The Journal of School Nursing
© The Author(s) 2021
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DOI: 10.1177/10598405211019228
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The structural and systemic inequities that preclude our nation’s ability to make sustained improvements in the health of our communities have been brought to the fore by COVID-19. We see this in the students we care for who often live with complex social constructs, which impact their health and education outcomes: economic stability, social and community context, and neighborhood/environmental influences. As school nurses, we have a moral imperative to be intentional and explicit in addressing these inequities. The role of 21st-century school nurse extends beyond simply providing individual health care interventions (National Association of School Nurses [NASN], 2020). A practice component of NASN’s Framework for 21st-Century School Nursing Practice (within the principle of community/public health) is addressing social determinants and health equity. In addition, the School Nursing Scope and Standards of Practice and the Code of Ethics for Nurses support school nurses’ advocacy for human rights and social justice (American Nurses Association & National Association of School Nurses, 2017; Olson & Stokes, 2016). Health equity is essential to social justice.
Health equity means that everyone has a fair and just opportunity to be as healthy as possible (Braveman et al., 2017). Many assume that improving access to health care is the key to improving health. Yet, researchers have consistently confirmed that clinical care contributes only 20% to healthy outcomes (Braveman et al., 2011; Catlin & Willems Van Dijk, 2020). Similarly, the Health Impact Pyramid demonstrates that addressing socioeconomic factors—those complex social structures some of our students live with—has the greatest impact on health outcomes (Frieden, 2010).
Social determinants of health have contributed to the structural and system inequities that plague our nation. As school nurses, we attend to the individual needs of students and families that are impacted by these factors—unstable housing, food insecurity. But, we must also meaningfully tackle these structural or systematic factors that we know negatively impact health equity. As we watch the news, and listen to nurses and educators on the frontlines, we wonder: Are we doing enough in our practices to address the structures and processes that exacerbate these inequities?
We urge school nurses to focus efforts in the following ways:
Unearth structural inequities through the populationlevel lens: As health care providers at the intersection of population health and individual care, we have a unique vantage point for seeing how structural inequities can translate into population-level health outcomes. We can, and should, examine how our schools and districts are perpetuating poor health and educational outcomes. For example, a school nurse supervisor mapped rates of poverty and students with chronic health conditions who required a physical health procedure at school. These “heat†maps illustrated that students who required G-tube feedings lived in low-income communities, yet their health needs placed them in schools outside their neighborhood. This information was used to improve equitable program placements for students with Individualized Education Plans and institute monthly meetings to ensure that the needs of medically fragile students were met (B. Parker, personal communication, June 4, 2018).
Examine systemic inequities in school policies, processes, and practices: Rules and policies may sanction discrimination and marginalization which, over time, translate into social norms. Whether they are deliberate or unintentional, they are harmful and long-lasting. For example, county-level rates of racial bias have been shown to correlate with racial disparities in schoolbased disciplinary actions (Aronowitz et al., 2021; Riddle & Sinclair, 2019). Despite data indicating that the behavior of Black, Indigenous, and People of Color (BIPOC) and White students do not differ significantly, Black students are disciplined more frequently than White students (Skiba et al., 2011). It was the response of educators and administrators to Black students’ behavior compared to their White peers that differed, setting Black students on a path with more negative impacts on their education, health, and life success. School nurses have the skills and insights to play a critical role in raising these issues, helping others to understand, not if (because they are there) but how these biases and inequities impact the health and education outcomes of the entire school community.
Reflect, engage, and act: Payton and Price (2014) reported that school nurses perceived that their role in addressing racial/ethnic disparities was through connecting families to resources; only half surveyed felt like they were adequately prepared for that role (Payton & Price, 2014). Additional training and education are needed to go beyond simply connecting families to resources and intentionally broaden our lens to look upstream for what is creating, reinforcing, and perpetuating the inequities our students experience. For example, consider the distribution of stated education funds and resources, and their implications for all students. What can school nurses do so students do not have to bus for 2 hours outside of their neighborhood to obtain a quality education (Flood, 2021) or so that school nurses are equitably distributed across communities with known social determinants of health (Gratz et al., 2020)? Importantly, this necessitates examining our own biases and behaviors that contribute to inequities, engaging in reflective practice and research, and committing to a lifelong journey of learning and acting to support our students. We need to first recognize our own positionality, then translate our self-discovery in anti-racism action, and not just endorse, but actively work toward a culture of equity and inclusion.
The Scope and Standards of Nursing Practice, and Code of Ethics tell us, health equity is an ethical and human rights imperative that school nurses must address. We have the education, skills, and power to implement actions to ensure that structural and systematic barriers are recognized and dismantled to ensure all students can achieve optimal health and academic outcomes. We ask you to join us in this powerful advocacy for our children’s future.
Mayumi A. Willgerodt, PhD, MPH, RN, FAAN, FNASNUniversity of Washington, Seattle, WA, USAErin Maughan, PhD, RN, PHNA-BC, FNASN, FAANNational Association of School Nurses, Silver Spring, MD, USABeth Jameson, PhD, RN, CNL, CSN-NJSeton Hall University, South Orange, NJ, USAKathleen H. Johnson, DNP, RN, NCSN-E, PHNA-BC, FNASN, FAANUniversity of Washington, Seattle, WA, USA
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Flood, B. (2021, April 1). Commitment to equity, community engagement earns UIC student national recognition. UIC Today. https://today.uic.edu/commitment-to-equity-community-engagement-earns-uic-student-national-recognition
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