The scope and standards of school nursing practice provide a mechanism for accountability of the specialty to the public. The scope describes the who, what, where, when, how and why of the specialty practice. The standards are the professional expectations for behavior that guide the practice of school nursing. The standards have practical and formal value in advocacy, decision-making, setting and describing professional values and roles, and framing issues. They are valuable resources for the school nurse to guide position descriptions, role expectations, performance appraisal tools, program quality and a communication tool regarding the essence of school nursing (Resha, 2019). Each of the standards is detailed in the associated competencies. Behaviors that meet the standards and competencies provide evidence of an expected standard of care.

While school nursing is rooted in the same fundamentals of all nursing care, it is important to define it given the unique population and setting (schools) in which care is provided. School nursing requires a comprehensive knowledge base of both the nursing and education fields. This unique understanding of the nexus of health and education allows school nurses to properly advocate for the health and safety of the student, family, and school community. Together, the scope and standards of school nursing practice describe the core of the specialty.

As noted in the preface, the scope and standards of school nursing practice highlight the specialty and professional expectations. In order to use the breath of this publication, it is essential to explore the scope (who, what, where, when, why and how); focus on the definition of school nursing; and review all the terminology in the glossary. The glossary provides clarity for all readers and is an important tool to fully understand the expectations of the standards and accompanying competency statements. Finally, the associated references and appendices provide the reader the opportunity to delve further the specialty practice of school nursing.

ANA’s
Nursing: Scope and Standards of Practice, 4th edition (American Nurses Association [ANA], 2021b), the
Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a) and its companion,
Guide to the Code of Ethics for Nurses: Development, Interpretation and Application, 2nd edition (Fowler, 2015) are the foundational documents that describe the comprehensive practice of nursing. Together they outline the expectations of the professional role of the registered nurse. They are critical resources for professional nursing practice and represent the standards of professional nursing practice for all registered nurses. The
ANA Scope and Standards document provides the structure upon which the
School Nursing: Scope and Standards of Practice, 4th Edition, is based. The scope and standards of school nursing describe a competent level of school nursing practice and professional performance

Registered nurses, practicing in the United States and abroad for the U.S. Department of Defense Education Activity (US DoDEA), as school nurses also have other key professional resources, such as the
Framework for 21st Century School Nursing Practice TM (Appendix A), NASN position statements and practice documents, and various school nurse textbooks and resources. These documents set the framework for registered nurses across all roles, levels, and settings. School nurses are further advised by the 2021 National Association of School Nurses
Code of Ethics for the School Nurse (NASN, 2021c) (Appendix A).

School nurses, school nurse administrators, and registered nurses are the primary audience of this professional resource. Healthcare providers, healthcare systems, agencies and organizations, other nursing specialties (such as public health nurses), school district administrators, school board members, nurse educators, school-based health center staff, and interprofessional colleagues will also find this a valuable reference in understanding the role of school nurses, the supervision of nursing personnel and unlicensed assistive personnel (UAP) in schools, and the development, maintenance, and evaluation of the school health program. In addition, students, families, groups, communities, and other populations using healthcare services in the school and in the community can use this document to better understand what comprises the practice of school nursing provided by registered nurses and graduate-level prepared nurses. Finally, legislators, regulators, legal counsel, and the judiciary system may wish to reference this document describing the scope of school nursing practice and the accompanying specialty standards of practice and professional performance.

School Nursing: Scope and Standards of Practice, 4th Edition, describes the professional responsibilities of all registered nurses engaged in school nursing practice, regardless of setting. As such it can serve as a basis for a range of uses, including:

· School nurse recruitment

· Position descriptions

· New employee orientation

· Performance appraisal/evaluation

· Agency policy, protocol, and procedure development

· Competency gap analysis

· Education of individuals regarding the role of school nurses

· Quality improvement systems and/or program evaluation efforts

· Development and evaluation of school nursing service delivery systems and organizational structures

· Educational offerings

· Database development, data collection, and research

· Establishing the legal standard of care

· Healthcare reimbursement and financing methodologies

· Regulatory review and revision

School nurses are uniquely positioned to enhance the quality of care and foster a national and local culture that supports the health and wellness of their school communities.

The definitions of nursing and school nursing provide the basis for the unique specialty scope and standards of school nursing practice. “Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity” (ANA, 2021b, p. 1).

“School nursing, a specialized practice of nursing, protects and promotes student health, facilitates optimal development, and advances academic success. School nurses, grounded in ethical and evidence-based practice, are the leaders who bridge health care and education, provide care coordination, advocate for quality student-centered care, and collaborate to design systems that allow individuals and communities to develop their full potential” (National Association of School Nurses [NASN], 2017a).

School nursing care and practice occur in the pre-K-12 educational setting, making children the primary focus of their practice. The practice is unique, often functioning as a solo healthcare expert, and rarely with physician oversight (Johnson, 2017a). School nurses interpret pre-K-12 education law, statutes & regulations integrating them with those pertaining to the practice of professional nursing. In the education setting, school nurses have a unique opportunity to promote developmentally appropriate student health care knowledge and self-reliance. The Framework for 21st Century School Nursing Practice TM (NASN, 2016) characterizes the student as the central focus of care and highlights the principles guiding school nurse practice that are evident in the
Standards of School Nursing Practice.

The scope of practice statement describes the “who,” “what,” “where,” “when,” “how,” and “why” of school nursing practice. Each of these questions must be sufficiently answered to provide a complete picture of the dynamic and complex practice of school nursing and its evolving and expanding boundaries (ANA, 2021b, p. 3).

The following statements provide an overview of school nurse practice:

· The “
Why” of School Nursing (p. 14) is explicitly centered around the student. School nurses support the health, well-being, and the ultimate educational success and lifelong achievement of all students as described in the social contract of nursing – including those that are well and especially those with chronic and acute health problems. School nurses intervene via tiered prevention efforts to keep entire school communities and the larger communities healthy. They intervene to promote healthy school environments, incorporate health in all school policies, and work to remove social determinants of health barriers for optimal health and learning. School nursing ethics underpin the why of school nursing practice.

· The “
Who” of school nursing addresses the
Characteristics of Professional School Nurses (p. 23) that include the education, licensure, and credentialing of professional school nurses. It includes measures of professional competence and statistics about school nurses. Members of the school nursing specialty include registered professional BSN nurses (RNs) and graduate-level prepared registered nurses who have been educated, credentialed, and maintain active licensure to practice.

· The “
How” of
School Nursing Practice Delivery (p. 36) is described by the art and science of nursing, the Nursing Process and the NASN
Framework for School Nursing in the 21st Century TM.

· ”
Where” the school nurse practices – School Nurse Settings (p, 44) – includes settings within schools which extend beyond a physical building to include the school community, off-campus school trips, athletic events, and home visits. In addition, special circumstances may necessitate the use of virtual platforms to provide nursing care. School nurses may be employed in an advisory, executive, or managerial capacity by Boards of Education, Public Health Agencies, healthcare institutions, state health and education departments, and within the federally funded school system of the Department of Defense Education Activity (DoDEA) in the U.S. and around the world.

· “
When” school nursing occurs is defined by School Nursing Services: Every Day, All Day (p. 47) and generally occurs during regularly scheduled school hours. It also includes extended coverage locations, such as boarding/residential schools, therapeutic settings, detention centers, and when enrolled students’ educational needs are being accommodated at home. The school nurse may also be asked to be “on call” or provide nursing services during times when the students are participating in off-campus field trips or work experiences. During periods of epidemic, pandemic, natural or community disasters, school nurses may be called upon as content experts to provide health leadership that extends beyond the regularly scheduled work hours.

· The “
What” of school nursing –
The Role of the School Nurse (p. 50) – is described in the definition of the specialty and translates into the roles that school nurses fill. It is a specialty practice of professional nursing that, in collaboration with families, school personnel, community members, and other healthcare providers, is responsible for the health and well-being of school students and the broader school community, generally in the pre-kindergarten to grade 12 setting and may include students with disabilities to age 21. The scope and role of school nursing is unique and varied and includes clinician, advocate, case manager, health educator, health counselor, researcher, liaison and interprofessional team member; sentinel for individual and student population health, and others (Wolfe, 2019).

The specialty of school nursing encompasses a broad range of nursing responsibilities and settings. The depth and breadth in which individual school nurses engage in the total scope of school nursing practice depends on their education, licensure, experience, role, work environment and workload, job description and the populations served.

School nursing practice is guided by foundational principles that include the following:

· Student health and well-being rely on access to school nurses, every day, all day (NASN, 2018b)

· The 21st Century Framework for School Nursing TM as a foundation to the practice (NASN, 2016)

· That interprofessional work is essential to coordinated care and educational access. This includes the nurse as the intersection between the education team and the student’s health care team and parents (Centers for Disease Control and Prevention [CDC], 2021c)

· The Whole School, Whole Community, Whole Child (WSCC) model that recognizes that collaboration between student, family, health services, educational services, and the larger community is a driver of student success (ASCD & Centers for Disease Control and Prevention [ASCD & CDC], 2014).

· The competent practice of school nursing is dependent on each entity involved in the care setting to attend to their responsibilities – including that of the employer to provide adequate resources (ANA, 2021b, Table 4)

· Nursing care is driven by a Code of Ethics that incorporates values and caring (ANA, 2015a; NASN, 2021c)

· School nurses have a unique perspective on the underlying causes of poor health, its impact on academic progress, and ways to address those causes (Braveman et al., 2018; NASEM, 2021; Odgers and Adler, 2018; Owen and Candipan, 2019).

· That education is a social determinant of health and as such, advocacy for social justice and equity in health and education access– particularly for vulnerable groups. – is an important element of school nursing (CDC], n.d.-b; NASEM, 202; World Health Organization [WHO], n.d.)

· That environmental health is an essential component of social justice (NASN, 2021b)

· That working to the “…full extent of their education and training will increase the types and amount of high-quality health care services that can be provided to those with complex health and social needs and improve both access to care and health equity” (NASEM, 2021, p. 7)

· That policy is not something that happens to nurses and does not constrict their influence on health (ANA, 2010; Shalala, 2014). School nurses are equipped to shape policy, whether within the school, in the community, or at the state or national level (Bergren, 2017; NASEM, 2021; Shalala, 2014).

· That school nurses should be compensated at a level that is comparable to nurses in other settings and payment mechanisms should reflect this (ANA, 2010; NASEM, 2021)

· That advocacy, including legislative advocacy, is an essential component for school nursing especially related to health equity and decreasing social determinants of health affecting school-aged youth and their families (NASN, 2018b).

· That school nursing practice is historically grounded in population health, and continues to not just care for individual students, applying upstream interventions to promote health and prevent illness within the entire school community (Campbell & Anderko, 2020)

The student is explicitly and deliberately at the center of school nursing practice. Greater than 90% of children in the U.S. attend school daily during the school year (Education Data Initiative, 2021b; United States Census Bureau [US Census], 2019). The school nurse serves in a pivotal role that bridges student health and education (Maughan et al., 2018). A student’s health is directly related to their ability to learn. Children with unmet health needs have a difficult time engaging in the educational process (American Academy of Pediatrics [AAP], 2016).

School nurses are essential for protecting communities from vaccine preventable diseases and provide surveillance at ground zero to detect disease outbreaks. School nurses are often the only available health care option for homeless, immigrant and refugee children, and the underserved in both rural and urban areas. School nurses typically live in the school districts they serve and are fluent in the culture of the community. They have long established relationships not only with the schools, but with health care providers, community members and leaders. The school nurse serves as an extension of the medical home, community health services, ensuring continuity, adherence, and professional supervision of care within the school setting (AAP, 2016).

Access to a school nurse is imperative to prevent or mitigate costly, debilitating, and life-threatening adult chronic health concerns (Maughan et al., 2018). School nurses provide care that prevents unnecessary primary care appointments and costly, unnecessary emergency room visits. They increase access to primary care in numerous ways, e.g., by facilitating telehealth visits with primary care providers and specialists and helping families overcome barriers, such as health insurance access and transportation. Daily access to a school nurse benefits children, families, and communities as well as the health care and the education system.

School nurses are an investment in the health of our nation’s most valuable resource – our children. They protect the current workforce by keeping the community healthy and parents at their jobs (Wang et al., 2014). They protect our future workforce — helping to grow our children into healthy and productive citizens.

The practice of school nursing requires vigilant attention to ethics. The school nurse is an advocate for the health and well-being of students, families, and school communities. The school nurse provides age-appropriate and culturally congruent care to students and the school community. The school nurse promotes active, informed participation in health decisions; respects the individual’s right to be treated with dignity; and applies the ethical and legal decision-making standards around an individual’s right to privacy and confidentiality. The school nurse treats all members of the school community equitably, regardless of race, gender, social or economic status, culture, age, sexual orientation, disability, or religion.

The school nurse maintains the highest level of competence by enhancing professional knowledge and skills; collaborating with peers, other health professionals, and community agencies; and adhering to
Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010),
Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a),
NASN Code of Ethics for the School Nurse (NASN, 2021c)[See appendix A], and this document,
School Nursing: Scope and Standards of Practice, Fourth Edition. School nurses participate in efforts to advance and use the standards of practice, expand the body of school nursing knowledge through nursing research, and improve conditions of the workplace environment. School nurses are expected to self-regulate as they are responsible to themselves and others for the quality of their practices as a condition of their license to practice. The school nurse is autonomous and must engage in personal accountability for quality assurance.

The degree to which the total school community supports school nursing practice affects the delivery of nursing care and, hence, the ethical nature of that care. Inadequate staffing may contribute to the ineffective delivery of care, compromise staff and student wellness, and contribute to conflict and stress among school nursing professionals. School nurses may face ethical challenges when responding to the increased demands of caring for children with complex health conditions. They may struggle to balance the needs of children with complex healthcare needs while assuring that the needs of the general school population are met. Additionally, the geographic distance between schools may become a barrier to care if nurses spend considerable time traveling, raising questions of ethical care delivery. Therefore, the acuity and holistic healthcare needs of the student population must be considered when evaluating staffing needs (National Association of School Nurses [NASN], 2020d).

School nurses straddle two statutory and regulatory systems at both the state and national levels, namely education and health. Because school nurses practice in a system focused on education, they face unique policy, funding, and supervisory issues that may present ethical dilemmas. For example, a school administrator’s request of the school nurse may conflict with practice regulations, or responsibilities to the school district may restrict competent nursing practice. School nurses must have the skills to communicate and advocate for student care within the healthcare and education arenas, applying appropriate ethical theories and principles to their practices (ANA, 2015a; NASN, 2021c). Nurses’ first duty is to the patient and this duty cannot be superseded by institutional policy, thus “nurses are challenged to thoughtfully analyze the balance of professional responsibility and risk, including moral obligations and options, in order to preserve the ethical mandates in situations of risk to the nurse or profession” (American Nurses Association [ANA], 2015b, p. 1).

Given the challenges school nurses face and the need to make often difficult decisions, the following ethical decision-making models and resources offer guidance to school nurses (see Table XX). Each model provides the process to identify the ethical dilemma/concern and steps to analyze what solutions may exist. These models are similar to the nursing process and include a cyclic process of continuous evaluation (ANA, 2021b, p. 18).

ANA (2021), p. 18 (*note: Table 2 will be reprinted upon copyright approval from ANA).

The Scope and Standards of Nursing (ANA, 2021b), the
Code of Ethics for Nurses (ANA, 2015a), the
School Nursing: Scope and Standards of Practice and The
Code of Ethics for School Nurses (NASN, 2021c) all explicitly require that school nurses address issues of social justice as part of their social contract with society. This tenent is also explicitly addressed by the NASN (NASN, 2020a) and the National Association of State School Nurse Consultants (NASSNC, 2020a). The ANA states that “…nurses must provide compassionate care that addresses the individual’s needs for protection, advocacy, empowerment, optimization of health, prevention of illness and injury, alleviation of suffering, and comfort and well-being” (ANA, 2021b, p. 19). The ANA calls for nurses to “…lead the effort to address social determinants of health (SDOH)” by improving diversity in nursing and engaging in “…unrelenting, unwavering, and encompassing efforts for equity, diversity, inclusion, and social justice” (ANA, 2021b, p. 20) for all people “regardless of origin, race, sexual preference, background or socioeconomic status” (ANA, 2021b, p. 23). “All nurses must be open to examining the impact of history on today’s laws and regulations to understand and acknowledge that the nursing profession itself has a historical and existing connection to policy and politics” (ANA, 2021b, p. 21) and recognize that the destructive and uneven impact of social determinants of health have created “…structural and systemic divides” (ANA, 2021b, p. 21).

Social determinants of health are defined by the CDC as the “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes” (CDC, 2021b). Education itself is a social determinant of health (Magnan, 2017), with the power to lift children out of poverty and advance their capacity to contribute to society (CDC, n.d.-a).

As an inherent part of social justice and the social determinants of health, the CDC identifies racism as “a system—consisting of structures, policies, practices, and norms—that assigns value and determines opportunity based on the way people look or the color of their skin. This results in conditions that unfairly advantage some and disadvantage others throughout society” (CDC, 2021a). Mapping the human genome tells us that we are 99.9% the same. According to the National Human Genome Research Institute of the National Institutes of Health “the vast majority of genetic variation exists within racial groups and not between them” (National Institutes of Health: National Human Genome Research Institute [NIH], n.d. , p. 1). This makes the perceived differences between races more of a social construct, not a genetic fact (Evans et al., 2021). We also know that clinical care explains only 10-20% of health outcomes with the remainder of health determined by influences such as physical environment, social and economic factors, and health behaviors (Magnan, 2017). These facts require that we examine and root out the social constructs that create structural barriers based on race and other ways of discrimination, and as school nurses, that we promote social justice by breaking down these barriers. Assuring that children have equitable access to health and educational opportunities is an essential component of social justice.

The ANA states that “respect is a basic human right” (ANA, 2021b, p. 22). “The trust that patients place in nurses is unique, incomparable, sacred, and must not be broken by biases that seep into care delivery and decision-making” (ANA, 2021b, p. 23). Biases create “avoidable suffering” that occurs because of a “lack of respect for others manifested by dysfunctional processes and inherent biases embedded within the systems of care” (ANA, 2021b, p. 22). Therefore, school nurses must reflect “unconditional positive regard” for every client (Bauer, Southard, & Kummerow, 2017 as cited by ANA, 2021b, p. 23). To accomplish this, the ANA “…demands that nurses know themselves…” (ANA, 2021b, p. 23) which requires “self-awareness, self-reflection, and self-critique” (ANA, 2021b, p. 23) and an examination of one’s own bias and privilege. These steps are required to develop a culture of humility that promotes a safe environment for students and families, and advocacy for social justice. Cultural humility is “ a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process” (Gonzales & Levitas, 2020 as cited by ANA, 2021b, p. 23).

School nurses have the privilege of practicing in the intersection of health and education – two sectors that have a tremendous impact on the future well-being of our nation’s children. School nurses have a window into the lives of children from every race, creed, religion, and belief system. Thus, school nurses have a unique and sacred opportunity to see, acknowledge and intervene to protect the safety, and physical and emotional well-being of children. Students who live with racism, sexism, homophobia, ableism, classism, and other structural barriers are inhibited from fully accessing the benefits of their education, and as a result, risk limitations on their adult potential to live a full and productive life. This is damaging to not only the student and their family, but to their community and our nation and the world. We cannot afford to waste any human potential. This duty requires limiting the “avoidable suffering” that impacts the outcomes of care that school nurses provide to their students.

To accomplish optimal outcomes for students, school nurses must examine their own privilege and bias and engage in continued education to minimize the impact of bias and structural ‘isms on their students and families. They must practice with cultural humility recognizing that it requires a “commitment of lifelong learning and exposure starting from providing dignity, respect, and grace to people regardless of origin, race, sexual preference, background, or socioeconomic status” (ANA, 2021b, p. 23).

The ANA recognizes that cultural humility requires attention to four guiding tenets:

· “Nurturing a life-long commitment to self-reflection, self-evaluation, and self-critique

· Redressing power imbalances in the person-clinician, educator-student, colleague-colleague, and academic center-community dynamic

· Developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities

· Stewarding an organizational-level development process that is also ongoing and parallels the first three tenets of cultural humility” (Tervalon & Murray-Garcia, 2021 as cited by ANA, 2021b, p. 24)

Finally, “Nurses must address unjust systems and structures and use their voices to advocate for transformative action-oriented policies and initiatives that mitigate inequality and promote social justice” (ANA, 2021b, p. 26). Because education is a social determinant of health, school nurses have a unique, and solemn opportunity to influence equity and inclusion within the schools to promote not just education but ultimately the health and well-being of our nation’s children and create a more just environment for our students’ own children.

The characteristics of a professional school nurse include their education, licensure and credentialing as well as measures of professional competence and statistics about school nurses. Members of the school nursing specialty include registered professional BSN nurses (RNs) and graduate-level prepared registered nurses who have been educated, titled, and maintain active licensure to practice.

Educational preparation of school nurses varies, however, the broad scope of the specialty practice of school nursing, and the complexity of issues addressed within a school community setting require advanced skills. These include the ability to practice independently, supervise others, and delegate care. Therefore, the NASN recommends (NASN, 2021a) and the ANA “has consistently affirmed” (ANA, 2021b, p. 44) that the minimal educational preparation for a school nurse be a Bachelor of Science in Nursing (BSN) degree from an accredited college or university. For nurses entering the field of school nursing without these credentials, acquiring the BSN degree and, where required, state licensure/certification credentials are expected. Additionally, without this minimum of a BSN degree, a nurse working in a school setting would not be able to attain national certification as a school nurse (NBCSN, n.d.). Regardless of the educational preparation of the school nurse, compliance with the standards of practice and professional performance for school nursing, and demonstration of the associated competencies is also expected.

School nurses may also be prepared at the master’s or doctoral educational level, Graduate-prepared nurses with degrees in nursing or related fields, such as public health, have the knowledge, skills, abilities and judgment that equip them to practice at an advanced level. Their advanced education may be in school nursing, administration, education, case management, nursing informatics, public health, research, or other health and nursing areas of study. In graduate programs of study, nurses advance their knowledge and skills in clinical areas as well as in research.

The American Association of Colleges of Nursing states that “Nurses with graduate preparation provide direct patient care at an advanced level, conduct research, teach online and in the classroom, impact public policy, lead health systems, consult with corporations and implement evidence-based solutions that revolutionize health care” (American Association of Colleges of Nursing [AACN], n.d.-a). Graduates of masters and doctoral education programs are prepared to perform at higher levels of activities – to translate, integrate, synthesize, lead, analyze, design, collaborate and coordinate more complex nursing activities (AACN, n.d.-b). A graduate-level prepared school nurse is expected to comply with the standards of practice and professional performance for school nursing, the associated competencies for all school nurses, and the additional competencies for a graduate-level prepared school nurse. Resources, such as
Nursing Administration: Scope and Standards of Practice (ANA, 2016), or
Public Health Nursing: Scope and Standards of Practice, 3rd edition (ANA, 2021c) may provide additional direction. Advanced Practice Registered Nurses (APRNs) are expected to meet the competencies of the
ANA Scope of Practice for Nurse Practitioners, (American Association of Nurse Practitioners [AANP], 2019) their certification, state nurse practice acts and compliance with their specific job description.

All school nurses must seek professional development and continuing education to increase their critical thinking skills and professional judgment as well as to maintain competence in their role. The ability to perform at the expected level requires a process of lifelong learning. School nurses must continually reassess their competencies and identify needs for additional knowledge, skills, personal growth and integrative learning experiences. (Adapted from ANA, 2021b, p. 45)). Continuing professional development is often required to maintain licensure and specialty certification, Membership in specialty nursing organizations at the national and state level provide opportunities for specialty specific continuing education. There may also be local opportunities such as those provided by the health services department of a local school district, state department of education, local pediatric hospitals, and some collegiate schools of nursing.

“Licensure is the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice” (National Council for State Boards of Nursing [NCSBN], n.d.). Licensure in nursing is granted by the regulatory body of the state, commonwealth, territory, or government based on educational preparation and a licensing exam. Licensure determines the scope of practice. School nurses are licensed as Registered Nurses or Advanced Practice Registered Nurses. States may also require licensure to practice as a school nurse through their state board of education.

Registered nurse (RN) is a regulatory title for persons who have graduated from a “…state approved school of nursing, passed the NCLEX-RN Examination and is licensed by a state board of nursing to provide patient care” (NCSBN, n.d.). The registered nurse is educated in the art and science of nursing, with the goal of helping individuals, families, groups, communities, and populations attain, maintain, and restore health whenever possible. (ANA, 2021b, p. 45).

Advanced practice registered nurse (APRN) is a regulatory title and includes the four roles of certified nurse-midwives (CNMs), certified nurse practitioners (CNPs), certified registered nurse anesthetists (CRNAs), and clinical nurse specialists (CNSs). Each has a unique history, shared a focus on providing clinical care for healthcare consumers, and is characterized by specific educational preparation, professional competencies, and certification requirements (ANA, 2021b, p. 46).

Some school nurses may have the authority for advanced practice granted by their state licensing board, and meet the standards identified for APRNs because of their education, experience, license, and skill, and have the authority for advanced practice granted by their state licensing board. In schools, APRNs may practice as nurse practitioners, clinical nurse specialists or school nurses. APRNs are often part of an enhanced school services team, a school-based health center, or a wellness center that provides direct medical diagnostic and treatment care to students. An APRN working in a combined APRN/school nurse role is expected to comply with the standards of practice and professional performance and associated competencies for all school nurses, the competencies for graduate level prepared school nurses, and the additional competencies for an APRN as delineated by their state nurse practice act and the APRN Consensus Model. The APRN role in the school may be limited by job description or agency policy.

Certification has been defined as the “formal process by which a certifying agency validates a nurse’s knowledge skills, and abilities in a defined role and clinical area of practice (Competency & Credentialing Institute [CCI], 2021). A number of studies have identified the intrinsic and extrinsic value of specialty certification both for the individual nurse, the organization and the outcomes of patient care (Gigli et al., 2020; Halm, 2021; Hung et al., 2020; Lasater et al., 2020; Van Wicklin et al., 2020).

The National Board for the Certification of School Nurses provides the national certification credential for the specialty of school nursing (National Board for Certification of School Nurses [NBCSN], n.d.-b). NBCSN is accredited by the Accreditation Board of Specialty Nursing Certification (ABSNC) (NBCSN, n.d.-a). The NASN endorses the attainment of the National Certification in School Nursing (NCSN) credential (NASN, 2021a). As with licensure, some states also have school nurse certification provided by their state board of education. Additionally, some school nurses may hold other specialty certifications, such as public health nursing, informatics, nurse executive, Lean Six Sigma, diabetes educator, asthma educator and others.

Professional competence, self-determination, and professional identity are important, interrelated concepts for nurses and the nursing profession. Development of competence in one area of life often facilitates risk taking, empowerment, and new learning in other areas (Maluccio, 1981 as cited by ANA, 2021b, p. 51). Development of professional competence enhances the concept of self-determination and helps promote formation and demonstration of a professional identity. This ongoing, transformational process in nursing integrates elements of both virtue ethics and the ethics of care (Crigger & Godfrey, 2014 as cited by ANA, 2021b, p. 51).

The school community has a right to expect school nurses to demonstrate professional competence throughout their careers. While individual school nurses are responsible and accountable for their professional competence, the nursing profession, regulatory agencies, employers, nursing organizations and credentialing and certification agencies also share responsibility for conditions that promote competence (See Table 4 below) .

ANA, 2021b, p.52 (* note: Table #4 will be reprinted upon copyright approval from ANA)

Several terms and concepts are central to the discussion of the ongoing demonstration of competence:

· An
individual who demonstrates competence is performing at an expected level.

· A
competency is an expected level of performance that integrates knowledge, skills, abilities and judgment.

· The integration of
knowledge, skills, abilities and judgment occurs in formal, informal, and reflective learning experiences.

·
Knowledge encompasses critical thinking, understanding of science and humanities, use of professional standards of practice and insights gained from context, practical experiences, personal capabilities, and leadership performance.

·
Skills include psychomotor, communication, interpersonal and diagnostic skills.

·
Ability is the capacity to act effectively. It requires listening, integrity, knowledge of one’s strengths and weaknesses, positive self-regard, emotional intelligence, and openness to feedback.

·
Judgment includes critical thinking, problem-solving, ethical reasoning, and decision-making. (ANA, 2021b, p. 52).

Competence is achieved through the synthesis of three types of learning that inform the nurse’s ongoing professional development plan:

· Formal learning most often occurs in structured, academic, and professional development practice environments

· Informal learning can be described as experiential insights gained from work, community, home and other settings

· Reflective learning is characterized as the recurrent, thoughtful, personal self-assessment, analysis and synthesis of strengths and opportunities for improvement and constitutes reflective learning (ANA, 2021b, p. 53).

School nurses are influenced by the context of the practice situation, which includes consideration of the setting; resources; and the individual, family, group, community, or population. Practice situations can either enhance or detract from the school nurse’s ability to provide quality care. The school nurse influences factors that facilitate and enhance competent practice and seeks to overcome barriers that constrain competent practice. The expected level of performance reflects variability depending on the school nursing practice situation and the selected practice framework or model. Thus, competence is situational, dynamic, and both an outcome and an ongoing process.

Competence can be defined, measured, and evaluated. Competence in school nursing practice must be evaluated by the individual nurse (self-assessment), school nurse peers, and nurses in the roles of supervisor, coach, or mentor or preceptor. In addition, other aspects of performance not exclusive to the practice of nursing (e.g., interpersonal and communication skills, team collaboration and networking, and classroom teaching) may be evaluated by professional colleagues, administrators, health care consumers, and others.

Evaluation of competence includes using tools to capture objective and subjective data about the individual’s knowledge and performance. Tools must be appropriate for the specific school nursing situation and the desired outcome of the competence evaluation. Such tools and methods include, but are not limited to, direct observation, records, portfolios, demonstrations, skills lab, performance evaluation, peer review, certification, credentialing, privileging, simulation, targeted continuing education with outcomes measurement, employer skills validation, and practice evaluations. However, no single evaluation tool or method can guarantee competence (ANA, 2021b, p. 53). Context, including the culture of innovation, determines what competencies are necessary and contributes to the development of professional identity. Competence and context are integral to the evolution and valuing of self-determination

Self-determination relies on the development of competence as reflected in the individual’s knowledge, skills, abilities, and judgement. It is strengthened by commitment to lifelong learning and is an inalienable right. Self-determination is an ongoing process informed and shaped through constant exposure to nursing’s professional culture, including its focus on caring and external professional constructs and guidance. External constructs and guidance include the
Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a); nursing professional scope of practice; standards of practice; specialty certifications; nurse practice. The independence of school nursing practice stresses the importance of self-determination (adapted from (ANA, 2021b, pp. 53–54).

Professional identity is defined as “…a sense of oneself, and in relationship with others, that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse” (Godfrey & Young, 2021, p. 363). In addition, the norms and values of the school nurse require an inclusive and culturally humble mindset to promote diversity, equity and inclusion. Growth of one’s professional identity as a nurse includes mindful flexibility and preparation for contingencies and loss as roles and professional status may abruptly change, such as through injury or illness, job loss, and eventual retirement (ANA, 2021b, p. 54).

As part of their professional identity and subject to their practice context, school nurses are encouraged to participate in mentoring novice school nurses. Mentoring is “…a singular dyad relationship or a grouping of dyad relationships that can be hierarchical or peer-to-peer (Hale & Phillips, 2019; McBride et al., 2017). McBride and colleagues (2017) suggest that the mentoring relationship seeks to support, teach, encourage, challenge, advise, protect, and sponsor a nurse protégé to realize and develop their own potential within the nursing profession (ANA, 2021b, p. 55). Mentoring promotes confidence through a safe relationship with a mentor and is now considered by the ANA to be a professional responsibility. Precepting students of nursing is also a valuable way to introduce future nurses to the specialty of school nursing.

A survey of the nation’s nurses was conducted in 2020 by the National Council of State Boards of Nursing (NCSBN) and the National Forum of State Nursing Workforce Centers (Forum). The total number of active nursing licenses in the U.S. at that time included 4,198,031 RNs and 944,813 LVN/LPNs. Of the respondents, approximately 3.1% reported their primary nursing practice setting as being in school health service (Smiley et al., 2021). Of note was the decline from a high of 3.3% reporting school health service in 2013 to a low of 2.6% of the total population of nurses in 2017.

The National Association of School Nurses conducted a workforce study in 2017 that looked at the percentage of schools that employ a school nurse. Full time nurses (> 35 hours) were employed by 39% of schools, 35% of schools employed part-time school nurses (< 35 hours) and 25% of schools did not employ a school nurse (Willgerodt et al., 2019). Public schools were more likely to have a full or part-time school nurse (81.9%) compared to private schools at 34.6%.

Table 1

Percent of Schools with Full / Part-time and No School Nurse (Willgerodt et al., 2019)

Willgerodt et al. further found that access to a nurse at school varies widely across the nation (See Table 2).

Table 2

Percent of Schools Without a School Nurse by Region (Willgerodt et al., 2019)

The education, age and gender of school nurses vary as depicted in Table 3. (Willgerodt et al., 2019).

Table 3

Characteristics of U.S. School Nurses (Willgerodt et al., 2019)

Models of school health delivery included 70% of schools that were served by an RN; 14% served by an RN and LPN combined; 5% served by an LPN alone; and 11% with no nursing service (Willgerodt et al., 2019).

Funding for school nursing services was primarily through local education dollars (see Table 4). Of note, while 51.1% of public schools bill for Medicaid services, only 1% of the overall Medicaid budget supports school health services funding (Willgerodt et al., 2019).

Table 4

Sources of School Health Services Funding by Source (Willgerodt et al., 2019)

School nursing is both an art and a science. The art of school nursing “is demonstrated by unconditionally accepting the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care” (ANA, 2021b, p. 5). The science of school nursing provides evidence-based care via the six-step nursing process. This integration of a core body of knowledge, objective data, critical thinking/judgment, creativity, and caring provide the foundation for the
Framework for 21st Century School Nursing PracticeTM (Framework) and support the art and science of school nursing. “It is perhaps the breadth of nurse activities subsumed within school nursing and the unique non-medical practice setting that creates this specialty practice and differentiates it from other nursing specialties” (Wolfe, 2006, p. 121).

The essence of the art of school nursing is caring. “A human caring relationship in nursing involves an intentional partnership of the care recipient and the nurse. The nurse must possess competence, professional maturity, interpersonal sensitivity, a moral foundation that supports caring actions, and the ability to create an environment conducive to caring” (ANA, 2021b, p. 7). With caring comes courtesy, kindness, and respect for those provided nursing care. Consequently, the art of school nursing is dependent on culturally congruent care practiced by school nurses, is based on complex interpersonal human relationships, and adherence to a strong code of personal and professional ethics (NASN, 2021c).

School nurses model caring via their image, actions, and sensitivity to the individuals, families, groups, communities, and populations they serve. School nurses meet unique cultural needs, champion eradication of barriers to health and education equity, and create environments of trust, acceptance, and tolerance. School nurses demonstrate caring and culturally congruent practice via self-reflection on personal attitudes and beliefs, engagement in the school community, and through evaluation and intervention to address community needs (National Association of State School Nurse Consultants [NASSNC], 2020b).

School nurses practice in a kind and compassionate manner working with many ethnicities represented within the heritage of the community’s citizenry. Immigrants, refugees, and those with work visas bring diverse languages, health, social needs, and cultural practices to the school community. “[C]ulturally competent nurses will increasingly serve as role models for novice clinicians, colleagues, and consumers and as leaders of change” (Marion et al., 2016, Conclusion: Call to Action section).

The practice of school nursing is built upon sound theory, research, and consensus models of practice drawn from a large body of published work in nursing. It relies on qualitative and quantitative evidence-based data as well as determination of the school nurse impact on specific student health outcomes. The actions of the school nurse focus on strengthening and facilitating students’ educational and health outcomes through the application of theory and the implementation of evidence-based nursing care. Nursing actions are directed to the students or aggregates within the school population, and/or those influencing students such as the family, the school community, the larger surrounding community.

The ANA recognizes that all nurses function via deployment of the nursing process, and notes :

“Regardless of the theoretical knowledge base upon which nursing and its practice are derived, that knowledge fits within the multidimensional nursing process, the analytical, critical-thinking framework guiding professional thinking and activities. The nursing process is conceptualized as a cyclic, iterative, and dynamic process, including assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.” (ANA, 2021b, p. 21)

And so, it follows that school nurses deploy the nursing process in a way that provides support and care for school age children, their families, and the school community. This unique setting, in which the school nurse bridges both health and education has been described in a framework for school nursing practice. This student-centered framework consists of five non-hierarchical, overlapping principles that capture contemporary school nursing practice.

The roles, functions and core concepts of the Framework TM (See Figure X) define the manner in which school nursing services are delivered (NASN, 2016) and align with the Whole School, Whole Community, Whole Child model (WSCC). The WSCC model calls for greater alignment, integration, and collaboration between education and health to improve each child’s cognitive, physical, social, and emotional development for successful learning outcomes and wellness. Furthermore, “the Framework identifies a collaborative and coordinated approach to health and learning” (Mazyck & Fekaris, 2021, p. 534) and can be employed by school nurses to describe the scope of school nursing practice to stakeholders, guide professional school nurse self-assessment and goal setting, and serve as the foundation for evaluation based on school nurse competencies.

The central focus of school nursing practice is the student, family, and school community. School nursing practice activates the five key Framework TM principles of Care Coordination, Leadership, Quality Improvement, Community/Public Health, and Standards of Practice. Each principle is further defined by practice components that are enumerated in Table XX.

Figure X: Framework TM (NASN, 2016)

*Reprinted upon copyright approval from NASN

*Reprinted upon copyright approval from NASN

The Future of Nursing Report 2020-2030 (NASEM, 2021) recognizes school nurses as “community and public health practitioners who bridge education, healthcare, and other sectors, linking to broader community health issues through the student populations they serve (p.2)” and notes the vital role of school nurses in advancing health equity. Through deployment of the Framework TM, school nurses integrate the five-core healthcare professional practice competencies; student centered practice, evidence-based practice, interprofessional collaboration, use of informatics, and continuous quality improvement (Institute of Medicine [IOM], 2003).

“Nursing occurs in any environment where there is a healthcare consumer in need of care, information, or advocacy” (ANA, 2021b, p. 3). School nurses provide care in the school environment and work setting, considering acuity of student needs and the unique attributes of the student body and surrounding community, including the social determinants of health. As dictated by job description, emergency or disease outbreak conditions, school nurses may also provide care to school staff.

Figure 1: Where school nurses work:

Figure 1 illustrates the settings where school nursing occurs locally, regionally, statewide, nationally, and globally. School nursing is not static, and school nurses flow between levels as a need or situation presents.

The majority of school nurses practice at the local level in individual schools or a cluster of schools (Willgerodt et al., 2019). School nurses serve in public, private, independent, and parochial schools starting in early childhood through 12th grade and in transition services for students and youth with disabilities under the Rehabilitation Act of 1973 and as amended by the Workforce Innovation and Opportunity Act (U.S. Department of Education, Office of Special Education and Rehabilitative Services [U.S. DOE], 2020). School nurses work in day care centers and preschools, in school-based health care centers, home care agencies and staffing agencies. Within those settings, the employer can be the local school district, public health agencies, healthcare systems, private school corporations, religious entities, and tribal agencies. Some school nurses make home visits, and in some states school nurses provide services to families with infants and toddlers with disabilities exclusively within their homes. Advocacy is fundamental to school nursing practice in all settings and may prompt flow from local to state or national settings simultaneously (ANA, 2021b, p. 3).

Regionally, school nurses may be responsible for populations of students within county and city departments of health, healthcare systems, in non-profit agencies that address student health care and via telehealth.

At the state level, State School Nurse Consultants serve school children and school health at the state departments of education or health (NASSNC, 2021). They support school nurses with guidance on nurse practice acts, standards of care, policies, and regulations. Other school nurses work at the state level for professional state nursing associations, state, and national non-profits, and may teach school nursing at universities and colleges.

School nurses at the national level serve more than 56 million school aged children in the United States (National Center for Education Statistics [NCES], 2020), work within professional associations such as the NASN, the American Public Health Association, and the AAP. National government agencies employ school nurses at the Department of Education and the Centers for Disease Control and Prevention. National non-profit agencies that are concerned with the health of school children, such as Healthy Schools Campaign, Robert Wood Johnson Foundation, and the Allergy and Asthma Network employ school nurses to assist in policy level initiatives and translating evidence into practice. School nurses contribute essential expertise to corporations and for-profit entities such as software developers.

Globally, school nurses serve school aged children throughout six continents. The Department of Defense Education Activity (DoDEA) provides school health services within primary and secondary schools serving the education needs of the dependents of citizens who are working abroad (Hudson & Tsurumaki, 2017). International health agencies such as the (WHO) and United Nations International Children’s Emergency Fund (UNICEF) employ school nurses as consultants to assess student health resources, capacities and needs.

Some schools have primary care clinics located on school premises. School-based Health Centers (SBHCs) provide primary healthcare services to students enrolled in the center and may provide primary healthcare services to community members external to the school. A SBHC cannot replace but rather supplements the services of a school nurse who provides school health services to the entire school population (NASN & School Based Health Alliance [SBHA], 2021), e.g., students who are enrolled for primary care in the SBHC, students who are enrolled in primary care practices in the community, and students without a healthcare home. School nurses and staff from the SBHCs, including advanced practice registered nurse (APRNs), work together in a collaborative relationship to meet the healthcare needs of the students and school community (NASN & SBHA, 2021).

School nursing occurs whenever there is a need to provide specialized nursing that advances the well-being, academic success and lifelong achievement of the student population. In partnership with the student, family, school staff, and other healthcare providers, the school nurse is able to influence actual and potential health problems.

School nursing happens any time a school nurse is present and should be every day, all day (NASN, 2018b). “Timing relates less to a point in time as measured by a clock and more to the continuum of life events that relate to past, present, and future health and responses to illness/injury” (ANA, 2021b, p. 42). The time for school nursing happens when there is a need for:

· Assessment of individual and population needs

· Identification and mitigation of barriers to learning including social determinants of health

· Health promotion, disease prevention, risk reduction and management, and wellness activities

· Physical and behavioral/mental health support of students/staff

· Accommodations for children with specialized healthcare needs

· Disaster or crisis prevention, mitigation, recovery, and/or planning

· Quality improvement related to individual experience and population outcomes

· Transitions, crisis intervention, and societal change

· Advocacy for students, equity, and a healthy school environment

School-aged children spend a significant part of the day away from their families. Thus, it is important for the school nurse to be able to practice equitably and effectively, communicate across multiple population groups, and facilitate change at the population level.

Recent events, including the COVID-19 pandemic and historic extremes of weather and climate related disasters, (Smith, 2021), highlight the imperative nature of emergency and disaster preparedness to school nursing practice (Shannon et al., 2019; NASN, 2019b).

The COVID-19 pandemic emphasized the critical and essential importance of the education sector as well as it’s vulnerability. Schools provide the tools children need to succeed in life and contribute to society, support optimal family functioning, and are the heart of their communities. Schools often serve as emergency shelters and community resource facilities and may provide social support that contributes to a student’s sense of safety after a disaster. Yet, schools are extremely vulnerable to disasters that disrupt the educational process, leading to disparate and potentially life-long losses in learning, and negative social, emotional, and mental health impacts (U.S. Department of Eduction: Office of Civil Rights [OCR], 2021). The broad and complex impact of major disasters such as hurricanes, fires and flooding have socio-ecological implications for children, schools and communities that affect resilience and recovery (Cadamuro et al., 2021). These impacts may spread to other communities because of mass displacement of students from their homes to other locations in the wake of the disaster.

Unprecedented challenges during disasters threaten normal educational operations. School closures related to COVID-19 exposed weaknesses in the resilience of school systems. Rising occurrences of severe weather events, including droughts, wildfires and resulting poor air quality, extreme heat, and heavy rains and flooding exacerbate these weaknesses (Masson-Delmonte et al., 2021).

School infrastructure has been chronically underfunded, resulting in a 2021 Infrastructure Report Card rating of D+ rating (American Society of Civil Engineers [ASCE], 2021b). Improving the infrastructure and sustainability of our schools and ensuring that all schools have a comprehensive emergency operations plan, (school EOP) are essential to keeping students safe and healthy and on track educationally. School EOPS should address a range of threats and hazards including natural and human caused, biological, and technological (U.S. Department of Education [USDOE] et al., 2013).

School nurses must participate in school and community disaster planning. School nurses are the professionals in the school setting with the education, expertise, and experience to design plans to mitigate health related barriers to learning and health care access, provide for continuity of care, prioritize needs, ensure accessibility for students with disabilities and other barriers to access such as economic and social barriers. They facilitate collaboration and communication to meet disaster related challenges and keep students healthy, safe, and ready to learn (NASN, 2019b; NASN, 2021d; NASN 2019).

School nurse participation on re-opening and re-entry planning teams post disasters, including the-pandemic, is essential to return to safe in-person learning (NASN, 2020c). School EOPs must be updated using lessons learned from the COVID-19 pandemic and evidence-based effective mitigation, adaptation, and education interventions to address natural and man-made disasters (K12 Climate Action: Aspen Institute, 2021). Finally, school nurses’ skills in program planning and evaluation make them ideal members of a task force to apply lessons learned from previous disasters and develop the tools necessary for future disaster preparedness.

School nursing is a dynamic area of public and population health (Wolfe, 2019). School nurses collaborate with students, families, their school, medical and dental homes, and the broader community to improve student health and academic outcomes (NASN, 2018b). School nurses address a wide range of issues affecting students including “…child abuse and or neglect; domestic and school violence; child and adolescent obesity and inactivity; mental health issues, including suicide and substance abuse; adolescent pregnancy and parenting; environmental health; physical and emotional disabilities and their consequences; chronic health needs, complex health conditions; and social determinants of health, such as family education, lack of health insurance coverage, homelessness, poverty, and more.” (ANA & NASN, 2017, p. 10). Based on the assessment of needs and assets the school nurse uses scientific knowledge to mitigate barriers to learning. The role of the school nurse in addressing health and racial equity became starkly evident as they supported students, families, schools, and communities during the coronavirus pandemic of 2020-21 (CDC, 2021; Combe, 2020a; Mazyck, 2021).

School nursing became its own specialized practice through the work of Lillian Wald and Lina Rogers more than 120 years ago. While some state that the role of the school nurse is expanding, today’s school nurses use much of the same tenants that Wald used to create the first school nurse positions within her community public health role. These include cultural humility, disease and infection prevention, health literacy and equity (Wolfe, 2019). Like Rogers and colleagues, the contemporary school nursing role bridges health, family and student, community, and education to promote student access to the learning environment.

School nurses are trusted healthcare providers (Brenan, 2018). They utilize evidence-based practice and must stay informed of trends and advances in nursing science and practice that contribute to better outcomes and resource stewardship. Regular self-appraisal of one’s nursing interventions and related health outcomes is critical. School nurses collect and analyze their data and that of public health, medical, nursing and education research to inform their practice. School nurses are leaders, connectors, holistic clinical experts, educators, and evidence-based critical thinkers (Advent Health University, 2020).

School nurse service delivery is changing as technology and school health needs continue to evolve. The school nurse is a member of a unique professional nursing specialty and is often the sole healthcare expert in an academic setting. The Framework for 21st Century School Nursing Practice TM is student-centered, occurring within the context of the student’s family and school community (NASN, 2016; NASN, 2018b). School nurses also work in complex environments that span multiple sectors including health and education. They focus on population health and individual care.

In addition to the complexity of their role and settings for school nurses, the oversight for quality benchmarks is most often the purview of local education agencies (LEA) whose quality metrics are focused on educational outcomes, and whose administrators have varying levels of experience with the metrics of quality healthcare services. In most healthcare systems, analysis of quality is driven by Donabedian’s Structure / Process / Outcomes (Donabedian, 2005 (reprinted from 1966); Wolfe et al., 2019). Traditional healthcare systems have these quality measures reinforced through evaluation by national bodies such as the Joint Commission or designation of Magnet status (ANCC, n.d.; Joint Commission, n.d.). The absence of similar quality oversight in school health services has resulted in wide variations in standards that assure quality systems (e.g., access to a nurse administrator, data management systems such as electronic documentation systems, nurse governance, new nurse induction programs, and data metrics for quality performance) (ANCC, n.d.; Willgerodt et al., 2019; Willgerodt & Johnson, 2020). These variations can also influence the current status of school health services.

Being aware of current and evolving trends in healthcare and practice requires school nurses to be deliberate and intentional about keeping abreast of change in the local and national health and education arena. The following section identifies issues that are impacted by the school health environment.

They are divided into structural, societal, student and nurse factors:

· Chronic underfunding of public health (Trust for America’s Health [TFAH], 2019) leaving schools and school health services to fill the gaps in health promotion, prevention, and protection

· Includes underfunding for disaster responses including pandemics, natural and man-made disasters, mitigation, testing, contact tracing, and vaccination

· Inequitable funding of education system and infrastructure (Education Data Initiative, 2021a)

· Crumbling infrastructure of the nation’s school buildings (ASCE, 2021b)

· Persistent lack of holistic, child-centered systems of care (Willgerodt & Johnson, 2020).

· Inconsistent processes for analysis and dissemination of effective school health innovations

· Development of benchmarks for school health delivery systems that create stable, predictable, and equitable structures for school nursing work (e.g., lack of structures that may be available in other settings, Magnet Status in healthcare institutions) (ANCC, n.d.; Joint Commission, n.d.)

· Use of Big Data from school nursing documentation to understand population health (Delaney et al., 2017; Johnson, 2019)

· Collecting national data for or about school nursing practices, student health services, and school infrastructure to measure the relevance and impact of school nursing on student health and well-being (school nurse sensitive student outcomes) (Johnson, 2017b; Johnson, 2019; Maughan et al., 2020).

· Integration of telehealth and hybrid learning settings due to pandemics or expanded mental and physical health needs of students and staff.

· Standardized entry into school nursing

· Development of a school nurse induction model for mentoring new practitioners.

· Development of programs for school nurse leadership skills from the local to national level.

· Integration and evaluation of emerging technologies, such as social media, electronic health records (EHRs), electronic monitoring, and telehealth, and their effects on collaboration, communication, and ethics (NASN, 2017c; 2019a)

· Incorporation of precepting pre-licensure nursing students to increase awareness of school nursing as a career

· Research funding opportunities that place community-based participatory methods on par with other research methodologies

· Racism as a public health emergency (NASN, 2020a; NASSNC, 2020a; Walensky, 2021)

· Increasing recognition of the harmful effects of structural impediments to health and education equity

· Rising impact of social justice issues on student, family and community well-being

· Addressing the impact of social media on the health literacy of students and their families’ access to appropriate health information and the rise of misinformation.

· Growth in frequency of infectious diseases, natural, environmental, and man-made disasters bring a need to address the capacity for surveillance, emergency response, mitigation, and recovery planning.

· Includes epidemics (H1N1, 2011), and pandemics (COVID-19); natural and environmental disasters (lead in drinking water, flooding, wildfires) and human migration (refugees, political or economic and social violence).

· Increasing focus by the health profession on public health and individual human health threats and inequities caused by climate change and the need for an accelerated response to mitigate and adapt to these threats (Watts et al., 2021).

· Increasing number of students with special health needs, e.g., allergies, infant surviving neonatal intensive care, survival to preschool and entrance to kindergarten; those with severe health conditions, cancer, and early hospital discharge with remaining complex care needs due to inequalities in healthcare (Perrin, et al., 2014).

· Increasing complexity of children’s health problems, in part due to positive and negative influences, such as advances in technology and adverse environmental factors (Johnson, 2017a; Perrin et al., 2014)

· Personalized health care driven by genomics (Seyhan & Carini, 2019)

· Families’ needs for support in managing increasingly complex health needs and concerns.

· Increasing incidence of violence, bullying, drug and substance abuse, teenage pregnancy

· Expansion of free Pre-K education thereby increasing the need for nursing support.

· Rising numbers of students who are homeless.

· Increasing use of data from high tech wearables such as continuous glucose monitors, fitness watches, phone apps. (Abroms et al., 2019; Capobianco, 2019)

· Advanced interventions, such as service animals for students with disabilities.

· Development of evidence and advocacy for inclusion of school nursing in ad hoc federal and state funding efforts (e.g., Every Student Succeeds Act).

· Funding models that promote competitive school nurse salaries, and recognize the cost savings to society that school nursing services provide (NASEM, 2021; NASN, 2018a)

· Widening disparity between school nurse salaries and nurse salaries in other sectors.

· Eliminating pay inequities for school nurses.

· Reimbursement for health services in school on a par with services reimbursed in other health care environmnts, (NASN, 2018a).

· The need for evidence on the disparities between school nurse workloads resources and acuity of student and community needs.

· Development of evidence-based staffing/service models to meet the needs of the school population.

· Increasing recognition of the school nursing role in population health, such as illness prevention, wellness/health promotion, mental/behavioral health, concussion training, and increasing care coordination resulting from expansion of health benefits for children from the Affordable Care Act.

· Prominent role of SN recognized by the 2021 Future of Nursing Report (NASEM, 2021)

· Multi-source feedback (i.e., 360 degree) reviews of school nurse leaders (Center for Creative Leadership [CCL], 2020)

School nurses continue to adapt their practices to an ever-changing world. Challenges continue to present themselves, as do improved tools to assist the school nurse in meeting these challenges. As technology advances, so does the school nurse’s practice. More students with more complex daily health needs, as well as those requiring intermittent, on-site nursing interventions, are in schools across America and in Department of Defense Education Activity (DoDEA) schools here and abroad. Technology is available not only as a classroom tool and for expanded school health record keeping, but also to allow students with health impairments greater access to the education and socialization they are entitled to receive. The tenets of the Whole School, Whole Community, Whole Child (WSCC) model call for greater alignment, integration, and collaboration between education and health to improve each child’s cognitive, physical, social, and emotional development for successful learning outcomes and wellness. The future of school nursing rests on the ability of the school nurse to successfully meet the challenges in the health and education communities.

Professional nursing and nursing specialty organizations have a responsibility to their members and to the public they serve to develop standards of practice. As the professional organization for all registered nurses, the ANA has assumed the responsibility for developing standards that apply to the practice of all registered nurses and serve as a template for the development of school nursing standards as specialty standards. The ANA has long recognized, “the need to develop consistent, standardized processes for recognizing specialty areas of nursing practice, approving specialty nursing scope of practice statements and acknowledging specialty nursing standards of practice” (ANA, 2021b, p. 6). It defines specialty nursing organizations as “the custodians and stewards of the respective specialty nursing scope and standards of practice” (ANA, 2021b, p. 7), and recognizes the National Association of School Nurses (NASN) as an “established specialty” based on “historical roots… recognized presence… a clearly defined scope and standards of practice” (ANA, 2021a, p. 8) The ANA recognizes that “…specialty nursing organizations also created specialty practice standards and guidelines to describe a distinct focus of practice” (ANA, 2021a, p. 6). Hence, as a specialty organization representing school nurses, NASN has developed and promoted the scope and standards of school nursing practice since 1983.

Throughout the early and mid-20th century, many school nurses and professional nursing groups attempted to define school nursing and articulate roles and functions, essential to the development of standards. Others outside of nursing also weighed in. For example, a joint committee of the National Education Association and the American Medical Association authored a paper titled,
The Nurse in the School, that defined and established a role for nursing in schools (Joint Committee of the National Education Association and the American Medical Association, 1941).

By 1960, no fewer than five groups were speaking for school nursing: the School Nurses Branch, Public Health Nursing Section of the ANA; the Committee on School Nursing Policies and Practices of the American School Health Association; Public Health Nurses Section of the America Public Health Association; National Council for School Nurses of the American Association for Health, Physical Education and Recreation; and the Department of School Nurses of the National Education Association (NEA), representing the majority of school nurses. These groups authored significant papers on the role and function of school nursing. By 1970, the Department of School Nurses of the NEA, later to become the National Association of School Nurses (NASN), had grown in influence among school nurses and published a role and function paper of its own (National Education Association: Department of School Nurses [NEA], 1970). In 1981, 13 members of the National Association of State School Nurses joined 10 others to develop the Standards of Practice for School Nurses (Burt, n.d., p. 1).

In 1983, after eight decades of describing and refining the role of the school nurse, the first national standards of practice were developed. Several organizations, all interested in school nursing, came together under the leadership and direction of the NASN to produce a set of standards modeled on a template laid down by the ANA (ANA, 1983). The current 2022 document,
School Nursing: Scope and Standards of Practice, Fourth Edition, is the latest set of published school nursing standards using an ANA-stipulated format and describing a competent level of nursing practice and professional performance common to and expected of all school nurses. A timeline of the development of school nursing standards is presented in Appendix C.

The Standards of School Nursing Practice accompany the Scope of School Nursing Practice. The Standards of School Nursing Practice are authoritative statements of the duties that school nurses, regardless of role, are expected to perform competently (adapted from ANA, 2021b, p. 4). The standards published herein serve as evidence of the standard of care, with the understanding that with the wide range of roles and functions of a school nurse, application of the standards are dependent upon individual job description and practice setting (McDaniel et al., 2013).

The dynamics of the school nursing specialty require standards to be periodically updated and revised. As expectations for the academic success and lifelong achievement of students evolve, and changes in societal trends occur, school nursing, the education community, and the public will develop and accept new patterns of professional practice. In response, nursing standards must have “formal, periodic review and revision” (ANA, 2021b, p. 4). The National Association of School Nurses (NASN) assumes this responsibility for the specialty of school nursing and completed the review and revision of
School Nursing: Scope and Standards of Practice, 3rd edition [2017] (Appendix D).

This fourth edition includes 18 standards statements that serve school nurses and school communities as a context for outlining an expansive scope of practice. The language is intentionally broad and serves to paint an overall picture of practice. The standards statements, upon further development and explication, become more effective as a comprehensive and refined listing of expectations essential to practice. Furthermore, “the roles and activities in which the school nurse engages, particularly as the nurse uses the nursing process, may be state and/or district specific, and the uniqueness of a given position cannot be fully understood, comprehended, or appreciated with the standards statements by themselves. “Standards statements, therefore, optimally serve nursing practice or the recipients of nursing care when further tailored to the specifics of the focus or setting” (Resha, 2019, p. 14).

Each standard’s statement is accompanied by several basic competencies. The competency statements in turn may be further specified as befits the practice setting. The competencies described for the generalist school nurse are applicable to all school nurses. Additional competencies may have been identified for the graduate-level prepared school nurse and for the Advanced Practice Registered Nurse. Competencies are specific, measurable elements that interpret, explain, and facilitate practical use of a standard. The competencies may be evidence of compliance with the individual standard but are not exhaustive and depend on the circumstances. Southall Wright and Campbell (NASN, 2017b) demonstrate how school nursing competencies associated with the Standards, guide the evaluation of school nurse performance by providing evidence of activities that demonstrate compliance. Competencies may be used by school nursing professionals to appraise professional performance and to provide a clearer understanding of the role of the school nurse to school administrators, faculty, staff, student families, and the entire school community (Davis et al., 2019). School nurses can use the standards to identify opportunities for development and improvement of their practice through self-evaluation.

The
Standards of School Nursing Practice consist of Standards of Practice and Standards of Professional Performance. The standards of practice are the six steps of the nursing process which direct the practice of the school nurse. Similarly, the standards of professional performance describe how the school nurse implements the standards of practice and conducts practice. Together, the Standards of Practice and the Standards of Professional Performance provide authoritative statements describing evidence of competent school nursing performance. Competence is dependent on context and other factors which are described on p. 21.

Figure 1

Scope and Standards of School Nursing Practice Model

The Standards of Practice for School Nursing describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. These standards encompass all significant actions taken by school nurses and form the “foundation” of the school nurse’s “decision-making” (ANA, 2021b, p. 4). The Standards of Practice Model (above) demonstrates that the six elements are not linear, but multidirectional and iterative as the school nurse uses and reuses the nursing process in practice.

· Standard 1: Assessment

· Standard 2: Diagnosis

· Standard 3: Outcomes Identification

· Standard 4: Planning

· Standard 5: Implementation

· Standard 5A: Coordination of Care

· Standard 5B: Health Teaching and Health Promotion

· Standard 6: Evaluation

Standards of Professional Performance for School Nursing

The Standards of Professional Performance for School Nursing describe a competent level of behavior in the professional role. All school nurses are expected to actively engage in professional role activities appropriate to their education, experience and position. School nurses are accountable for their professional actions to themselves, their students, families, and school communities, the profession, and, ultimately, to society (adapted from ANA, 2015b, p. 5).

· Standard 7: Ethics

· Standard 8: Advocacy

· Standard 9: Respectful and Equitable Practice

· Standard 10: Communication

· Standard 11: Collaboration

· Standard 12: Leadership

· Standard 13: Education

· Standard 14: Scholarly Inquiry

· Standard 15: Quality of Practice

· Standard 16: Professional Practice Evaluation

· Standard 17: Resource Stewardship

· Standard 18: Environmental Health

The Standards of School Nursing Practice are authoritative statements of the duties that all school nurses are expected to perform competently. The standards published herein may be utilized as evidence of the standard of care, with the understanding that application of the standards is context dependent. The standards are subject to change with the dynamics of the nursing profession and school nursing, as new patterns of professional practice are developed and accepted by the nursing profession, the school nursing community, and the public. In addition, specific conditions and clinical circumstances may also affect the application of the standards at a given time, e.g., during a natural disaster, a school lockdown or other crisis, or workload issue. The standards are subject to formal, periodic review and revision.

The competencies that accompany each standard may be evidence of compliance with the corresponding standard. The list of competencies is not exhaustive. Whether a particular standard or competency applies depends upon the circumstances. The competencies related to each of the standards identify the minimum measurable level of nursing performance of all school nurses. Experienced generalist school nurses, however, may perform competencies consistent with advanced education. Graduate-level prepared school nurses (master’s or doctoral level such as Ph.D., Ed.D., D.N.Sc., D.N.P.) focus on populations, systems, complexity of issues, and growth of the specialty, so additional competencies are listed for those school nurses.

Standard 1. Assessment

The school nurse collects pertinent data and information relative to the student, family, group, school community, or population.

Competencies

The school nurse:

1.1 Recognizes the impact of one’s own personal attitudes, values, and beliefs on the assessment process.

1.2 Creates the safest environment possible for conducting assessments.

1.3 Uses evidence-based assessment techniques, instruments, tools, available data, information, and knowledge relevant to the situation to identify patterns and variances in student’s health.

1.4 Conducts a whole child assessment related to health, education, and quality of life in an interprofessional, systematic, ongoing manner.

1.5 Recognizes the student and their parent/guardian as the decision-makers regarding their own health. 

1.6 Identifies barriers to effective written, verbal, and nonverbal communication based on personal, cognitive, physiological, ethnic, cultural, psychosocial, literacy, environmental and financial considerations.

1.7 Integrates evidence-based knowledge from current local, national, and global health initiatives and environmental factors into the assessment process. 

1.8 Prioritizes data collection based on the student’s acute health needs or the anticipated health needs of the student or situation. 

1.9 Adheres to ethical, federal, state, and district laws, guidelines and policies in the collection, maintenance, use, and dissemination of data.

1.10 Synthesizes data analysis results to enable interpretation of findings and formulation of conclusions about the student’s health status, health outcomes, disparities and health conditions of the school community. 

1.11 Validates the analysis with the student/parent/guardian and interprofessional team. 

1.12 Documents data accurately and, in accordance with federal, state, and district privacy regulations, in a manner accessible to the interprofessional team. 

1.13 Uses national and regional standardized data sets and systems whenever possible.

1.14 Attains knowledge regarding emerging technologies that may impact the assessment process (e.g. telehealth, artificial intelligence). 

1.15 Participates in school community assessment using principles of community engagement, nursing, social ecology and a systems perspective. 

Additional competencies for the graduate-level prepared school nurse 

In addition to the school nurse competencies, the graduate-level prepared school nurse:

1.16A Assesses the effect of interactions among the student, family, community, and social systems on health and illness on a systems level. 

1.17A Synthesizes aggregate data from multiple sources leading to clinical understanding on a systems level. 

1.18A Partners with populations in need, as well as with relevant health professionals, school colleagues, and other stakeholders to attach meaning to population-focused data

1.19A Conducts the school community assessment using principles of community engagement, nursing, social ecology and a systems perspective.

1.20A Assess the readiness for change in the school and community.

1.21A Mentors colleagues in the use of data collection processes

1.22A Identifies gaps, redundancies, and other limitations in systems level assessment data. 

1.23A Designs assessment data collection processes using information technology resources.

1.24A Engages community members, partners, health professionals, and other stakeholders to attach shared meaning to collected data.

Standard 2. Diagnosis

The school nurse analyzes assessment data of the student, family, group, school community, or population to describe actual or potential diagnoses
.

Competencies

The school nurse:

2.1 Identifies system-level gaps, and actual or potential risks or barriers to health and safety including interpersonal, systemic, cultural, or environmental circumstances.

2.2 Identifies the student and family’s strengths and abilities, including support systems, health literacy, and engagement in self-care.

2.4 Uses assessment data, standardized classification systems, and technology to articulate actual or potential diagnoses.

2.5 Verifies the diagnoses with the student, family, community, population, and interprofessional colleagues.

2.6 Prioritizes diagnoses based on mutually established goals to meet the needs of the student across the health–illness continuum. 

2.7 Documents diagnoses in a manner that facilitates the determination of the expected outcomes and plan.

2.8 Interprets both the nursing and interprofessional diagnoses to the student, family, and appropriate school staff.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

2.9A Uses information technologies to analyze diagnostic practice patterns of school nurses to inform population or community diagnoses.

2.10A Identifies systems level gaps in federal, state, and district laws, guidelines and policies.  

2.11A Employs aggregate-level data
to articulate diagnoses and unmet needs of the student, family, group, school community, or population.

2.12A Formulate community or population diagnoses based on the community’s strengths and assets, including support systems, health literacy, and access to care to address unmet needs.

Standard 3. Outcomes Identification

The school nurse articulates measurable expected outcomes for a plan individualized to the student, family, group, school community, or population.

Competencies

The school nurse:

3.1 Engages the student, family, stakeholders, and interprofessional team in partnership to develop expected goals and outcomes that are specific, measurable, attainable, realistic, time limited, inclusive, and equitable (S.M.A.R.T.I.E.)

3.2 Formulates holistic, expected outcomes derived from assessments and diagnoses that reflect the student and family’s culture, values, and ethical concerns.

3.3 Integrates evidence and best practices to identify expected outcomes taking into account risk reduction strategies, benefits, costs, and clinical effectiveness.

3.4 Modifies expected student outcomes based on changes in health/wellness status.

3.5 Develops expected S.M.A.R.T.I.E. goals and outcomes for population interventions in partnership with stakeholders.    

3.6 Seeks new scientific evidence and best practices to achieve expected outcomes.

3.7 Documents expected outcomes.

Additional competencies for the graduate-level prepared school nurse,

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

3.16A Takes an active role in educating others on trends and student outcomes to guide district planning for future school health programs. 

3.13A Synthesizes cost/benefits data, clinical effectiveness and evidence to promote better outcomes.

3A.12 Analyzes school nurse sensitive student outcomes to inform school nursing practice.

3.15A Acts as a resource for the school community in the development of population-based health and education outcomes.

3.17A Identifies systems level quality outcome measures in relation to expected outcomes, safety, and quality standards.

Standard 4. Planning

The school nurse develops a course of action that prescribes strategies to attain expected, measurable outcomes that address the student, family, group, school community, or population.

Competencies

The school nurse:

4.1 Develops an individualized, holistic, evidence-based plan in partnership with the student and their interprofessional team.

4.2 Integrates primary preventive care into planning including collaborations with the medical and/or dental home. 

4.3 Develops a plan to address the needs of the school community and student populations. 

4.4 Prioritizes plan elements based on the assessment of the student’s level of risk, safety needs, assets (or strengths), and social determinants of health.

4.5 Designs the plan to include responsible and appropriate use of health and medical interventions to maximize student health and independence in the least restrictive environment. 

4.6 Includes innovative nursing practices in the plan.

4.7 Designs the plan to address each of the identified diagnoses.  

4.8 Creates an implementation pathway that describes timeline, steps, and expected outcomes. 

4.9 Develops a plan that reflects compliance with current statutes, rules and regulations, and standards.

4.10 Modifies the plan according to the ongoing assessment of the student’s response,
and other outcome indicators such as health behavior change theory, and new knowledge.

4.11 Documents the plan using standardized language or recognized terminology.

4.12 Partners with community members, health professionals, and stakeholders, to prioritize assessment findings, diagnoses, and expected outcomes to support the development of population-based plans. 

4.13 Participates in development of the emergency operation/disaster plans.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

4.14A.  Designs strategies and plans to meet systemic, multifaceted, and complex needs of students, the school, and the community.

4.15A Leads the development of plans that include the interprofessional team to address gaps in relevant systems of care. 

4.16A Actively participates in the development and continuous improvement of systems that support the planning process.

4.17A Integrates the evaluation plan as an integral part of the program planning.

4.18A Uses systems-level methods, planning models, epidemiology to analyze the determinants of health when developing and tailoring population-level interventions.

4.19A Modifies program plans through ongoing assessment of population outcomes. 

4.20A Analyzes determinants of health data and information to guide program planning that is culturally sensitive and understandable for the communities of interest.

4.21A Uses program planning skills and community-based participatory research (i.e., collaboration, reflection, capacity building) to engage marginalized/disadvantaged populations in making decisions that affect their health and well-being.

Standard 5. Implementation

The school nurse executes an agreed upon plan/intervention for student, family, group, school community, or population.

Competencies

The school nurse:

5.1 Translates evidence and clinical practice guidelines into practice for safe, quality health care, and student, family, and school community satisfaction.

5.2 Partners with the student, family, or community to implement the plan in a safe, effective, efficient, timely, student-centered, and equitable manner.

5.3 Integrates interprofessional collaboration and communication in the implementation of the plan.

5.4 Develops professional therapeutic relationships with students promoting developmentally appropriate independence. 

5.5 Provides culturally sensitive inclusive, holistic care that focuses on the student and school community and addresses and advocates for the needs of diverse populations.

5.6 Uses evidence-based interventions and strategies to achieve the mutually identified student-centered goals and outcomes specific to the problem or needs.

5.7 Integrates critical thinking and technology solutions to implement the plan.

5.8 Delegates according to the health, safety, and welfare of the student and considering the circumstance, person, task, direction or communication, supervision, evaluation, as well as the state nurse practice act regulations, institution, and regulatory entities while maintaining accountability for the care.

5.9 Documents implementation and modifications of the plan.

5.10 Integrates traditional, alternative, and complementary healthcare practices as appropriate.

5.11 Provides prescribed interventions, including medication administration, treatments, counseling, and crisis intervention for students. 

5.12 Utilizes systems, organizations, school, and community resources to implement the plan.

5.13    Coordinates implementation of the emergency operation/disaster plan.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

5.14A Applies quality principles, while articulating methods, tools, performance measures, and standards as they relate to implementation of the plan.

5.15A Serves as a consultant to provide additional insight and potential solutions to complex situations.

5.16A Uses implementation science to effect organizational or system change.

5.17A Leads in the continuous improvement of organizational systems that support the implementation of the plan.

5.18A Participates in the development and implementation of written policies and procedures for the clinical services, healthy school environment and programs addressing school health and wellbeing.

5.19A Mentors and collaborates with other school nurses on appropriate implementation of plans. 

5.20A Identifies innovations in nursing care delivery to improve student health and learning outcomes.

Standard 5A. Coordination of Care

The school nurse aligns care for student, family, group, school community, or population.

Competencies

The school nurse:

5A.1. Coordinates creation and implementation of plan(s).

5A.2 Provides care coordination among all members of the student’s interprofessional education and health care team including parents/guardians. 

5A.3 Manages a student’s care and promotes developmentally appropriate independence to reach mutually agreed upon student-centered outcomes.

5A.4 Facilitates student’s access to care.

5A.5 Communicates with the student, family, stakeholders, interprofessional team, and community-based resources to effect safe transitions in continuity of care
.

5A.6 Establishes the expectation of dignified, culturally congruent, developmentally appropriate, student centered, and holistic care by the interprofessional team.

5A.7 Documents the coordination of care.

5A.8 Incorporates the individualized healthcare plan into the student’s educational day and school-sponsored activities.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

5A.9A Manages identified populations with specific care needs.

5A.10A Coordinates education and healthcare systems and community resources that enhance delivery of care across settings and situations.

5A.11A Synthesizes data and information to identify gaps in services and to support and provide necessary system and community interventions, including modifications of school environments.

Standard 5B. Health Teaching and Health Promotion

The school nurse employs strategies to improve the health and safety of students, family, group, school community, or population. 

Competencies

The school nurse:

5B.1 Provides opportunities for the student and school community to identify needed health literacy, health promotion, disease prevention, and self-management topics.

5B.2 Engages health promotion/health teaching considering the student and school communities’ values, beliefs, health practices, developmental level, learning needs, readiness to learn, language preference, spirituality, culture, and socioeconomic status.

5B.3 Uses evidence-based learning principles to communicate health promotion and disease prevention information to the student and school community.

5B.4 Engages consumer alliance and advocacy groups in health teaching and health promotion activities for students and the school community.

5B.5 Provides anticipatory guidance to students and families to promote health and prevent or reduce the risk of negative health outcomes.

5B.6 Collaborates with other school health professionals to provide appropriate and timely health promotion and health education to the student, family and school community.

5B.7 Promotes health principles through the Framework for 21st Century School Nursing Practice and the Whole School, Whole Community, Whole Child model for students and the school community.

5B.8 Evaluates health information resources within the area of practice for accuracy, readability, and comprehensibility to help the school community access quality health information.

5B.9 Serves as a primary resource to the school community regarding health information and wellness.

5B.10 Conducts personalized health teaching and counseling considering evidence-based learning principles.

5B.11 Participates in the evaluation of health curricula and other health instructional materials and activities.

5B.12 Works in partnership with faculty, librarians, and community partners to integrate health literacy, health promotion and illness and injury prevention into cross-curricular content.  

Additional competencies for the graduate-level prepared school nurse
:

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

5B.13A Assess alignment of health education curricula within the context of national health education standards.

5B.14A Identifies health education and health promotion focus based on local, state, or national data sets.

5B.15A Designs health education information and programs for school community education appropriate to age, developmental level, learning needs, readiness to learn, and cultural values and beliefs of the target audience.

5B.16A Evaluate effectiveness of health promotion programing using health education curriculum analysis tools.

Standard 6. Evaluation

The school nurse systematically and continuously appraises progress toward attainment of student and school population goals and outcomes.

Competencies

The school nurse

6.1 Utilizes applicable standards and defined criteria in the evaluation process (e.g. Quadruple Aim).

6.2 Determines, in partnership with the student, family and other stakeholders, the safety, timeliness, effectiveness, efficiency, equitability, and patient-centeredness (STEEEP) of the strategies in relation to the responses to the plan and attainment of outcomes.  

6.3 Collects data to conduct holistic, systematic, ongoing, and evidence-based evaluation of the goals and outcomes to revise the diagnosis, outcomes, plan, implementation, and evaluation strategies as needed. 

6.4 Conducts process evaluation of evidence-based interventions to determine fidelity and application within the school setting (e.g. Seizure Guidelines, Open Airways for Schools, peak flow meters). 

6.5 Documents the results of the evaluation, including recommendations for improvement of the plan as identified by the school nurse, student(s), family(ies), education and community partners.

6.6 Shares evaluation data and conclusions with the student, family and other stakeholders in a timely, clear and transparent manner in accordance with federal, state, and local regulations.

6.7 Analyzes feedback and evaluations from the student, parents, staff, school community members to determine the effectiveness of the employed strategies

6.8 Uses results of the evaluation to recommend process, policy, procedure, or protocol revisions.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

6.9A Uses a variety of quantitative and qualitative data collection strategies to measure the process and outcomes of programs 

6.10A Leads school nurses in evaluation of structure, process and outcomes of the student and program plans.

6.11A Synthesizes evaluation data from the student, family, community, population and/or institution to determine the effectiveness of the plan.

6.12A Analyzes program evaluation data using appropriate statistical methods.

6.13 A Engages in a systematic process to revise the plan to improve program effectiveness and inform decisions about future programming.

6.14 A Leads process, policy, procedure, or protocol adjustments that support student health and learning. 

Standards of Professional Performance

Standard 7. Ethics

The school nurse integrates moral principles in all aspects of practice
.

Competencies

The school nurse:

7.1 Integrates the
Code of Ethics for Nurses with Interpretive Statements and the
Code of Ethics for the School Nurse to guide nursing practice and articulate the moral foundation of school nursing.

7.2 Demonstrates commitment to self-reflection, self-care, and ethical competence through continued personal and professional development.

7.3 Integrates caring, kindness, social justice, and respect for the inherent autonomy, dignity, worth, and unique attributes of all people into nursing practice and policy.

7.4 Promotes student and family engagement in informed decision-making and self- determination.

7.5 Utilizes ethics guidance or resources in situations where the rights of the student and parent conflict with evidence-based practice.

7.6 Demonstrates their primary commitment is to the student regardless of setting, situation, or institutional policy.

7.7 Maintains therapeutic relationships and professional boundaries.

7.8 Safeguards the privacy and confidentiality of students, their data and information within ethical, legal, and regulatory parameters (i.e., Family Educational Rights & Privacy Act [FERPA] and Health Insurance Portability and Accountability Act [HIPAA]).

7.9 Contributes to the establishment and maintenance of an ethical environment that is conducive to safe, quality health care in the educational setting.

7.10 Collaborates with other health professionals and the public to protect human rights, promote health diplomacy, enhance cultural sensitivity and congruence, and reduce health disparities.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

7.11A Acts as an educational resource by providing leadership in ethical competence, ethical decision-making to address emerging and recurrent ethical issues. 

7.12A Engages stakeholders in the establishment and operation of an ethics committee for the school district.

7.13A Creates a safe culture for interprofessional teams to address ethical risks, benefits, and outcomes.

7.14A Represents the profession as a subject matter expert, advisor, or consultant, locally, statewide, regionally, nationally, and internationally.

Standard 8. Advocacy

The school nurse champions the voice of the student, family, and community to promote student health, safety, education and rights.  

Competencies

The school nurse:

8.1 Advocates for the rights, health, and safety of the student and school community.

8.2 Promotes removal of individual barriers and pervasive systemic inequities to optimize well-being, health, and educational achievement.

8.3 Advocates for adequate school nurse staffing models to improve student, school, and community health. 

8.4 Promotes safe and evidence-based care of students, positive school environments, and sufficient allocation of culturally appropriate resources to optimize health and educational outcomes.

8.5 Empowers all members of the school team to include the student and family in care decisions.

8.6 Promotes self-advocacy by students, families, communities, and populations.

8.7 Participates in healthcare initiatives on behalf of the student, family, school, and community.
 

8.8 Informs the political arena about the complex and holistic needs of the student, the role of the school nurse, and the vital components of optimal healthcare delivery in schools. 

8.9 Embraces diversity, equity, inclusivity, health promotion, and healthcare for students and families of varied geographic, cultural, ethnic, racial, gender, and spiritual backgrounds.

8.10 Leverages the ANA and the NASN Code of Ethics to develop policies, programs, and services to improve educational and health care delivery and access for underserved and vulnerable populations.

8.11 Promotes policies, regulations, and legislation at the school, local, state, and national level to improve healthcare access, equity, and delivery of health care.

8.12 Advances policies, programs, and practices in the school and community that maintain, sustain, and restore the environment and natural world.

8.13 Incorporates societal, political, economic, and cultural factors to address social determinants of health.

8.14 Highlights the urgent need for a diverse and inclusive workforce as a strategy to improve outcomes related to the social determinants of health and inequities in the healthcare system. 

8.15 Models personal commitment to advocacy for students, the school nursing profession, the school community, and the public at large.

8.16 Contributes to professional organizations to collectively advance advocacy efforts.

Additional Competencies for the Graduate-Level Prepared School Nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

8.17A Champions mitigation of the impacts of geographic, societal, political, economic, and cultural factors on healthcare disparities.

8.18A Disseminates evidence of the impact of geographic, societal, political, economic, and cultural factors on healthcare disparities.

8.19A Informs policy makers (e.g., leaders, legislators, governmental agencies, nongovernmental organizations, and international bodies) of the impact of geographic, societal, political, economic, and cultural factors on healthcare disparities.

8.20A Engages
with groups aligned with student, school, and community advocacy goals.

8.21A Pursues adoption of policy, programs, and resources to enhance school health services and outcomes.

8.22A Mentors nurses on establishing effective partnerships and evidence based messaging.

8.23A Authors Op-Eds and policy briefs to advance advocacy goals for students, families, communities and the specialty.

8.24A Serves as an expert for schools, communities, and other stakeholders in promoting school health policies and services.  

Standard 9. Respectful and Equitable Practice 

The school nurse practices in a manner that is congruent with cultural diversity, equity, justice, and inclusion principles.

Competencies

The school nurse:

9.1 Inventories one’s own values, beliefs, cultural heritage and implicit biases via critical self-reflection to improve culturally congruent practice.

9.2 Identifies the cultural-specific meaning of interactions, terms, and content. 

9.3 Engages community partners to identify cultural norms and values.

9.4 Demonstrates respect, equity, justice, cultural humility, and empathy in actions and interactions with all students, families, and the school community.

9.5 Seeks to understand the effects and impact of discrimination and oppression within and among vulnerable cultural groups.

9.6 Respects student and family decisions based on age, tradition, belief and family influence, and stage of acculturation.

9.7 Communicates with appropriate language and behaviors, including the use of professional and competent adult interpreters and translators in accordance with the student’s and family’s healthcare preferences and state and local regulations.

9.8 Utilizes terminology and salutations, communication characteristics, and written material vetted for the culture, literacy, and language of the population served.

9.9 Engages students, families, key stakeholders, and others in designing and establishing internal and external cross-cultural partnerships.

9.10 Advocates for policies, procedures, programs, services, and practices that promote health, prevent harm, and improve equitable access to care for culturally diverse students and families. 

9.11 Advances equitable access to school health services, interventions, health promotion programs, enrollment in research, health and academic education, and other opportunities.

9.12 Promotes equity for students and families by educating nurse colleagues, other professionals, and community stakeholders about cultural similarities and differences of students and families in the school community.

9.13 Models safe, respectful, inclusive, accepting, just, and culturally congruent school nurse practice.

9.14 Collaborates to establish a culture of safety for vulnerable students or groups.

9.15 Documents student and family’s cultural practices, preferences, beliefs, language(s), as well as interventions and outcomes.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

9.16A Leads interprofessional teams to identify the cultural and language needs of students and families in the school community.

9.17A Evaluates tools, instruments, and services provided to culturally diverse school communities for safety, timeliness, efficiency, equity, inclusion and student centeredness.

9.18A Promotes the use of culturally appropriate tools and instruments. 

9.19A Develops, in partnership with representatives of cultural groups, programs for school nurses and their colleagues focused on reduction of disparities and improved equitable care.

9.20A Conducts or aids in research efforts to improve health care and healthcare outcomes for culturally diverse students.

9.21A Develops recruitment and retention strategies to achieve a multicultural workforce.

9.22A Evaluates hiring practices for school health services to eliminate bias in application, interview and vetting processes.

Standard 10. Communication

The school nurse effectively conveys information in all areas of practice.

Competencies

The school nurse:

10.1 Assesses the effectiveness of their own communication skills. 

10.2 Engages in continuous improvement of communication skill based on identified learning needs. 

10.3 Applies laws and regulations pertaining to privacy and confidentiality in all communications.

10.4 Uses communication styles and methods that demonstrate professionalism, caring, respect, empathy, cultural humility, sensitivity, active listening, authenticity, and trust.

10.5 Utilizes evidence-based health counseling techniques as effective communication strategies.

10.6 Incorporates appropriate alternative strategies to communicate effectively with those who have disabilities as well as visual, hearing, speech, language, or communication difficulties.

10.7 Conveys accurate information in appropriate formats that takes into account the communication ability, health literacy, resources, and preferences of students, families, stakeholders, and members of the interprofessional team.

10.8 Confirms that the recipient of the communication heard and understands the message.

10.9 Contributes the nursing perspective in interactions and discussions with students, families, stakeholders, and members of the interprofessional team.

10.10 Maintains communication with the interprofessional team and others to facilitate safe transitions and continuity in care delivery. 

10.11 Communicates to the appropriate authority concerns about care processes and decisions, potential or actual hazards, deviations from the standard of care, errors in care, or the practice environment.  

10.12 Communicates student and school community outcomes and the school health program to the community, administrators, and the school board and key stakeholders.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

10.13A Leads in creating and shaping environments that promote healthy, effective and ongoing communication.

10.14A Advances student, district, and community wide communication systems to meet student, family, nursing and administrative needs.

10.15A Establishes the system of communication and access to communication for the student, family and stakeholders, and members of the interprofessional team within the school community, including..

10.16A Evaluates the effectiveness of student, district, and community wide communication systems.

Standard 11. Collaboration

The school nurse works jointly with students, families, and key stakeholders in the conduct of nursing practice.

Competencies

The school nurse:

11.1 Explores the areas of expertise and contribution of self, other professionals, and key stakeholders.

11.2 Articulates the school nurse’s education, scope of practice, role and responsibilities within the team and community.

11.3 Adheres to standards and applicable codes of conduct that govern behavior among peers and colleagues to create a work environment that promotes cooperation, dignity, respect, inclusion, and trust.

11.4 Leverages the unique and complementary abilities of all members of the team to optimize attainment of desired outcomes.

11.5 Translates knowledge of community health systems and populations, as well as the synergy between families, schools and communities to enhance effective collaboration on population health issues.

11.6 Leads efforts to establish, improve, and sustain collaborative relationships to achieve safe, quality care for the school community that reflects values for justice, equity, diversity, and inclusion.

11.7 Partners with students, families, stakeholders, and members of the interprofessional team to create, implement, and evaluate a comprehensive plan for change that leads to positive outcomes and quality care. 

11.8 Facilitates partnerships between families, schools, communities and other agencies to support student health and education goals.  

11.9 Promotes engagement through consensus building and conflict management.

11.10 Uses effective group strategies to enhance team performance.

11.11 Develops health policies, procedures, and programs in collaboration with school administrators and other stakeholders.

11.12 Documents the outcomes and decisions of collaborative planning.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

11.13A Participates in interprofessional activities, including but not limited to education, consultation, management, technological development, or research to enhance outcomes.

11.14A Advances interprofessional plan-of-care documentation and communications, rationales for plan-of-care changes, and collaborative discussions to improve student outcomes.

11.15A Synthesizes clinical data, theoretical frameworks, and evidence when providing program consultation.

11.16A Develops health policies, procedures, and programs in collaboration with school administrators and other stakeholders.

Standard 12. Leadership

The school nurse leads within their professional practice setting and the profession.

Competencies

The school nurse:

12.1 Establishes a culture of respect, trust, dignity, and integrity.

12.2 Embraces evolution in practice and role performance to attain professional goals.

12.3 Uses evidence-based leadership strategies to promote effective relationships, influence others, and manage change to achieve quality outcomes and a culture of safety.

12.4 Adopts evidence-based conflict management strategies to facilitate critical conversations and diffuse tense situations among team members, students, parents, school staff, and community partners.

12.5 Directs the health services program within the school and community

12.6 Accepts authority, ownership, accountability and responsibility for the quality of school health services. 

12.7 Contributes to the evolution of the profession through participation in professional organizations.

12.8 Influences policy to promote health for students and school communities at the local, state and national and global level.

12.9 Serves in key roles in the school and work settings by participating on and leading committees, councils, and administrative teams.

12.10 Values people as the most precious asset in an organization.

12.11 Promotes recognition of school nursing accomplishments and the achievements of school nurse colleagues.

12.12 Demonstrates inclusiveness and recruits diverse school nurses.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

12.13A Facilitates innovation in school health delivery models.

12.14A Influences decision-making bodies to improve the professional practice environment and student, family and school community outcomes.

12.15A Provides direction to enhance the effectiveness of the interprofessional team.

12.16A Champions social justice initiatives to eradicate structural barriers to health and education equity in the school and greater community.

12.17A Promotes graduate level nursing and role development by interpreting its role for students, families, the school community and policy makers.

12.18A Models expert practice to interprofessional team members and the school community. 

12.19A Establishes protocols or guidelines to reflect evidence-based practice, to reflect accepted changes in care management or to address emerging problems.

12.20A Embraces leadership roles in professional nursing associations, interprofessional associations and in community and national health care organizations.

12.21A Promotes advancement of school health and of the specialty through publications and presentations.

12.22A Pursues appropriate funding sources for school district nursing and health services.

12.23A Serves as a mentor and resource to others on effective program management.

12.24A Initiates changes throughout the school healthcare delivery system, as appropriate, using the results of school health environmental needs assessments, analysis of evaluation data, and quality-of-care activities.

12.25A Demonstrates knowledge of existing school health programs and current health trends that may affect health care; the sources of funds for such programs; and local, state, and federal laws governing each.

12.26ASupervises school nurses and the healthcare team across the district, where applicable.

12.27A Leads public health efforts across the school community.

12.28A Implements effective strategies in collaboration with professional nursing organizations to exert influence with the legislative process at state and national levels related to student health issues and trends.

Standard 13. Education 

The school nurse seeks knowledge and competence that reflects current nursing practice and promotes innovative, anticipatory thinking. 

Competencies

The school nurse:

13.1 Commits to lifelong learning through critical thinking, self-reflection, and inquiry for personal growth and learning.

13.2 Identifies their own learning needs based on continual self-assessment and analysis of gaps based on nursing knowledge and the changing needs of the school population and the broader community. 

13.3 Acquires learning experiences to maintain and advance knowledge, skills and abilities relative to the school nurse role, the population of students, their families, the school community, and the status of local or global health.

13.4 Participates in continuing professional development activities related to school nursing, interprofessional knowledge bases, and professional topics.

13.5 Demonstrates application of education and knowledge via formal consultation and informal discussion to address issues in school nursing practice.

13.6 Shares new knowledge from educational findings, experiences, ideas and pertinent information relative to optimal healthcare delivery in an educational setting with peers. health and education colleagues.

13.7 Supports acculturation of school nurses new to their roles by role modeling, encouraging, and sharing pertinent information relative to optimal care delivery.

13.8 Facilitates an environment supportive of ongoing education of school nurses, nursing students, healthcare and interprofessional colleagues.

13.9 Maintains professional certification including national school nurse certification and required state credentials.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

13.10A Expands clinical knowledge, skills, abilities, and judgments for the enhancement of role performance and to increase knowledge of professional issues via investigation of current issues, trends, healthcare research findings and other evidence. 

13.11A Compares student, community, and population health needs with current healthcare research to plan, develop, design, implement and evaluate professional development and higher education programs at the local, state, and national levels.

13.12A Develops sustainable local, system-wide, or global programs and initiatives that facilitate professional role competence and growth.

13.13A Provides evidence-based educational opportunities for colleagues and others.

Standard 14. Scholarly Inquiry  

The school nurse integrates scholarship, evidence, and research findings into practice.

Competencies

The school nurse:

14.1 Articulates the value of research and its application relative to the practice of school nursing. 

14.2 Identifies questions in school nurse practice that may be resolved through research.

14.3 Participates in data collection such as surveys, pilot projects, and formal studies, including the school nursing national dataset.

14.4 Engages with the scientific literature that is foundational to school nursing practice.

14.5 Advocates for the ethical conduct of research and translational scholarship with particular attention to the protection of the student as a vulnerable research participant.

14.6 Investigates processes for team members to have continuous access to evidence-based practices and guidelines.

14.7 Shares peer-reviewed research findings with colleagues to integrate knowledge into school nursing practice.

14.8 Collaborates with researchers from outside the educational system.

14.9 Complies with institutional, district, state, and federal policies regarding the safe conduct of research. 

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

14.10A Uses current interprofessional healthcare research findings and other evidence to expand school nurse practice.

14.11A Connects theory and research to school nurse practice.

14.12A Encourages other nurses to develop research skills by participating in school health research activities on a local, state, national and global scale.

14.13A Performs rigorous critique of evidence derived from databases to generate meaningful evidence for school nursing practice.

14.14A Promotes a climate of collaborative research and clinical inquiry.

14.15A Disseminates evidence-based practice outcomes and research findings through activities such as presentations, publications, consultation, and journal clubs.

14.16A Contributes to school nursing and interprofessional knowledge through scientific inquiry to improve healthcare outcomes.

14.17A Develops evidence-based implementation strategies to accelerate the translation of evidence into practice (e.g. toolkits). 

14.18A Develops Clinical Practice Guidelines for school nursing practice.  

Standard 15. Quality of Practice         

The school nurse contributes to nursing practice excellence.

Competencies

The school nurse:

15.1 Engages in nursing practice that is safe, effective, efficient, equitable, timely, and student-centered.

15.2 Identifies barriers to and opportunities for improvement of healthcare safety, effectiveness, efficiency, equity, timeliness, and student centeredness.

15.3 Documents school nursing practice in a manner that supports quality and performance improvement initiatives across the interprofessional team.

15.4 Uses a systematic, ongoing process to monitor the quality of care, implement corrective actions, and evaluate the outcomes of corrective actions.

15.5 Collects structure, process, and outcomes data on school nursing practice and the practice of non-licensed school health staff.

15.6 Analyzes data to monitor the structure, processes and outcomes of school nursing practice and the practice of non-licensed school health staff.

15.7 Prioritizes quality initiatives based on importance, severity, timeliness, trends and readiness.

15.8 Develops specific, measurable, achievable, realistic, timely, inclusive, and equitable (S.M.A.R.T.I.E.) objectives.

15.9 Collaborates with interprofessional and stakeholder team members (administrators, teachers, staff, parents, or community members) in all stages of the quality improvement process.

15.10 Uses creativity and innovation to enhance school nursing care, school environment, and access to learning.

15.11 Provides regular and critical review and evaluation of policies, procedures, and guidelines to improve the quality of healthcare and delivery of school health services.

15.12 Engages in formal and informal peer review processes.

15.13 Contributes to annual performance evaluation by conducting a self-assessment of competencies and setting goals for improvement.

15.14 Achieves professional certification as a Nationally Certified School Nurse and required state credentials.

15.15 Adopts available technology appropriate to the work setting.

Additional competencies for the graduate-level prepared school nurse

In addition to the competencies for the school nurse, the graduate-level prepared school nurse:

15.16A Analyzes trends in healthcare quality data, including integrating the impact of cultural influences and factors.

15.17A Promotes a practice environment that supports evidence-based health care and school health services delivery.

15.18A Develops a quality improvement process to evaluate, and revise policies, procedures, and guidelines to improve healthcare quality.

15.19A Incorporates quality improvement processes and innovations such as the Plan, Do, Study, Act (PSDA) cycle. 

15.20A Uses data and information in system-level decision-making.

15.21A Uses change leadership skills to improve systems level outcomes.

15.22A Designs innovative studies, initiatives, and programs to improve health and education outcomes in diverse school communities.

15.23A Establishes benchmarks as a means to evaluate practice at the individual, departmental, or organizational level.

15.24A Achieves professional certifications beyond the National Certified School Nurse, e.g., Certified in Executive Nursing Practice, Certified Professional in Healthcare Quality, Nursing Informatics, and Lean Six Sigma.  

Standard 16. Professional Practice Evaluation

The school nurse appraises one’s own and others’ school nursing practice.

Competencies

The school nurse:

16.1 Engages in self-reflection and self-evaluation of nursing practice on a regular basis, identifying areas of strength as well as areas in which professional growth would be beneficial.

16.2 Adheres to professional practice guidance as specified in the
School Nursing: Scope and Standards of Practice, the
Code of Ethics for Nurses with Interpretive Statements, the NASN
Code of Ethics for School Nurses
and other defined criteria (e.g., Quality and Safety Education for Nurses [2020]). 

16.3 Ensures that nursing practice is consistent with regulatory requirements pertaining to licensure, relevant statutes, rules, and regulations.

16.4 Uses organizational policies and procedures to guide professional practice, including use of accepted tools in self-evaluation and peer evaluation.

16.5 Provides evidence for practice decisions and actions as part of the formal and informal evaluation processes.

16.6 Seeks formal and informal feedback regarding one’s own practice from students, families, peers, colleagues, supervisors, and others.

16.7 Provides peers and others with formal and informal constructive feedback regarding their practice or role performance.

16. 8 Acts to achieve learning needs and goals identified during the evaluation process.

16.9 Maintains a professional portfolio based on the school nursing standards of practice that provides evidence of individual competence and lifelong learning.

16.10 Prepares self-evaluation based on the school nursing standards of practice for annual performance appraisal

16.11Documents the evaluative process
, including strategies to enhance one’s own and others’ school nursing practice.

16.12 Participates in the formal performance evaluation of school health support personnel. 

Additional competencies for the graduate-level prepared school nurse, 

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

16.13A Disseminates best evaluation practices through activities such as presentations, publications, and consultations.

16.14A Evaluates professional practice data and benchmarks to enhance their own and other’s practice at the systems level.

16.15A Develops evidence-based evaluation standards and guidelines in school nursing which reflect school nursing scope and standards of practice.

16.16A Leads implementation and translation of evidence-based evaluation standards and guidelines into practice.

16.17A Participates in development of school nurse job descriptions that reflect the full scope and standards of practice.

16.18A Participates in development of school health support staff job descriptions that reflect their education and preparation.

Standard 17. Resource Stewardship        

The school nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and used judiciously.

Competencies

The school nurse:

17.1 Assesses student care needs and available resources to achieve desired outcomes.

17.2 Designs and articulates persuasive justifications for needed resources.

17.3 Assists in analyzing costs, risks, and benefits in decisions about care and delivery of school health services, including health promotion, health education, and maintaining a healthy and safe environment.

17.4 Assists the student, family and community in identifying and securing appropriate services to address needs across the healthcare continuum.

17.5 Delegates in accordance with applicable legal and policy parameters, such as state nurse practice acts, NASN
Principles of Practice for Delegation and the NCSBN
National Guidelines for Nursing Delegation
.

17.6 Identifies impact of resource allocation on the potential for harm, complexity of the situation, and desired outcomes.

17.7 Advocates for resources that support and enhance school nursing practice and delivery of school health services.

17.8 Integrates appropriate and available telehealth and mobile health technologies into practice.

17.9 Uses organizational and community resources to implement interprofessional plans and programs.

17.10 Confronts discriminatory healthcare practices and community and neighborhood inequities and the impact on resource allocation.

17.11 Synthesizes data on all aspects of resource utilization, including delegation and staff training.

17.12 Report data on all aspects of resource utilization, including delegation and staff training.

17.13 Contributes data to the budget analysis for basic annual school nursing service needs such as regular and substitute staffing, technology and software, general supplies, furnishings, health equipment procurement/maintenance/calibration, continuing education, current clinical reference publications, and materials. 

17.14 Participates in disaster planning, anticipating needed resources and supplies.

Additional competencies for the graduate-level prepared school nurse, 

In addition to the competencies of the registered nurse, the graduate-level prepared registered nurse:

17.15A Creates school health services budget that meets the care needs of the students in the school and across the district.

17.16A Identifies professional education needs in budgeting, strategic, and financial planning.

17.17A Identifies gaps in community services.

17.19A Supports alternative payment models for school nurses’ delivery of value- based based care that improves outcomes.

17.20A Advocates for school health services resource optimization by leveraging sustainable revenue streams (e.g., Early and Periodic Screening, Diagnostic, and Treatment, Medicaid, insurance, and health systems partnership funding). 

17.21A Procures school health funding resources through donations, grants, and contracts.

17.22A Designs solutions that utilize appropriate and available resources and personnel necessary to maintain quality care without added waste. 

17.23A Provides evaluation strategies that address cost effectiveness, cost benefit, and efficiency factors associated with school nursing practice.

17.24A Synergizes organizational and community resources to formulate and implement interprofessional collaborative plans to reduce redundant and uncoordinated resources.

17.25A Forecasts resource needs such as regular and substitute staffing, benefits, technology and software, general supplies, furnishings, continuing education, current clinical reference publications and materials, repairs and maintenance, and staff training.

Standard 18. Environmental Health  

The school nurse practices in a manner that advances environmental safety, justice, and health.

Competencies

The school nurse:

18.1 Recognizes the environment as a determinant of health that impacts student educational, health, and social equity.

18.2 Assesses the school and community to identify environmental determinants of health and the impact on holistic student health and education. 

18.3 Integrates evidence-based environmental health concepts into school nursing practice including upstream environmental health strategies to ensure safe, healthy, and ecologically sound schools and communities.

18.4 Collaborates with school and community partners to develop and implement strategies that promote safe, healthy, and ecologically sound workplace, school, and community environments.

18.5 Communicates information about environmental health risks, mitigation, and adaptation strategies to promote and protect student health and well-being (e.g., lead, radon, pests, climate change, ecological destabilization, and environmental injustice).

18.6 Addresses environmental health risks for students, populations, and communities through mitigation, advocacy, and education. 

18.7 Advocates for the safe, judicious, and appropriate use of products and environmentally safe disposal of waste in the workplace, school, and community.

18.8 Uses products or treatments consistent with evidence-based practice to reduce environmental threats and hazards.

18.9 Incorporates equipment and technologies to promote safe practice environments including personal protective equipment (PPE) and ventilation.

18.10 Incorporates identified environmental health learning needs in individual professional development plans.

Additional competencies for the graduate-level prepared school nurse.

In addition to the competencies of the school nurse, the graduate-level prepared school nurse:

18.11A Analyzes the influences and interaction of community-wide social, political, economic, and environmental conditions and the impact on student, community, and ecological health, particularly among vulnerable populations. 

18.12A Uses community assessment data in collaboration with students, families, school administrators, local and state agencies, and other stakeholders to develop policies, recommendations, and programs that address environmental health threats including climate change and ecological destabilization, to prevent hazards and promote and protect safe, healthy, and sustainable environments. 

18.13A Leads school nurses in implementing environmental health and justice principles in school nursing practice. 

18.14A Creates school, local, state, and national partnerships and collaborations that focus on the identification and prevention of exposure to environmental hazards and promotion of environmentally healthy, just, and sustainable schools and communities.

18.15A Contributes to research addressing the connections between the environmental conditions and student health status.

Ability. A characteristic of nursing competency that describes the capacity to act effectively. It requires listening, integrity, knowledge of one’s strengths and weaknesses, positive self-regard, emotional intelligence, and openness to feedback.

Accountability. To be answerable to oneself and others for one’s own choices, decisions and actions as measured against a standard such as that established by the
Code of Ethics for Nurses with Interpretive Statements (ANA, 2015a, Provision 4)

Acculturation. The acquisition of a first culture that is essential to survival. Acculturation is further defined as “cultural modification of an individual, group, or people by adapting to or borrowing traits from another culture” (Mirriam-Webster, 2021).

Advanced practice registered nurse (APRN). A subset of graduate-level prepared registered nurses who have completed an accredited graduate-level education program preparing the nurse for special licensure and practice for one of the four recognized APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), or certified nurse practitioner (CNP); has passed a national certification examination that measures the APRN role and population-focused competencies; maintains continued competence as evidenced by recertification; and is licensed to practice as an APRN, as applicable.

Advocacy. The act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy can be in support of persons (whether as an individual, group, population, or society) or for an issue, such as potable water or global health (ANA, 2015a, Provision 3).

Aggregate: a group of students or persons that share a commonality, e.g. grade, health condition, age

Assessment. A systematic, dynamic process by which the registered nurse collects and analyzes data through interaction with the [student] family, groups, communities, populations, healthcare providers, and interprofessional colleagues. Assessment may include, but not limited to, the following dimensions: physical, functional, psychosocial, emotional, cognitive, educational, spiritual, transpersonal, sexual, cultural, age-related, lifestyle, environmental, and economic (ANA, 2021b, p. 109)

Autonomy. The capacity of a nurse to determine own actions through independent choice, including demonstration of competence within the full scope of nursing practice.

Bias. Prejudice in favor of or against one thing, person, or group compared with another, usually in a way considered to be unfair.

Collaboration. A professional healthcare partnership grounded in a reciprocal and respectful recognition and acceptance of: each partner’s unique expertise, power, and sphere of influence and responsibilities; the commonality of goals; the mutual safeguarding of the legitimate interest of each party; and the advantages of such a relationship.

Compassionate presence. Loving, kindness, harmony, authentic presence; spiritual awareness, nonjudgmental listening and interacting, open to unknowns (Watson & Smith, 2002).

Competency. An expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment, based on established scientific knowledge and expectations for nursing practice. Competency statements are specific, measurable elements that interpret, explain, and facilitate practical use of the standard (ANA, 2014, p. 3).

Crisis management plan. Plan developed by multiple constituencies in preparation for a school wide or community disaster or crisis

Culture of health. A way of thinking, behaving, or working that puts well-being at the center of every life, decision, and policy.

Delegation. The assignment of the performance of a nursing activity to a non-nurse. The school nurse, after assessment of the non-nurse’s capabilities, makes a prudent decision regarding the advisability of delegation. Accountability remains with the registered nurse; state laws and regulations and school regulations must be followed; and standards of school nursing practice must be upheld. The registered nurse may decide against delegation for safety, regulatory, and legal issues; school staffing or student health status issues; or unlicensed assistive personnel (UAP) competence or ability.

Diagnosis. The second step of the nursing process in which the analysis of assessed data results in a clinical judgment expressed as a statement of the student’s response to actual or potential health needs or conditions. The diagnosis provides the basis for determining a plan to achieve expected outcomes.

Disease. A condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms (Mirriam-Webster, 2021)

Ecological – Of or relating to the environments of living things or to the relationships between living things and their environment​​. The environments and systems that students live in and interact with are central to their development (Bronfenbrenner, 2004).

Ecological Destabilization. Crises in the environment which interfere with survival

Electronic Health Record (EHR). A platform for digital health record documentation that provides real-time data. EHRs can contain health history, intervention data, IHPs, immunization records, allergies; support data informed decision-making; and improve healthcare staff efficiency (Healthit.gov, 2019).

Emergency Care (or Action) Plan (ECP or EAP), a child- specific guide for school staff to facilitate quick and appropriate response for an individual student emergency

Enculturation. The process by which an individual learns the traditional content of a culture and assimilates its practices and values (Mirriam-Webster, 2021)

Environmental Injustice. The environmental threats disproportionally affect marginalized individuals and communities.

Equity. The quality of being fair and impartial.

Ethical decision-making Determination of the right course of action via a deliberative process that reflects knowledge of ethical principles, theories, and professional codes.

Evaluation. The sixth and final step of the nursing process in which the nurse systematically and continuously appraises progress toward attainment of outcomes; measurable elements that interpret, explain, and facilitate practical use of the standard.

Evidence-based practice (EBP). A problem-solving approach to health care using healthcare provider expertise, the best scientific evidence, and the consumer’s values and preference to determine and guide the plan of care.

Expected outcomes. End results that are measurable, desirable, and observable, and translate into observable behaviors.

Family. The family of origin or significant others as identified by the student.

Fidelity. The actual nursing intervention implementation is faithful to the intended evidence based implementation. Erratic implementation makes it difficult to know what “version” of the intervention was implemented and, therefore, which version produced the outcomes (U.S. Department of Health and Human Services Centers for Disease Control and Prevention. Office of the Director, Offie of Strategy and innovation [CDC], 2011).

Formal learning. A means of integrating knowledge, skills, abilities, and judgment, which most often occurs in structured, academic, and professional development environments.

Graduate-level prepared school nurse. A nursing leader in school nursing and health, prepared at the masters or doctoral level, who possesses specialized knowledge and skills in school nursing, public health, organization and management, health education, health promotion, administration, or other areas of study necessary to promote the health and academic success of the student and professional school nursing practice.

Health. An experience that is often expressed along a continuum of wellness and illness, and may occur in the presence or absence of disease or injury.

Health care. The prevention, surveillance for, treatment, and management of illness; the preservation of mental and physical well-being; and the promotion of health through services offered by a healthcare provider or health professional.

Health Equity. “… every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment” (Centers for Disease Control and Prevention [CDC], 2020).

Healthcare consumer. The student, family, group, school community, or population who is the focus of attention and to whom the school nurse is providing services as sanctioned by state regulatory bodies. In school nursing, the student and those who influence students such as the family, school community, the larger surrounding community, aggregates within the school population, or the entire school population are the healthcare consumers.

Healthcare provider. A person with special education and expertise who provides healthcare services or assistance to students and their families. The school nurse is considered a healthcare provider.

Healthy work environment. An employment atmosphere characterized by optimal physical, psychological, economic, and political conditions conducive to maximum productivity, including worker and the school community’s safety, employer support and encouragement, absence of undue stress, and reasonable and sustainable staffing conditions and caseloads.

Holistic care. Integration of body-mind-spirit-sexual-cultural-social-energetic-environmental principles to promote health and well-being and actualize human potential.

Illness. An unhealthy condition of body or mind(Mirriam-Webster, 2021)

Implementation. The fifth step of the nursing process in which the nurse acts to bring about the plan. In the standards of practice, the process of implementation has several components that include coordination of care; health teaching and health promotion; consultation; and, for the APRN, prescriptive authority and treatment, when allowed.

Individual Education Plan (IEP). This student specific plan is required for each student who qualifies under IDEIA and sets out learning goals for a specified period of time. The IEP can allow for modification of curriculum.

Individual Family Service Plan (IFSP). a multidisciplinary plan, specific to infants, toddlers, and preschoolers with special needs, and inclusive of their families

Individualized Health Plan (IHP).The individual health plan (nursing plan of care) developed by the professional school nurse that assists in translating student healthcare into the educational setting. The school nurse formulates the IHP in collaboration with the student, parent, healthcare provider and educational colleagues.

Individualized Educational (Program) Plan (IEPP/IEP) – a multidisciplinary and multifaceted plan for students 5 through 21 years (older in some states) who meet special education program requirements under state and federal law.

Individualized Healthcare Plan (IHP), a plan of care written by the registered nurse for a student with or at risk for physical or mental health needs. [70]

Individuals with Disabilities Education Improvement Act (IDEIA). Federal law that provides procedural safeguards for students with qualifying disabilities and requires states to provide a free and appropriate education to said students (FAPE).

Inequity. Lack of fairness or justice.

Informal learning. A means of integrating knowledge, skills, abilities, and judgment into experiential insights gained in work, community, home, and other settings.

Inherent suffering[71] —The suffering that occurs due to the illness, injury, or disability experienced by the healthcare consumer, family, and community.

Injustice. An unjust act or occurrence.

Interprofessional. Reliant on the overlapping knowledge, skills, and abilities of each professional team member. This can drive synergistic effects by which outcomes are enhanced and become more comprehensive than a simple aggregation of the individual efforts of the team members.

Interprofessional collaboration. Working together with others as appropriate to improve health and academic outcomes.

Intersectionality[73] —The complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups (Mirriam-Webster Dictionary, s.v. “intersectionality”).

Interprofessional. Reliant on the overlapping knowledge, skills, and abilities of each professional team member. This can drive synergistic effects by which outcomes are enhanced and become more comprehensive than a simple aggregation of the individual efforts of the team members.

Judgment. A characteristic of nursing competency that includes critical thinking, problem-solving, ethical reasoning, and decision-making.

Justice. Justice, a principle and moral obligation to act on the basis of equality and equity, is a standard linked to fairness for all in society. “Justice requires that vulnerable groups receive special attention” (ANA, 2015a, p. 48)

Knowledge. A characteristic of nursing competency that encompasses thinking, understanding of science and humanities, professional standards of practice, and insights gained from practical experiences, personal capabilities, and leadership performance.

Liaison. A person whose function it is to maintain communication between or among individuals and an organization, parts of an organization, or between two or more organizations acting together for a common purpose.

Licensure: in general, licenses are awarded by governmental bodies and certifications by non-governmental bodies (U.S. Bureau of Labor Statistics, 2021).

Mentoring. Power-free, often long-term, relationship using skills similar to coaching with the goal of professional development. Advice may be more directive and always confidential.

Multidisciplinary team. A team of school or community professionals with a variety of skills, abilities, and disciplinary backgrounds who work together for a common purpose. In the context of the school, this goal is to achieve the best academic and/or health outcomes for students, their families, or others within the school community.

N
ational Association of School Nurses (NASN). A professional organization serving the needs of school nurses nationally and internationally. As such, the NASN supports the health and educational success of children and youth by developing and providing leadership to advance school nursing practice by specialized registered nurses. As the expert voice for school nurses, the organization has as its core values: child well-being; ethics; scholarship; leadership; excellence; collegiality; integrity: innovation; and diversity and inclusion (NASN, 2020b).

National Association of State School Nurse Consultants (NASSNC). A professional organization serving professional registered nurses employed by a State Department of Education and/or State Department of Health, or other title as these agencies are known in individual states for nurses who assume the nursing responsibility for statewide support and consultation for school health services.

Nursing. Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity (ANA, 2021b).

Nursing diagnosis. “NANDA [North American Nursing Diagnosis Association] International believes that the structure of a Nursing Diagnosis as a statement including the diagnosis label and the related factors as exhibited by defining characteristics is best clinical practice, and may be an effective teaching strategy (NANDA International [NANDA], 2010).

Nursing process[77] . A circular, continuous, and dynamic critical-thinking process comprised of six steps that is client-centered, interpersonal, collaborative, and universally applicable. The six steps are assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. The nursing process encompasses all significant actions taken by registered nurses and forms the foundation of the school nurse’s decision-making.

Nursing research. [78] —“Systematic inquiry designed to develop knowledge about issues of importance to the nursing professions” (Polit & Beck, 2018, p. 737).

Outcomes identification. The third step of the nursing process wherein measurable, expected, realistic, and attainable expectations for the student are stipulated.

Plan Do Study Act (PDSA). A quality improvement framework used to evaluate change in practice (Institute for Healthcare Improvement [IHI], 2021)

Peer review. Collegial process for accountability in practice that included both inter- and intra-professional collaboration.

Planning. The fourth step of the nursing process in which the nurse formulates a comprehensive outline of care to be implemented for attainment of specific measurable outcomes. In school nursing, examples are the Individualized Healthcare Plan (IHP), the Americans with Disabilities Act (504 Plan), the Individualized Educational Program Plan (IEPP) from the Individuals with Disabilities in Education Act, the Emergency Care Plan (ECP), and others.

Population. A group of persons who have identified similarities, and includes aggregates and communities.

Population Health. Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” (Kindig & Stoddart, 2003, p. 380)(ANA, 2021b)(Centers for Disease Control & Prevention [CDC], 2020)

Quadruple Aim. The Institute for Healthcare Improvement (IHI) defines the Triple Aim as improving the health of populations, enhancing the experience of care for individuals, and reducing the per capita cost of health care. Some organizations have now added a fourth aim, such as attaining joy, health equity and readiness. IHI supports an organization’s additional aim if it assists in achieving the Triple Aim (Feely, 2017).

Quality. Degree of excellence of something. The degree to which nursing services for healthcare consumers, families, groups, communities, and populations increase the likelihood of desirable outcomes and are consistent with evolving nursing knowledge.

Race. “Race is a fluid concept used to group people according to various factors including, ancestral background and social identity. Race is also used to group people that share a set of visible characteristics, such as skin color and facial features. Though these visible traits are influenced by genes, the vast majority of genetic variation exists within racial groups and not between them. Race is an ideology and for this reason, many scientists believe that race should be more accurately described as a social construct and not a biological one” (NIH, n.d. ).

Registered Nurse (RN). An individual registered or licensed by a state, commonwealth, territory, government, or other regulatory body to practice as a registered nurse.

Resources. “a stock or supply of money, materials, staff, and other assets that can be drawn on by a person or organization in order to function effectively” (Google, n.d.).

Respect“a way of mattering so that other persons matter in the same way os one matters to themselves” (ANA, 2021b, p. 21). (ANA, 2021 p 21)

Safety. “The condition of being safe from undergoing or causing hurt, injury, or loss” (Mirriam-Webster, 2021)(Merriam-Webster Dictionary, s.v. “safety”). The condition of being protected from harm or other undesirable outcomes.

Scholarly inquiry[84] —The logical, organized process of searching for answers to questions via research, assessment of findings from literature searches, and examination of other knowledge sources.

School. An institution, organization, or group dedicated to the provision of educational services for children and youth from birth through age 21 or older. Schools include public, private, and military entities.

School community. All those who study, work in, or are formally affiliated with a school district or school setting. The school community is expanded, when appropriate, to community agencies, faith-based groups, students’ families, and others. To a limited extent, the school community is a consumer of school nurse services.

School nurse administrator. A professional registered school nurse who also is recognized or employed in the capacity of supervision of school nurses or others and expected to carry out school health or other administrative responsibilities in the school setting. This role can include such as coordination of school health services across the school district, development of school health policies and procedures, establishment of professional development for school nurses, development of school health budgets, and evaluation of school health programs.

School nursing. School nursing, a specialized practice of nursing, protects and promotes student health, facilitates optimal development, and advances academic success. School nurses, grounded in ethical and evidence-based practice, are the leaders who bridge health care and education, provide care coordination, advocate for quality student-centered care, and collaborate to design systems that allow individuals and communities to develop their full potentials (NASN, 2017a).

Scope of school nursing practice. A statement describing the complex and unique practice of the school nurse, including its considerable depth and breadth. The scope statement describes the “who,” “what,” “where,” “when,” “why,” and “how” of school nursing practice. The statement is intended for those who practice school nursing in the United States and its territories, and in Department of Defense Education Activity (DoDEA) locations around the world and for all constituencies.

Section 504 Accommodation Plan. An interprofessional plan developed in accordance with Section 504 of the Rehabilitative Act of 1973 to assure physical and mental health along other educational accommodations are implemented for children with disabilities.

Skills. A characteristic of nursing competency that includes psychomotor, communication, interpersonal, and diagnostic skills.

Social determinants of health. The influence on health outcomes by a person’s social environment, including educational level, neighborhood, socio-economic status, and social supports, and access to health care.

Social justice. “a form of justice that engages in social criticism and social change. Its focus is the analysis, critique, and change of social structures, policies, laws, customs, power, and privilege that disadvantage or harm vulnerable social groups through marginalization, exclusion, exploitation, and voicelessness” (ANA, 2021b, p. 25).

Stakeholders. Person(s) with an interest or concern related to student health, school health, health services or school nursing.

Standards. Authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform. Within school nursing, standards are the professional expectations that guide the practice of school nursing.

Standards of Practice. The
Standards of Practice describe a competent level of nursing practice demonstrated by the critical-thinking model known as the nursing process. The nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse’s decision-making.

Standards of Professional Nursing Practice. The standards are authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting are expected to competently perform. These published standards may serve as evidence of the standard of practice, with the understanding that application of the standards depends on context.

Standards of Professional Performance. The Standards of Professional Performance describe a competent level of behavior in the professional role. All registered nurses are expected to engage in professional role activities, including leadership, reflective of their education, experience, and position.

Standardized [Nursing] Languages. The use of standardized nursing language helps describe nursing care with nursing specific terms, and to document and describe nursing interventions. Standardized language improves patient care, enhances data collection improves evaluation of care outcomes and nursing competency, and increases adherence to standards of care (Rutherford, 2008). Standardized nursing language “enables the storage of data on nursing care in EHRs, contributes to improved quality and patient safety, improves the efficiency and effectiveness of care, and enables the autonomy and control of professional practice for nursing to grow as a profession and science (Jones et al., 2010, p. 13).

State School Nurse Consultant (SSNC). SSNCs are liaisons to state boards of education and nursing, other state agencies, and legislators on behalf of local school health programs (NASSNC, 2020). They monitor, interpret, synthesize and disseminate relevant information to schools associated with changes in health and medical care, school nursing practice, legislation, and legal issues that impact school health services and remove barriers to student’s access to education.

STEEP. An analytic framework for quality assessment put forth by the Institute of Medicine (IOM), which includes the following six aims for the health care system: safety, timeliness, effective, efficient, equitable, and patient-centered (Agency for Healthcare Research & Quality [AHRQ], 2018).

Student. The healthcare consumer for a school nurse; a youth attending pre-kindergarten through Grade 12 or up to 21 years of age if identified as a student with special needs under the Individuals with Disabilities Education Act.

Student Population. A group consumer of school nurse provided healthcare to all students within a school or school system, e.g., health education, health fairs, school-located vaccine clinics. School population can also refer to larger groups of students across cities, states and/or nations when addressing data surrounding health and education outcomes.

System. Any group of interacting, interrelated, or interdependent elements forming a complex whole.

Transition plan. A multidisciplinary plan designed to facilitate smooth transition among and between schools or school levels for students with special needs.

Unlicensed assistive personnel (UAP). A person without a nursing license who has been delegated certain appropriate, routine, standardized nursing tasks by a registered nurse.

Values—Personal and professional values inform and direct nurses’ decisions. A personal value can be defined “as a belief upon which one acts by preference” (Olpin & Hesson, 2015, p. 135). Personal values are formed over time and can be influenced by family, culture, education, and the environment. Instrumental values are personal characteristics the nurse may aspire to, such as being caring and compassionate, while terminal values are those considered most important in achieving one’s goals, such as independence and security.

Wellness. The active pursuit of activities, choices, and lifestyles that lead to a state of holistic health(Global Wellness Institute, n.d.) .

Whole Child Assessment. A Whole Child Assessment incorporates questions about exposure to and risk of Adverse Childhood Experiences (ACEs), as well as other social determinants, safety, substance use, mental health, relationships, sleep, physical activity, nutrition, dental care, tuberculosis risk, and interval history (Loma Linda University, 2021; 2021).

Framework for 21st Century School Nursing Practice TM

NASN Code of Ethics for School Nurses

NASN Code of Ethics

Acknowledging the diversity of the laws and conditions under which school nurses practice, the National Association of School Nurses (NASN) believes in a commonality of moral and ethical conduct. As such, NASN adopts the American Nurses Association’s (ANA)
Code of Ethics for Nurses with Interpretive Statements (2015), which establishes an ethical foundation for all nurses. Furthermore, this foundation is supported by the
School Nursing: Scope and Standards of Practice, 3rd Edition (ANA & NASN, 2017) and ethical guidelines provided by state boards of nursing. School nursing practice, built upon these ethical foundations, is grounded in the NASN core values of child well-being; diversity; equity, and inclusion; excellence; innovation; integrity; leadership; and scholarship (NASN, 2020).   The school nurse is responsible for complying with applicable federal, state, and local laws, regulations, ordinances, executive orders, policies, and any other applicable sources of authority, including any applicable standards of practice (NASN, 2016b). 

School Nurse Ethics  

“School nurses straddle two statutory and regulatory frameworks, health and education. Because school nurses practice nursing in an educationally focused system, they face unique legal, policy, funding and supervisory issues that may also have ethical dimensions” (ANA & NASN, 2017, p. 37). Examples of challenges to school nurses’ ethical foundation include:

· Unsafe school nurse to student workloads,

· Accountability for care delegated to Unlicensed Assistive Personnel (UAP),

· Documentation expectations that do not align with the standards of nursing practice. 

· Assignment of nursing tasks to Unlicensed Assistive Personnel without the input of the school nurse, and

· Attempts by non-licensed school administrators to direct practice.

As such, school nurses must have not only the skills to communicate within both the healthcare and education arenas, but also the requisite knowledge and skills to interpret applicable laws, regulations, and professional standards, as well as apply ethical theories and principles common across all nursing specialties (ANA & NASN, 2011).

Provision 1

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person (ANA, 2015, p.1).

School nurses deliver care in a manner that promotes and preserves student autonomy, dignity, and rights, delivering care in an inclusive, collaborative manner to embrace diversity in the school community. School nurses promote equitable treatment of all students, regardless of health, race, gender, socio-economic status, culture, age, sexual orientation, gender identity, ability, or religion. The school nurse supports and promotes each student’s unique abilities to achieve the highest quality of life. School nurses develop long-term trusting relationships and recognize the necessity to maintain clear boundaries that support student and family inclusion in decisions surrounding care (ANA & NASN, 2017). In the same light, school nurses recognize the value of input from and collaboration with their educational colleagues to facilitate student health planning with the classroom in mind. Respect, collegiality, and civility serve clear communication and improved student health outcomes

Provision 2 

The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population (ANA, 2015, p.5). 

School nurses provide primary, secondary and tertiary interventions to support individual students, groups of students and entire school populations at a micro and macro level. As public health practitioners, school nurses are aware of social needs, social determinants of health, and partner with families and other community members to reduce health disparities. School nurses work within educational institutions to define and implement professional nursing standards of practice and development of school health policy to meet the needs of the school community.

Provision 3 

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient (ANA, 2015, p. 9)
. 

School nurses are student advocates and support student rights in navigating the educational environment. Regardless of the setting or the situation, the school nurse endorses and understands that the primary commitment is to the student. School nurses support transition planning as students navigate multiple transitions during a PK-12 education – from classroom to classroom, school-to-school, and PK-12 education to college or adult life. School nurses actively promote student health, safety, and self-worth.  In order to safeguard student privacy, school nurses maintain confidentiality within the legal, regulatory, and ethical parameters of health and education, and inform others about student health record protection in accordance with the Family Educational Rights and Protection Act (Family Educational Rights and Privacy Act, 1974), Health Insurance Portability and Accountability Act (Health Insurance Portability and Accountability Act, 1996), and other applicable federal and state laws and regulations 

Provision 4 

The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal patient care (ANA, 2015, p. 15). 

School nurse workplace environments impact the quality of health care; therefore, school nurses collaborate to improve these environments.  Working within educational institutions, and in collaboration with education partners, school nurses inform, define, and implement professional standards of practice and school health policy. School nurses must have knowledge relevant to meet the needs of students and maintain the highest level of competency by enhancing professional knowledge and skills. Self-evaluation as well as evaluation by administrators with healthcare experience, based on applicable laws, regulations and policies; professional standards of practice; and the Framework for 21st Century School Nursing PracticeTM assists the school nurse in identifying areas to grow competence and expand practice (NASN, 2016a).  As allowed by state nurse practice acts, and in accordance with established best practice, school nurses assume responsibility and accountability for the delegation or assignment of tasks. School nurses take appropriate action when encountering illegal, unethical or inappropriate behavior that places student health and safety at risk.

Provision 5 

The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth (ANA, 2015, p. 19)
. 

As lifelong learners, school nurses must have knowledge relevant to meet the needs of the individual students and entire student populations. Maintenance of high levels of competency is enhanced through collaboration with peers, other health professionals, and community  agencies. National school nurse certification recognizes school nurse competence and expertise (ANA & NASN, 2017). School nurses recognize that wholeness of character extends to students, families, school staff, school leaders, and all others with whom they engage. Personal and professional integrity are maintained via careful attention to verbal, non-verbal, and written communication that is culturally informed, unbiased, truthful, accurate and well-planned. Supervisory evaluation by an experienced school nurse informs continuous improvement of each school nurse’s practice. The potential tension between administrators and school nurses can result in ethical dilemmas resulting in moral distress for the nurse (ANA & NASN, 2017, p. 37; Savage, 2017). It is incumbent upon the school nurse to advocate for evidence-based practice decisions that are based on respect of self and others.

Provision 6 

The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care (ANA, 2015, p. 23).

School nurses exert a positive impact on the quality of healthcare via collaborative decision making within the educational setting to establish work environments are supportive of student health, safety, and learning. School nurses work within educational institutions to define and implement professional standards of nursing practice as well as school health policy development, implementation and evaluation.   

Provision 7 

The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy (ANA, 2015, p. 27). 

School nurses are life-long learners in pursuit of knowledge, training and experiences that enhance the quality of their nursing practice. They work within PK-12 education institutions to define and implement professional standards of nursing practice and school health policy development. School nurses utilize available evidence in developing health programs, individual plans of care, and interventions. School nurses engage in quality improvement projects in pursuit of better health outcomes for students. With school district approval, school nurses may collaborate with researchers in research activities that will advance student health and school health services. 

Provision 8 

The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities (ANA, 2015, p. 31). 

School nurses are aware of social determinants of health impacting the school community, provide healthcare to all students, support school staff, and partner with families and other community members to reduce health disparities. They utilize evidence-based interventions designed to mitigate the effects of adverse childhood experiences and other social determinants of health. School nurses refer students to other health professionals and community health agencies as needed to promote health and well-being. Lastly, school nurses are advocates for policy change to protect and promote health rights to reduce health disparities. 

Provision 9 

The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy (ANA, 2015, p. 35). 

Engagement with professional associations, such as the National Association of School Nurses, and state affiliate organizations allows the school nurse to work collaboratively to ensure evidence-based professional practice aligned with nursing values focused on student education, health equity, and social justice. School nurses work within educational institutions to define and implement professional standards of practice and school health policy. To ensure equitable access to school health services and in accordance with state nurse practice acts, school nurses delegate or assign nursing tasks, while retaining accountability for these tasks. 

References

American Nurses Association. (2015).
Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursebooks.org.

American Nurses Association & National Association of School Nurses. (2011).
School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD:  Nursebooks.org.

American Nurses Association & National Association of School Nurses. (2017).
School nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD:  Nursebooks.org.

Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g; 34 CFR part 99 (1974).

Health Insurance Portability and Accountability Act, P.L. No 104-191, 110 Stat. 1938 (1996).

Appendix C

The Development of School Nursing Standards: Foundational Documents, 1900s to Present

School Nursing Scope and Standards of Practice, 3rd Edition, 2017