The State of School Nursing

1. The State of School Nursing Child Health, Nursing Practice, and Future Policy Robin Fleming, PhD, RN December 7, 2011

2. The State of School Nursing Today’s Agenda • Background and History • Demographics • Challenges of Providing Nursing Services in Educational Settings • Medication Delegation • School Nurse Authority • Recommendations • SNOW’s Response to Recommendations

3. The State of School Nursing Assembling the Pieces • Multiple Stakeholder Meetings • SNOW Member Input • Medication Delegation • Nurse-to-Student Ratios • Nurse Supervision • Nurse Autonomy • Literature Review

4. The State of School Nursing Demographics and School Nurse Practice

5. The State of School Nursing Demographics of Student Populations • Increased numbers of children with complex medical needs • Asthma • Seizure Disorders • Diabetes • Obesity • Anaphylactic allergies • Mental Health disorders

6. The State of School Nursing Data provided by Jill Lewis, Seattle Public Schools

7. The State of School Nursing Demographics of Student Populations • Increased numbers of immigrant children • 1 in 5 children is an immigrant • Immigrant children have higher risks for: • Poverty • Academic failure • Health problems associated with generational status

8. Health Status

9. The State of School Nursing Demographics of Student Populations • Increased numbers of children with IHPs and 504s • In Seattle, health concerns rose by 163% over a five-year period • No data publicly available for numbers of children with 504s, but they have increased • 17% of children in Washington state have special health care needs • Increased numbers of immunization out of compliance or exemptions

10. The State of School Nursing Demographics, Legal Mandates, and School Nurse Practice • Increased numbers of children with IHPs and 504s require obligatory notification. • Increased numbers of health plans must be written • Increased supervision required for medication delegation • Increased number of screenings • Increased amount of unpaid time at meetings

11. The State of School Nursing School Nurse Practice in Educational Settings

12. The State of School Nursing Accountability and Reform • “Quick fix” punitive environment… • …leads to short-term (i.e. mostly ineffective) solutions

13. The State of School Nursing Accountability and Reform • Nursing services viewed as ancillary • Lack of understanding about how and the extent to which nursing service influences academic outcomes • Effects of improved health occur over time and in collaboration with other stakeholders, lending it not part of a “quick fix” solution

14. The State of School Nursing Headlines • Six Huntsville school nurses among 137 to be laid-off • More School Nurses To Disappear With Education Budget Cuts (Huffington Post, November, 2011) • In Wichita, Kan., similar cuts are in the works, with schools considering replacing registered nurses with less trained, and therefore less expensive, practical nurses.Posted: Mon, Nov. 14, 2011, 9:50 AM • Budget ax threatens school nurses (Philadelphia Inquirer, November, 2011)

15. The State of School Nursing Medication Delegation

16. The State of School Nursing Medication Delegation: Issues • Inconsistencies in statutory law vs. nurse practice acts • Differences in delegation needs depending on location of practice (urban vs. rural) • Nurse-to-student ratios • Safety!

17. The State of School Nursing State Responses to Medication Delegation Comparison of State Laws in Medication Administration in Schools • Medication Administration: Nurses Only* 5 • Medication Administration: UAP may administer (with conditions) 42 • UAP may administer Diastat** 7 • UAP may not administer Diastat*** 4 • Delegation to UAP allowed only for emergency medications **** 6 • Number of states • * Delaware, Hawaii, Mississippi, New Mexico, South Dakota • ** Kentucky, Oregon, Louisiana, Montana, Ohio, Tennessee, Virginia • *** Alabama, California, Iowa, Washington • **** Hawaii, Georgia, New Jersey, New York, Rhode Island, South Carolina

18. The State of School Nursing Medication Delegation: Possible Solutions • Put a school nurse in every building every day! • Rewrite laws and policies • Hire certified personnel

19. The State of School Nursing Nursing Authority and Decision Making

20. The State of School Nursing Sources of Nursing Authority • In most states and school districts, educational administrators have authority over school nurse practice, to the extent that such authority does not override state law or nurse practice acts • Most school nurses are not evaluated by nurses Sources of Authority in Guiding Medication Administration and Delegation in Schools by State

21. The State of School Nursing Summary • Increasing numbers of children with chronic and more severe diseases • Increasing number of immigrant children • Persistent health and academic disparities • Increased demands on school nurses with fewer resources • Presence of issues needing attention (ratios, nurse practice, nurse authority)

22. The State of School Nursing Recommendations

23. The State of School Nursing School Nurses • Organization • Join SNOW, NASN • Serve as preceptor • Educate colleagues • Participate in your area of expertise! You are needed now more than ever.

24. The State of School Nursing What Your Colleagues Think Members of the School Nurse Organization of Washington (SNOW) who participated in a recent survey (n=158) identified stable funding for school nurses (89.2%), reduction of school nurse-to-student ratios (81.7%), and children’s health care coverage (65.0%) as leading legislative priorities. In order to bring these priorities to fruition, school nurses must lend their expertise, their money, and their time to the state and national organizations that lobby on their behalf, and on behalf of the children, families, and communities who school nurses serve.

25. The State of School Nursing Policy & Research • Economic analyses of school nursing needed (requires data collection) • Legislative efforts to protect and promote school nursing authority

26. The State of School Nursing Higher Education • Interdisciplinary collaboration • Increase nursing recruitment efforts • Emphasize school nursing as a public health sub-specialty • Incorporate student health needs and responses as part of teaching education

27. The State of School Nursing Employer Actions • Increase nursing authority • Include school nurse representation on school boards, school health advisory committees, and other policy-making institutions

28. The State of School Nursing SNOW Responses • Task Force to respond to White Paper Recommendations: • School Nurse Actions (PR, Legislative Agenda, improved data collection, increased SN autonomy, evidence-based practice • Employer Actions (

29. The State of School Nursing Child Health, Nursing Practice, and Future Policy Robin Fleming, PhD, RN December 7, 2011