Exploring Innovative U.S. School Health Delivery Models: A Narrative Review.

School health services have been described as the "hidden healthcare" system because of their isolation within schools and from other healthcare providers. This isolation may inhibit innovations in school healthcare delivery. Hence, there is a need to identify and characterize various delivery models. This review examines models to identify innovative approaches and formulate suggestions for public health departments, local and state educational agencies, and policymakers. Toward this goal, published and gray literature were studied and synthesized, identifying three delivery models: the traditional model of school-based nursing and two alternative models: school-based health centers and community partnerships. Mechanisms of delivery included telehealth, mobile clinics, and system-level care. Although no innovative, comprehensive approaches to school health services models were found, innovation generally focused on improving equitable delivery to vulnerable populations. Policies must be formulated and funded to integrate such innovations into a comprehensive, preventative approach, including improved care coordination and data sharing.

The History of US Menstrual Health, School Nurses, and the Future of Menstrual Health Equity.

In the United States, adolescents suffer from inadequate menstrual health, meaning that adolescents are unprepared for menarche, lack the practical resources they need to comfortably and confidently manage menstruation, and receive inadequate health education and care for menstrual pain and disorders. In this article, we provide a historical analysis of the role of school nurses in addressing menstruation from the early 20th century up to the present day. We contextualize the current realities of school nursing and menstrual health education and clinical support. We argue that the decentralized US school system, a cultural aversion to open discussion about menstruation, and the outsized influence of commercial menstrual product manufacturers have hampered the ability of school nurses to deliver menstrual health education along with menstrual health support. Finally, we discuss implications for today's schooling experiences as well as recommendations for how to support school nurses in aligning our national approach to menstrual health toward the public health perspective of menstrual equity. (Am J Public Health. 2024;114(9):903-908. https://doi.org/10.2105/AJPH.2024.307705).

The Global Shortage of School Nurses.

Calzolari and colleagues invited others to have an "open…professional dialogue" on how Italy can introduce school nurses into their system. This editorial is a response to that invitation. Although factors such as a broader nursing shortage and limited health resources definitely contribute to a global shortage of school nurses, three foundational reasons continue to challenge the demand for school nursing globally. The three reasons are traditional views and lack of understanding of the role of school nurses to address modern days challenges, inadequate system support and integration within education, and lack of data to illustrate value. These challenges must be addressed when discussing the inclusion of school nurses in education.

A Cost-Benefit Analysis of School Nursing in One Large Urban School District.

This study is a cost-benefit analysis examining an urban district's partial school nurse coverage conversion to full-time coverage. Through a partnership with a health care system, the district received funding, resulting in the hiring of full-time nurses to cover all K-8 elementary schools. Researchers compared the cost of nursing services to the savings in teacher, secretary, principal, and parent productivity, reduced medical procedure costs, and grants nurses managed. The year before implementing additional nurses, the return on investment (ROI) to the community for nursing services was calculated to be $1.59 for every dollar invested in schools with full-time coverage and $1.29 for schools with partial coverage. After implementing full-time nurses in each school, there was an ROI of $1.50 during the 2015-2016 school year, $1.64 for 2016-2017, and $1.67 for 2017-2018. The analysis provides evidence that full-time coverage could result in a positive ROI for schools and the community.

A Mixed Methods Exploration of Texas School Nurses' Involvement in Addressing Substance Use and Sexual/Reproductive Health Among Students in Alternative High Schools.

Students in alternative high schools (AHSs) have higher levels of substance use and risky sexual behaviors than students in traditional high schools. In this mixed methods study, we examine school nurses' efforts in Texas AHSs to address substance use and sexual/reproductive health. The nurses addressed substance use and sexual reproductive health mostly at the individual level, after students initiated risky behaviors. Nurses' efforts were influenced by district, school, and community factors (e.g., understaffing, outdated programs that weren't evidence-based or tailored to AHS students' behaviors, and family involvement). Usually, nurses were not practicing to their full scope as outlined by the National Association of School Nurses Framework. Substance use was a common reason for AHS placement and could contribute to the school-to-prison pipeline, and AHSs did not always have Narcan on campus to address drug overdoses. Our findings suggest implications for providing equitable health services to this underserved, understudied student population.

Feasibility Assessment of a School Nurse-Led Approach Using Chronic Absenteeism to Establish the School-Based Active Surveillance Process.

This article shares what was learned from the feasibility assessment of a nurse-led school-based active surveillance (SBAS) pilot to track chronic absenteeism using myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as an exemplar. This pilot encompassed a 3-year period with training and feedback from school nurses (SNs) on data collection and ME/CFS. SNs found that the SBAS process helped them effectively identifying undiagnosed conditions. The assessment revealed the importance of focusing outreach efforts and establishing relationships with the school leadership in developing health policies and programs in the school setting. The pilot data were used to develop a manual to guide SNs for the SBAS process. This can be viewed as a model for SNs in establishing a surveillance to identify and track conditions like ME/CFS. With overlapping symptoms of Long COVID to ME/CFS, this assessment may provide insights for additional efforts to understand the impact of Long COVID on students' education.

School Nurse Staffing in Texas Alternative High Schools: A Mixed Methods Exploration.

School nurses represent cost-effective investments in students' health and educational success. Alternative high schools (AHSs) serve an understudied population of youth who are at risk for school dropout and face numerous social inequities, heightening their risk for poor health outcomes. In this two-phase explanatory sequential mixed methods study, we examined school nurse staffing in Texas AHSs. Findings suggest Texas AHSs face understaffing for familiar reasons common across districts (e.g., lack of funding), but also reveal potential deeper inequities. Quantitative findings indicate 71% of Texas AHSs have some form of nursing support, most often an on-call or part-time nurse. Qualitative findings support and enrich this finding with insights into the negative consequences of not having a full-time nurse, indiscriminate approaches to staffing AHSs, and how AHSs can be the only school in the district without a full-time nurse. Altogether, our findings reveal opportunities to better support AHSs with adequate nursing support.

The Role of School Nurses During the 1918 Pandemic: Lessons That Apply to COVID-19.

The current COVID-19 pandemic has been compared with the Spanish Flu of 1918 that devastated the United States. With so many parallels being drawn, what could be learned from 1918 regarding the role of school nurses? Many of the activities from 1918 are still being done today. School nurses have worked tirelessly to assure the health and safety of students and school. The purpose of this article is to compare the role of school nurses in two pandemics, as well as provide suggestions on how school nurses' important contributions to history are not lost. The recommendations have an added benefit of providing school nurses with healing and building their resilience.

Defining the social determinants of health for nursing action to achieve health equity: A consensus paper from the American Academy of Nursing.

BACKGROUND: The 2019-2020 American Academy of Nursing (Academy, 2019) policy priorities document states that "they have a clear and distinct focus on social determinants of health and uses this lens to advance policies and solutions within each of the three overarching priorities" PURPOSE: This consensus paper seeks to establish conceptual clarity and consensus for what social determinants of health mean for nursing, with emphasis on examples of health policies that advance planetary health equity and improve planetary health-related quality of life. METHODS: Volunteers from five Expert Panels of the Academy met via videoconference to determine roles and refine the focus of the paper. After the initial discussion, the first draft of the conceptual framework was written by the first three authors of the paper and, after discussion via videoconference with all the co-authors, successive drafts were developed and circulated for feedback. Consensus was reached when all authors indicated acceptance of what became the final version of the conceptual framework. FINDINGS: A conceptual framework was developed that describes how the social determinants of health can be addressed through nursing roles and actions at the individual, family, and population levels with a particular focus on the role of health policy. The paper provides a specific health policy example for each of the six key areas of the social determinants of health to illustrate how nurses can act to improve population health. DISCUSSION: Nursing actions can support timely health policy changes that focus on upstream factors in the six key areas of the social determinants of health and thus improve population health. The urgent need to eliminate systematic and structural racism must be central to such policy change if equity in planetary health-related quality of life is to be attained.

Future of Nursing 2030: The Future Is Bright for School Nursing.

The National Academies of Sciences, Engineering, and Medicine recently released The Future of Nursing 2020-2030: Charting a path to achieve health equity. The 2021 report emphasized the role of nursing in addressing social determinants of health and inequities, as well as the need for nurses at all levels to work to their full scope of practice. The report harmonizes with the scope of practice outlined in the National Association of School Nurses' Framework for 21st Century School Nursing Practice. This article outlines how frontline school nurses, state affiliates, and school nurse leaders will adopt the recommendations in their practice and in the schools and communities they serve.

Relationship Between Perceived Supervisor Support and Workplace Bullying in School Nurses in Virginia.

Workplace bullying among school nurses is a significant problem with supervisors either contributing to or preventing such behavior. This study aimed to determine if support from nursing and school supervisors is associated with workplace bullying among Virginia school nurses. In this analysis of a cross-sectional survey, responses from 159 school nurses with two supervisors to the Survey of Perceived Supervisor Support and Short-Negative Acts Questionnaire were examined. Multiple linear regression analysis was performed. Findings demonstrated a significant, inverse relationship between perceived support from both supervisors and workplace bullying, accounting for 27.7% of the variance. No relationship was found between bullying and frequency of supervisor contact. The research suggests quality and not quantity of supervisor support may protect school nurses against workplace bullying.

Development and validation of an instrument to measure scope of practice in school nurses.

AIMS: The aim of the study was to develop and psychometrically test a new instrument to measure the scope of school nursing practice. DESIGN: Methodological study. METHODS: Data were collected in Spring 2018. Frontline school nurses in the United States (N = 3099) completed the 39-item Scope of School Nursing Practice Tool (SSNPT) with two domains (current practice and importance to practice). One half of sample data (N1 = 1521) were used for exploratory factor analysis, item analysis, Cronbach's alpha, and Spearman-Brown to estimate validity and reliability of the instrument. Sample data from the other half (N2 = 1578) were retained for future analysis. RESULTS: Factor analysis resulted in a stable four-dimension solution: (A) Using the Nursing Process; (B) Applying Evidence to Improve Practice; (C) Connecting with Community; and (D) Leveraging the School and Family Team, accounting for 50.48% (current practice) and 53.31% (importance to practice) of total variance. Cronbach's alpha and Spearman-Brown ranged from .73 to .90 and .73 to .92, respectively. Item-total correlations ranged from .36 to .82. CONCLUSION: Initial psychometric properties indicate the new SSNPT is valid and reliable to assess the scope of practice of frontline school nurses. IMPACT: School nurses play a key role in population health and frequently serve as the sole provider of healthcare in schools worldwide. However, variability in school nursing practice affects the health, safety and educational outcomes of children and youth. No instrument exists that measures the scope of practice of school nurses. Frontline school nurses can use the SSNPT to assess practice, school nurse administrators can use the tool for resource utilization and school nurse researchers can use the tool to examine school nursing practices' impact on student/community health and academic outcomes. The SSNPT may provide a template for others who wish to examine specialty nursing scope of practice.

Characteristics Associated With School Health Services for the Management of Chronic Health Conditions.

It is unknown how health services staff (school nurse or school physician) or school characteristics are associated with the number of services provided for chronic health conditions in schools. Using data from the 2014 School Health Policies and Practices Study, four services (identification or school-based management, tracking, case management, and referrals) were analyzed using a multivariable ordered logistic regression. Approximately 57.2% of schools provided all four, 17.5% provided three, 10.1% provided two, 5.8% provided one, and 9.4% did not provide any such services. Schools with a school nurse were 51.5% (p < .001) more likely to provide all four, and schools with access to consult with a school physician were 15.4% (p < .05) more likely, compared to schools without one. Schools comprised of mostly racial/ethnic minority students (less than or equal to 50% non-Hispanic White) were 14.7% (p < .05) less likely to provide all four, compared to schools with greater than 50% White students.

School Nursing for the 21st Century: Assessing Scope of Practice in the Current Workforce.

A gap analysis was used to examine the scope of school nursing practice in the United States. An investigator-developed 39-item self-assessment survey of scope of school nursing practice was modified from an existing validated tool, organized around the five principles of the National Association of School Nurses' Framework: Standards of Practice, Quality Improvement, Care Coordination, Community/Public Health, and Leadership and also explored barriers to practice. The survey was sent to a national convenience sample of practicing school nurses. The survey was completed by 3,108 practicing school nurses. Gaps were identified for all principles and were greatest for Quality Improvement and Community/Public Health practice. All practice items were rated more important than the ability to practice that item (p < .001). Self-identified barriers including workload, school/district expectations, and state regulations accounted for significant variances in practice across four of five principles (p < .05, p < .001). Recommendations include support for population-focused evidence-based school nursing practice.

Show Me the Evidence: COVID-19 and School Nursing in the 21st Century.

The emergence of COVID-19 and how to control its spread has highlighted the importance of understanding and applying evidence-based decisions into school nursing practice. This is the fifth and final article in NASN's series on how the Framework for 21st Century School Nursing PracticeTM is a mind-set that can be applied to everyday school nursing practice and will focus on the principle of Standards of Practice, and particularly how evidence-based practice decisions are made during COVID-19.

The National School Health Data Set: Every Student Counts! New Data Platform.

The National Association of School Nurses' (NASN's) data initiative The National School Health Data Set: Every Student Counts! (Every Student Counts!) is getting a new platform! This article reviews what Every Student Counts! is and shares some of the new features of the platform. For more information on NASN's initiative and to learn how school nurses can join the data revolution go to http://nasn.org/everystudentcounts.

School Nursing Data Collection During COVID-19.

COVID-19 has affected the 2020-2021 school year for everyone and thrust school nurses into the spotlight. Some school nurses are too overwhelmed to even think about data; others want to collect data differently to illustrate the value of the role of the school nurse. This article provides guidance on data collection during this unique time period. The article is based on a blog originally posted on National Association of School Nurses's website.