School nursing is an integral part of the United States educational system. While the institution of school nursing began with the single purpose of improving public health through the treatment and containment of infectious diseases, it has evolved into a multi-dimensional profession. The most significant expansion in the role of school nursing during the second half of the 20th century was in the area of children with disabilities. Today, nurses also oversee school health service programs and help treat students with mental health issues. Because of a nurse shortage, many schools find themselves without a full time nurse. These schools have employed a number of innovative methods to ensure that they meet their students' medical needs.
Keywords Chronic Illness; Disability; Mental Health; National Association of School Nurses (NASN); Public Health; School Health Service Program; School Nursing; Terminal Illness
In the century that has passed since its inception in 1902, school nursing has become an integral part of the United States educational system. While the implementation of school nursing varies from school to school, the goal of school nursing remains the same everywhere: to support the overall health and wellness of school children, and thereby enable them to avoid absences, focus in the classroom, and achieve their full academic potential (Wolfe & Selekman, 2002). The National Association of School Nurses (NASN) defines school nursing as "a specialized practice of professional nursing that advances the well being, academic success, and life-long achievement of students" (Wolfe & Selekman, 2002, p. 406). School nursing is so critical because more than 53 million children living in the U.S. spend more than one-third of every weekday at school (Hootman, Houck, & King, 2003). School is often the central context within which children develop - physically, mentally, and socially. By monitoring these developmental tracks and providing timely interventions when necessary, school nursing helps to meet the fundamental health needs of the nation's children.
School nurses are the most commonly found healthcare providers practicing in schools today (Hootman & Desocio, 2004). As such, they provide an overall "health safety net" for the nation's children, ensuring that all students enrolled in public schools receive primary health care services, adequate nutrition, mental health care services, and disability services (Vessey & McGowan, 2006, p. 256). These services are especially valuable when poverty or other conditions at home compromise a child's access to outside medical care. For these students, school nurses often serve as de facto primary care physicians (Wolfe & Selekman, 2002).
While the institution of school nursing began with the single purpose of improving public health through the treatment and containment of infectious diseases, it has evolved into a multi-dimensional profession. School nurses are direct care providers, case managers, and consultants (Hootman et al., 2003). They must master skills associated with pediatric nursing, community health nursing, psychiatric nursing, emergency-room nursing, and home-care nursing, as well as health education, policy making, social work, and office management. When serving students with chronic medical problems, school nurses become liaisons who must coordinate between a child's parents, primary care physician, and teachers (Broussard, 2004). Often, school nurses manage and implement a larger school health service program, or coordinated school health program, which includes health education, counseling, physical education, nutrition, and immunizations, along with many other services (American Academy of Pediatrics, Committee on School Health, 2001; Wolfe & Selekman, 2002). Increasingly, school nurses are engaging in research as well. By documenting the positive outcomes and cost-effectiveness associated with their practices, school nurses hope to encourage districts to invest more funds in school nursing (Edwards, 2002).
School Nursing During the Early 20th Century
School nursing was first established in the United States in New York City in 1902 as a way to combat the rampant absenteeism that plagued the city's schools. During this period, New York was overcrowded and unsanitary. Large waves of immigration during the late 19th Century had resulted in slums and tenement neighborhoods where infectious diseases were widespread (Vessey & McGowan, 2006). Prior to the institution of school nursing, New York City schools were monitored by physicians who would visit one a week and examine children for symptoms of contagious diseases such as whooping cough, measles, and scarlet fever. Infected students were not treated, but sent home with their diagnosis written on a slip. It was assumed that parents would receive this diagnosis and seek medical care for their children. This policy was largely ineffective for several reasons. Immigrant parents were often unable to read English and thus could not understand their child's diagnosis if and when they received it. Even if parents wanted to seek medical treatment for their children, poverty often made this impossible. Finally, even though contagious children were removed from schools, they still interacted with and infected their classmates and peers at home, on playgrounds, and in the streets (Broussard, 2004; Wolfe & Selekman, 2002; Vessey & McGowan, 2006).
In order to address the widespread absenteeism that resulted from its current school health system, the New York City Board of Education and the City Health Commissioner turned to Lillian Wald, a social reformer and advocate for the city's immigrant poor. Using a program established in London in 1893 as a model, Wald commissioned the nation's first school nurse: Lina Rogers (Wolfe & Selekman, 2002). Rogers' primary goal was to contain the spread of communicable diseases in the city's schools. She achieved this goal by treating the illnesses she diagnosed, often making home visits in order to administer medicines and educate parents about preventative measures such as proper hygiene. Rogers' method was so immediately effective that within one month the city hired 14 more nurses. Within a year, absentee rates had dropped by 90%; within three years Los Angeles and Boston had begun their own school nursing programs (Vessey & McGowan, 2006).
School Nursing Today
While school nursing began as "one of the most successful experiments in public health" in U.S. history, its focus soon expanded outside of the domain of public health to include other pertinent student-health related issues (Vessey & McGowan, 2006, p. 255). The 1950's and 1960's saw a dramatic proliferation in school nursing, with schools across the nation hiring full-time nurses. During this period, the focus of school nursing shifted from public health to screening efforts and referrals to primary care physicians. Children were screened for scoliosis, hearing loss, and vision problems; parents were notified if their children tested abnormally and told to seek further care from a primary care physician. During the 1960's and 1970's, health classes were added to many high school curriculums. School nurses either taught these classes or consulted with teachers in order to help develop their content. During the 1980's, many high schools developed health services focused on an adolescent population. Reproductive health, HIV and STD infection, as well as mental health, all became the domain of school nursing (Broussard, 2004).
Students with Disabilities, Chronic Illnesses,
The most significant expansion in the role of school nursing during the second half of the 20th century was in the area of children with disabilities. During this period, advances in pediatric medical care and changing attitudes about children with disabilities resulted in decreased rates of institutionalization for children with physical, psychosocial, and developmental disabilities. Children who would have formerly been institutionalized were now being raised at home and attending public schools. These children often needed more medical care during the school day than their peers, and legislation was passed guaranteeing them the right to such care. The Individuals with Disabilities Education Act (IDEA) of 1975 and the Education for All Handicapped Children Act of 1975 (also known as Public Law 94-142) mandated that all children, regardless of physical or developmental disabilities, must be given access to and accommodated in the nation's public schools. The task of removing barriers that had formerly prevented children with disabilities from participating in school was allocated to school nursing services. This new role for school nursing was reinforced in 1999, when a Supreme Court ruling further stipulated that public schools are financially responsible for providing nursing services for children with special medical needs if they need these services in order to have access to, and benefit from, public education (Wolfe & Selekman, 2002).
It is estimated that 11% of school-aged children in the United States today have at least one disability (Hootman et al., 2003). Currently, the services provided by school nurses enable students in wheelchairs, students with digestive disorders, diabetes, ADHD, autism, depression, mental...
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