The Journal of School Nursing2021, Vol. 37(6) 431–440© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519887413journals.sagepub.com/home/jsn
The demand for schools to provide complex health-care services for students with chronic conditions has induced districts to hire licensed vocational nurses (LVNs). Questions remain about how overlapping responsibilities and skills of nursing staff works to facilitate care. The purpose of this mixed-methods descriptive study was to examine the use of LVNs to identify factors related to the supports and impediments to school nurse (SN) practice. The sample consisted of members of the California School Nurse Organization, and methodologies consisted of an online survey and one-on-one interviews. LVNs perform duties within their scope of practice, allowing SNs time for activities related to the Framework for 21st Century School Nursing PracticeTM, confirming appropriate use, and alignment with National Association of School Nurses guidance on the utilization of LVNs. Identified areas of concern included role definition and orientation and supervision of the LVN. Insights into best practices for the effective addition of the LVN to the team are provided.
role promotion/development, best practices/practice guidelines, collaboration/multidisciplinary teams, administration/management, delegation/UAP
Over the past decade, the demand for schools to provide more frequent, time-consuming, and complex health-care services for students with chronic conditions has increased (Knauer, Baker, Hebbeler, & Davis-Aldritt, 2015). Without a single source for data about students with chronic health conditions in schools, a clear understanding of the scope of the issue is difficult. The US Department of Health and Human Services, Office of Adolescent Health (2016) helps illustrate the problem by estimating that approximately 22% of adolescents have one chronic health condition, and 25% have two or more conditions, including asthma, diabetes, epilepsy or seizure disorder, hearing or vision problems, and bone or joint problems among other diseases.
In response to these changes in health-care delivery in the schools, districts have moved to adding licensed vocational nurses (LVNs; known in some states as licensed practical nurses [LPN]) to assist the school nurse (SN), typically licensed as a registered nurse (RN). Licensure for the LVN provides for a broader scope of practice than an unlicensed assistant, and often more autonomy within the boundaries of their individual state’s nurse practice acts. A staffing mix that includes care by providers with different licenses has left many school administrators and nurses with questions about the nursing role and function for each type of licensure. Despite each nurse having a distinct position, questions remain about how this mix of individuals with overlapping responsibilities, obligations, and skills works to facilitate the care of students and the SN’s specific role.
The literature on the topic of the utilization of LVNs in schools is sparse. Over the past two decades, much of the focus of school nursing publication has been on policy, procedure, and guideline development related to issues of training, supervising, and collaborating with Unlicensed Assistive Personnel (UAP). While discussions of policy and training can be useful for SNs working with anyone providing support, there are gaps in the literature associated with understanding the effective utilization of different licensed professionals.
Care delivery models describe the elements including who will perform which tasks, who is responsible for what duties, and who makes what decisions to meet patient care needs and provide quality care in the most efficient and costeffective way possible. Models of nursing care delivery vary from district to district and between states. In districts where SNs cover more than one school building, or care for large numbers of students, a model where the SN is responsible for assessing, planning, directing, and evaluating the care, while the school nursing support personnel (UAPs or LVN/LPNs) carry out the interventions and functional responsibilities of care, is sometimes used. This model has the advantage of freeing the SN to be more purposeful and effective, with care delivery tasks done by so-called nurse extenders. However, the additional layer of responsibility for training, oversight, and supervision of assistive staff adds to the SN’s duties and can be a drawback.
Emphasis on the critical role that health status and attendance play in achieving academic success makes examining any area related to these ends essential, timely, and relevant. It has been established that regular school attendance is related to academic success, decreased academic and social risk, and the development of productive members of society (Attendance Works Healthy Schools Campaign, 2015; Chang & Romero, 2008; Ginsburg, Jordan, & Chang, 2014; Knopf et al., 2015; Moricca et al., 2013; Vinciullo & Bradley, 2009). Understanding how to utilize personnel most effectively can be beneficial as the delivery of health services, care coordination, chronic disease management, and necessary medical procedures allow children to attend school.
An LVN, under the supervision of a RN, utilizes scientific and technical expertise and manual skills to provide nursing care. In California, delegation to an LVN must occur within the scope of practice. The SN then supervises the nursing care provided by monitoring performance to assure compliance with established practice standards, policies, and procedures (California Code of Regulations, Title 16, Section 1443.5). Duties within the scope of practice of the LVN in California typically include, but are not limited to, hygienic care, measurement of vital signs, basic assessment, performance of prescribed medical treatments and nursing interventions, administration of prescribed medications, observation and of responses to treatments and interventions, documentation, participation in the development of nursing care plans, and some patient education (California Business and Professions Code, Division 2, Chapter 6.5). Because SNs and LVNs both provide licensed-level care, there is overlap in some roles and responsibilities. This confusion can lead to inappropriate or inefficient utilization of health staff and can impact the workload, efficiency, and effectiveness of school nursing practice.
The criteria for practice as a SN in the United States differ widely by state, with some requiring only licensure as a RN, while others necessitate a bachelor’s degree. Some states have provisions for education beyond the bachelor’s degree, leading to certification or credentialing (Prager & Zimmerman, 2009). In California, RNs are required to have a bachelor’s degree and complete additional coursework including a clinical practicum with a credentialed SN preceptor, leading to a credential that is renewable every 5 years (California Commission on Teacher Credentialing, 2016). Credentialing programs in California ensure that SNs receive education that allows the provision of services set forth in state education code, including specialized training to conduct health and developmental assessments and interpret findings to design health maintenance plans, provide in-service training for school personnel and act as a resource, develop and deliver health education curriculum, and refer students and families for services as needed (California Education Code, Section 49426).
Currently, there is a lack of knowledge about how LVNs are being utilized in schools in California and about how students, schools, and SNs are impacted by this care delivery model. Despite the existence of position statements, legal provisions, and scope of practice documents delineating the parameters of their function in schools, the most effective use of the LVN position in schools is yet to be determined (National Association of School Nurses [NASN], 2015a).
The aim of this study was to examine trends related to the use of LVNs in California preschool, elementary, and secondary schools in order to identify factors related to the supports and impediments to evidence-based SN practice. This study had five objectives: (1) identify how LVNs are currently utilized in California schools, (2) understand reporting relationships between SNs and LVNs, (3) examine SN self-report of experiences working with LVNs, (4) understand the effect on workload for SNs working with LVNs, and (5) understand implications for best practice use of the LVN position to maximize SN impact on student health and safety.
This two-part descriptive study used a mixed-method approach. Part 1 consisted of an electronic survey of members of the California School Nurses Organization. The survey had short-answer questions related to LVN duties, meeting attendance, contributions to the five aspects of the NASN Framework for 21st Century School Nursing Practice™ (also referred to as the Framework), and the reporting relationship of the LVN to the SN or to a school administrator (NASN, 2015a). For each question, participants were also permitted to submit open-ended text responses. For qualitative content analysis, the open-ended responses were combined with the responses received in Part 2, a telephone interview with a purposive sample of participants from different regions of the state. The California State University Fullerton (CSUF) Institutional Review Board provided approval for this study.
Sample. The survey was distributed to all 1,300 SNs members of the California School Nurse Organization (CSNO), a professional association offering voluntary membership for a fee. The volunteer respondents were thus a convenience sample. It was estimated by the CSNO president Sheri Coburn that approximately 50% of SNs in California are members of this organization; as such, this sample was likely to reflect the population. However, there is potential bias associated with membership in a professional organization, where members may be more in tune with professional issues related to the SN role. In order to minimize this bias, an attempt was made to locate and invite SNs not on the CSNO membership list to complete the survey. To compile a list of SNs employed within each county in order to locate and invite non-CSNO member SNs to participate in the study, investigators contacted county offices of education and requested contact information for SNs employed by districts within the county. An invitation to complete the survey was sent to all nurses on the list. This effort yielded 11 respondents who were not CSNO members.
CSNO distributed notice of this research opportunity to all 1,300 members with a cover letter indicating eligibility, consent was implied with survey completion, and a link to the Qualtrics-based electronic survey was included. To assure a confidence level of 95%, a sample of approximately 300 respondents from a pool of 1,300 members was needed. In survey research, the confidence level describes how often the true percentage of the population surveyed would pick that answer within a certain margin of error, and in this survey, we picked a margin of error of five (Qualtrics, 2019).
Since it was not known how many districts in California employed LVNs, difficulty in obtaining an adequate sample size of participants was anticipated. To obtain sufficient participation in both the survey and interviews, incentives in the form of an opportunity drawing for completion of the survey and a gift card for interview participants were offered. Results were separated from any participant names entered for the opportunity drawing. The survey utilized for this study was developed by the principal and coinvestigator team, one is a former SN and both are SN educators. The survey was reviewed by a nursing faculty who provided input on pertinence of content and design and by two working SNs in the field who commented on face validity and ease in survey completion. The final survey had two parts, the demographic section, consisting of six questions, and the main survey section, which had 44 questions related to working with LVNs.
The six demographic questions included the five-digit zip code for the location of the district, the composition of the school district (“Unified,” which includes Kindergarten–12th grade, Kindergarten–8th Grade, County Office of Education, or high school–only district), number of students in the district, highest degree earned, number of years in practice, and whether or not participants were members of CSNO and NASN. This background information helped in understanding participant responses in context.
The 44 questions related to working with LVNs included 24 questions about LVN responsibilities (e.g., do they provide G-tube feedings, do they provide medication administration). There were nine questions about attendance and participation in Individualized Education Plan (IEP), 504, and Student Study Team (SST) meetings, six questions about supervisory and reporting relationships, and five questions about perceived workload impact related to the NASN Framework. To all questions, SN participants indicated their answers using a yes/no response. After each of the question sets about meeting attendance, supervisory and reporting relationships, and perceived workload impact, participants were able to write comments to further explain or describe their impressions or experiences in working with LVNs in the school setting. Qualtrics was used to calculate descriptive statistics.
The first objective of this study was to identify how LVNs are currently utilized in California schools. Respondents were asked to indicate what treatments LVNs currently performed or could perform. SNs indicated that LVNs did or could perform all of the listed interventions. The scope of practice for LVNs in California allows most treatment interventions to be performed by LVNs, with the exception of vision and hearing screenings, and responses suggest the suitable use of this licensed professional (California Business and Professions Code, Division 2, Chapter 6.5 Vocational Nursing). Characteristics of survey respondents and their school districts are shown in Table 1. Table 2 shows the percentages of LVNs performing various treatment interventions.
Other nursing functions performed by LVNs in the school. In contrast to treatment procedures and medication administration, LVNs also performed other functions such as sharing of health information with teacher and school staff and contacting providers to obtain or clarify procedure and/or medications orders. LVN involvement in hearing and vision screening was also assessed. These activities are displayed in Table 3. Of these activities, the most commonly performed is reporting and obtaining heath information from school staff and parents (44–69%) followed by contacting health provider (33%) for new or clarified treatment/medication orders. These commonly performed duties by LVNs in California schools are permitted by their licensure. However, in schools, the responsibility for communicating health information to staff and parents and for calling providers to obtain or clarity orders is less clear and is typically related to the policies outlining the role of the SN or LVN within a given district.
SNs were asked whether LVNs collect and analyze data, but no specific question about the type of data or analysis was included. Rather than examining specifics about the type of data collected or analyzed, the question sought to gain information about activities being performed. Nurses completing the survey (n = 308) reported that a large percentage of LVNs (80.2%) are collecting data, but very few (5.5%) are analyzing data. Nurses reported that few LVNs were completing health history assessments (5.5%). In future studies, additional information about the type of health data being collected and the nature of the analysis being completed by LVNs would help clarify the LVN role in data collection and analysis. Under California law, LVNs can assist with basic vision and hearing screenings if they are under the immediate supervision of a SN, but they cannot perform screenings or make referrals (California Code of Regulations § 2950). Very few LVNs were conducting hearing (2.3%) and vision (5.8%) screening.
Completing activities related to the Framework. For each of the five major categories of the Framework, standards of practice, care coordination, leadership, quality improvement, and community and public health, SNs were asked, via open-ended question, whether and how working with LVNs helps performing activities related to each item. Respondents overwhelmingly affirmed that working with LVNs helps with the ability to do activities related to the NASN Framework. The Framework activities supported most were those related to care coordination (87%) followed by standards of practice and community public health (76%). The areas supported least (70%) were leadership and quality improvement. Respondents gave illustrative comments of how LVNs supported these activities (see Table 4).
The common thread among responses was that working with LVNs allows the SN to have more time to perform actions and activities related to the Framework. In explaining how LVNs help SNs carry out activities related to the Standards of Practice, many respondents noted the provision of less direct care of students and more time to perform higher level nursing functions that more closely align with Framework-based SN practice, such as providing education, performing assessments, creating care plans, attending trainings, focus on standards of practice, and student follow-up.
In contrast to the positive comments about how the presence of an LVN helps SNs work within the Framework, there were also comments about ongoing staffing issues that are a barrier to carrying out SN Framework duties. Limited LVN and SN staff in the district required SNs to prioritize delivery of direct care duties.
Reporting relationships between SNs and LVNs. Understanding reporting relationships between SNs and LVNs was the second aim of this study. To meet this objective, SNs were asked about their responsibility for directing the day-to-day work of LVNs and 81.5% (n = 308) affirmed this duty. Of those nurses, 66.6% indicated that they have input on the formal routine performance evaluation of LVNs. Additionally, 70.8% of SNs (n = 308) indicated that if they have concerns about the assignment an LVN has been given, there is a formal or informal process to handle the situation. If SNs (n = 304) have concerns about the safe performance of interventions by LVNs, 80.3% indicated that there is a process for dealing with these issues. Of concern are the almost 20% of nurses who do not feel there is a formal or informal process for voicing their concerns about a LVNs assignment or performance, despite the SN being legally responsible for the supervision of LVN’s duties. While over 80% of responding SNs (n = 308) are leading and are responsible for the day-to-day work of LVNs, about one third of those do not have input on LVNs’ performance evaluations.
Sample/setting. Upon completion of the survey, participants were offered the option to volunteer for a 15-min semistructured recorded interview and 156 indicated willingness to be interviewed. These individuals were divided into three groups by zip code. Researchers started at the top of their list and contacted each volunteer in order. Each interviewer phoned respondents from their assigned state area; all volunteers contacted were willing to be interviewed. Interviewers determined that we would compare interview notes after conducting 10 interviews each. In that discussion, it was decided that further interviews were not needed as saturation had occurred. Although 30 interviews of respondents across the state were conducted, but due to technical errors, only 28 were recorded and utilized in the results of this study.
Consent to participate and be audio-recorded was obtained prior to beginning each interview.
The third and fourth aims of this study were to identify factors related to the supports and impediments to evidence-based SN practice, examine the SN’s self-report of experiences, and understand the effect on workload for SNs working with LVNs. Interview discussions allowed participants to share their thoughts and experiences related to their preparation for working with LVNs and the qualities of working with LVNs that enhanced or created barriers to practice. Participants were also asked a final open-ended question to elicit insight about working with LVNs not covered by the previous questions. Investigators utilized this methodology for its ability to provide detailed descriptions of this complex phenomenon, engage participants, and provide an initial exploration into the factors most helpful for successful utilization of the LVN in the school setting. The semi-structured interview questions that guided the interviews, to enrich understanding of survey findings, asked for examples of training received for SNs to work with LVNs and inquired about the nurse’s perceived supports and barriers to Framework-based SN practice when working with LVNs. Along with probing follow-up questions, interviewees were asked if they had anything else to add about their experience working with LVNs in the school setting. See Table 5 for interview questions.
The recordings were transcribed by a paid service, and then transcriptions were checked against the original tapes by the primary investigator. A conventional content analysis, where concept themes originate directly from the text data, was performed (Hsieh & Shannon, 2005). This qualitative analysis technique allows authors to pull out themes directly from the data to allow insights to emerge. The investigators and a practicing SN graduate student assistant reviewed and drew concept themes from the transcripts separately to increase interpreter reliability and limit bias. The strongest themes, with accompanying quotes, are presented in the results section.
Part 2—Interview results. Analysis of the interview questions resulted in five distinct themes: (a) lack of consistent, specific, or standardized professional development or training to work with and supervise LVNs; (b) presence of LVNs allows SNs more time to carry out activities related to the Framework; (c) confusion over supervisory responsibility, evaluation, and utilization of LVNs when (the LVN is) hired through an agency versus employed by the district; (d) confusion about the role of LVNs by staff, administrators, students, and parents; and (e) staffing issues impact the delivery of care even when LVNs are present.
Theme 1—Lack of consistent, specific, or standardized professional development for SNs and LVNs for health work and supervision in the school setting. Most nurses reported having some form of preparation, ranging from a breakout session or workshop at a local, regional, or state school nursing conference to self-study of the CSNO’s “The Green Book of Guidelines for Specialized Physical Healthcare Services in School Settings,” state education code, or Nurse Practice Acts for RNs and LVNs (CSNO, 2012). Others stated that they relied on word of mouth from other SNs, their background as RNs and experience in other settings, their bachelor’s or master’s degree coursework, or their postbaccalaureate SN credential program training.
Specific training for SNs related to the supervision of LVNs as well as skills and competencies for LVNs working in the school setting was exemplified by the following comments:
There’s not adequate training for nurse supervisors in working with LVNs. That’s part of it because I know, in reality, very little about LVN education. So [school nurses] have a certain assumption of what they’re allowed to do and what they’re not allowed to do. When we hired our first LVN, I just went online to look at their practice act because I didn’t know what they were actually able to do. So I think one of the things is if we’re going to use LVNs, nurse managers need to be trained.
Education for [school nurses, administrators and LVNs] is needed and the relationship has to be set up correctly by the school nurse. I don’t think anything can replace the registered credentialed school nurse, but when used appropriately, [LVNs] can really help, can really be a nice relationship that the school nurse can have to really help free them up to do a lot of the other assessments and case management … that we need to do.
One of the things we created in our program after I came here is we created an LVN-specific training that we perform at the beginning of the year that pretty much does all of their competency signoffs. We deal with legal aspects. It’s a full-day LVN training to get everybody ready for the beginning of the year. That has helped out LVNs immensely.
Theme 2—Presence of LVNs allows school nurses more time to carry out activities related to the NASN Framework for 21st Century School Nursing PracticeTM. In alignment with findings from the survey and open-ended comment section of the study, 26 of 28 nurses interviewed highlighted the value of the use of LVNs to address health room and day-to-day school site procedures so that the school nurses had more time to address broader activities related to the heath of students, such as providing case management, ensuring standards of care and quality improvement, and providing leadership (see descriptive quotes in Table 4). Respondents stated that the use of LVNs allows school nurses,
to concentrate on case management and concentrate on … development of IEPs, health plans, emergency care plans …. It gives them … the credentialed school nurse a peace of mind knowing that the clinical part, the procedures are being done correctly so that they can concentrate on the things that they need to do.
[LVNs] give us more time … otherwise we’re just the nurse doing all the procedures and then those children gets all of our attention, whereas now you’ve got children that you can do preventative teaching on [their health]. You know you can work with the diabetic students [and] other students, you’ve just got so much more time with. You’ve got more time working with not only the students, [but also] the teachers, the administration so they can see what it is that the nurse contributes [beyond direct care.].
I know as a school nurse as I practice, I definitely could not survive without my LVN. I can tell you that right off the bat. On the days that she was absent and I had to cover because we couldn’t find a sub, I can tell you that there’s no way I could have done what she does and my work on top of that without her. I know that the days that I did have to cover, I didn’t get anything of my assigned work done just because I was busy doing really two jobs, the LVN’s procedures as well as trying to get my work in as a case manager. That was just impossible. LVNs really need to be there to do procedures … so the school nurse can take care of all the IEP paperwork. So they’re critical. They’re very critical to credentialed school nurses in California.
Theme 3—Concerns related to differences in use and supervision of agency-hired versus district-employed LVNs. In districts that contracted with staffing agencies to provide LVN services, school nurses noted concerns about confusion over supervision, the transience and lack of bonding with school nurses in the district, and the underutilization of the LVN due to their contracted assignment. Nurses interviewed noted a difficulty in knowing what their role was in training LVNs to work with students and when and how to bring concerns about performance to the attention of administrators. Others mentioned that LVNs hired via an agency are often assigned to a single student and so are not utilized for things that might help the school nurse complete Framework tasks. Still other school nurses noted that as agency LVNs, there is less opportunity to get to know the nursing staff and children, leaving the school nurse feeling like the LVN is not really part of the team. Significant quotes about this theme are as follows:
So, the gray area comes when we don’t know to what extent that our supervisory responsibilities entail in terms of outside agency hired LVN hired. I mean it’s easier if the LVN were district hired. We understand when they’re ours, so we … have to [supervise]. So, [when there is a performance problem] it’s just like a lot of redirecting and spending more time to … train them, especially with an outside agency ….
Nurse respondents were asked to describe or explain the process that occurs when there is concern about a LVNs assignment or job performance. The majority of school nurses indicated that a discussion with the supervisor or responsible administrator, who may or may not be a nurse, was an important action. Several nurses wrote that they would have a direct conversations with the LVNs themselves. Those working in districts that contract with an agency who employs the LVN indicated that a report to the agency could be made. A few nurses suggested that they were personally responsible for LVN assignments and that if there were concerns, they would assess the situation and based on the evidence gathered make assignment changes as needed. One respondent indicated that in an effort toward transparency and equity, a team approach and data are used to create assignments. A few nurses described themselves as being the final authority for deciding on the appropriateness of LVNs assignment based on their expertise and credentialing.
Unfortunately, several respondents wrote that while there is a process for voicing concerns, those worries are sometimes not addressed. “The problem that I have encountered, LVNs ‘step outside their scope of practice,’ because administrators do not understand the difference in licensure.” More than one nurse indicated that LVNs have been placed in situations where they are working outside of their scope of practice or skill level and that the confusion about their scope of LVN practice by nonnurse district administrator, such as a principal, was the likely cause.
The School Nurse rarely works directly with the LVN. The principal will sometimes tell the LVN what to do. It may be an assignment that is clearly not within the LVN scope of practice (create and send letters home to parents; be a 1:1 health aid plus work in the health office ….) but the LVN will not know that. LVNs require a large amount of indirect/direct supervision from the school nurse.
A few nurses described the process for addressing these issues as less than optimal due to their own assignment or lack of action by administrators when the school nurse does not have evaluation authority.
Due to being assigned to multiple school sites, there’s not enough time to follow-up and observe the safe performance of the LVN at my school site.” Another wrote, “I speak with my supervisor [about LVN performance concerns] but generally there is no action taken.
In contrast, one school nurse manager found working with an agency a valuable relationship, particularly in the case of LVN evaluation and absence,
We retain the ability to oversee them and supervise what they’re providing their services during the school day, but if we feel they’re not doing something appropriate or we have a concern on the way that they’re demonstrating a skill, we can call the agency and ask them to be either retrained or provide us with another staffing person, but additionally because of substitutes and we don’t have a pool of LVNs and these are students who need to have an LVN with them at all times in school, if the LVN would call in sick and they were an internally hired person, the district’s response to that was well we’ll just have one of the credentialed nurses sub in the role of the LVN … for the day because the child needs nursing services as opposed to just UAP services. So with an agency, they have a LVN pool and they are responsible to provide us the substitute.
Theme 4—Confusion about the role of LVNs by staff, administrators, students, and parents. Nurses interviewed were, for the most part, clear about the differences in the role and responsibility of LVNs. However, many were concerned about the confusion between the roles of the school nurse and the LVN by school site staff and administrators, parents, and students. Because many LVNs are assigned to a single site throughout the day, they are a more visible and therefore an active part of the daily operation of the school. In these scenarios, the LVN becomes the onsite “go-to” person about health matters. For routine matters, this is appropriate. However, problems may arise when the school nurse is not included in situations that require the scope of practice, skills, and expertise of the school nurse such as when a student is pregnant or cutting themselves or when a parent comes in to discuss nursing services provided in their child’s IEP.
Additionally, several respondents spoke about the fear that the increased use of LVNs is aimed at hiring fewer school nurses or replacing school nurses. Comments such as the following demonstrate these points:
We have to be very careful with the scope of practice and what is allowed for the LVN to do because to the school staff, a nurse is a nurse and they don’t recognize sometimes that the higher functioning level of the credentialed school nurse as opposed to the LVN. So, when you have the LVN in the school setting 5 days a week, and in our district, my school nurses are only at a school site 1 day a week monitoring and supervising health and that type of thing … but the LVN is there in the office and sometimes [he/she is] recognized as the school nurse instead of the [credentialed] school nurse ….”
One nurse remarked that the comparison between the supportive role of the LVN to that of a teacher’s aide could help demonstrate the need for the credentialed school nurse as well as the LVN.
The teacher’s aides are extremely important in the role of a school setting and can add much to the classroom. We certainly would never start decreasing our number of teachers because we have enough aides and we’ll just have one teacher cover two or three classes while we have the aides do the majority of the teaching. So I think that’s part of our, again, our charge will be as credentialed school nurses to ensure that while they are a tremendous support, they certainly are not a replacement.
Two nurses described working with LVNs with the title of “treatment nurse.” This distinction in responsibility by job title along with verbal differentiation by the LVN seems to minimize confusion. Additionally, several nurses reported a series of steps that they personally take to ensure clarity, including discussing and describing roles and responsibilities with LVNs one-on-one, as well as in groups, in addition to staying in close contact with administrative staff and with school staff about when to see the LVN and when to call the school nurse. The following quotes exemplify this theme,
There can be lines that are blurred between the school nurse and the LVN … because the LVN in my circumstance, they’re there for 4 days a week if the acuity is there and I’m there 1 day a week. The staff and the school tend to view them as the school nurse just because of the hours that are spent there. Some of the treatment nurses [LVNs] are very good at differentiating, no, I’m the treatment nurse, and others are not. So, it might be more of a personality issue than a power struggle, but I do see that the confusion can happen. I try to stay in really close contact with my administrators. I do e-mail the entire school with updates and suggestions when to see the nurse, when not to see the nurse, things like that. What I do with my name as the school nurse and make sure it’s clear the difference in our roles.
The findings of this study mirror recommendations for the use of LVNs in the schools and other settings as part of a team providing comprehensive nursing services (American Association of Occupational Health Nurses, 2017; NASN, 2015b). This survey revealed that LVNs were primarily being used to provide direct care services required by students with health needs that might otherwise impact school attendance. LVNs also extended the reach of the credentialed school nurse by helping to gather needed information from parents. While the survey results indicate that LVNs are primarily working within the parameters of their scope of practice and legal statute, clarification of the legal parameters of some activities would be helpful. For example, results indicate that some LVNs were doing hearing and vision screening, a service limited to the credentialed school nurse in California, while performance of these screening services may be allowed in other states.
This descriptive study has implications for the effective use of LVNs as a member of the school nurse health team. The findings of this study outline issues related to the provision of health services, care coordination, chronic disease management, and necessary medical procedures that need to be addressed. Recommendations for best practice utilization of the LVN as part of the school health team are highlighted below.
Most credentialed school nurses found the addition of the LVN helpful to ensure that students’ direct care needs are handled in a safe and effective manner, thus freeing up time for the credentialed school nurse to attend to broader aspects of care for the school community, such as care coordination, leadership, quality improvement, and community public health outreach/integration. Addition of the LVN was most helpful when the LVN was identified as part of the school health team with a clearly defined role. One example was the naming of the LVN as the “treatment nurse” to help differentiate LVN’s scope from the broader scope of the school nurse.
As part of clear role definition, orienting the LVN to the school setting and procedures and parameters for patient care is seen as important. This was mentioned as particularly important when LVNs come from inpatient settings or work extra shifts in acute and continuing care settings where their role expectations differ. This speaks to the need for a clear job description of the school LVN both to use for orientation and evaluation processes. Nursing practice acts generally require that vocational nursing duties be practiced under the direction of a licensed physician or RN. It is recommended that the school nurse be the performance evaluator of the LVN, rather than a nonnurse administrator. School nurses should develop guidelines for supervision and evaluation of LVNs and other health assistive staff that recognizes both the nursing professional and the administrative educational input that a school district may require.
While the level of licensure needed for employment as a school nurse varies per state, this research is important to nurses in states other than California who are struggling with the same or similar issues. A better understanding of these implications gives guidance to school nurses and school administrators about how best to utilize licensed staff in order to maximize the quality and in turn the effectiveness of school nurse practice.
Both survey and interview results indicated the value of the LVN in providing care within schools. Guideline and policy development is an important adjunct to role definition in order to maximize resources for better outcomes and to provide direction to nurses and administrators. Moving forward, developing models of care that clearly define the respective roles of school nurses and LVNs within school is a necessary intervention for improved practice.
When LVNs are used, an effective orientation to their role is essential. Having clearly defined elements related to care provision, including who will perform which tasks, who will be responsible for which duties, and who will make what decisions, is necessary to minimize confusion and ambiguity. Additionally, LVNs and school nurses should both have a clear understanding of the purpose of the job they are doing, the main tasks of the job, and which qualifications and key competencies are required to perform the job. This definition and delineation of roles would be helpful at both school site administrative levels and also at the district; in addition, the role definition will be helpful to teachers, other school staff, to parents and to school nurses and LVNs.
Both administrative and nursing supervisions should be unified, and, to the extent possible, LVNs should be district employees to minimize additional layers and confusion related to supervision and to promote continuity of care for the medically fragile children served. Creating and supporting an atmosphere of mutual respect and value for the critical role that LVNs play in the care of children can also strengthen and enhance the working relationships of providers.
Rachel McClanahan and Penny C. Weismuller contributed to the conception of the manuscript idea. Rachel McClanahan, Penny C. Weismuller, and Sandra Johnson contributed to the acquisition and analysis of the data, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Manuscript was drafted by Rachel McClanahan and Penny C. Weismuller.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: American Nurses Foundation (Grant ID: 5857).
Rachel McClanahan, DNP, RN, NCSN https://orcid.org/0000-0003-0124-8369
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Rachel McClanahan is an assistant professor at the School of Nursing and the coordinator of School Nurse Credential Program at the School of Nursing and is also a member of the National Association of School Nurses Consortium of School Nurse Educators.
Penny C. Weismuller is a professor and the Director of the School of Nursing at California State University Fullerton and serves on The Journal of School Nursing editorial panel.
Sandra Johnson is a school nurse, a graduate of the California State University Fullerton School Nurse Credentialing and Graduate programs, and serves on the School Nurse Organization of Washington Research Committee.
1 School of Nursing, California State University Fullerton, CA, USA
2 Evergreen Public Schools, Vancouver, WA, USA
Corresponding Author:Rachel McClanahan, DNP, RN, NCSN, School of Nursing, California State University Fullerton, 800 North State College Blvd., Fullerton, CA 92831, USA.Email: rmcclanahan@fullerton.edu
