Advocate for having full-time registered nurses (RNs) in local schools, and work to establish ongoing two-way communication and a more collaborative partnership between patients’ schools and medical homes: This is what the American Academy of Pediatrics wants pediatricians to do, according to its recommendations in a new policy statement.

“School nurses, working with pediatric patient-centered medical homes, school physicians, and families, are in a critical position to identify unmet health needs of large populations of children and adolescents in the school setting,” wrote the AAP Council on School Health Executive Committee. “Promoting the presence of a qualified school nurse in every school and a school physician in every district fosters the close interdependent relationship between health and education” ( Pediatrics. 2016 May; 137(6):e20160852 ).

The Council noted that academic achievement, attendance, and graduation rates all can improve when children’s medical, family, and educational homes work together and recognize the inseparable link between good health and learning. Since the first U.S. school nurse appointment in 1902 dramatically reduced absenteeism, the position has become more common and even standard throughout most of the United States. Along with the increase of school nurses has been growth in their responsibilities, ranging from chronic disease management and emergency preparedness to behavioral health assessment and ongoing health education.

“I think as a society that having kids with lots and lots of different chronic health conditions in schools without medical care is horrifying,” said Dr. Breena Welch Holmes , a clinical associate professor of pediatrics at the University of Vermont, Burlington, and one of the lead authors of the statement. One goal of the policy statement is to ensure educators, administrators, and pediatricians recognize the role they can play in improving school health. “It’s the first time in a long time in my career that health has something to offer education that’s concrete,” she said.

The need for a school nurse in each school has become especially critical now that legal changes guarantee access to education for all students, including those with disabilities who often need ongoing case management. In addition, survival rates of extremely preterm infants have increased dramatically, and chronic illnesses such as food allergies, obesity, and type 1 and type 2 diabetes, have been increasing.

“As the number of students with chronic conditions grows, the need for health care at school has increased,” the Council wrote. “The rise in enrollment of students with special health care needs increases the need for school nurses and school health services.”

In addition, school has become a safety net for students with chronic illnesses, said Anne Sheetz, MPH, RN, former director of School Health Services at the Massachusetts Department of Public Health, Boston, and the other lead author of the policy statement. Even for students without chronic illnesses, the implications of not having a registered nurse on site are troubling, she said.

“Children don’t schedule their emergencies when the nurse is there,” she said, adding that it really needs to be a registered nurse, not simply a licensed practical nurse or aide.

Many families face barriers to health care access on their own, and increased awareness about behavioral and mental health issues among children and adolescents means school nurses can play a critical role in screening and referrals.

“School nurse offices and school nurses are a social and emotional support for the students,” Dr. Holmes noted. “It’s the place you go without stigma when you can’t quite get yourself to your next class or you’re an elementary school kid who has experienced all sorts of trauma or chaos or doesn’t have a coat for recess.”

Four recommendations

The policy statement emphasizes four recommendations, starting with pediatricians’ advocacy for having at least one full-time professional school nurse in every community school, as well as a school physician assigned to the overall district to provide medical oversight for the nurses.

“We’ve already established that school nurses can save schools money,” Ms. Sheetz said. One study found “for every $1 spent on school nurses, $2.20 was saved in teacher time, parent loss of work time, and treatments done in the school setting versus the clinical setting.”

The second recommendation encourages pediatricians to ask their patients about issues related to school at each visit, such as whether a health or medical problem is causing them to miss school. Pediatricians can then provide this information to the school under the Meaningful Use guidelines for sharing electronic health records. Some doctors and school nurses may hesitate to share information that could inadvertently violate Health Insurance Portability and Accountability Act (HIPAA) or Family Educational Rights and Privacy Act (FERPA) laws. Dr. Holmes recommends getting the necessary permission forms signed at the start of the year.

“As part of the obtaining school health information from parents, school nurses get parental permission for information sharing,” she said. “Also, pediatricians have parents sign consent [forms] to talk with school nurses about children with chronic health conditions.”

The first and second recommendations lead to the third: establish a working relationship with school nurses to help manage students’ chronic health conditions. Such a relationship would include standardized communication, permission, and information forms, which can help when developing Individualized Health Care Plans.

Finally, the AAP recommends that pediatricians include nurses as part of the health care delivery team for children and teens, working toward designing integrated health systems with school-based health centers.

Intimidated by the idea of community advocacy or implementing these other recommendations? Dr. Holmes said the first step is to learn about the community.

“We want pediatricians to know where their patients go to school, and then we want them to know if that school has a nurse,” Dr. Holmes said. “Then they can decide where their advocacy best fits, but it often best fits at the school board.”

One next step might be asking the district to form a school health advisory committee, with at least one local pediatrician member, if one doesn’t exist, Ms. Sheetz said. She described a variety of ways that communication systems could be set up and listed the various tasks that school nurses can do to help pediatricians understand what’s happening at local schools, such as in-school screenings.

“The best model is for a school district to have a school physician who coordinates with school nurses to assure communication with community pediatricians, including creating communication expectations,” Dr. Holmes added. “Since this model is not common, we encourage pediatricians to know who the nurses are in their district, and to treat them as part of the team.”

Funding or other models

Funding is definitely a serious concern for many districts, but pediatricians can investigate other successful models, such as hospitals or the Department of Health paying for nurses in schools, university programs who “lend” nurses to schools, and programs where pediatric nurses in physician offices share time in schools.

Ms. Sheetz also recommended joining forces with parents who can pressure the district to address health in schools. Parents of children with chronic illnesses often are especially motivated to advocate for better care availability in the school setting.

“The parents have the biggest stake in all of this,” Ms. Sheetz said. “If there’s no school nurse there for an emergency or to manage chronic illnesses or to respond to an emotional issue, it’s the parent and child that gets hurt.”


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