August 2022School Nurse Job Descriptions in Urban Districts: Alignment With the Framework for 21st-Century

School Nurse Job Descriptions in Urban Districts: Alignment With the Framework for 21st-Century School Nursing Practice
Virginia Reising, DNP, RN, PHNA-BC¹

, and Heide Cygan, DNP, RN, PHNA-BC²

The Journal of School Nursing © The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520963621journals.sagepub.com/home/jsn2022, Vol. 38(4) 410–417img1
AbstractIt is recommended that every student has daily access to a school nurse and that school nurses work in alignment with the Framework for 21st-Century School Nursing Practice (Framework). Little is known about Framework alignment with school nursing practice. The purpose of this study is to describe the alignment between the Framework and school nurse job descriptions in large, urban school districts across the United States. Using content analysis, with a directed approach, researchers used the Framework to analyze school nurse job descriptions for 16 school districts, analyzing 375 individual job responsibilities. The majority of job responsibilities reviewed (86%) were related to principles within the care coordination and community/public health nursing component, while job responsibilities within the key principles of leadership and quality improvement components were limited (14%). The Framework can be a useful tool to guide school nurse practice and however needs to be intentionally brought into job descriptions.Keywordsquantitative research, school nurse characteristics, role, promotion/development, policies/procedures, administration/managementBackgroundSchool nurses play an essential role in the future of our communities, bridging the gap between two very complex systems: education and health care. School nurses are held to the highest standards of both systems as they are required to maintain the same standards of practice and ethics as nurses in traditional health care settings and are also required to follow education standards set at federal and state levels (Johnson, 2017). Often, school nurses are the only health care professionals within the school setting, making their role difficult for educators and administrators to understand (Institute of Medicine, Committee on comprehensive school health programs in grades K–12, 1997; National Association of School Nurses [NASN], 2018b). Furthermore, education professionals with limited understanding of the role of the school nurse are charged with writing school nurse job descriptions, setting standards for practice within individual schools and districts, and supervising and evaluating school nurses (NASN, 2018c). These factors combined leave many nurses underutilized and working out of alignment with professional standards.Fig1Figure 1. Framework for 21st-century school nursing practice™. Note. National Association of School Nurses’ Framework for 21st-Century School Nursing Practice (the Framework) provides structure and focus for the key principles and components of current day, evidence-based school nursing practice. It is aligned with the Whole School, Whole Community, Whole Child model that calls for a collaborative approach to learning and health. Central to the Framework is student-centered nursing care that occurs within the context of the students’ family and school community. Surrounding the students, family, and school community are the nonhierarchical, overlapping key principles of care coordination, leadership, quality improvement, and community/public health. These principles are surrounded by the fifth principle, standards of practice, which is foundational for evidence-based, clinically competent, quality care. School nurses daily use the skills outlined in the practice components of each principle to help students be healthy, safe, and ready to learn. Source: Association for Supervision and Curriculum & Centers for Disease Control and Prevention (2014).In addition to the NASN recommendation that every student has direct access to a school nurse each day, this professional organization recommends that school nurses practice in alignment with the Framework for 21st-Century School Nursing Practice™ (the Framework; NASN, 2015, 2016a, 2016b). The Framework (Figure 1) provides guidance for school nurses to take a student-centered approach in supporting success in health and academics while contributing to a safe school environment (NASN, 2016a, 2016b). The Framework is grounded in evidence-based nursing practice, called the standards of practice that encircles four additional, overlapping key principles: care coordination, leadership, quality improvement, and community/public health nursing (NASN, 2016a, 2016b). Each of the key principles is further defined by a specific set of practice components. For example, care coordination includes direct care and collaborative communication; leadership includes advocacy and professionalism; quality improvement includes data collection and evaluation; and community/public health nursing includes disease prevention and access to care (NASN, 2016a).Table 1. Description of School Districts.Tab1Together, the Framework’s key principles and practice components lay a strong foundation for evidence-based school nursing practice that bridges education and health (NASN, 2016a). However, school nurses have expressed a lack of understanding about how the Framework should be used in daily practice (Best et al., 2018). Furthermore, little is known about how school nursing practice aligns with the Framework in the field (Best et al., 2018). Original research about the application of the Framework is extremely limited. There has been one study in which 3,108 school nurses were surveyed on the principles of the Framework both in their practice and their perceptions of importance (Davis et al., 2019). Results from this study indicated that nurses spend the majority of their time conducting activities in the care coordination and leadership principles (Davis et al., 2019).The limited availability of literature limits the ability of school nurse experts to create practical guidelines for Framework implementation, modify organizational policies related to school nursing job responsibilities, and develop state and national standards for school nursing. Examining how the Framework has been operationalized is recognized as a gap in the literature that requires attention (Best et al., 2018). This project aims to fill that identified gap. The purpose of this project is to describe the alignment between the Framework and urban school nurse job descriptions for the 20 largest school districts in the United States.MethodSample and Data CollectionThe sample for this study included the 20 largest, urban school districts in the United States, as determined by the number of students served. For these 20 schools, school nurse job descriptions publicly available in the English language were included in the data analysis. School nurse job descriptions were collected from a variety of publicly available sources including school district and health department websites and employment search engines (i.e., Linkedin.com). As all data used were publicly available, this research study does not constitute human subjects research; thus, institutional review board’s approval was not required. Researchers carefully reviewed job descriptions to ensure that only school nurse positions were reviewed, omitting job descriptions for school health aids and other health-related positions.Data AnalysisTable 2. Frequency of Responsibilities Within Each Component and Key Principle.Tab2Tab2aResearchers, one a certified school nurse who previously worked in a large, urban school district and one an expert and researcher in school health, used a qualitative approach for data analysis. They developed a data analysis tool using Microsoft Excel version 16.4 in which job description elements from each district were compared against all components within each of the four key principles of the Framework. The standards of practice principle was not used in this study because all nurses, regardless of job description, have a duty to follow the components listed under this principle (i.e., nurse practice acts and scope and standards of practice). For the purpose of this study, each element of a job description is referred to as a responsibility, as typically, the elements fell under a heading titled “job responsibilities.” Job descriptions were analyzed individually using a summative content analysis approach (Hsieh & Shannon, 2005). Researchers reviewed job description responsibilities and identified which Framework components best represented the responsibility. Researchers then met to discuss and compare individual data analysis results. Results were finalized after reaching 100% agreement on the match of responsibilities with Framework components. Finally, researchers used Microsoft Excel for quantitative data analysis to calculate descriptive statistics.ResultsSchool DistrictsData were collected between January 2020 and May 2020 for the 20 largest, urban school districts in the country. Of these 20 districts, 80% (n = 16) fit data analysis criteria (Table 1). Detroit City School District, Fairfax County School District, and Hawaii Department of Education were excluded because school nurse job descriptions were not publicly available. Puerto Rico Department of Education was excluded because the school nurse job description was not publicly available in English. Districts included in data analysis were located in eight states (California, Florida, Illinois, Maryland, New York, Pennsylvania, Nevada, and Texas). The average student population served per district was 290,634 (range: 125,846–1,066,215). The average number of schools in each district was 338 (range: 174–1,213).Key Principle and Component FrequenciesThrough the qualitative data analysis approach described above, researchers matched each school nurse job description responsibility with a Framework key principle and component. Researchers calculated the frequency of each key principle and each component. Table 2 includes counts and frequency for each key principle and component.A total of 375 school nurse job description responsibilities were analyzed. Responsibilities of the job descriptions matched most frequently with the care coordination key principle, 57% (n = 215). Next, 29% (n = 108) of the responsibilities reviewed matched with the community/public health key principle, 9% (n = 34) matched with the quality improvement key principle, and 5% (n = 18) matched with the leadership principle.Care coordination is the principle with the highest frequency of represented responsibilities. Within this key principle, the most represented practice components were direct care (24%, n = 51) and interdisciplinary teams (19%, n = 40) while transition planning was the least represented (1%, n = 2). Within the key principle of community/public health (29%, n = 108), the most frequently represented components were screenings/referral/follow-up (22%, n = 24), disease prevention (17%, n = 18), and health education (17%, n = 18). Cultural competency and health equity were not represented in any job description. Within the key principle of quality improvement (9%, n = 34), the most represented component was documentation/data collection (79%, n = 27) while continuous quality improvement and uniform data set were not represented in any job description. Between the four, leadership was the least represented key principle, 5% (n = 18). Within this key principle, the most represented components were systems-level leadership (33%, n = 6) and lifelong learner (28%, n = 5) while advocacy, change agents, education reform, and health care reform were not represented in any job description. In examining data across the entire Framework, direct care, from the care coordination key principle, was the most frequently identified practice component (14%, n = 51).DiscussionThe purpose of this article was to describe the alignment between school nurse job descriptions and the Framework. There was a wide variety of responsibilities within job descriptions across school districts. Researchers identified several areas of alignment between the Framework and job descriptions; however, there were several areas in which alignment could be improved.Alignment Between Framework and Job DescriptionsBased on the data analysis, it is clear that school nurses are expected to be the provider and coordinator of direct health care for students in the school setting, as 57% (n = 215) of the responsibilities reviewed related to the key principle of care coordination. This is in alignment with a literature review by Best et al. (2018) that found that the majority of school nursing interventions aligned with the care coordination key principle. However, our results differed from this review as Best et al. (2018) found the most frequent practice component to be chronic disease management, while we found that within this key principle and across all key principles, direct care was sited most frequently (14%). These findings suggest that while job descriptions and nursing interventions most often align with the care coordination key principle, there may be differences in how job descriptions are operationalized as actual nursing interventions focus on different components within the key principle than written job descriptions. Future research is needed to better understand the differences between school nurse job descriptions and daily school nursing practice.Secondary to the direct care of students, there is an expectation, based on job descriptions, that school nurses will be also responsible for the care of the school community with 29% (n = 108) of the job descriptions including responsibilities within the component of community/public health. This is in alignment with professional standards as NASN has published in a variety of position statements that place school nurses at the forefront of addressing important public health issues such as racism, childhood obesity, and climate change (NASN, 2018a, 2019, 2020b). Additionally, a literature review found that about one quarter of nursing interventions fell into the key principle of community/public health (Best et al., 2018). Together, this suggests that there is an alignment between emphasis placed on this key principle in school nurse job descriptions and in school nursing interventions.Misalignment Between Framework and Job DescriptionsUnfortunately, the job descriptions reviewed in this study demonstrate a limited expectation of school nurses to serve as leaders of the school community as only 5% (n = 18) of responsibilities align with the leadership key principle. Leadership within a school setting comes from many different positions, and school nurses have the skills and expertise to serve as leaders in the school community (NASN, 2016a). It is essential that school administrators understand this leadership capacity. One way in which school nursing leadership is operationalized in the school setting is through school wellness teams (action-orientated groups that focus on the health and well-being of school communities). There have been national movements to increase the development of school wellness teams (Alliance for a Healthier Generation, n.d.; Centers for Disease Control and Prevention, 2014; U.S. Department of Agriculture, 2016). Evidence of school nursing engagement in school wellness teams is conflicting. A qualitative study at a large, urban school district found that school nurses were not represented on school wellness teams (Cygan et al., 2019). Conversely, another study found that 69% of the teams surveyed did have a nurse as a team member (Kanauss, 2017). In this study, no job descriptions specifically called for the school nurse to be a leader or participant of such teams (Kanauss, 2017). By intentionally including school community leadership roles, such as leading school wellness teams, in school nurse job descriptions, school nurses are more likely to work in a leadership capacity, fully realizing their roles.Only 9% (n = 34) of job responsibilities fell within the quality improvement key principle. Further, only two responsibilities were aligned with measuring meaningful student outcomes. This is directly in opposition to statements made by NASN and school nurse researchers that call for the intentional measurement of the impact of school nurses on student outcomes (Best et al., 2018; NASN, 2016a). Without the measurement of meaningful student outcomes included in job descriptions, related tasks will likely not be seen as priorities for districts or school nurses.In the current climate where our society works to address the impact of systemic racism and other cultural inequities, it is highly concerning that none of the job descriptions for school nurses included responsibilities aligned with cultural competency or health equity. Nurses are positioned to address inequities in the school setting and should be seen as change agents in the school setting to meet the needs of diverse populations (NASN, 2020a).It should also be noted that only 2% (n = 7) of the job responsibilities fell under the principle of environmental health. With more and more schools planning for and responding to disasters, natural and man-made, the school nurse should be seen as an essential part of the team charged with addressing environmental health concerns. When schools across the country had to shutter in 2020 due to the novel coronavirus SARS-CoV-2 (COVID-19), the need to consider the impact of environmental health on the educational setting was amplified. As schools reopen for in-person learning, the school nurse will have significant responsibilities related to keeping the environment safe. Considering environmental health is lacking from nearly all job descriptions reviewed, school districts and school nurses will need to coordinate efforts to ensure students are kept safe and school nurses are empowered to practice to their full capacity in this area.Opportunities Within the FrameworkThe Framework was developed in 2016, and there has been little research documenting the application of the Framework since then. After using the Framework to analyze these job descriptions, the authors identified one specific opportunity for improved utilization. Until July 2020, there was no dictionary to accompany the Framework; thus, there are no operational definitions for the key principles or components (NASN, 2020b). As this study was completed prior to this publication of this dictionary, the authors of this study agreed upon definitions throughout the process. Having easy access to predefined descriptions would make the tool more useful especially if it is to be used by non-health personnel. For example, an area in which the authors had to differentiate operational definitions was between the principles in the care coordination component and the community/public health component. The authors defined the principles under care coordination as those relating to individual students, while the principles under community/public health related to those concerning population-based health. For example, individual health-promotion responsibilities were coded under care coordination, while health promotion aimed at groups was coded under community/public health. While this process was successful for the purposes of this project, it is not entirely clear whether this was the intent of the authors for the Framework. It is possible that the scope of school nursing practice survey developed for the study by Davis et al. (2019) could be useful in developing a companion dictionary for the Framework.LimitationsWhile the researchers attempted to gather all job descriptions from the 20 largest, urban school districts, this report is missing five of those due to lack of availability. This study also focuses on large, urban school districts. It is possible that within smaller and/or rural school districts, there is a difference in alignment between school nurse job descriptions and the Framework. Researchers did not specifically evaluate the inclusion of the scope and standards in job descriptions as it is a professional duty for all nurses to practice in alignment with these standards. Including scope and standards in future projects may lead to the identification of additional gaps in alignment between the framework and school nurse job descriptions.Recommendations for PracticeAfter completion of this study, recommendations can be made to three distinct groups: professional nursing organizations, school districts, and school nurses.Professional nursing organizations. While the Framework continues to be a novel and comprehensive model for what the school nursing role should encompass, more work is needed to promote and support the Framework. Professional organizations should work to develop an operational guide for implementation of the Framework whereby all components and key principles are clearly defined. Professional organizations should also fund and support research and dissemination by school nurses and nurse researchers related to application of the Framework. During this review, job description exemplars were discovered. Professional organizations should promote such exemplars as the gold standard for school districts aiming to align their job descriptions with the Framework.School districts. Job descriptions need to be reviewed and rewritten on a regular basis to ensure they are kept up-to-date with best practices for all roles within a school setting. School nurse experts should be engaged in the process of writing school nurse job descriptions. When districts lack formal school nurse leadership, they should partner with universities or professional organizations with expertise in the field of school nursing. Through these partnerships, job descriptions will likely align with the Framework and school nursing scope and standards.School nurses. School nurses should use the Framework in discussions with school administrators to advocate for the expansion of their role in the school setting. School nurses play a pivotal role in documenting the impact of their work through dissemination of quality improvement and research projects.ConclusionsThe Framework was developed to help school nurses take a student-centered approach to support both health and academics in the school setting (NASN 2016a, 2016b). The Framework can be a useful tool to guide school nurse practice. However, it is only through job descriptions written with intentional alignment with the Framework that it will be operationalized beyond individual practice.Author ContributionsVirginia Reising and Heide Cygan contributed to conception, design, acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.FundingThe author(s) received no financial support for the research, authorship, and/or publication of this article.ORCID iDsVirginia Reising, DNP, RN, PHNA-BC

https://orcid.org/0000-0002-8500-2771Heide Cygan, DNP, RN, PHNA-BC

https://orcid.org/0000-0003-2811-2170
ReferencesAlliance for a Healthier Generation. (n.d.). School wellness committees. Retrieved July 1, 2020, from https://www.healthiergeneration.org/take-action/schools/wellness-topics/policy-environment/school-wellness-committeesAssociation for Supervision and Curriculum & Centers for Disease Control and Prevention. (2014). Whole school whole community whole child: A collaborative approach to learning and health. http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdfBest, N. C., Oppewal, S., & Travers, D. (2018). Exploring school nurse interventions and health and education outcomes: An integrative review. The Journal of School Nursing, 34(1), 14–27. https://doi.org/10.1177/1059840517745359Centers for Disease Control and Prevention. (2014). Putting local school wellness policies into action. U.S. Department of Health and Human Services. http://www.cdc.gov/healthyschools/npao/pdf/SchoolWellnessInAction.pdfCygan, H., Tribbia, C., & Tully, J. (2019). School health policy implementation: Facilitators and challenges. Journal of School Nursing. Advance online publication. https://doi.org/10.1177/1059840519846089Davis, D., Maughan, E., White, K., & Slota, M. (2019). School nursing for the 21st century: Assessing scope of practice in the current workforce. The Journal of School Nursing. https://doi.org/10.1177/1059840519880605Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. https://doi.org/10.1177/1049732305276687Institute of Medicine, Committee on Comprehensive School Health Programs in Grades K–12. (1997). School Health Services (Chapter 4) InD. Allensworth E. Lawson L. Nicholson & J. Wyche (Eds.), Schools & health: Our nation’s investment. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK232689/Johnson, K. (2017). Healthy and ready to learn: School nurses improve equity and access. The Online Journal of Issues in Nursing, 22(3). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-22-2017/No3-Sep-2017/Healthy-and-Ready-to-Learn.htmlKanauss, L. (2017). School wellness teams: What professions/credentials are represented? International Journal of Health, Wellness & Society, 7(1), 85–93. https://doi-org.proxy.cc.uic.edu/10.18848/2156-8960/CGP/v07i01/85-93National Association of School Nurses. (2015). School nurse workload: Staffing for safe care (position statement). https://www.nasn.org/advocacy/professional-practice-documents/positionstatements/ps-workloadNational Association of School Nurses. (2016a). Framework for 21st century school nursing practice. https://www.nasn.org/nasn/nasn-resources/professional-topics/frameworkNational Association of School Nurses. (2016b). The role of the 21st century school nurse (position statement). https://www.nasn.org/advocacy/professional-practice-documents/positionstatements/ps-roleNational Association of School Nurses. (2018a). Overweight and obesity in children and adolescents in schools—The role of the school nurse (position statement). https://www.nasn.org/advocacy/professional-practice-documents/position-statements/psoverweightNational Association of School Nurses. (2018b). The school nurse’s role in behavioral/mental health of students (position statement). https://www.nasn.org/advocacy/professional-practice-documents/position-statements/ps-behavioral-healthNational Association of School Nurses. (2018c). Supervision and evaluation of the school nurse (position statement). https://www.nasn.org/advocacy/professional-practice-documents/position-statements/ps-supervisionNational Association of School Nurses. (2019). Climate change impacts on child health (position brief). https://www.nasn.org/advocacy/professional-practice-documents/positionbriefs/pbclimate-changeNational Association of School Nurses. (2020a). Eliminate racism to optimize student health and learning (position brief). https://www.nasn.org/advocacy/professional-practice-documents/positionbriefs/pb-racismNational Association of School Nurses. (2020b). Framework for 21st century school nursing practice™: Clarifications and updated definitions. NASN School Nurse (Print), 35(4), 225–233. https://doi.org/10.1177/1942602X20928372U.S. Department of Agriculture. (2016, November). Local school wellness policy outreach toolkit. https://www.fns.usda.gov/tn/local-school-wellness-policy-outreach-toolkitAuthor BiographiesVirginia Reising, DNP, RN, PHNA-BC, is an assistant clinical professor at the University of Illinois Chicago.Heide Cygan, DNP, RN, PHNA-BC, is an associate professor at the College of Nursing in the Rush University.¹ College of Nursing University of Illinois Chicago, IL, USA² College of Nursing, Rush University, Chicago, IL, USACorresponding Author:Virginia Reising, DNP, RN, PHNA-BC, College of Nursing University of Illinois Chicago, 845 South, Damen Avenue, Chicago, IL 60612, USA.
Email: vmontg2@uic.eduJournal CoverSchool Health adVersoAmplivox adNASN ad (eyes of hope)Shine a Light on School NursesEmergency Medication Access and Administration in Schools: A Focus on EpinephrineEffects of Life Skill Training on the School Violence Attitudes and Behavior among ElementarySustained Effects from a School-Based Intervention Pilot Study for Children with Asthma and AnxietySelf-Concept Profiles of Youth at Risk for Maladaptive BehaviorsEffects of Child Sexual Abuse Prevention Education Program Using Hybrid Application (CSAPE-H)Risk Factors Associated With Bullying at School and Electronic Bullying in U.S. Adolescent FemalesAn Intervention to Promote Adherence to Glasses Wearing Among Urban Public Elementary SchoolBody Weight Perception and Health-Related Behaviors Among U.S. Adolescents: Mediating EffectsSchool Nurse Job Descriptions in Urban Districts: Alignment With the Framework for 21st-CenturySAGE ad - author servicesSAGE ad - perspectivesSAGE ad - researchIEL + NASN ad adNASN ad - stay connected