School nursing is grounded in population health. School nursing is grounded in population health. The school nurse role is often viewed as providing episodic care to individual children, and more recently, highly skilled care to chronically ill and medically fragile children. However, the true value of school nursing is in health promotion and illness prevention. This article reviews the past, present, and future of school nursing to offer insight about this role in the context of population health.

The Past

Impact of Henry Street Settlement
In 1893, nurses Lillian Wald and Mary Brewster established public health nursing in the tenements in New York City’s Lower East Side (Fee & Bu, 2010). The Lower East Side was home to the city’s most recent and poorest immigrants. Wald and Brewster addressed social and economic ills of the community, in addition to treating illness and disease. In 1895, they expanded their operation, naming it the Henry Street Settlement (Fee & Bu, 2010). Child health was a major focus of the Henry Street Settlement and public health nursing.

In the 19^th century, school health was limited to “health inspections,” a physician-led model of screening for and excluding students with communicable diseases. In the 19^th century, school health was limited to “health inspections,” a physician-led model of screening for and excluding students with communicable diseases. The model resulted in excluding 10 to 20% of students from schools without treatment (Struthers, 1917) and created a persistent, chronic truancy that damaged children, families, and society. On October 1, 1902, an experiment was launched to interrupt this ineffective cycle. Lillian Wald assigned Lina Rogers, a Henry Street Settlement nurse, to promote hygiene and preventive health measures to approximately 10,000 children in four New York City schools (Struthers, 1917). Nurse Rogers worked with a physician screener, treating children who could be sent back to class (Struthers, 1917). Children who had symptoms of contagious diseases were sent home, and received a subsequent visit from Nurse Rogers. The focus of the experiment was illness prevention, which included: teaching personal hygiene and cleanliness; establishing playgrounds; partnering with charitable institutions for food, warm coats, and boots; and connecting adults with employment (Struthers, 1917). Students’ homes were inspected for sanitation and safety, and landlords in violation of housing standards were reported to the Board of Health (Struthers, 1917).

School nursing began by utilizing the public health, population-based approach and effectively resolved rampant communicable disease and chronic absenteeism. At the end of one month, the experiment was a success. Nurse Rogers reduced school absenteeism by 50% and markedly improved the health of children by decreasing easily treatable illnesses and preventing others (Struthers, 1917). Lina Rogers was hired by the New York City Board of Health to work in the city schools. A month later, in December 1902, 12 additional nurses were hired, and the cumulative results on absenteeism were striking (Struthers, 1917). By the end of the school year, New York City had invested in 27 school nurses who each served approximately 10,000 students in 4 to 5 schools (Struthers, 1917). School nurses were soon introduced in Los Angeles, Boston, and Philadelphia. “The highest objective of all efforts was to teach children how to be healthy and how to stay healthy” noted Struthers (1917, p. 40). School nursing began by utilizing the public health, population-based approach and effectively resolved rampant communicable disease and chronic absenteeism.

Other Factors
World Wars I and II again brought the poor state of the health of school children into focus. World Wars I and II again brought the poor state of the health of school children into focus. Many recruits were not able to enlist due to health conditions resulting from poverty and malnutrition (Institute of Medicine [IOM] Committee, 1997). The health and fitness deficiencies of the nation’s children were viewed as a threat to national security. A renewed interest in promoting the health, physical conditioning, and nutrition of all students led to the adoption of physical education and school nutrition programs. School nurses continued to provide population based health services such as immunizations, health screenings, and follow-up (IOM Committee, 1997). In the 1960s, the Great Society legislation recognized the impact of poverty on health and learning and led to increased funding for school nurses to serve in schools with high need students (IOM Committee, 1997).

The Present

The School Nurse Role Today
The school nurse role is one of the broadest nursing roles, and school nursing is one of the few subspecialties responsible for direct care of individuals as well as care of the school community and environment. The legacy of population health that defined the origin of school nursing continues today. The school nurse role is one of the broadest nursing roles, and school nursing is one of the few subspecialties responsible for direct care of individuals as well as care of the school community and environment. The number of students who come to school with tracheostomies, gastrostomy tubes, and ventilators has increased exponentially due to improved survival rates of premature infants and infants with disabilities (Stoll et al., 2015). Students with chronic conditions (e.g., asthma, diabetes obesity, epilepsy) make up 25% percent of student caseloads (Van Cleave, Gortmaker & Perrin, 2010). The intense and persistent needs of students with existing health conditions often diverts media and public attention from the school nurse’s current and enduring role in population health.

However, there are many examples to illustrate that the traditional role of the school nurse in population health continues. Nurses enforce mandated vaccines for school enrollment, protecting the entire community from communicable disease. The role of the school nurse in surveilling infectious disease; reinforcing handwashing; and promoting proper techniques for coughing, sneezing, and hand hygiene is always important, and was especially prominent during the H1N1 pandemic (Rebmann, Elliott, Swick, & Reddick, 2013). Vision and hearing screening, with referral for treatment, is conducted across the United States, helping to ensure that children get the highest benefit possible from school instruction. School nurses consistently provide education about health concerns to students and parents. Nurses in many school communities are deeply involved with provision of oral health sealants and fluoride rinse programs to prevent tooth decay.

The intense and persistent needs of students with existing health conditions often diverts media and public attention from the school nurse’s current and enduring role in population health.In addition to these traditional primary prevention activities, over the last decade a number of initiatives strengthened the contribution of the school nurse role to enhance the health of school aged children, families, and the community. In 2009, the Robert Wood Johnson and Institute of Medicine’s (IOM) Future of Nursing (2011) initiative was designed to improve the quality and delivery of healthcare by maximizing the contribution of nurses. The Future of Nursing initiative encourages care systems to utilize nurses to the full scope of their license. Nurses are urged to earn national specialty certification and to advance their education to the bachelors, masters and doctoral levels. The Future of Nursing tenets fully embrace the role of nurses who work in the community to improve the quality, experience, and outcomes of care. Testimony from leaders from the National Association of School Nurses (NASN) about the contribution of school nurses toward those outcomes was delivered at one of three national public forums. The NASN testimony included the idea of tapping nurses embedded in the community to reach the health goals of the nation (Bergren, 2010).

Impact of Recent Legislation
Federal legislation and, later, Obama White House programs provided synergy for school nurse health promotion efforts. Through the Child Nutrition and Women, Infants, and Children (WIC) Reauthorization Act of 2004 (Public Law 108-265, 2004), the United States Congress required all school districts with a federally-funded school meal program develop and implement local wellness policies that address nutrition and physical activity by the start of the 2006-2007 school year. The adoption of local level school wellness policies, followed in 2010 by Michelle Obama’s Let’s Move (2017) campaign, gave school nurses a seat at the table and momentum to partner with like-minded educators and community health champions to create healthier school environments.

Many school programs have promoted healthier choices and disease prevention, not for just students, but also for school staff and faculty. School nurses, with the support of these national initiatives and local stakeholders, were able to champion more nutritious school food; decrease or eliminate empty calories in school; adopt universal breakfast; increase physical education and classroom physical activity; and establish and lengthen recess time (Healthy Schools Campaign, 2017; Oaker, 2017). Many school programs have promoted healthier choices and disease prevention, not for just students, but also for school staff and faculty (Healthy Schools Campaign, 2017).

The advent of the Patient Protection and Affordable Care Act (2010) has further emphasized the population context of the school nurse role. With the focus on prevention and population health and incentives to reduce community level costs for care (i.e., beyond acute and primary healthcare systems), the school nurse is ideally situated where children live, learn, and play.

Leadership Programs
Leadership programs that reinforce the population health role and change leadership skills of school nurses have created a critical mass of such nurses implementing community needs assessments; evidence based program planning; and implementation and evaluation of population level interventions (Gibbons, Wesoloski, Lawinger, & Fishman, 2012; Healthy Schools Campaign, 2017; Johnson & Johnson, 2016). The leadership programs reinforce the importance of community health partnerships, but also provide skills and tools needed to bring about sustainable change. School nurses who receive leadership training as change agents learn to be sensitive to community norms and beliefs; to assess and manage local, county, and state politics; and to coordinate multiple community stakeholders with competing agendas around common goals (Carr & Modzeleski, 2014; Healthy Schools Campaign, 2017; Johnson & Johnson, 2016).

Leadership programs have guided school nurse and community teams to resurrect the community needs assessment as a starting point to create population based change. Leadership programs have guided school nurse and community teams to resurrect the community needs assessment as a starting point to create population based change. These programs have changed the approach to student health issues in districts across the county. For example in California, Oakland Public Schools uses a windshield survey during its annual orientation for new school nurses to ensure the nurses observe not only health and social inequities of the community, but also strengths of the neighborhoods where students live (Center for Community Health and Development, 2017).

Using Frieden’s Health Impact Pyramid (2010), as a guiding conceptual framework, the leadership programs reinforce the need to choose programs with community partners that meet the needs of the community, and to choose comprehensive evidence based interventions as opposed to the more traditional health education-only approach. For example, school nurses in Austin, Texas launched a comprehensive population based program to prevent mental health distress before it escalates (Schwind, Freeman, Garcia, & Roberts, 2014). The program reduces demand on local mental health professionals, allowing them to direct their services to students at highest risk. In Illinois, school nurses established Walking School Bus Programs where parents accompany groups of children to safely walk to school rather than be driven or ride the bus to increase their daily physical activity (Gibbons et al., 2012).

School nurses are stronger and more skilled in population health practices than they were a decade ago. Other school nurse teams have addressed redesigning the immunization delivery system in rural communities; launching prescription drug abuse prevention across communities and states; and increasing access to fresh fruits and vegetables through expansion of community farmers’ markets. School nurses are stronger and more skilled in population health practices than they were a decade ago. As academic preparation and professional development for school nurses continues to build on this capacity (Cogan, Conway, & Atkins, 2016), the impact of the collective population health interventions promises to deliver healthier students, healthier families, and healthier communities.

Conclusion: A Look to the Future

The next challenge is to transform the delivery of care in the community and to accept leadership for healthy initiatives and policy change at the local, state, and national level. Population health has been the foundation and the strength of school nursing. School nurses have grown in their ability to assess community needs, deliver evidence based programs, and evaluate population based interventions. The next challenge is to transform the delivery of care in the community and to accept leadership for healthy initiatives and policy change at the local, state, and national level.

The IOM Future of Nursing (2011) initiative has had a visible impact on the number of school nurses pursuing doctoral degrees. The Doctor of Nursing Practice (DNP) prepares implementation specialists, or nurses who are expert in translating evidence based interventions into practice (American Association of Colleges of Nursing [AACN], 2006). DNP programs educate school nurses to implement systems change, in their own institution; within health systems and communities; in policies; and in legislation (AACN, 2006). Doctorally prepared (PhD and DNP) school nurses understand the questions and structures that both impede and promote health in the schools and communities they serve. PhD prepared school nurses can advance population based research to create the knowledge needed to develop and test population based interventions, financing strategies, and cost-effectiveness (Cowell, 2016). As the ranks of both DNP and PhD prepared school nurse increase, the nature and context of population based programs and research will be more sensitive to unique cultural nuances of schools and communities.

Challenges that face school nurses are faced by all nurses. In order for nurses to be seen as leaders, they must see themselves as leaders (IOM, 2011). Nurses must see policy as something they can shape rather than something that happens to them, whether within the school, in the community, or at the state or national level (Shalala, 2014 ). The IOM Future of Nursing report challenges nurses to be full partners in redesigning healthcare in the United States (IOM, 2011). School nurses must accept that challenge. To achieve this goal, school nurses belong on the boards of directors of public health departments, hospitals, non-profits, and schools. These boards will benefit from the perspective of a nurse who lives and works in the community and can translate the impact of social determinants of health. School nurses, more than any other professional, understand the impact of healthy school environments, school funding, chronic conditions, on the health and education of children (Bergren, 2017). With 98% of all school aged children attending school every day (National Center for Education Statistics, 2016), school nurses must now and in the future accept the challenge to change health systems and health policies to improve child, family, and community health.

Author

Martha Dewey Bergren, DNS, RN, NCSN, APHN-BC, FNASN, FASHA, FAAN
Email: bergren@uic.edu

Dr. Bergren has a Doctorate in Nursing Science, and is the Director of Advanced Population Health Nursing at the University of Illinois-Chicago where she teaches health promotion behavior interventions, policy and evidence based practice to doctoral students.  She was Director of Research at the National Association of School Nurses 2008-2011.

Oaker, C. (2017). Making healthy choices the easy choice: What the record shows. Retrieved from: https://letsmove.obamawhitehouse.archives.gov/blog/2017/01/01/making-healthy-choice-easy-choice-what-record-shows

Patient Protection and Affordable Care Act (PPACA) Pub. L. No. 111-148, §2702, 124 Stat. 119, 318-319. (2010). Retrieved at www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf

Rebmann, T., Elliott, M.B., Swick, Z, & Reddick, D. (2013). U.S. school morbidity and mortality, mandatory vaccination, institution closure, and interventions implemented during the 2009 influenza A H1N1 pandemic. Biosecurity and Bioterrorism, 11(1), 41-48. doi:10.1089/bsp.2012.0050

Rutgers, Center of Alcohol Studies. (2017). Addiction education: Application overview. Retrieved from http://education.alcoholstudies.rutgers.edu/node/52