The Case for School Nursing Reform and Standards

By Nick Dobrzelecki, MBA, BSN, RN, Managing Partner and co-founder 

As a company founded by healthcare providers we’d like to address what we see as a significant issue in the United States: the need for school nursing reform and standards. In a nutshell, it’s high time that we have consistent guidance across every state regarding school nurse certification, education and specific job duties and roles. While some federal legislation has been drafted to improve the amount of school nurses, nothing has yet been pushed through and additional issues (beyond nurse-to-student ratio) need to be considered. 

Generally speaking, there’s no question that national improvement and reform needs to happen across both the public and private school systems in the U.S. regarding nursing. While much focus has understandably been put on expanding funds to support school resource officers, the reality remains that many children in this country do not have access to healthcare in any form outside of school, including children with acute and chronic issues.

Current best practice for determining school nurse staffing levels involves analyzing several factors including number of students, local social determinants, student’s health acuity levels, other responsibilities, barriers to care outside of the school, access to technology, and scope of practice of the nurse to adequately meet the health and safety needs of the children whose care is entrusted to schools.2 The National Association of School Nurses identifies schools as primary locations to address student health issues, since a school nurse is the health care provider that many students see on the most regular basis. Unfortunately, according to 2017 data from the National Association of School Nurses, only 39.3 percent of schools employ a full-time school nurse, while 35.5 percent of schools employ a school nurse only part-time, and 25.2 percent do not have a school nurse at all. The American Academy of Pediatrics has recognized the crucial role that school nurses play in children’s health and has called for having a full-time school nurse every day and in every school building.3

Lastly, in addition to individual and public health care, school nurses are a critical part of the interdisciplinary team that creates individual education plans (IEPs) and 504 plans to ensure students of all abilities receive proper education. 

To move school nurse reform forward we have identified three things that need to happen: 

  1. National standards for school nurse education requirements
  2. National standards defining the school nurse’s scope of care
  3. National standards for insurance reimbursement for in-school healthcare services in order to decrease the financial burden on the school system
  1. Licensing and education requirements. A random look at a few states offers a glaring example of the lack of school nurse education standards in the U.S. In Minnesota you have to register as a public health nurse (PHN) which requires you to have a bachelor’s degree and then you can apply to be a licensed school nurse (LSN).4 To become a school nurse in North Carolina you have to be a RN and obtain your bachelor’s degree and NCSN within three years.5 Florida only recommends school nurses to have an NCSN.6  In short, with no national best practice or requirements to become a school nurse, our nation’s children are getting a wide variety of care quality and knowledge. A national standard for education level should be applied to the school nursing profession.

  2. More specifically defining “Scope of Care.” School nurses need defined roles, or a generally accepted “scope of care” regarding treating students. Nurses should be required to have a minimum level of education and experience in common in-school health issues such as illness breakout, chemical burn treatment, bone injuries, skin lacerations, concussion protocol, etc. — and be tested against these agreed-upon care points on a regular basis (i.e. annually). The scope of work should also include requiring the nurse’s input on developing IEPs, 504s etc., especially if any recognized learning disability is the result of a medical issue, behavioral issue or other health concerns. This would require a minimum level of education regarding common learning disabilities and behavioral issues, including how to spot them. Lastly, our nation’s schools should agree on where care can be received by the student in question. Should nurses be limited only to treatment within the school’s four walls? Or should they be allowed to execute home visits or refer students to public health officials? All questions that should be discussed.

  3. Payment model. The question of who pays for in-school medical treatment varies state by state, creating a confusing and often unfair financial system regarding student healthcare. In the state of Washington, as example, schools can bill the insurance companies directly for qualifying in-school treatment. In Ohio, however, as soon as the child is in the care of the school (including riding the bus to and from), a family’s personal insurance is not responsible for anything that happens on school property. This creates a large financial burden on school systems resulting in them deciding what they are willing and able to pay for. This can result in students with high acuity needs missing out on educational opportunities. On top of these two examples and everything in between, we have many U.S. children on Medicaid bringing a whole other level of process into the mix. This is very challenging since school systems typically do not have the skill set of healthcare insurance reimbursement.

In the following months we are going to go more in depth regarding each of these three recommendations. We welcome any comments from you — do you agree with these three points? What would you include as national standard-setting for school nurses? In the meantime, we wish you and yours a very healthy holiday season.







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