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Documentation and School Nursing Research

Historically, the contributions of school nurses to the achievement of positive educational outcomes have been largely invisible. This is because nursing documentation issues within the school setting lag substantially behind other nursing settings. It is not that standardized nursing documentation languages don’t exist, it is simply that they have for the most part, failed to be implemented in the school setting. With no one universal standardized school nursing vocabulary, school nurses are unable to describe and measure children’s health issues and the complex nature of professional school nursing practice, not to mention how school health services contribute to educational outcomes. This lack of standardization of data has made school nursing research very difficult. It is no wonder that there is poor public comprehension of the value of school nursing, particularly as it relates to educational outcomes.

      School nurses need to move towards a research-based practice that is able to scientifically measure the cost-effectiveness, and the quality of outcomes of school health services and school nursing (Hootman, 2002). Only when there is sufficient hard data to verify the connection of school nursing services to educational outcomes for children, will school health services receive the funding it needs to provide the educational outcomes that are mandated (Costante, 2002). School nurses must be able to scientifically prove that health is fundamental to the educational process (Costante, 2002). Once again, this begs for the practice of school nurses, to join other nursing specialties, and becomes research-based. 

Nationally there are approximately 30,000 nurses caring for 42 million students. That averages to one nurse for every 1400 students. This is the situation despite the fact and the U.S. Department of Health and Human Services, in its publication, Healthy People 2010, and the National Association of School Nurses have issued recommendations for student to nurse rations to be 750:1 for the general school population; 225:1 for the mainstreamed population; and 125:1 in special needs/medically fragile populations (HHS 2002, NASN, 2002). It is doubtful that the poor student to nurse ratios that exist today will change until school nurses can produce statistically significant data that proves the cost-effectiveness of lower student to nurse ratios. School nurses are in a powerful position in the school district, but only by expanding visibility can it be a viable one.

If school nurses cannot prove that what they do makes a difference or show what nursing interventions are needed to ensure optimal student performance, then how can school nurses advocate for increased school health services? Improved documentation systems will lead to smaller school nurse to student ratios, the validation of specific school nursing interventions, and provide the basis for establishing credible nursing services as they relate to positive educational outcomes.


Issues of Confidentiality

One of the most conflicting issues for school nurses is confidentiality of health information. Conflicts about confidentiality exist between members of the school staff and the school nurse, between parents/guardians and the school staff, and minors and their parents. School staff often believe they have a right and responsibility to know all about a student’s personal health issues, whereas school nurses are committed to protecting each individual student’s privacy related to health information (Costante, 2002). Often a parent/guardian will not permit certain information to be shared with the education team, despite the fact that school nurse might believe that some members of the school staff  could benefit from knowing about a student’s health status in order to serve him or her appropriately. And thirdly, while parents generally hold legal authority to make health care decisions for their children, there are sometimes divergent interests between what minors may want their parents to know and parents/guardians feel is their right to know.

      There are those who believe that minors with decision-making capacity, regardless of their age, should be involved in their health care decisions (Dickey, 2002). There are those who believe the opposite is true. The school nurse is often in a unique position to promote the inclusion of minors in their day-to-day health care decisions, particularly as the health office is a “safe” place where students can go for a variety of concerns without parental presence.

      When a minor is married, pregnant, or a parent of his or her own child there are often state statutes that allow for them to make autonomous decisions regarding health care for a variety of service, including family planning, testing and treatment for HIV and other sexually transmitted disease, prenatal care and delivery service, treatment for alcohol and abuse, and outpatient mental health care (Dickey, 2002). This could, depending on the state, allow a 14 year old mother of an infant leave school without parental permission to go to her 6-week post-partum check-up, or allow her to be tested for a sexually transmitted disease, or even allow for the 16 year old father of the infant to leave school without parental permission to accompany the mother and infant to a pediatrician’s appointment (Schwab, 2002).

      Let’s say a minor is not married, pregnant, or a parent of his or her own child, what statutes allow for them to make autonomous decisions regarding their own health care? Their rights to seek health care independently of their parents are generally in proportion to the age and competence of the minor, the type of health care the minor seeks (how invasive), and potential consequences to the minor and the community if her or she refuses to seek care (such as the treatment of an STD, or the refusal of to seek treatment for drug and alcohol problems) (Guidelines, 2002).

      There is an active movement to ‘restore’ parental rights and to legislate parental control over minors’ reproductive health care decisions. With the exception of abortion, lawmakers have generally revisited attempts to impose parental consent or notification requirement on minors’ access to reproductive health care and other sensitive services (Boonstra & Nash, 2002). Further complications may arise with independent consent when parents are held liable for financial debt incurred by their children when they did not have a say in the decision-making process (Dickey, 2002).

In health care, on the other hand, the legal rights of parents to make decisions for their children gives way, in part, to the right of competent minors to seek and make their own decisions regarding certain types of health care. In education, however, the legal right of parent to make decisions for their minor children is upheld almost without qualification (guidelines, 2001). In this litigious age, this paradox is not likely to be resolved, as it is becoming increasingly difficult for school nurses to defend the autonomous health care decisions of minors as ethically valid (Dickey, 2002).


Who has Access to a Students Health Record?

The Federal Education Rights Privacy Act, also known as the Buckley Amendment, which was passed in 1975, is a federal law that requires that students consent to parental access to their education records. Are school health records education records or health records? FERPA does not provide special protection for health information that a competent minor student may want to keep confidential, even though, under state health laws, the information may be protected from access by others, including parents. If a school nurse protects student health information, it often puts him or her at odds not only with a federal law, but also with the expectations of school administrators and teachers regarding what student health information school nurses can or should share with them.

      Exceptions to FERPA are personal notes of the school nurse. In order for a notation to be classified as a personal note, however, they must not be included in the health record, and they must not be shared with any member of the education team. In other words, if a student discusses possible date rape with a minor, he or she may choose not to document in the health record, and instead choose simple to write a “personal note.” But in order for a ‘personal note’ to stay confidential, the school nurse must not share its content with anyone, not even a social worker currently working with a family. Once the ‘personal note’ is shared with anyone,’ it falls under the education law, FERPA, and allows full parental access.

Currently there are no provisions, despite recommendations from the Centers for Disease Control, to hold ‘personal notes,’ and/or health education records, to the same standards of confidentiality observed in health care settings outside the office of the school nurse (guidelines, 2001). Further complicating the issue is that in the school setting, is the fact that school nurses typically have non-nursing on-site supervisors, most often the school principal.


Accessing Health Care

Accessing health care is broader than accessing medical care. In addition to medical care for acute and chronic illness, health care includes health promotion and disease prevention services. Unfortunately, not all children have an ideal connection with the health care system for comprehensive health care. Multiple barriers to accessing comprehensive health care exist, including geographic, financial, transportation, sociocultural, coverage criteria and availability of services.

Ensuring access to quality health care is an important component of school nursing practice. Knowledge about the health care system (e.g. legal mandates, funding sources, and programming), specific regional resources and health policies can bridge the gap between the health care needs of students, their families, and school staff and accessibility to services. The school nurse can assist in the elimination of geographic, transportational, sociocultural and financial barriers to accessing health care by suing his/her knowledge and expertise about health needs and the health care system.


The Future of School Nursing

The Advanced Practice Nurse

            The dynamic, expanding and comprehensive nature of the practice of school nursing demands an educational and skill level that enables nurses to meet the complex health needs of students. As the specialty of school nursing evolves, the requirement for a master’s degree will become increasingly appropriate. Advanced Practice Nurse is a term used to identify the professional registered nurse functioning in an extended role. This nurse must have a baccalaureate degree, as well as a master’s degree, and/or certification as a nurse practitioner or a clinical nurse specialist.

The Advance Practice Nurse in the school setting will always be challenged by issues such as teen pregnancies and medically fragile students, downsized staffing, and cultural diversity of school populations. Costs prompt shorter hospital stays so that children are discharged earlier to home and schools. School nurses need to keep pace with technological advances particularly those that address students with special health care needs.  Participation in professional organizations is paramount. These not only include state and national school nurse associations, but also organizations that deal with specific health care issues such as the American Diabetes Organization, National Education Association, National Association of Nursing Research, and even the national Pediculosis Association.  The Advance Practice Nurse will promote improved quality of health services in schools. Educational programs to expand the skills and scope of practice of the Advance Practice Nurse in the school setting should be established in each state.


Coordinated School Health Program

Although the traditional childhood diseases have diminished, new health problems that have a negative influence on student achievement and success have emerged. These “new morbidities” include an increase in chronic health conditions such as asthma, allergies, diabetes, addictions, teen pregnancies, HIV/AIDS, STDs, suicide and auto accidents.  Many of these health problems are the result of poverty, homelessness, poor nutrition, lack of exercise, smoking, early and/or unprotected sexual activity, substance abuse, stress, and depression.

The national Coordinated School Health Initiative has emerged in response to the state of children’s health and education. It is an organized set of policies, procedures, and activities designed to protect and promote the health and well being of students and school staff. It is a holistic approach to health an education. The school nurse participates actively in each of the eight components of a coordinated school health program. (The eight components are: school health services, health education, health promotion programs for faculty and staff, counseling psychological and social services, school nutrition services, physical education services, health school environment and family and community involvement.)


Participation in Public Policy, Legislative and Regulatory Government Relations

School nurses need to continue to promote public policy, and legislative and regulatory action, which are favorable to students. It is imperative that professional school nurses continue to be involved in the policy arena to impact the health and education of students and the practice of school nursing. They need to advocate for the removal of health related barriers to educational success. Past successes include the Supreme Court mandated inclusion of school nursing services in the federal law, IDEA, and the inclusion of lower school nurse to student ratios in the objectives of Healthy People 2010. It is up to the professional school nurse to take direct action regarding public policy that directly affects the well-being of students as well as the his or her professional status.




























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