Abstract
Competency-based continuing education is critical to the professional development of school nurses to ensure the application of timely, age-appropriate clinical knowledge and leadership skills in the school setting. School nurses are responsible for a large number of students with a variety of complex and diverse health care needs. Benner’s theory of novice to expert provides a framework for the development of roles and competencies in the practice of school nursing. This manuscript synthesizes research reviewed in 15 articles. Common themes found in the articles include the importance of continuing education and identified barriers to attainment. In response, methods to access continuing education and financial resources are presented.
INTRODUCTION
Continuing education (CE) is critical to the professional development of school nurses to ensure the application of advanced clinical knowledge and skills in the school setting. The specialty of school nursing practice involves working with a culturally diverse population with a wide variety of health problems in a nonmedical setting. According to the national sample survey of registered nurses conducted by the Department of Health and Human Services, 57,954 registered nurses are employed as school nurses to provide health care services for more than 52 million students in the United States (National Association of School Nurses, 2002, 2003a).
Along with the wide scope of practice and large number of students, another challenge facing school health programs is the difference in school nurse educational backgrounds, which vary according to local and state requirements. The formal education and preparation of a school nurse may be the completion of a vocational program, a diploma program, an associate’s degree, a bachelor’s degree, or a master’s degree. To bridge the gap among the varying educational backgrounds of nurses who work in the school setting, CE is an essential component of school nursing practice development. However, many school nurses face time constraints and financial barriers that prevent their participation in CE experiences.
CE is defined by the National Association of School Nurses (NASN) as a systematic professional learning experience developed to enhance knowledge, skills, and attitudes (2003b). Standard 8 in the Standards of Professional Performance section of the American Nurses Association’s (ANA) and NASN’s School Nursing Scope & Standards of Practice identifies measurable criteria for evaluating the school nurse’s participation in CE. Basically, Standard 8 states that to meet the standard, the school nurse must demonstrate a commitment to lifelong learning and participate in current knowledge and skill-based CE related to school nursing practice (ANA & NASN, 2005).
Other factors that contribute to the importance of CE for school nurses include a diverse student population with varied health needs and legal mandates. The practice of school nursing involves functioning independently to meet a variety of health care needs for a large number of students, without peer support or a nurse supervisor in an educational environment. The goals of this manuscript are to analyze the importance of CE for school nurses, examine barriers to the attainment of CE, identify methods by which school nurses access CE, and suggest financial resources.
To locate pertinent literature related to CE and school nursing practice, the CINAHL, PubMed, and Health and Wellness Resource Center databases were searched using these index words: school nurse, school nursing, continuing education, school nurse education, and distance learning. A manual search of The Journal of School Nursing since 1990 was also conducted. The articles included in this literature review focus on school nurse education and preparation.
THEORETICAL FRAMEWORK
A theoretical model used in the research about CE for school nursing includes Benner’s novice to expert theory. On the basis of research on clinical practices, Benner identified and described 31 competencies of nursing practice that led to the development of the seven domains of nursing practice (Tomey & Alligood, 2002). These domains correlate with the multiple roles of school nurses that include (a) helping, (b) teaching and coaching, (c) diagnostic client monitoring, (d) effective management of rapidly changing situations, (e) administering and monitoring therapeutic interventions and regimens, (f) monitoring and ensuring quality health care practices, and (g) organization and work role competencies (Benner, 2004).
Two studies examined in this literature review presented Benner’s theory as a framework. In a qualitative study measuring school nurses’ perceptions of autonomy, Simmons (2002) proposes that Benner’s model explains the transformation that occurs as school nurses become proficient at practicing their art. In addition, Poster and Marcontel (1999) infer that the study, utilization, and demonstration of competencies impact the progression of nursing growth from the novice level to the expert level.
Competencies and Roles
At the Southern Regional Education Board (SREB) workshop, a list of expected entry-level practice competencies was identified by school nurse participants (Aiken, 2000). These competencies included collecting and managing data, developing action plans, implementing plans, evaluating results, and seeking professional development opportunities. In addition, Oda (2001) stresses the importance of school nurses possessing effective communication competencies. Costante (2001) states that competency-based undergraduate and CE courses for school nurses promote collaboration, an understanding of health care issues and school nursing practice, and a higher quality of care for children.
In addition to competency-based practice, the multiple roles of the school nurse are often discussed in the literature. The American Academy of Pediatrics’ (AAP) School Health Committee describes the roles of the school nurse as being providers of acute, chronic, episodic, and emergency health; being a link to state health insurance plans; and functioning as health educator, counselor, and advocate for students with disabilities (AAP, 2001). Periard, Knecht, and Birchmeier (1999) identify several school nurse roles that include conducting health screenings, implementing and evaluating health promotion efforts, serving as a liaison and an advocate for handicapped and abused children, functioning as a health curriculum resource for teachers, acting as a health educator for students and staff, serving as a consultant for school health policies, and managing nonnursing personnel. Because of the large number of health services and maintenance needs of chronic health condition, to meet the health needs of students, school nurses require leadership skills and adequate time to teach, monitor, and supervise nonmedical staff who are often required to provide health care for individual students (Costante, 2001).
To appreciate the dimensions and various roles of the school nurse, role clarification is essential. A written job description clarifies role expectations among nurses, as well as for the school administration, special education coordinator, and faculty (Battin, Battaglin, & Byrd, 2001). In addition, the clarification of roles enhances the delivery of health care services and establishes a strategy for measuring quality care outcomes, cost effectiveness, and student achievement (Costante, 2001).
LITERATURE REVIEW
Today, the primary goal of school nursing is to promote and maintain the health of students, ultimately increasing students’ academic success (NASN, 1999). Miller and Rector (2002) describe the position of school nurses as, “one foot in the education department and the other in the nursing department” (p. 339). Costante (2001) reiterates that school nurses require expertise in the fields of health care, education systems, and the impact of health on student academic success. To meet these goals, four major issues emerged from the literature review: (a) the importance of CE for school nurses, (b) barriers to attaining CE, (c) identification of ways to access CE, and (d) suggestions for meeting CE-associated costs.
Importance of Continuing Education for School Nurses
Multiple factors, such as the wide scope of nursing practice, diverse student population, student health care legal mandates, and varied education and preparation of school nurses, contribute to the importance of CE for school nurses. Benner (2004) describes formal nursing education as a curriculum of biological and psychosocial sciences, as well as the art and science of nursing. This education prepares the novice nurse for a wide scope of practice with flexible judgment skills and knowledge that provides a framework for advanced-skill acquisition and safe patient care (Benner, 2004). This level of expertise exceeds offerings in formal education programs. Therefore, for the school nurse to advance from novice to expert, the nurse must incorporate clinical experience with ongoing completion of current theory and knowledge (Benner, 2004).
Multiple factors, such as the wide scope of nursing practice, diverse student population, student health care legal mandates, and varied education and preparation of school nurses, contribute to the importance of CE for school nurses.
Student Population
Along with the varied educational backgrounds, the number of students or schools assigned to one nurse varies in each community. Even though the national health initiative Healthy People 2010 and NASN recommend 1 nurse per 750 students, school nurses continue to be responsible for a much larger number of students and for the families and school staff in one or more schools (Gregg & Wozar, 2003). Battin and colleagues (2001) note that some Florida schools received special school health funding or grants to employ a full-time registered nurse and health aide for every 1,500 students. Other schools without funding are required to share a nurse among 10 to 12 schools for a total of 4,000 students (Battin et al., 2001). In a study describing an Internet resource course for school nurses, Gregg and Wozar (2003) found that the nurse to student ratio in Pennsylvania is 1 school nurse per 1,500 students.
Today, one third of the U.S. population younger than 19 have a chronic health condition or special care need. The student population and their health needs increase the complexity of school nursing (Bullock, Libbus, Lewis, & Gayer, 2002). Gregg and Wozar (2003) report that common health issues school nurses deal with daily include medication administration, first-aid response, head lice assessment, asthma and allergy management, teenage pregnancy, epilepsy control, and diabetic care. Additionally, the SREB report written by Aiken (2000) describes additional health problems faced by school nurses include sexually transmitted diseases, substance abuse, child abuse, behavioral problems, and learning disabilities. Bullock and colleagues (2002) add that school nurses must have knowledge of chronic illnesses, disabilities, and technical skills, such as insulin pump functions, tube feedings, and catheter care, to effectively deliver care to students.
In addition to the general health care needs of children with disabilities or chronic illnesses, school nurses are responsible for health promotion and disease prevention education for all students and the school community. Standard 5B of the ANA’s and NASN’s Standards of School Nursing Practice (2005) requires that school nurses provide students, based on the identified needs, learning ability, and school culture, a general health education that promotes a healthful lifestyle, risk-reducing behaviors, activities of daily living, and preventive self-care and safety. School nurses are in a position to affect the nation’s health goals by implementing programs that teach skills and strategies for reducing the risks of disease and promoting wellness throughout the life span (NASN, 2004).
Legal Mandates
The Rehabilitation Act of 1973, the Education for All Handicapped Children Act of 1975, and the Individuals with Disabilities Education Act (IDEA) of 1990 have had a profound impact on the practice of school nursing. Simmons (2002) reports that special education legislation guarantees free public education access for every child. The IDEA Amendments Act of 1997 legally obligates schools to address barriers to learning and provide health care services that promote academic success for disabled students (Costante, 2001). In addition, guidelines (individualized educational plans and section 504 plans) and medically fragile students who require one-to-one nursing services are increasing (Miller & Rector, 2002).
These acts alert school administrators to the importance of comprehensive health services to assist every student’s academic performance. In a posteducation survey of Missouri school nurses, Bullock and colleagues (2002) concluded that chronic health conditions are associated with a risk of failure because of excessive absences. School nurses can affect a student’s academic performance by providing health services so that a student with health needs can remain in school. In addition, nurses are essential to maintaining good health and incorporating the student’s health care needs within the constraints of the daily school schedule.
In addition to the disability acts, Medicaid reimbursement for school services has also caused school administrators to become proactive in establishing school health programs guided by school nurses (Miller & Rector, 2002). Although the positive impact of school health services on academic performance is evident, school nurses frequently have to educate administrators and faculty about their roles, priorities, and responsibilities (Simmons, 2002). Furthermore, despite evidence that school nursing is a pertinent component of academic success, research demonstrates barriers to school nursing practice.
Varied Education Background
The literature revealed that throughout the nation, school nurses come from different educational backgrounds. Although both the NASN (2002) and the AAP (2001) recommend that school nurses possess state licensure as a registered nurse and a bachelor’s degree, school nurses today have education from vocational schools, diploma programs, community colleges, and universities. Simmons (2002) compared 12 interviews (6 novice school nurses to 6 experienced school nurses) and determined that the formal education of school nurses ranged from an associate’s degree to a master’s degree.
In a literature review and synthesis written by Costante (2001), the future framework for school health addresses the need to support the bachelor’s degree as the foundation for autonomy, independence, and proficient clinical judgment skills, as well as a justification for school health services and competitive school nurse salary. However, Battin and colleagues (2001) performed an investigation related to a statewide orientation workshop that showed that the educational requirements for school nurses are actually dictated by the agency employing them, which can be a local school district, county health department, hospital, or community agency.
In addition, requirements vary according to state regulations. Miller and Rector’s (2002) study of California describes the state requirements for school nurses, which include having a bachelor’s degree in nursing or a related field and a state-mandated health services credential. In contrast, the state of Florida does not require a minimal education degree or certification (Battin et al., 2001). Although most of the literature revealed that a bachelor’s degree in nursing provides adequate community health knowledge and case management and leadership skills, recommended national mandates directing requirements for entry-level school nurses do not exist.
Barriers to Attainment of Continuing Education
Unfortunately, school nurses are challenged by barriers when attempting to acquire current specialty CE. According to the literature, time constraints, family responsibilities, and a lack of finances limit the accessibility to CE for school nurses (Miller & Rector, 2002). Periard and colleagues (1999) found that often only one school nurse serves a certain population, without backup coverage, making access to CE for that nurse difficult during the school year.
In addition to time limitations, the lack of paid release time, of reimbursement for education expenses, and of national education standards interfere with school nurses’ attendance at CE programs. Bullock and colleagues (2002) state that education obstacles are interrelated with insufficient school budgets and administrators’ hesitancy to pay course fees, reimburse for travel, or provide paid leave. Besides finances, the lack of equal CE requirements between nurses and teachers creates a barrier. Costante (2001) explains that school nurses need the same advanced professional preparation and CE allotment as the academic faculty.
In addition to time limitations, the lack of paid release time, of reimbursement for education expenses, and of national education standards interfere with school nurses’ attendance at CE programs.
Furthermore, Simmons (2002) reflects that without nationally accepted school-nursing-practice education standards, varied educational backgrounds will continue to be a detriment to the advancement of the school nursing profession. Collaboration and leadership among school nurses is essential to the development and adoption of policies that comply with NASN’s minimum recommendation of a bachelor’s degree for school nurse preparation (Periard et al., 1999). In addition to formal education requirements, Costante (2001) states that professional certification supports the foundation for competency-based school nursing practice.
CONTINUING EDUCATION FOR SCHOOL NURSES
A variety of CE courses for school nurses are available at the local, state, and national levels. These courses may be offered at seminars and conferences, via distance learning linked with universities, as E-learning, or in computer enhanced laboratories that use the latest technology of virtual learning. In addition, as the future follows a technological path, school nurses must have the capability and skills to access online CE, links to Web-based health resources, tele-health consultations, and on-line discussions. Table 1 illustrates different methods of CE programs with examples, time requirements, advantages, and disadvantages of each method.
In addition to a variety of CE methods, several funding resources related to nursing CE exist. School nurses are often faced with the barrier of limited financial support or funding to obtain competency-based school nursing CE. Locating potential funding sources for CE is essential to the attainment of CE. Strategies to overcome this barrier include budget planning, nursing implications, community involvement, and Internet access to locate funding resource Websites. Table 2 lists strategies and Websites that assist the school nurse in obtaining financial support for CE programs.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
The practice of school nursing is a rewarding and challenging specialty of the nursing profession. School nurses are required to function independently and autonomously in a nonmedical environment as educators, emergency responders, primary care providers, case managers, counselors, student advocates, leaders, collaborators, data collectors and researchers. The current state of dynamic health, social, and emotional needs of children and families contribute to the complexity of providing health care services to a large number of students, families, and school faculty. Multidimensional roles, increased demands of health care, legal mandates, and varied educational backgrounds support the necessity to cultivate professional development of knowledge and skills through current competency-based CE. Benner’s (2004) skill acquisition model provides a set of observable and measurable skills and competencies related to the roles of the school nurse. The model establishes a common language for developing role clarification, evaluation, and a school nurse job description.
School nurses, however, often face barriers, such as time limits, family responsibilities, administration hesitancy, lack of financial resources, and a lack of national school nurse education standards to support the need for CE. In addition, school nurses possess a range of education preparation from associate’s degrees to master’s degrees. Although seminars are the traditional method of education delivery, computer technology enhances access to CE through distance learning and virtual learning by eliminating travel, time constraints, and face-to-face instruction.
School nurses must become proactive in establishing national standards for school nurses, acquiring CE, and overcoming barriers. In addition, collaboration with professional organizations to develop education standards and policies at the local, state, and national levels are needed. School nurses’ involvement with community health is necessary to meet the increasingly complicated job responsibilities and duties school nurses face daily. With the current trend of technology being used as an adjunct to nursing education, attention to technology support, computer access, and financial resources of the school health service community is warranted.
With the current trend of technology being used as an adjunct to nursing education, attention to technology support, computer access, and financial resources of the school health service community is warranted.
It is financially and strategically important for school administrators to support competency-based CE for school nurses because educated school nurses will provide cost-effective, quality health care that promotes academic success by keeping students healthy, in attendance, and physically and mentally prepared for the stressors of standardized testing. Often, school nurses serve on individualized education plan committees, enabling the school to comply with legal mandates and meet IDEA goals. Finally, school nurses who have been provided timely, current, competency-based training are better prepared to partner with the school administration and act as liaison between parents and the school community when major health, sociological, and catastrophic events occur.
CONCLUSION
As a result of providing quality health care services and implementing programs that promote health and disease prevention, school nurses impact the academic success and lifelong wellness of students, families, and school communities. School nurses must recognize the critical need for school-nursing-specific CE and become proactive in advancing their education. School health communities and school nurses can strengthen school nursing programs by endorsing the establishment of professional school nurse standards and goals, such as a mandated bachelor’s degree minimum, annual CE hours, and specialty certification. The development of school nurse job descriptions and contractual agreements clarify the roles of the school nurse and outline predetermined expectations for CE attainment. Barriers such as limited time, access, technological support, administrative support, and funding must be overcome to ensure CE opportunities for school nurses. Finally, to meet competency-based CE needs for school nurses, current school-nursing-specific courses must be developed and accessible. Achieving competency-based CE for school nurses is critical to the development of cost-effective, quality school health services.