail, so that a person can make an informed decision.

School nurses... often try to include children in some decisions as appropriate... Parents or guardians are the legal decision-makers for students; there may be a few exceptions for emancipated or mature minors. School nurses, and other pediatric nurses, often try to include children in some decisions as appropriate and according to the child’s developmental abilities to make an informed decision (Dickey et al., 2002). Some children as young as 11 have demonstrated the same capabilities of informed decision-making as adults (Weithorn & Campbell, 1982), but Salter (2017) argues that decisional capacity of children does not confer decisional authority and parents should remain the final decision-makers for children.

Beneficence. Beneficence is “doing good” or bringing about good. Healthcare providers intend to “do good” when they provide healthcare. If a school nurse intervenes with an epinephrine injection to treat a life-threatening allergic reaction, thereby saving the child’s life, the intervention is “doing good.” However, what is “good” may be in dispute. For example, a school nurse may administer a medication to a child having a seizure. Although uncommon, it is possible that the child may experience respiratory arrest from that medication, necessitating resuscitation and transfer to the ED. The “good” of attempting to stop the seizure resulted in the “harm” of respiratory arrest.

Often an act can reflect both beneficence and nonmaleficence. Nonmaleficence. The principle of nonmaleficence means “preventing harm.” Often an act can reflect both beneficence and nonmaleficence. In the example above, giving the anticonvulsant injection was a good act in that it restored the child to the pre-crisis condition, but also a harmful act since the child’s condition progressed to respiratory arrest. Most, if not all, nursing actions are intended to prevent harm through adherence to professional standards; community standards; policies and procedures; and maintenance of competence, particularly in the specialty area.

The school nurse’s time is an issue of justice. Justice. The principle of justice has many meanings, but the most prominent meaning in bioethics is fairness, in terms of equity and fair allocation of resources. The school nurse’s time is an issue of justice. The nurse must prioritize his activities based on a number of variables, such as which activities are mandated and which require documentation within a certain time period. Which activities, if not performed, could adversely affect the health of one or more students? If there are competing duties, how does the nurse decide which should take precedence? For example, should the school nurse spend the time with students newly diagnosed with diabetes or doing a parenting class for pregnant teens? An ethical decision-making model might be useful for making these types of decisions, and this process is discussed in the next section.

Ethical Decision-Making

Ethical decision-making is a process much like the steps in the scientific process—data collection, plan development, implementation and evaluation. There are many resources for ethical decision-making in the literature. In general, many ethical decision-making models follow a familiar, step-wise pattern:

  1. Identify the ethical problem
  2. Identify and consider the alternatives
  3. Implement a choice
  4. Evaluate the decision-making process and its outcome (Bosek & Savage, 1999, p. 75)

Below is an exemplar that demonstrates the application of an ethical decision-making model to an ethical issue facing the school nurse.

A field trip to a local farm is planned for the entire day. Holly, an 8 year old, is eagerly looking forward to the trip. She does not yet self-manage her diabetes, which has been difficult to control. The school nurse is concerned that there is no RN available to go on the field trip. Holly’s parents are also not available. The school nurse realizes that she cannot exclude Holly from the field trip. She analyzes the ethical issues in this situation.

  1. There are several ethical principles involved in this ethical problem. The problem the school nurse is considering is how to prevent harm should Holly experience hypo- or hyperglycemia in transit and on the field trip. The ethical principles in conflict are nonmaleficence (preventing possible harm to Holly) and autonomy (respecting Holly’s right to be included on the field trip), and justice (in terms of possible cancellation of the field trip).
  2. Possible options are for the school nurse to cancel the trip, reschedule the field trip on a day the school nurse could participate, or see if there might be a qualified adult (parent, RN, or diabetic care aide) available to go on the field trip
  3. The school nurse discusses the situation with Holly’s mother and they identify a qualified adult who could go on the trip: the mother’s sister (Holly’s aunt) who is available and willing to go. She occasionally keeps Holly overnight, and is competent in managing Holly’s diabetic care. If she were not available, the school nurse would investigate the availability of a trained diabetic care aide.
  4. The school nurse reviews the process of planning field trips and requests that to be included in this process. She explains that she can anticipate student needs and in doing so, hopefully prevent problems (nonmaleficence) that could be harmful to the students, ensure all students are included on field trips (justice), and assure that children with specific health needs have appropriate accommodations to participate (autonomy).

Using ethical principles may not be enough to guide ethical decision-making. School nurses often face more complicated ethical challenges, though. Using ethical principles may not be enough to guide ethical decision-making. One of the more well-known models for clinical ethical decision-making is the 4-Topics model (Jonsen, Siegler, & Winslade, 2015), commonly referred to as the “4-Box Method.” Jonsen et al’s (2015) entire book is dedicated to describing this method of ethical analysis, but for the purpose of this article, a brief description and illustration is offered. The box is divided into four quadrants (see Table 2); this description includes appropriate information in each box to illustrate the process, using the brief field trip scenario above.

Table 2. Application of 4-Topics Model (Jonsen et al, 2015)

Clinical Indications

Patient Preferences

Clinical indications include Holly’s diabetes and the possibility a life-threatening complication on the trip. The principles of autonomy, nonmaleficence, and justice apply.

Patient preferences are the desire of the child (and the parents) for her to participate in the trip. Autonomy, to the extent that the children’s preferences are considered, as well as the parents’ preferences, applies.

Quality of Life

Contextual Features

Quality of life pertains to the balance of risk versus benefit, from the child’s perspective. This prompts several questions to consider:

  • Is it worth the risk to go on the field trip without an adult who can manage any problem associated with the diabetes?
  • What about the quality of life of the other children if the trip is cancelled?
  • When in conflict, whose preferences take precedent?

Autonomy of the child (and parents) to make choices consistent with their desired quality of life is applicable, but also justice, in terms of the effect of the choice on the other children.

The last quadrant is contextual features, which also elicits questions for thought.

  • Are there other acceptable options?
  • Are there any rules or policies to inform and guide this decision?

In doing this sorting, the school nurse can more clearly articulate the ethical issues and the justification for final decision. Consideration of the information in the Clinical Indications and Patient Preferences boxes should take precedence in the decision, but if this process does not help to resolve the issue, the lower boxes of Quality of Life and Contextual Features should be explored. This is a very brief analysis of the 4-Topics model (Jonsen et al., 2015), but it illustrates how a number of factors and guiding questions can be considered. Depending upon those factors, all the ethical principles may be applicable. In doing this sorting, the school nurse can more clearly articulate the ethical issues and the justification for final decision.

There may be situations where school nurses experience some discomfort or uneasiness, but may not realize the source of that distress. This distress can sometimes provide an impetus for resolving an uncomfortable situation. Jameton (1984) gave us the language to name this as moral distress. In recent years, there has been more attention to identifying sources of moral distress and ways in which to prevent or ameliorate it. Moral distress, and several other relevant concepts such as moral courage, legislative advocacy, and social justice are considered below.

Other Relevant Concepts

Moral Distress
Jameton (1984) described three situations nurses can face: uncertainty, dilemma, and distress. Uncertainty means that the nurse is unsure if the situation is an ethical situation. Dilemma is when there are two equally unpleasant alternatives, such as, a patient’s decision to 1) either remain on life-support (e.g., a ventilator); or 2) forgo life-support and die. The last situation, commonly referred to as moral distress, is when nurses believe they know the right course of action to take, but believe they are constrained from acting.

An example of distress is when parents express to the school nurse a wish to forgo resuscitation of their child when at school, but school policy prohibits a Do Not Resuscitate (DNR) order. The nurse, despite efforts to change the policy, feels constrained to withhold resuscitation, so experiences the distress of being unable to act in a way that respects the parents’ wishes. The nurse would be legally compelled to resuscitate the child, despite knowing the parents do not want this action. School nurses may experience moral distress if they feel they cannot deliver the quality of care that they believe is consistent with the parents’ wishes. nurses often have too great a workload to deliver the care they believe is needed. As discussed earlier, Powell et al. (2017) reported nearly half of the nurses in their study rated their level of moral distress between 4 and 6 on a 10 point scale, and this reading was even higher in nurses with larger caseloads. School nurses work with parents, students and others to develop care plans; yet, Powell et al’s (2017) findings suggested that school nurses often have too great a workload to deliver the care they believe is needed. They have the additional challenge of articulating to non-nurse administrators the importance of having qualified school nurses.

School nurses, individually and collectively, can make the case for why their presence, skills, and knowledge are critical to student performance. There may be a lack of appreciation of the value of a school nurse instead of unlicensed assistive personnel (UAP) to carry out a number of nursing tasks that only a school nurse should perform. The NASN (2015) has articulated in position statements the challenges and evidence for careful calculation of workloads; issues related to delegation to UAPs (NASN, 2016a); and the value to students in having daily access to qualified school nurses (NASN, 2017). School nurses, individually and collectively, can make the case for why their presence, skills, and knowledge are critical to student performance. Administrators should be (but often are not) aware of standards and regulations governing nursing practice and rely on school nurses to uphold those standards. Table 3 presents two additional fictional situations related to staffing and caseload that may create moral distress for school nurses, and highlight the need for communication with school administrators and other professionals.

Table 3. Two Examples of Staffing/Caseload Situations that May Create Moral Distress

Example 1

PROBLEM: The school nurse is experiencing increased demands for his time and requests that the school hire another nurse. The administrator denies his request and tells him to delegate tasks to classroom aides (e.g., volunteers or student teachers). The nurse will not delegate nursing tasks to non-nurses, so he explains to the administrator why he cannot delegate. The administrator tells him that he authorizes him to delegate and he will accept the responsibility as his supervisor. Respectfully, the nurse explains that the administrator cannot take responsibility for activities that fall within the nursing scope of practice.

ACTION: The nurse must be cognizant of his scope of practice, his legal and ethical responsibilities, and the students’ rights. The nurse should present the reasons for not complying with the administrator’s request, quoting the state Nurse Practice Act. Beyond the licensure issue, there is the ethical imperative that supports the Nurse Practice Act. The nurse must impress upon the administrator his ethical responsibility to prevent harm (i.e., nonmaleficence) that could result from the inability to provide direct nursing services.

Example 2

PROBLEM: The school district social worker and psychologist ask the school nurse (the only school nurse in the county) to conduct a screening of all students (~800) to determine their risk for suicidal behavior, because a 15-year old girl and a 16-year old boy have committed suicide after viewing the Netflix movie “13 Reasons Why.” (Yorkey, 2017) Although the school nurse believes that there may be value in conducting this screening (principle of nonmalefience), she has some concerns. Her current workload does not support including a project of this magnitude, even with the three of them conducting the screening.
ACTION: The school nurse believes that there is a need to seek a commitment from the principal in advance to assure that mental health services are available and accessible to students whose screenings reveal they need further assessment. Realizing the need for this screening, and with a desire to participate, she can begin negotiation there. This will show her willingness to meet student needs but also acknowledge the realization that the project will require additional resources for implementation.

Ideally, ethical arguments should be persuasive, but often it is necessary to invoke legal imperatives, such as policies, regulations, laws, court mandates. Nurses in every setting occasionally have to remind administrators that, in addition to their ethical responsibilities, they have legal responsibilities and boundaries that govern their practice and cannot be waived or altered. These actions require moral courage in the face of moral distress.

Moral Courage
The school nurse may need to have a difficult conversation with an administrator, parent, or teacher. The value of moral distress is that it usually motivates one to find a resolution and relief from the distress. Taking action, though, requires moral courage. The school nurse may need to have a difficult conversation with an administrator, parent, or teacher. Beyond the difficult conversation, the school nurse may have a real concern that his position could be in jeopardy should he push for change or defy an unethical directive from an administrator.

Preparation for any meeting is essential. The school nurse needs to have data (e.g., summaries of student cases or needs; applicable rules, regulations, laws, and/or mandates) and a cogent argument. Emotions can run high as the people involved may feel disrespected, offended, threatened, or angry.

Being individually prepared is essential, but the school nurse may also consider inviting allies into the discussion. Hutchinson, Jackson, Daly, and Usher (2015) provide a framework for nurse leaders in mental healthcare, but their approach could be used by school nurses. The authors note that “honest and courageous” conversations can “facilitate ethical decision-making by creating shareable moral meaning and providing opportunity through dialogue to contest taken-for-granted narrative and practices” (p. 332). Being individually prepared is essential, but the school nurse may also consider inviting allies into the discussion. An ally may be another school employee or school nurse, a parent, or someone with moral authority on the topic at hand. These steps are often uncomfortable for those who avoid risk-taking, but may be necessary.

At some point, the nurse may recognize that these efforts are not effective, and a stronger approach is needed. Hopefully there are others who collectively support the nurse’s actions, but it is possible that the nurse must face the issue alone and decide if the issue is worth loss of employment. There are stories of heroes who take these types of stands and are rewarded, and those who suffer extreme consequences. Hopefully, the school nurse can resolve the issue to his satisfaction, short of sacrificing his position and career. Advocacy may be the courageous action that the school nurse can take to bring attention and resources to the ethical issues he identifies.

Legislative Advocacy
Conversations may go beyond the nurse’s own school or school district to state legislators... As with most healthcare systems, school resources are often scarce. Nonetheless, the school nurse should strive to advocate for enough resources to ensure a level of safety to fulfill ethical responsibilities and be in compliance with all local, state, and federal regulations. Conversations may go beyond the nurse’s own school or school district to state legislators who control budgets and pass relevant laws and mandates for school systems.

Many school nurses may not feel prepared to advocate at this level. The state nurses’ association and state chapter of the NASN may provide advocacy training and possibly (in some cases) lobbying services. Endsley (2016) maintains that advocacy and legislative engagement is the responsibility of every school nurse. She offers a guide for building and fostering relationships with legislators. The “Organizational Ethics” section of the NASN Code of Ethics (2016b) notes that the school nurse is responsible to support their role “through advocacy, integrity, and participation in public policy development and social justice” (p. 217).

Social Justice
Social justice is concerned with the “collective good” for society (Shi & Singh, 2012, p. 59). Societal resources should be allocated in a way to promote and maintain the health of its citizens, regardless of their ability to pay. In the broad scope of school nursing, nurses frequently see students in conditions that put them at a disadvantage for learning. Poverty; homelessness; domestic and/or street violence; human trafficking; substance abuse; ignorance and neglect; discrimination; and undiagnosed mental health problems are just a few of the conditions students may experience (Selekman, 2013; Combe, et al., 2015). The school nurse alone cannot fix these problems, but can identify the needs of individual students and mobilize resources for students.

At times the school nurse may be the only reliable and trustworthy adult in a student’s life. At times the school nurse may be the only reliable and trustworthy adult in a student’s life. In the context of promoting social justice, the school nurse may establish relationships with a network of professionals outside the school system who may be able to assist students and families. Collectively, the school nurse can provide data to demonstrate a need for certain services for individual students and families. With data, she can lobby for development of services in concert with other agencies (e.g., both governmental and private) that serve children. She can also participate in research by collecting data, providing documentation, or presenting de-identified student cases to legislators in an effort to initiate or support programs.

Recommendations and Resources

This section offers several recommendations for school nurses as they consider ethical dilemmas in practice. Table 4 lists additional resources that may be helpful. Note that a textbook dedicated to specific dilemmas in the context of school nursing is a potential need, although there is information in the NASN Code of Ethics (2016b) and on the NASN website.

  1. Use an ethical decision-making model whenever possible. Employing an ethical decision-making model may assist the school nurse in managing the ethical issues that occur in the school setting. Many, if not most healthcare settings have a mechanism for resolving ethical situations. The Joint Commission included this mandate for hospitals to have some mechanism for nurses to bring ethical concerns, and most hospitals chose to have an ethics committee, ethics consultation service, or both. Some smaller healthcare facilities (e.g., nursing homes or outpatient facilities) have a relationship with another institution’s ethics committee or have an ethics consultant who provides consultation and education. Some schools may have such a body within a school system that can provide ethics consultation to school nurses, teachers, and others.
  2. Take advantage of existing resources. Table 4 lists selected potentially helpful resources. While most are not specific to school nursing, any may offer helpful information to school nurses considering an ethical dilemma or planning an educational session specific to ethical concerns for schools and school nurses. There also may be a resource for ethics questions within the National Association for School Nurses. The American Nurses Association has a Center for Ethics and Human Rights that fields phone and email inquiries ( about ethical issues.
  3. Require regular ethics focused education specific to school nursing. Annual competencies or continuing education hours required for school nurses should include some review of ethics and ethical decision-making in school nursing. It is often the discomfort of the distress that moves one to action, whether the distress emanates from a close call concerning a student’s health or conflict with a school administrator. School nurse conferences should also include a topic on ethics, such as managing moral distress. As Powell et al. (2017) recommended, discussing moral distress with school administrators is the first step in developing strategies to combat the distress.

Table 4. Selected Ethics Resources for Nurses

Selected Websites

American Nurses Association Center for Ethics and Human Rights website:

National Association of School Nurses website/tab for Professional Topics: (see Code of Ethics, Position Statements, School Nursing Scope and Standards of Practice)

Selected Ethics Journals

American Journal of Bioethics (AJOB)

Cambridge Quarterly of Healthcare Ethics

Journal of Clinical Ethics

Kennedy Institute of Ethics journal

Nursing Ethics

The Hastings Center Report

Selected Ethics Textbooks

Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics. (7th ed.). NY: Oxford University Press.

Burkhardt, M.A., & Nathaniel, A. (2013). Ethics and issues in contemporary nursing (4th ed.). Clifton Park, NY: Delmar Cengage Learning.

Butts, J.B., & Rich, K.L. (2016). Nursing ethics: Across the curriculum and into practice (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Caplan, A.L., & Arp, R. (2014). Contemporary debates in bioethics. Malden, MA: Wiley Blackwell.

Devettere, R. J. (2016). Practical decision making in health care ethics: Cases, concepts, and the virtue of prudence (4th ed.). Washington, DC: Georgetown University Press.

Grace, P. J. (2017). Nursing ethics and professional responsibility in advanced practice. Burlington, MA: Jones & Bartlett Learning.

Lewenson, S.B., & Truglio-Londrigan, M. (2015). Decision-making in nursing: Thoughtful approaches for leadership (2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Ulrich, C.M. (2012). Nursing ethics in everyday practice. Indianapolis, IN: Sigma Theta Tau International.


It is imperative that school nurses, and all professionals in the school environment, work together to meet ethical challenges that present in the school setting. Good health is essential to learning and school nurses are a vital resource to promote and maintain a student’s health. Navigating the roles of both educators and nurses, school nurses have tremendous challenges to keep abreast of the breadth of pediatric conditions they may encounter, and the rules, regulations, policies, and laws that govern the nursing and the educational environment in which they practice. Their ethical responsibilities are often impacted by the legal mandates of their position. It is imperative that school nurses, and all professionals in the school environment, work together to meet ethical challenges that present in the school setting. School nurses, individually and collectively, shape the future through diligent care and persistent advocacy for the rights of students.


The author wants to acknowledge the assistance of these school nurse faculty who gave generously of their time and knowledge in the development of this article: Martha Dewey Bergren, Eileen Moss, Angela Lepkowski, Robin Adair Shannon, and Cathy Yonkaitis.


Teresa A. Savage, PhD, RN

Teresa Savage is a Clinical Associate Professor in Women, Children, and Family Health Science at the University of Illinois at Chicago College of Nursing. Her clinical background includes neonatal intensive care and follow-up, and working with children with neurological conditions, including intellectual and developmental disabilities. As an ethicist, she has provided consultation at a major academic medical center, a pediatric residential facility, and a rehabilitation hospital. She is a member of two hospital ethics committees and has over 175 publications and presentations.


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© 2017 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2017

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