The Role of the School Nurse in Supporting Students with Special Health Needs

LINDA C. WOLFE, EdD, RN

STATE SCHOOL NURSE CONSULTANT

Children with DisabilitiesIDEA - "Children with disabilities" or "students with disabilities" means children or students who require special education because of: autism; deafblindness; deafness; developmental delay; emotional disturbances; hearing impairment; intellectual disability; multiple disabilities; orthopedic impairments; other health impairments; specific learning disability; speech or language impairment; traumatic brain injury; visual impairment, including blindness (Center for Parent Information & Resources)

Section 504 / ADA – A disability is (1) a physical or mental impairment that substantially limits a major life activity; (2) a record of such impairment; or (3) being regarded as having such impairment.

Medicaid/SSI - A child with a disability must have a physical or mental condition, or a combination of conditions, that result in “marked and severe functional limitations.”

Working Definition: Any child with a physical or mental health deviation from generally accepted standard that significantly interferes or limits his/her ability to fully participate in family, education, or community activities. The limitation can be temporary or permanent, slight or severe.

Improved Health Outcomes

Working Definition: Improved physical or mental health condition as measured by the child’s ability to more fully participate in family, education, or community activities.

School Nurses See ALL Students

Healthcare systems see members of the community with access to their services.

School-based Health Centers see students, who are enrolled in their program.

National Center for Educational Statistics

A State Example: North CarolinaExceptional Children

North Carolina Annual School Health Services Report, 2014-2015

School Nurses See ALL Students

Screening requirements (established by states) require screening for all students, e.g., vision & hearing Early identification

Important to IEP process to address health impact of struggles to learn

Students in poverty seek school nursing services more than their peers (Fleming, 2011)

Part of the continuum of care (AAP, 2016) AAP recommends one school nurse per school.

Nursing delegation does not negate the need for the full time nurse

Roles of the School Nurse

School nurses assume many roles to meet the needs of their clients. It is perhaps the breadth of nurse activities subsumed within school nursing and the unique nonmedical practice setting that creates this specialty practice and differentiates it from other nursing specialties (Wolfe, 2013).

Clinician

Care Coordinator

Early Identifier

Liaison / Collaborator

Counselor

Health Educator

Advocate

Clinician

Direct Nursing Care for illness, injury, and chronic health conditions

There is a demonstrated relationship between health and education. A child’s health status supports the child’s ability, or inability, to learn. An adult’s educational status influences their health status. (ASCD, 2014).

School nurses are “specialized instructional support personnel” who provide “assessment, diagnosis [nursing], counseling, . . . and other necessary services (including related services . . .) as part of a comprehensive program to meet student needs” (ESSA, 2015).

A State Example: New HampshireHealth Care Procedures in Schools

*Bladder Program

Blood Glucose Testing

*Bowel Program

Catheterization by Nurse or Aide

Catheterization by child/youth

Dialysis (Peritoneal)

*Diapering/Personal Toileting

Feeding Assistance (oral)

*Glucose Testing

*Nebulizer

Medications Intramuscular

Medications Intravenous

*Medication Oral

*Medications Subcutaneous

Range of Motion Exercises

Respiratory Care (i.e. oxygen, postural drainage)

Stoma Care

Suctioning

Tracheostomy Care

Tube Feedings

Ventilator Assisted Care

Vaccinations

Special Medical Services School Nurse Survey, 2014

A State Example: New MexicoTreatments & Medications Provided

New Mexico Annual School Health

Services Report, 2014-2015

Care CoordinatorActivities Referrals

Connecting families with resources and services

Planning for care in the school setting, including emergency preparedness

Training for staff

Equipment and medication availability

Transition Planning

“It is the position of the NASN that all children with chronic health conditions should receive coordinated and deliberate transition planning to maximize lifelong functioning and well-being” (National Association of School Nurses, 2014).

Care CoordinatorSchool nurse coordination improves readiness to learn, classroom participation, and academic performance for students with special health needs (Bethell, et. al., 2012)

6.5% of students experience a chronic health illness that impacts education performance (Hainalt, 2013)

School nurses can reduce the long-term impact of chronic health conditions on children through care coordination (McClanahan & Weismuller, 2015)

In a 4-year project with school nurse case management, 84% of students improved in one or more areas: attendance, behavior, academic performance, quality of like and health compliance (Bonaiuto, 2007).

School Nurse case management of student s with asthma in one study resulted in >90% with emergency action plan, 67% reduced asthma triggers in the school environment, 67% of student less respiratory episodes, >80% increased knowledge and self-care skills, 100% of those targeted has fewer absences, 66% improved family collaboration, 70% improved utilization of healthcare provider, 69% decreased emergency room visits. The later two measures were associated with increased asthma control. (Engelke, Swanson, & Guttu, 2014)

Early IdentifierHearing

Vision

Medical conditions◦ Early identification and

treatment of conditions improves clinical outcomes, e.g., head injuries (Bayreuthe & Maconochie, 2008)

Frequent absences

Emotional concerns

New Mexico Annual School Health Services Report,

2014-2015

Liaison / Collaboration with School and Health Communities

School nurses are “bilingual” – education-ese & medical-ese

School nurses work with families – education, access care, coordinate care (Jacobsen, Meeder, & Voskuil, 2016)

School nurses bridge the gap in services

Cost effective approach For every $1.00 spent on school nursing services, $2.20 is saved in medical cost

and time for parents and teachers (Wang, et. al, 2012)

School nurses help students with disabilities to better address teasing and bullying situations (Vessey, 2011)

Counselor, Health Educator, & Advocate Typically are the first healthcare provider to see the child for health complaints, which may be more emotional-health related Work closely with school counselors, psychologists, and social workers when

available

School nurse is the resident health expert Opportunities for health education in the classroom, one-on-one, small groups of

students, families, educators, community

Children with Type I Diabetes reported nurses play a “key role” with hyper- and hypo-glycemia levels by providing appropriate treatment. The students also said that he nurse can also “help by educating classmates about their diabetes”. Further, the lack of school nurses at after-school events kept them from participating (Lehmkuhl & Nabors, 2007)

Tools for Schools Individual Education Program (IEP)

Section 504 Accommodation Plan (504)

Individualized Healthcare Plan (IHP)

Emergency Action Plan (EAP) Emergency Healthcare Plan (EHP)

Student Health Outcomes impacted by School Nursing Services

Early Identification

Reduced Absences Less absenteeism and fewer early dismissals in schools with a full-time school nurse (Maughan, 2016)

“Education is free. Healthcare is not.” School nurse provide and bridge the gap for families in poverty or living in healthcare deserts (Maughan, 2016)

“Children with chronic illness are absent from schools for an average of 16 days a year compared to a 3-day average for health children” (McCabe & Shaw, 2008)

“School nurses were involved with 75% of high-absence students as compared to 66% of low-absence students; they were also more involved with students who had previously identified health conditions” (Weismuller, et. al, 2007).

Better Health through management of chronic conditions Occurs through individual case management

Students have increased access to education and improved health, which benefits providers & insurers

Step Up & Be Counted! (https://www.nasn.org/Research/StepUpBeCounted)

References & ResourcesAmerican Academy of Pediatrics, Council on School Health. (2016). Policy statement: Role of the school nurse in providing school health services. Pediatrics. Retrieved on March 27, 2017 from http://pediatrics.aappublications.org/content/early/2016/05/19/peds.2016-0852.

Americans with Disabilities Act (ADA).

ASCD. (2014). Whole school, Whole Community, Whole Child: A Collaborative Approach to Learning and Health. Retrieved on April 2, 2017 from http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdf.

Bayreuther, J. & Moconochie, I. (2008). The evidenced-based care behind the early management of head injured children. Trauma, 12, 85-92.

Bethell, C., Forrest, C., Stumbo, S., Gombojav, N. Carle, A., & Irwin, C. (2012). Factors promoting or potentially impeding school success: Disparities and state variations for children with special health care needs. Maternal & Child Health Journal, 16(Supp1), S43-S43.

Bonaiuto, M. M. (2007). School nurse case management: Achieving health and educational outcomes. Journal of School Nursing, 23(4), 202-209.

References & ResourcesCenter for Parent Information & Resources. (2017). Categories of Disability Under IDEA. Retrieved on April 2, 2017 from http://www.parentcenterhub.org/repository/categories/.

Engelke, M. K., Swanson, M., Guttu, M. (2014). Process and outcomes of school nurse case management for students with asthma. Journal of School Nursing, 30(3), 196-205.

Every Student Succeeds Act (ESSA). (2015). Public Law No: 114-95. Retrieved on April 2, 1027 from https://www.congress.gov/114/plaws/publ95/PLAW-114publ95.pdf.

Fleming, R. (2013). Use of school nurse services among poor ethnic minority students in urban pacific northwest. Public Health Nursing, 28(4), 308-316.

Hainault, B. (2013). Educating children with chronic illnesses (published master’s thesis). Northern Michigan University, MI. Retrieved April 2, 2017 from https://www.nmu.edu/education/sites/DrupalEducation/files/UserFiles/Hainault_Brandi_MP.pdf.

Jacobsen, K., Meeder, L., Voskuil, V. (2016). Chronic student absenteeism: The critical role of school nurses. NASN School Nurse 31(3).

References & ResourcesLehmkuhl, H. & Nabors, L. (2007). Children with diabetes: Satisfaction with school support, illness perceptions and HbA1C levels. Journal of Development and Physical Disabilities, 20, 101-114.

McCabe, P. C., & Shaw, S. R. (2008). Hospital-to-school transition for children with chronic illness: Meeting the new challenges of an evolving healthcare system. Psychology in the School, 45(1), 74-87

McClanahan, R. & Weismuller, P. (2015). School nurses and care coordination for children with complex needs: An integrative review. The Journal of School Nursing, 31(1), 34-43.

Mitchell, K., Butler, M., & Collins, E. (2014). Special Medical Services School Nurse Survey 2014. Retrieved on April 2, 2017 from http://www.education.nh.gov/instruction/school_health/documents/schoolnursesurvey-2014.pdf.

National Association of School Nurses. (2012). Position Statement: Chronic Health Conditions Managed by School Nurses. Retrieved on April 1, 2017 from https://www.nasn.org/Portals/0/positions/2012pschronic.pdf.

National Association of School Nurses. (2017). Website. https://www.nasn.org/

References & ResourcesNational Association of State School Nurse Consultants. (2017). Website. http://www.schoolnurseconsultants.org/

National Center for Educational Statistics. (2016). Children and Youth with Disabilities. Retrieved on April 2, 2017 from https://nces.ed.gov/programs/coe/indicator_cgg.asp.

New Mexico Department of Health. (n.d.) Annual School Health Services Summary Report 2014-2015. Brochure retrieved on April 2, 2017 from http://ped.state.nm.us/sfsb/reports/2016/ASHSR%20Summary%20Report%202014_2015_FINAL_12.17.15.pdf.

North Carolina Public Health & North Carolina Healthy Schools. (n.d.) North Carolina Annual School Health Services Report 2014-2015. Brochure retrieved on April 2, 2017 from https://www2.ncdhhs.gov/dph/wch/doc/stats/14-15AnnualSHSBrochure.pdf.

Social Security. (n.d.) Disability Evaluation Under Social Security, Part I – General Information. Retrieved on April 2, 2017 from https://www.ssa.gov/disability/professionals/bluebook/general-info.htm.

Texas School Nurses Organization. (n.d.) TSNO ESSA Response – Literature Review (unpublished).

References & ResourcesVessey, J. A. (2011). Helping student with disabilities better address teasing and bullying situations: A MASNRN study. Journal of School Nursing, 27(2), 139-48.

Wang, L. Y., Vernon-Smiley, M., Gapinski, M. A., Desisto, M., Maughan, e., & Sheetz, A. (2014). Cost-benefit study of school nursing services. JAMA Pediatrics, 168(7), 642-648.

Weismuller, P. C., Grasska, M. A., Alexander, M., White, C. G., & Kramer, P. (2007). Elementary school nurses interventions: Attendance and health outcomes. Journal of School Nursing, 23(2), 111-118.

Wolfe, L. C. (2013). The profession of school nursing. In J. Selekman (Ed.), School Nursing: A Comprehensive Text, pp. 25-47. Philadelphia, PA: F. A. Davis Company.