Overview and Summary: Back to Class: Perspectives on School Nursing

For many years, I have heard the beauty of the nursing profession was the ability to change careers many times and stay within the profession. This is still true, but with advances in science and technology, along with the complexity of many of our patients’ conditions, subspecialties in nursing have become more uniquely focused. This has led to less understanding about what other specialized nursing areas do and their unique and needed contribution to patient care along the continuum. One consequence is unintended silos within the nursing profession, which can cause duplication and other complications for our patients.

Evidence-based practice and funding reforms continue to emphasize care coordination for better health and improved costs. Technology has advanced so that data can more easily be shared across settings via electronic health records. Part of the process of transferring a patient to a new unit is to provide a hand off report to assist the new unit providers continue to provide care of the patient. Better understanding of nursing subspecialties can help in these hand-offs. This is especially critical when children are ‘transferred’ back into community.

For many children with chronic conditions, they transition to the unit of ‘school.’ School nurses are critical members of the healthcare team, but many outside of the school setting may not realize the critical thinking and skill set associated with this specialization and its evidence-based practice. At the same time, some of the emerging issues faced by school nurses (e.g., addressing equity; care coordination and interprofessional practice; population-based care; ethical issues; meeting the needs of a global society) are also faced by nurses in other subspecialties. This OJIN topic focuses on the profession of school nursing, while addressing issues that all nurses may face.

The first article, “Healthy and Ready to Learn: School Nurses Improve Equity and Access” by Johnson, looks at the historical foundation and legal roots of school nursing, with specific focus on students with chronic conditions and the rules and regulations that impact students. Federal laws, such as the Rehabilitation Act first passed in 1973, forbid discrimination against students attending public schools. The article describes challenges that school nurses face in different regions or states of the country. Johnson highlights the impact that state nurse practice acts, along with variable funding, may have on school nurse staffing models. In addition, she outlines opportunities that technology may provide to enhance care and share data (via electronic health records). The content of this article will help fellow nursing professionals better understand the important role school nurses play in advocating for students in the school setting; address the continuum of care after patients are discharged or leave the office and return to their normal life; and realize why school nurses may ask for certain paperwork or documents.

The next article, “Interprofessional Collaborative of Practice and School Nursing: A Model for Improved Health Outcomes,” builds upon the importance of teamwork and interprofessional collaboration. Authors, Fleming and Willgerodt, share an overview of the relevant principles and background, including the core competencies for interprofressional collaborative practice. Examples of these core competencies draw on the role of school nurses. School nurses work in teams from education, health, and even the broader communities of their schools. Anyone who impacts the health of their students is a partner. For students with chronic conditions, school nurses use care coordination and case management skills, working with everyone involved to support student success. This also requires the development of an individualized healthcare plan to direct care formed during the school day in accordance with goals of the student, family, and team. The article concludes by outlining some challenges to interprofressional practice. Fleming and Willgerodt’s article will provide insight into the roles that school nurses play in teams, but the principles of the article can apply to any nursing subspecialty.

The article, “School Nursing and Population Health: Past, Present, and Future” by Bergren, may seem to switch gears by addressing an evidence-based topic that has emerged in recent years in healthcare discussion: population health. Although new to some areas of healthcare and nursing, population health has always been a key responsibility of school nurses. In fact, the historical roots of school nursing began by addressing the population of immigrant children living in the tenement housing of the lower east side of New York City. Early on Lillian Wald, the founder of school nursing, saw the interconnection of factors in society and homes that influence health. Bergren discusses the evolution of population health over time, and then shares the current role of school nurses today. Examples include identification of health inequalities; vaccination compliance; infectious disease surveillance; nutrition; and health education about a variety of subjects. School nurses also support broader population efforts through participation on school wellness councils. Nurses from other professions may address some of these topics and/or see the impact of these concerns in their practices. In reality, this article provides another example of the interprofessional practice of nursing, through the lens of school nurses.

Another topic applicable and critical to all areas of nursing is ethics. The American Nurses’ Association (2015) has provided the Code of Ethics to guide nurses. Yet how do the principles of ethical practice and decision making impact daily practice? In the article, "Ethical Issues in School Nursing," Savage outlines how the unique position of school nurses considers both how healthcare laws and practices and education laws and practices can cause ethical dilemmas. After a brief review of the literature specific to school nursing and ethics, she shares two common ethical theories and applies them to school nursing situations, such as medication in the school, student responsibility, and suspected child abuse. Savage outlines principles that can apply when making ethical decisions, and provides additional examples of this process. The article offers a rich discussion of other ethical concerns and principles that apply to all areas of nursing, such as moral distress, moral courage, legislative advocacy, and social justice. She ends with materials and resources that are helpful to all.

Finally, the topic expands from a local community perspective to a global perspective. In the article “U.S. Licensed School Nurses Working in an International Setting,” Hudson and Tsurumaki share the fascinating world of international student health. First, they discuss the history, location, funding and governance, and families that attend two different types of oversea schools: United States Department of Defense Schools and international schools. The authors then compare and contrast some of the student challenges and nursing roles in these schools. They bring their rich personal experiences and examples to discuss nursing challenges faced while working in international settings. Their insight will be helpful to any nurse interested in working overseas, as well as for nurses in the United States who work with children returning from other countries, known as Third Culture Kids (TCK). A global concept, TCK are students who have lived outside their ‘native’ country, have integrated into another culture, and return to their country of origin. The authors provide implications for practice to help these students navigate the challenges related to culture and adjustment.

The principles and concepts addressed in these OJIN topic articles, while offered in the context of school nursing, are often applicable in any nursing setting. The articles provide insight and skills that will assist every nurse toward more holistic practice: no matter your work setting. In school or otherwise, we care for the same patients. Each is a holistic being who is part of a family, and community beyond the walls of the institution where we work. As nurses, we see different aspects of patients, depending on where and when we have the privilege to work with them.

In many areas of healthcare, nurses see patients during their most vulnerable times in a clinic or hospital setting. School nurses are in the unique position to see students and their families in their vulnerable times, as well as their best moments of wellness, and in their own homes and community. School nurses' documentation of care are valuable resources for the entire health team. Understanding how care continues when patients are in the community will help all subspecialties of nursing work together, as a stronger nursing force to meet the health and well-being of all.

An added bonus to reading these articles is the opportunity to learn and better understand the role that school nurses play to define and address health needs in the continuum of care for students and their families. The concepts in the articles also address some key roles of school nurses as outlined in the Framework for 21^st Century School Nursing Practice (NASN, 2017). For more information on this framework please go to https://www.nasn.org/framework.

The journal editors invite you to share your response to this OJIN topic addressing school nurse perspectives either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Erin D. Maughan, PhD, MS, RN, PHNA-BC, FNASN, FAAN
Email: emaughan@nasn.org