Framework for 21st Century School Nursing Practice

Abstract

The National Association of School Nurses (NASN) developed the Framework for 21st Century School Nursing Practice to reflect current school nurse practice. The Framework of practice was introduced in June 2015, and feedback was requested and obtained from practicing school nurses in a variety of ways. The final version of the Framework is introduced in this article. This article updates (and replaces) the articles in the July 2015 NASN School Nurse related to the Framework. Central to the Framework is student-centered nursing care that occurs within the context of the students’ family and school community. Surrounding the student, family, and school community are the nonhierarchical, overlapping key principles of Care Coordination, Leadership, Quality Improvement, and Community/Public Health.These principles are surrounded by the fifth principle, Standards of Practice, which is foundational for evidence-based and clinically competent quality care. Each of these principles is further defined by practice components. Suggestions are provided regarding how the Framework can be used in a variety of settings to articulate and prioritize school nursing practice. The ultimate goal is to provide a resource to guide school nurses in their practice to help students be healthy, safe, and ready to learn.

Keywords

school nursing practice care coordination leadership quality improvement community/public health standards of practice

School nursing has changed over the years to meet the evolving health needs of students. The number of students with health needs, the number of students at risk for health concerns, and the complexity of their health needs have increased. Social determinants, such as living in poverty and lack of access to care, have also impacted students’ health (Viner et al., 2012). Additionally, healthcare reform has increased the focus on community-based, coordinated care and the use of technology to improve communication with family, healthcare providers, and local public health departments. The changes in student health needs and the changes in healthcare during the 21st century have greatly impacted school nursing practice. These changes impelled the National Association of School Nurses (NASN) to develop a visual, conceptual Framework that explains the key principles of school nursing and provides structure and focus to current evidence-based school nursing practice.

Development and Feedback of the Framework

The development of the Framework began with a review of the current needs and healthcare topics of school-age children, the health care climate, evidence-based literature, and critical skills needed to meet student health challenges. Outside experts in conceptual Framework development were consulted. The draft framework was reviewed by numerous individuals and groups, presented at NASN’s 2015 annual conference during three feedback sessions, and shared at several state and local meetings where feedback was obtained. The draft Framework was published in the July 2015 NASN School Nurse with a link to a survey for school nurses and others to provide additional information. NASN nursing staff consolidated and merged the information to develop the final version of the Framework and expand the practical implications of the Framework. The NASN Board of Directors reviewed the finalized Framework and voted to adopt it. This article describes the finalized Framework and replaces the articles found in the July 2015 issue of NASN School Nurse.

Explanation of the Framework

NASN’s Framework for 21st Century School Nursing Practice is aligned with the Whole School, Whole Community, Whole Child model, which calls for a collaborative and coordinated approach to learning and health (ASCD & Centers for Disease Control and Prevention [CDC], 2014). Central to the framework is student-centered nursing care that occurs within the context of the students’ family and school community (see Figure 1). Surrounding the student, family, and school community are the nonhierarchical, overlapping key principles of Care Coordination, Leadership, Quality Improvement, and Community/Public Health. These principles are surrounded by the fifth principle, Standards of Practice, which is foundational for evidence-based, clinically competent, quality care. Each of these principles is further defined by practice components, which are bolded in the text and listed in Figure 2.

Figure 1.

Framework for 21st Century School Nursing Practice

Figure 2.

Components of the Framework’s Principles

Framework Principle: Care Coordination

In daily practice, school nurses implement some or all of the practice components of Care Coordination based on an assessment of the student and family needs. A school nurse–led case management program for students improves outcomes, fosters self-management and family support, and improves health care coordination (Engelke, Swanson, & Guttu, 2014). The school nurse facilitates the student and family preferences, and needs are obtained by intentionally organizing and sharing information among appropriate persons and sites (American Nurses Association[ANA], 2012). Care Coordination is further defined by several practice components of school nursing as described below.

Case management

The terms care coordination and case management are used interchangeably by some school nurses, insurance companies, and hospitals (McClanahan & Weismuller, 2015). According to Engelke, Guttu, Warren, and Swanson (2008), case management is defined as follows:

A process in which the school nurse identifies children who are not achieving their optimal level of health or academic success because they have a chronic illness that is limiting their potential. It is based on a thorough assessment by the school nurse and involves activities that not only help the child deal with problems but also prevent and reduce their occurrence. Case management includes direct nursing care for the child and coordination and communication with parents, teachers, and other care providers. Interventions are goal oriented based on the specific needs of the child and evaluated based on their impact on the child. (p. 205)

School nurses engage in chronic disease management activities to provide for the best health, academic, and quality-of life outcomes possible, with emphasis on efficient care and student education leading to self- management.

School nurses must communicate effectively to coordinate care.

Collaborative communication is clear, cooperative communication used by school nurses to enhance collaboration with other members of the school and community health team (e.g., the medical home, healthcare provider, family, specialists, other community organizations) to meet the health care needs and goals of students (NASN, 2011).

Care coordination provides for the direct care needs of the student. The specific care that nurses and others provide to students includes routine treatments, medication administration, and addressing acute/urgent needs.

Interdisciplinary teams

Interdisciplinary teams rely on the overlapping knowledge, skills, and abilities of each professional team member. The student health outcomes are enhanced with interdisciplinary teams, as compared with the individual efforts of the team members (ANA & NASN, 2011).

Motivational interviewing/counseling

Communication skills are essential for the school nurse to successfully provide care coordination for students. School nurse counseling involves educating and assisting students with health needs, self-care, and coping. Counseling often has an individual student focus, although it can be done with groups as well (Minnesota Department of Health [MDH], 2001). Motivational interviewing is a specific, well-researched form of counseling that empowers the students to identify their concerns and solutions, as opposed to the nurse providing solutions (Bonde, Bentsen, & Hindhede, 2014).

The school nurses’ coordination of care may include the delegation of nursing tasks. Nursing delegation is a process used by the nurse to lead another person to perform nursing tasks (ANA & National Council of State Boards of Nursing, 2006). In the school setting, nursing delegation requires the registered professional school nurse to assign a specific nursing task—in a specific situation for an individual student—to unlicensed assistive personnel, while providing ongoing supervision and evaluation of the unlicensed assistive personnel and the student’s health outcomes (Bobo, 2015). Delegation is further defined and regulated by state nurse practice acts and state laws.

Student care plans

Student educational and health care plans are integral to the process of care coordination. School nurses develop health care plans, including the Individualized Health Care Plan (IHP) and Emergency Care Plan, and contribute to the development of student educational plans (e.g., 504 Plan, Individualized Education Program). Student-centered health documents are developed by the school nurse, based on his or her assessment and healthcare provider orders, and they follow the nursing process to address concerns and established goals and the interventions to address those goals (NASN, 2015). An IHP may include activities related to direct care, delegation, student self-empowerment, case management, chronic disease management, and transition planning. Emergency Care Plans flow from the IHP and address what to do during a health emergency/crisis situation.

Student-centered care is provided at the individual or schoolwide level (e.g., caring for students with special health care needs, promoting a positive school climate). School nurses work in partnership with students and their families and caregivers to ensure that decisions include students’ needs and that desires are addressed (Institute of Medicine [IOM], 2001b). Student-centered care also includes providing the individual education and support that students/families need to be decision makers in their own care, including health promotion and disease prevention behaviors. Student-centered care promotes student self-empowerment by respecting student autonomy and by helping students realize their own power and capabilities in managing their health conditions (Tengland, 2012).

Transition planning refers to two different transitions. In the health care arena, transition planning refers to a patient transferring from one health care setting to another (Geary & Schumacher, 2012). School nurses facilitate the transitioning of students from other health care settings to the school setting. The Individuals with Disabilities Education Act (2004) refers to transition services related to preparing students with disabilities for future employment, education, and postsecondary schools. The term also encompasses students transitioning from elementary to middle to high school, thereby facilitating their preparation for the new environment and developmental transitions for chronic disease self-management.

Framework Principle: Leadership

Leadership is a mind-set, not a formal position. School nurses are well positioned in schools to lead in the development of school health policies, programs, and procedures for the provision of health services, as they often represent the only health care professional in the educational setting (NASN, 2011). Leadership is a standard of professional performance for school nursing practice (ANA & NASN, 2011) with competencies closely related to the practice components of this principle.

Advocacy, change agents, policy development and implementation, health care reform, and education reform

Advocacy is the ability to successfully support a cause or interest on one’s own behalf or that of another, and it requires skill in problem solving, communication, influence, and collaboration (ANA, 2015). As advocates for students, the school nurse provides skills and education that support self-management, problem solving, effective communication, and collaboration with others (ANA, 2015). This overlaps with the Care Coordination principle. As an advocate for the profession, the school nurse engages in the deliberate process of influencing those who make decisions, including school administration and local and state political leaders (ANA, 2015).

As school nurses advocate for changes, they become change agents. When school nurses participate on interdisciplinary teams, their perspectives on health promotion, disease prevention, and care coordination for students and the school community bring about change in policy development and implementation related to plans and protocols that address children’s health issues within the school and community setting (ANA & NASN, 2011; IOM, 2010; Robert Wood Johnson Foundation [RWJF], 2009).

As leaders, change agents, and full partners shaping the future health and academic success of young people, school nurses need to be aware and involved with health care and education reform (Duncan, 2014; IOM, 2010; RWJF, 2009, 2010). Reform changes may impact school nurse responsibilities, work environment goals, and student academic and health outcomes. Understanding current reforms, such as the Affordable Care Act of 2010 and the Elementary and Secondary Education Act, affords opportunities for school nurses to advocate for changes that best serve students, articulate how school nursing fits into the reform, and validate their role so that it is not lost (American Public Health Association [APHN], 2013b).

In addition to reform efforts, it is important that school nurses be aware of emerging models of practice for school nursing practice. The delivery of school health services varies across the United States. Some school nurses oversee the students in one building; some have responsibility for students in several buildings; and some have health aides or others to whom they can delegate specific tasks. Often the model of practice is influenced by the perspective of the employer (e.g., school district, health department, hospital, health care system, community groups), although school nurses can use the framework to articulate the breadth and scope of school nursing practice and influence changes in models, as needed. Nurse Practice Acts and state laws regulating nursing practice also influence models of practice.

Funding and reimbursement also impact models of practice. Traditional funding depends on school district budgets to pay for school nursing services. Innovative methods of funding are emerging, including support from health care systems, public health, community care organizations, community clinics, and/or reimbursement for services. Reimbursement can come from Medicaid or private insurance. As budgets tighten and health reform looks to more community-based care models, school nurses can step up, lead, and define how the role of the school nurse will look in new models of practice.

Lifelong learner and Technology

Being aware of evolving trends in reform and practice requires school nurses to be lifelong learners. The school nurse shows commitment to lifelong learning when engaging in advanced academic education, certification, and activities that support competent professional practice, knowledge development, and skills acquisition (ANA, 2015; ANA & NASN, 2011). Professional growth also involves staying current with both medical and information technology. In school nursing, technology encompasses telehealth, computer skills, and the use of web-based resources to collect and manage data (e.g., electronic health records, immunization information systems), overlapping with the Quality Improvement principle and data collection practice component. Technology allows for retrieving evidence-based education, communicating through social media, and using practice applications (i.e., apps; Anderson & Enge, 2012; NASN, 2012).

Systems-level leader

Systems-level leadership targets a health care system or education system level. School nurses, often in partnership with public health, lead efforts that align emerging systems of care for population health improvement (APHN, 2013a). System-level leaders understand the strategic interconnection between and among organizations, policies, processes, and systems (Senge, n.d.).

In order to apply any of the identified practice components for the Leadership principle, school nurses must exhibit professionalism (Campbell & Taylor, n.d.). Professionalism includes the attributes of accountability, maturity, problem solving, collaboration, proactivity, positivity, professional speech, appropriate dress, and activities that align with current, evidence-based, student-centered practice. Professional behaviors were identified by principals, educators, and others as the most influential factor when school nurses were seen and understood as valuable members of the educational team (Maughan & Adams, 2011).

Framework Principle: Quality Improvement

Quality Improvement (QI) is a continuous and systematic process that leads to measurable improvements and outcomes and is an integral part of current standards of practice (Agency for Healthcare Research and Quality, 2011; Health Resources and Services Administration [AHRQ], n.d.). If school nurses make the QI process part of their daily practice, they will better understand which of their activities have the greatest impact on student health and outcomes and which do not. This knowledge will help school nurses prioritize activities amid very busy schedules and time demands and better explain their choices to administration. QI will help change practice and build the critical evidence base for school nursing practice. QI, also referred to as Continuous QI or the Deming cycle of Plan-Do-Check-Act, is really the nursing process in action: assessment, identification of the issue, developing a plan, implementing the plan, and evaluating if the goals/outcomes are achieved (AHRQ, n.d.; ANA & NASN, 2011).

Data is the cornerstone of QI (Health Resources and Services Administration, n.d.). Data collection includes school nurse documentation of daily activities, progress toward meeting student health goals, and other events. Through documentation, the variety of roles and activities of school nurses are illustrated, (such as how time is spent), the impact that nursing care has on students’ health and readiness for school is shown, and trends over time are identified (overlapping with the practice component surveillance of Community/Public Health). Data can clearly show educators and policymakers the impact of school nursing on the health and academic success of students. Electronic health records can save school nurses time by helping them manage and share data.

Data collection includes participation in Step Up and Be Counted!, a joint initiative between NASN and the National Association of State School Nurse Consultants to develop a uniform data set so that all school nurses across the country collect data the same way (Maughan et al., 2014). The ability to combine data will allow researchers to determine which school nurse interventions are most effective and to better understand models of school nursing practice and workforce models and their impact on student health.

Evaluation is the sixth step of the nursing process and sixth standard of school nursing practice (ANA & NASN, 2011). Generally speaking, evaluation is the assessment of the attainment of outcomes. For school nurses, evaluation includes measuring meaningful health and academic outcomes and determining whether the processes and interventions used were appropriate. Evaluation should occur for all the components of the student’s IHP, which is a practice component of the framework principle of Care Coordination. Data and evaluation should also be used for performance appraisal of the school nurse’s work goals and job performance.

Research is included in the principle of QI. Many of the concepts of research and QI overlap, yet QI and research are different. QI determines if evidence-based practice standards are effective. Research is a more formal process for testing an intervention to gain new knowledge that is hopefully, generalizable beyond the given situation (AHRQ, 2011; IOM, 2001a; U.S. Department of Health and Human Services [USDHHS], 2009). Formal school nursing research is needed to ensure that school nurse practice is based on the best current evidence. Data from research are also needed by school nurses as they advocate and illustrate how they impact student health and academic outcomes. School nurses can and should be involved in research by identifying research questions, completing research surveys, collecting data for research projects, or assisting expertly trained researchers to design studies appropriate for school settings and students.

Framework Principle: Community/Public Health

School nursing practice is grounded in community/public health and is consistent with the core functions of public health, even though not all school nurses are fully aware of this (Schaffer, Anderson, & Rising, 2015). Including Community/Public Health as one of the five principles of the framework helps school nurses recognize how they include community/public health in their specialty practice of school nursing (ANA & NASN, 2011; NASN, 2013).

Population-based care

The Community/Public Health principle expands the focus beyond the individual to populations (e.g., school community) with similar health concerns. Interventions for school populations are guided by group assessments that target the student, family, school, and community systems. Healthy People 2020 —the United States’ national health promotion and disease prevention agenda for populations—helps school nurses prioritize assessments and interventions and provides measurable guideposts that are applicable at the national, state, and local levels (USDHHS, 2010a).

Levels of prevention

Individual and population-based interventions can be categorized by levels of prevention: before the health issue occurs (i.e., primary prevention), when the health issue has begun but before complications and/or signs and symptoms (i.e., secondary prevention), or after the health issue has occurred (i.e., tertiary prevention). Several of the practice components relate to the levels of prevention.

Health education is one example of implementing primary prevention. Other examples include promoting immunizations, health promotion programming, and advocating for a positive school environment. The activities of primary prevention overlap with the principle of Leadership’s components of change agent and advocacy. Screenings, referrals, and follow-up activities are secondary prevention strategies that detect and treat health concerns in their early stages often before signs and symptoms appear—and modify, remove, or treat them before the health concerns become serious. Secondary prevention focuses on risk reduction and disease prevention. Tertiary prevention includes strategies that limit further negative effects from an existing health problem and promote optimal functioning. School nurses provide care at all three levels but place extra emphasis on primary prevention.

Social determinants of health

Social determinants are factors that impact health, such as income/social status, housing, transportation, employment/working conditions, social support networks, education/literacy, neighborhood safety/physical environment, access to health services, and culture (USDHHS, 2010c). Social determinants are important because they are known to cause 80% of health concerns (Booske, Athens, Kindig, Park, & Remington, 2010).

Access to care is having available comprehensive, quality health care services (USDHHS, 2010b). It includes access to a school nurse, referrals to health care services, insurance coverage, transportation to care, and timeliness of care. Limited access to health care impacts the ability for people to reach their full potential.

Culture is another social determinant. It encompasses the customs, values, and beliefs of an individual and/or population. School nurses must continually work at obtaining cultural competency, which is a set of behaviors, attitudes, and skills that allow effective care to be delivered in cross-cultural situations (Office of Minority Health, 2013). Failure to be culturally sensitive to students and families can decrease trust, leading to decreased communication and management of a health condition, resulting in adverse student health outcomes.

Social determinants of health and health disparities (health inequity) are closely related. For example, children of racial minorities are more likely to have untreated asthma and be obese (USDHHS, 2012; Wang, 2011). School nurses are in the critical position to address health disparities of students and families and provide equitable health services (health equity) because of their intimate knowledge of the environments where students and families live, play, and access care.

Environmental health

The environment—including air, water, food, pollution, chemicals, biological agents, and psychological influences—is a fundamental determinant of individual and community health. Children are vulnerable to environmental threats that may exist in schools due to their daily exposure. School nurses assess for factors that negatively affect health in the school environment and promote policy and practices that reduce environmental health risks and promote emotionally and physically healthy school communities (ANA & NASN, 2011; MacNeil, Prater, & Busch, 2009).

Surveillance, closely aligned with nursing assessment, is a key school nursing and community/public health practice component. Surveillance is the ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementing, and evaluating practice. It is usually proactive and includes disseminating the data to those who need it to prevent or control health conditions (CDC, n.d.). School nurses practice surveillance when they monitor and describe an increase in strep throat cases or influenza-like illness. Surveillance and use of the data overlap with the principle of QI.

Outreach, like surveillance, is proactive and involves identifying individuals or populations at risk, providing education about the health risk, strategizing ways to reduce the risk, and finding services to assist (MDH, 2001). For example, school nurses outreach to students with undiagnosed asthma who exhibit signs or symptoms, educating them and their families, and connecting them with appropriate health care services.

Framework Principle: Standards of Practice

Standards of Practice for school nursing direct and lead every part of the framework and incorporate a wide range of practice and performance standards that are essential in the specialty of school nursing, regardless of the role, population served, or specialty within school nursing (ANA & NASN, 2011). Specialized knowledge, skills, decision making, and standards for practice are required to provide the best possible nursing care with the best possible outcomes. The Standards of Practice and the related practice components are vital and overarching for the other principles of the framework.

Clinical Competence means that the school nurse successfully performs at an expected professional level that integrates knowledge, skills, abilities, and judgment. The school nurse maintains a high level of competency and professional knowledge and skills through continuing education and collaboration with peers and community health professionals, all while adhering to the standards of school nursing practice (ANA & NASN, 2011).

Clinical guidelines are determined by the systematic review of the evidence and direct the practice of school nursing. Clinical guidelines assist school nurses to provide best practice and facilitate positive health outcomes that influence academic outcomes (Maughan & Schantz, 2014). Following clinical guidelines advances the professional practice of school nursing.

Code of Ethics is a part of every nurse’s professional life (ANA, 2015). School nurses provide care, advocate for families, outreach to those at risk, and collect data with compassion, honesty, and integrity that protect the dignity, autonomy, rights, and client confidentiality within the legal limit of the health and educational systems (ANA, 2015; ANA & NASN, 2011).

Critical thinking is a dynamic, vital, and continuing part of every step in the nursing process. Critical thinking uses knowledge and reasoning skills to make sound clinical decisions that influence nursing practice (ANA & NASN, 2011; Weismuller, Willgerodt, McClanahan, & Helm-Remund, 2015).

Evidence-based practice incorporates the best available research and scientific evidence that inform decision making and promote best practices for optimal health outcomes (Jacobs et al., 2012). School nurses are obligated to recognize that evidence-based practice replaces empirical and authority-based care (Bultas & McLaughlin, 2013) and that it is the basis and standard of health care practice (Adams & McCarthy, 2007) for the 21st-century school nurse.

Position statements from the NASN are documents that present the official position of the NASN Board of Directors. These position statements include historical, political, and scientific facets of topics relevant to school nursing, school health services, and children’s health care.

Nurse Practice Acts (NPAs) are guiding and governing laws that determine the lawful scope of practice of nursing. NPAs have authority to develop rules and regulations for the practice and licensing of nursing to protect the health of society. Nurses must follow the NPAs of their state, commonwealth, or territory (National Council of State Boards of Nursing, n.d.). It is NPAs and state guidelines that determine if nursing delegation can occur, and they greatly impact the framework’s principle of Care Coordination.

Scope and Standards of Practice define the practices that school nurses are expected to perform competently. The scope affirms the broad range, essence, and evolving boundaries of school nursing practice. The standards of practice describe the level of competency expected for each step of the nursing process. The standards of professional performance describe the competent level of behavior in the professional school nurse role (ANA & NASN, 2011).

School Nurse Application of the Framework

School nurses already include the framework’s principles in their practice. When school nurses are engaged in developing care plans and working with students’ families, healthcare providers, and teachers, they exemplify the Care Coordination principle in their practice, and as they advocate for the needs of their students, they demonstrate the Leadership principle. As they review their documentation and notice an increase in the number of times that a student is coming to their office and so adjust their interventions, they utilize QI in their nursing practice. The principle Community/Public Health is exemplified when school nurses extend their view to address hazards seen in the school, and when all of these efforts are done using the most current evidence with clinical competence, school nurses exemplify the principle of Standards of Practice. The framework provides a visual to articulate such activities.

The framework should be used to guide personal school nursing practice as well as districtwide practice. The framework can be printed in a poster format for quick referencing. Novice school nurses using the framework will enhance their understanding of the expectations of school nursing practice, facilitate personal professional development, and gain a vision of how daily activities fit into a higher vision of keeping students healthy, safe, and ready to learn. Experienced nurses using the framework will identify areas to expand or prioritize their activities and provide a base for personal goal setting and career ladder opportunities. The framework will also guide the development of continuing education and school nurse orientation programs and even serve as a guide for student nurses doing their practicum with practicing school nurses. School nursing supervisors should use the framework for annual performance appraisals and for recruitment, development of job descriptions, and interviewing of potential school nurse and administrative hires. The framework also provides focus for evidence-based practice projects and research (Cowell, 2015).

The framework should be a helpful tool beyond local school nursing as well. State or regional school nursing programs can use it as they develop strategic plans or search for funding sources. The framework provides for all school nurses a visual way to explain to educators, school board members, and legislators about the vital role of school nurses in keeping students healthy, safe, and ready to learn. School nurses using data documented throughout the year will describe how they impacted health and academic outcomes.

Mindful use of the Framework for 21st Century School Nursing Practice fundamentally separates technical from professional school nursing practice, potentially leading to a shift in practice for all school nurses. It is critical that school nurses articulate what they do and how it impacts students’ health, as health care leaders continue to investigate and identify ways to reform the health care system to facilitate improved health and education outcomes. School nurses daily use the skills outlined in the practice components of each principle to promote students who are healthy, safe, and ready to learn. ■

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