The Journal of School Nursing
2022, Vol. 38(1) 110–120© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211001459journals.sagepub.com/home/jsn
The bioethical concept of best interest standard is cited in courts across America and considered to be an effective method of managing pediatric health care decision-making. Although the best interest standard is referred to in an abundance of nursing, medical, legal, and bioethical literature, refinement and a clear definition of the concept are lacking in the context of school health. An exhaustive and methodical search was conducted across six databases revealing 41 articles from the past decade. The Wilsonian methodology was used to analyze, refine, and clarify the concept of best interest standard by presenting original case vignettes (model, contrary, related, and borderline) and an innovative conceptual model as it applies to school nursing. This concept analysis provides school nurses with a deeper understanding of the best interest standard to navigate the complex nature of making school health care decisions.
concept analysis, best interest standard, pediatric health care decision, nursing, bioethics, school health, school nurses
The best interest standard (BIS) is a prevailing ethical principle in pediatric decision-making. Making health care decisions for children who do not have the capacity to choose for themselves is challenging. Every decision comes with its own set of unique circumstances requiring a flexible ethical framework for protecting, promoting, and optimizing the well-being of each individual child. The BIS is grounded in the four main principles of health care ethics: autonomy, beneficence, nonmaleficence, and justice (American Nurses Association [ANA], 2015; Beauchamp & Childress, 2001; Bester, 2019a, 2018b). Autonomy may be exercised by the parent/guardian, the child, or both. If the child has been deemed autonomous, this autonomy is a “right in trust†or one that may be saved for the child to exercise in their future for forward-looking interests and should not be violated in advance (Bester, 2018b; Hubbard & Greenblum, 2019). Beneficence refers to the provider and parent/guardian choosing health care options most beneficial for the child. Nonmaleficence dictates the obligation to protect the child from harm. Justice states the child’s welfare should not outweigh reasonable interests of others, including their own family members (Bester, 2018b). It is important to note the BIS is not only rooted in general ethics but also serves as a guide on how to handle competing ethical demands.
Historically children were considered paternal property in the eye of the law. The absolute power of a parent was not lifted in the United States until the 1800s with the advent of general best interest laws (Bester, 2019b; Carbone, 2014; Child Welfare Information Gateway, 2016; Kohm, 2008). After this, a paradigm shift occurred where children were not seen as just property, but individuals with rights and privileges of their own. BIS was first used to settle custody disputes or handle juvenile criminal cases but soon became the predominant moral and ethical standard for pediatric health care decisions in the late 19th and 20th centuries (Kohm, 2008; Silva, 2014). BIS laws vary from state to state in America, but the country as a whole asserts the same moral standard be upheld by all (Brummett, 2019; Child Welfare Information Gateway, 2016).
Health care provider law has moved away from paternalistic control and may include input from the child. Children are deemed a vulnerable population with diminished decisional capacity; however, some children may be capable of forming their own medical decision prior to the legal age of adulthood (18 years old; De Clercq & Ruhe, 2018; Sabatello et al., 2018). In fact, self-determination and individual wellbeing are two ethical values threaded throughout the BIS concept (Quist, 2019), and the autonomy of a sufficiently capable child is encouraged (Appel, 2015; Hubbard & Greenblum, 2019).
School nurses are often the sole provider of health care in the academic setting and at the interface of decisions impacting multiple parties including school administrators, children/adolescents, parents/guardians, and other health care services. In this position, complex situations may lead to ethical challenges. Some ethical challenges identified by school nurses are related to conflicts with administrators and/or parents, delegation of nursing tasks, confidentiality, resuscitation policy, and mandatory reporting (Savage, 2017). COVID-19 has introduced further ethical dilemmas for school nurses including a lack of role clarity, challenges in delivering continuous nursing care for students attending virtually, hybrid, or otherwise, a lack of PPE, and ambiguous reopening guidelines (Combe, 2020; Heggestad et al., 2020). Ethical challenges may be emotionally charged and lead to moral distress whereby school nurses feel they are prevented from what they feels is the correct action. Moral distress may be mitigated, and ethical competence enhanced by using an ethical framework. However, little is known about the ethical frameworks employed by school nurses. Qualitative interviews from a small sample of school nurses in rural, suburban, and urban settings revealed that ethical frameworks were not used by school nurses making school health related decisions (Solum & Schaffer, 2003). A comprehensive and working knowledge of the BIS can provide an ethical framework for school nurses; inform communication strategies with parents; enhance care coordination between home, family, and school; and increase quality improvement processes. However, the application of the BIS to school health situations is hindered because it is poorly defined and lacks clarity within the school health context. Therefore, the primary purpose of this article is to provide clarity and gain a deeper understanding of the BIS as an ethical framework for school nurses by examining components of the BIS using the Wilsonian concept analysis approach.
The Wilsonian method was selected to analyze this concept because the BIS has been described as vague, and this method is particularly effective in addressing vague concepts (Rodgers & Knafl, 2000; Wilson, 1969). A Wilsonian concept analysis requires the analyst to isolate a question of concept and subsequently arrive at the “right†answers by exploring essential and nonessential elements (Rodgers & Knafl, 2000). There are three types of questions according to Wilson: questions of fact, values, and concept. Questions of fact can be answered by existing knowledge. Questions of value can be answered by individual or societal moral principles. Questions of concept pertain to meaning. The questions of concept are the focus of the Wilsonian approach because meaning may change over time or differ between disciplines underscoring the importance of revealing a concept’s essential elements through analysis. Arriving at the “right†answer for a question of concept is dependent upon the lens or context through which the analyst is looking, and the answer may not be singular. The question of concept posed for this best interest concept analysis is: What components define the concept of the BIS in the context of school health?
Expert librarians from the health sciences, business and economics, and humanities and social sciences fields were consulted to ensure an exhaustive literature search and proper selection of databases. The databases searched include PubMed, ProQuest, Legal Source, Education Resources Information Center, Cumulative Index of Nursing and Allied Health, and PsychINFO. The key phrase searched was “best interest standard†with delimiters of publication date in or after the year 2010 and written in the English language. This time frame was chosen to ensure the inclusion of a seminal piece, published in 2011 (Diekema, 2011). Inclusion criteria also required a primary legal perspective of the United States because laws and policies, as well as medical options, vary between countries. The search process identified a total of 428 potential articles for the concept analysis. After eliminating 135 duplicates and screening 293 titles and abstracts, 210 were excluded, leaving 83 full-text articles to be read in their entirety. Forty-two full-text articles were excluded because they were not largely based in the United States, focused on the neonatal population who do not yet attend school, were reviews, or concentrated on end-of-life issues. A total of 41 articles were extracted for an inclusive representation of literature of the concept and quality of research found (see Figure 1). Concurrent with the data collection process, both content and thematic data analyses were conducted to qualitatively describe and explore patterns within and across multiple pieces of work. Content analysis was systematically conducted to identify and quantify key words and phrases found in the text; meanings or relationships were then analyzed. Thematic analysis was used to search for common themes, or elements of the concept, and then interpreted to identify patterns.
The purpose of isolating a question of concept is to define and clarify associated terminology as well as explore similar concepts to the BIS. No single definition of the BIS is universally accepted. Numerous professional organizations, including the World Medical Association, the American Medical Association, the ANA, the American Psychological Association (APA) and a President’s Commission Report, refer to the BIS despite the lack of consensus for the BIS definition (APA, 2012; Bester, 2019a; Casey, 2019; Hester, 2019; Ross, 2019b; Salter, 2012). Previous definitions or explanations of the BIS were explored during the process of analyzing the concept. These definitions and explanations are provided in Table 1.
This concept analysis uses the BIS definition written by one of its most recently outspoken proponents, bioethicist Johan Christiaan Bester. This definition states that the BIS is a general ethical principle that optimally protects and promotes the welfare interests and well-being of a child, all things considered. The welfare interests and well-being of the child include both subjective and objective components (Bester, 2019a). Subjective components relate to a person’s perspective of good and their values pertaining to good. Objective components relate to human functioning and absence of disease (Bester, 2019a).
This definition of the BIS is further clarified by asking two questions to evaluate whether the parent/guardian decision is ethically sound or requires further action.
First, can a reasonable argument be offered that the decision is best for the child, all things considered? Second, does the decision expose the child to obvious risk of harm, thought of as clear and readily understood significant insult to an interest crucial to the child’s welfare? (Bester, 2018b, p. 17)
The BIS is not simply maximizing benefits and minimizing harms, it is also flexible and intended to be a regulative ideal, not strict nor taken literally (Diekema, 2019; Ross, 2019a; Ross & Swota, 2017). Family dynamics, psychosocial, health, relational, cultural, developmental, temporal, financial, and other externalities or practical constraint factors are all considered influential contextual aspects of the BIS to promote and protect the child’s well-being (Affdal & Ravitsky, 2018; Bronfenbrenner, 1979; Gomez et al., 2016; Stewart & De Marco, 2018). The BIS definition does not stop with the immediate needs of a child but is also applicable to the future interests of a child (Affdal & Ravitsky, 2018; Bester, 2019a, 2018b; Hubbard & Greenblum, 2019; Salter, 2012). This BIS definition is particularly applicable to school nurses because it is grounded in the same ethical commitments and moral frameworks used by medicine and other nursing specialties. According to the law, the BIS provides the foundation for a health care practitioner’s prima facie obligation or the idea that the current decision should be accepted as correct, unless one can show otherwise (Bester, 2019b; Kopelman, 2018). In sum, the BIS is a legal standard, a guiding principle, and a limiting or intervening principle.
Similar concepts. There are several other pediatric decisionmaking frameworks, such as constrained parental autonomy (CPA), the zone of parental discretion (ZPD), satisficing versus optimizing parentalism, BISbc (for “best choiceâ€), and the harm principle (HP). Of these, the most recognized alternative concept for BIS is the HP (Blustein, 2012; Diekema, 2011, 2019; Jacobs, 2018; Lantos, 2018; Paquette, 2019; Winters, 2018). Proponents of the HP assert that the BIS is appropriate as a guiding standard but is too vague to be an intervening or limiting principle (Diekema, 2019; Ross, 2019a; Shah et al., 2018; Truog, 2020). Supporters of BIS respond to this criticism in four main ways. First, the foundation on which the HP is built, a moral framework grounded in utilitarianism and written in the late 1800s about society, state, and the importance of individuality, is inapplicable to the context of making pediatric health care decisions (Bester, 2018b; De Clercq & Ruhe, 2018; Mill, 1874). Second, the BIS is intentionally flexible because decisions that must be made for a child and their family are more complex than the HP can accommodate (Bester, 2018a; Kopelman, 2018; Millum, 2018; Pope, 2018). Third, the HP is incorporated in the BIS because the ethical principle of nonmaleficence, or do no harm, serves as one of the core pillars of the BIS. Since a clear and nuanced way of treating harm is already part of the BIS, there is no need for the HP as an independent concept in pediatric decision-making (Bester, 2018b; Hester et al., 2018). Finally, the HP sets the minimum standard of imminent harm to a child as the threshold for making a pediatric health care decisions. Advocates of the BIS ask why anyone, especially children, should have to accept the minimum standard from their parents or health care providers (Bester, 2018c).
Uses of the concept. Determining how the BIS concept has been used in the past and how it may be used in the context of school health facilitates the development of the “right†answers. The BIS is widely used in law, medicine, nursing, and psychology, as well as across diverse subgroups including the elderly, neonates, and cognitively or developmentally impaired populations of all ages. The BIS’s application across these diverse disciplines and subgroups contribute to its place as the prevailing ethical paradigm for pediatric decision-making. The BIS has been used to facilitate health care decisions regarding growth hormone treatments, gender assignment surgeries, life support withdrawal, vaccination choice, child organ or tissue donation, nonbeneficial research participation, and elective surgeries for schoolaged children (De Vries, 2013; Gomez et al., 2016; Klein & Saroyan, 2011; Noggle, 2013; Sullivan et al., 2015). The BIS has also facilitated decisions that involve family discord and the active or passive choice of a parent/guardian to not make a decision (Brown, 2018; Piasecki et al., 2015; Sachdeva & Morris, 2013; Taylor, 2018). The BIS has also been applied to ethically challenging situations that require assessment of a child’s level of understanding regarding a medical decision being made for them and consideration of the psychological damage that may occur by intervening to override the original decision based on religious or cultural beliefs (Appel, 2015; Kon, 2015). In sum, these uses of the BIS illustrate the multidimensionality and versatility of the concept for school nurses.
While there is limited evidence that the BIS has been applied in school health, the BIS is frequently used to facilitate pediatric health care decisions. Therefore, several parallels can be drawn from pediatric health care decisions to school health related decisions. In both pediatric and school health decisions, decision-making is complicated by the addition of a third party, the child’s parent(s)/guardian(s) (Marron, 2018). The central focus of the BIS is the child although parents/guardians typically make health care decisions for children. Thus, it is essential that open and honest communication takes place between members of the patient–provider–parent triad all the while recognizing that parents/guardians and providers have different roles and responsibilities to the very same child (Casey, 2019; Marron, 2018).
Parent(s)/guardian(s) are presumably the ideal health care decision makers for their child for several reasons. The close proximity and constant engagement between the child and their parent(s)/guardian(s) create an intimate bond that may provide important information informing the health care decision. Parents/guardians often have insight into their child’s current wishes and incur much of the burden associated with pending health care decisions, including financial burdens (Salter, 2012). Parents/guardians know that the health care decision they make for one of their children may affect other family members, including the child’s siblings. On the other hand, the health care provider’s responsibility is concentrated on promoting the child’s best health care interests (Navin & Wasserman, 2019). The role of the provider and school nurse include educating, informing, and even nudging the parent(s)/guardian(s) with decisional authority (Gorin et al., 2017; Ross, 2019b). Further action is only required when a disagreement occurs between parties. As Rhodes & Holzman (2014) explain, “Even when people agree on the factors that are most relevant to a specific judgement, they can prioritize them differently and, therefore, reach different conclusion about what is best†(p. s122).
Both the following operational definition and the identified essential elements are two separate but connected ways toward providing a comprehensive clarification of the BIS concept. In sum, the operational definition of BIS arising from this concept analysis is that the BIS is a general ethical principle that optimally protects and promotes the subjective and objective welfare interests and well-being of a child, all things considered. The essential elements of the BIS that have been identified include (1) an assessment of the student’s immediate and forward-looking well-being, rights, and interests; (2) a consideration of practical, emotional, and cultural family/parent/guardian matters; (3) and the involvement of all parties—while adhering to the four ethical principles of autonomy, beneficence, nonmaleficence, and justice toward making a health care decision.
Conceptual model. The BIS conceptual model illustrated in Figure 2 proposes seven complex elements derived from the analysis process when applying the BIS to school health care decision-making. These elements include (1) general health and well-being; (2) moral fitness and parental/guardian capacity to provide care; (3) rights, wishes, and perspectives of the child; (4) consideration of immediate and forwardlooking interests; (5) practical constraints (financial, other children in the family, etc.); (6) the emotional relationship between parent and child; and (7) cultural, spiritual, or religious beliefs of the parent and/or the child. Each of these elements may be assessed collaboratively by an interdisciplinary school team and are considered in relation to the ethical principles of autonomy, beneficence, nonmaleficence, and justice during the decision-making process. Once a decision has been made, BIS can be achieved in one of two ways. The first occurs when all parties involved in making the school health decision are in agreement. The second requires the intermediary step of state intervention or ethics committee involvement. This model proposes that the BIS can be successfully applied when making a school health decision for the good of the child regardless of whether there is unanimous agreement or whether state/ethics committee involvement is needed.
The Wilsonian method of concept analysis presents results through model, contrary, related, and borderline cases synthesized from the literature to illustrate the concept. The case scenario approach is an effective way of defining essential, nonessential, and potential features of the BIS in the context of school health. Essential features identified are italicized in the cases below.
Model case. Model cases are a crucial part of the Wilsonian analysis process. Model cases are designed through an iterative process to provide conceptual exemplars. The model case uses the working definition of BIS to identify essential features of the concept.
A high school junior has been visiting the school nurse frequently. After the third trip within 2 weeks with no apparent health concerns, the school nurse begins building trust using open and honest communication while encouraging the student to do the same. The teenager confides in the nurse feeling overwhelmed by the stresses of balancing her honors and Advanced Placement (AP) classes, college application deadlines, being the captain of a varsity sport team, working a part-time job, and taking care of her younger siblings. Through several of these conversations, the school nurse identifies the teen as someone eligible for, and in need of, school-based mental health services (SBMHS). The stresses are impacting the teen’s daily life. The school nurse reaches out to the school counselor or a community partner liaison, such as the mental health coordinator at the local Young Men’s Christian Association (YMCA), who connects with the student’s parent to offer SBMHS by licensed mental health professionals. “The school nurse immediately recognizes the need to protect and promote the teenager’s general well-being.†The community partner explains to the teen’s parent that sessions are scheduled at a time convenient for everyone, even during school hours, and held in a location of the student’s choosing. The family’s health insurance is government-funded Medicaid and Children’s Health Insurance Program (CHIP), meaning the community partner can bill directly so the parents will not incur any cost. “Objective measures such as practical constraints are considered and addressed all while the community partner begins their assessment of parental moral fitness, subjective values, parent–child relationship, and reasonableness during the conversation.†The teenager’s parents thank the community partner for the information and will call back after discussing the situation with each other and their daughter. After a long discussion, the teen’s parents sit down with the teen and talk about how she feels, if she wants SBMHS, and how this may affect their family as a whole.
Consideration of the teenager’s developmental capacity, allowing her to exercise autonomy, her immediate interests of successfully finishing her junior year, sports, etc. and future interests of getting into college, benefits and potential harms of not using the service, and the family dynamic of taking care of her younger siblings are discussed as influential contextual factors when deciding to participate in SBMHS.
The teen and her parents decide together it is in the best interest of the teen to do whatever is necessary to get her the SBMHS she needs. The teenager’s mother calls the community partner with her daughter to schedule the first session.
This model case exhibits all of the essential elements of the BIS. The student’s well-being, rights, and interests are assessed; practical, emotional, and cultural family matters are considered; and all parties are involved while adhering to the four ethical principles (autonomy, beneficence, nonmaleficence, and justice) toward making a health care decision.
Contrary case. The contrary case describes what the BIS is not. Identifying aspects of the contrary case helps provide insight into what features are important to the BIS. While the context of the following contrary case is the same as the model case, the essential features of the BIS are grossly absent.
A high school junior has been visiting the school nurse frequently, but in the contrary case, the nurse allows the teenager to rest yet again only to return to class. “The school nurse misses the opportunity to ask and explore if anything other than a physical ailment (general well-being) is bothering the teenager.†A teacher notices the same teenager requesting extensions for her assignments, has become introverted, and appears disheveled. Even though the teacher is not aware the school offers SBMHS, the teacher asks the student if everything is alright in passing and the student responds by silently nodding yes. Both parties move on with their day. “The teacher is unaware of the available resources and misses the opportunity to confer with the school nurse or possibly call the teenager’s parents.†The teenager is unable to handle the stresses of balancing her honors and AP classes, college application deadlines, being the captain of a varsity sport team, working a part-time job, and taking care of her younger siblings. This time the teenager’s needs go unnoticed by her parents and her best interests are not met.
Multiple breakdowns occur, from the school nurse, to the teacher, to the teenager’s parents. There is no mention of the student’s general well-being or situation, no engagement between school staff or the parents and the teenager, and no consideration of the student’s immediate or forwardlooking interests, among other core features of the BIS. Nothing about this case shows how the BIS was applied or even considered.
Related case. Related cases are connected to the concept being analyzed but do not share all of the essential features or occur in different contexts. Critically examining this network of similar yet different concepts through related cases helps to gain insight into the defining features of the BIS concept. Related concepts might include pediatric wellbeing or family health care decision-making.
A high school junior has been visiting the school nurse frequently. The school nurse builds a trusting relationship which leads to the teenager confiding in the nurse about feeling stressed and overwhelmed. Through several of these conversations, “the school nurse immediately identifies the teen as someone eligible for, and in need of SBMHS need to protect and promote the teenager’s general well-being.†The stresses are impacting the teen’s daily life, so the school nurse reaches out to a community partner who connects with the student’s parent to offer SBMHS by licensed mental health professionals. The community partner explains to the teen’s parents that sessions are scheduled at a time convenient for everyone, held in a location of the teenager’s choosing, and the family’s government funded health insurance will cover all costs. “Objective measures such as practical constraints are considered and addressed all while the community partner begins their assessment of parental moral fitness, subjective values, the parent-child relationship, and reasonableness during the conversation.†The teenager’s parents thank the community partner and will call them after discussing the situation with each other. After their discussion, the teen’s parents decide not to involve their daughter in their decision and call the community partner to decline the SBMHS.
The child’s autonomy is not considered and the closed discussion between the parents suggests unknown factors may be influencing their decision. It is possible they need their teenage daughter to watch the younger siblings for the parents to earn a living, fear of stigma within the community, or cultural norms of requiring academic excellence may be seen as more important than what the parents think is something their daughter can work through on her own.
The community partner respectfully questions why the parents are refusing consent, if they are willing to share, and asks them to re-consider. Once the parents reiterate their position without specifying a reason, the community partner informs them if their daughter meets certain criteria, an ethics committee may be requested by the school to ensure her safety and best interests are being met. The parents verbalize they understand but still refuse for their daughter to participate in the SBMHS.
A few days later, the teenager heads back to the school nurse’s office with complaints of a headache and refuses to return to class after rest. “The BIS is not being met, harm may be possible, and reasonableness of the parent’s decision has not been established.†The school nurse requests the school ethics commission (may vary state to state) convene to discuss revisiting the teenager’s participation in SBMHS with the parents. Members of the ethics committee, parents, and community partner meet to explain the benefits of SBMHS and delve deeper into the needs of their daughter and family unit. After careful consideration, the teenager’s parents consult their daughter, change their minds, and agree to a trial period of SBMHS as they now understand them to be in the best interest of their child.
After the parents decline SBMHS for their daughter and her mental health continues to decline, it is clear the student’s best interest is not being met. It is not until after the school requests the involvement of an ethics committee that advancement is made towards the successful application of the best interest concept. This related case shares some of the hallmark features of the concept, but not all.
Borderline case. Borderline cases exhibit most, but not all of the essential features of the BIS concept. This borderline case is intentionally designed to be difficult to classify but serves to further define and determine essential elements of the BIS concept being clarified. Other pediatric decisionmaking frameworks mentioned above include CPA, the ZPD, satisficing versus optimizing parentalism, BISbc (for “best choiceâ€), and the HP.
A teacher notices a high school junior in her class is requesting extensions for her assignments, has become introverted, and appears disheveled. The teacher asks the teen to stay after class and tells the student she is available to talk anytime. The teacher also confers with the school nurse who reports the same student has been to the nurse’s office three times in the past 2 weeks with no overt health concerns. “The teacher immediately recognizes the need to protect and promote the teenager’s general well-being.†The school nurse takes that opportunity to educate the teacher on the SBMHS available in case the teenager reaches out. The school nurse also makes a mental note to build trust using open and honest communication the next time this student comes to the office while encouraging the teenager to do the same. Indeed, the student returns to the nurse’s office the same week. During this visit, the school nurse clearly identifies the teen as someone eligible for and in need of SBMHS due to the fact that the teen’s stresses are impacting daily life. “The school nurse immediately recognizes the need to protect and promote the teenager’s general well-being.†The school nurse reaches out to a community partner who connects with the student’s parent to offer SBMHS by licensed mental health professionals. The community partner explains to the teen’s parents that sessions are scheduled at a time convenient for everyone, held in a location of the teenager’s choosing, and the family’s government funded health insurance will cover all costs. “Objective measures such as practical constraints are considered and addressed all while the community partner begins their assessment of parental moral fitness, subjective values, the parent-child relationship, and reasonableness during the conversation.†The teenager’s parents thank the community partner for the information and will call them after discussing the situation with each other. “The teenager’s developmental capacity and her autonomy are not considered, however the potential harms of not using the service is.†The parents decide in order to prevent the teenager from any harm, they will consent for their child to participate in SBMHS. The teenager’s mother calls the community partner to schedule the first session.
Several of the essential features are present such as assessing the student’s well-being, rights, and interests and considering practical, emotional, and cultural family matters while observing the four ethical principles of autonomy, beneficence, nonmaleficence, and justice. However, this is a borderline case because while the outcome is the same, it is not clear whether the HP is guiding the parent’s decision or the BIS.
This analysis affirms the centrality of the BIS within the context of school health. The BIS is an important concept for school nurses because of the unique position they hold in facilitating school health decisions. The BIS essential elements of (1) assessment of the student’s immediate and forward-looking well-being, rights, and interests; (2) consideration of practical, emotional, and cultural family/parent/guardian matters; (3) and involvement of all parties—while adhering to the four ethical principles of autonomy, beneficence, nonmaleficence, and justice toward making a health care decision provide a clear picture of the process for applying the BIS to school health decision-making. Clarifying the BIS for school nurses is important because the practice of school nursing straddles both health and educational regulatory frameworks that impact individual students, their families, and the school population.
The BIS conceptual model developed in this conceptual analysis complements the National Association of School Nurses (NASN) Code of Ethics. The NASN Code of Ethics provides general principles to guide school nurse decisionmaking in the face of ethical dilemmas (NASN, 2016). There are 33 statements for school nurses within this Code of Ethics under seven domains including child well-being, diversity, excellence, innovation, integrity, leadership, and scholarship. Therefore, school nurses and school nurse leaders may find that the BIS conceptual model provides an efficient and parsimonious approach to effectively assist with ethical decisions in the context of school health. Moreover, the BIS conceptual model provides a pathway for action in situations when agreement is lacking between parties involved in the decision-making process.
In sum, it is critical that school nurses employ an ethical framework to ethical challenges. The demand for an effective and efficient framework can only be anticipated to mount in the future. This demand may be driven by increases in medically fragile students, as well as students who have or are at risk for chronic physical, developmental, behavioral, or emotional conditions (Center for Disease Control, 2020; Mayer-Davis et al., 2017; Ogden et al., 2016; Perrin et al., 2014; Sheldrick & Carter, 2018). School nurses may also benefit from an effective and efficient ethical framework as they continue to lead efforts in their communities that address the social determinants of health and to face challenges that pandemics such as COVID 19 will bring to their school communities.
There are several implications for nursing policy, education, and research related to applying the BIS in the context of school health. At the policy level, nursing and other disciplines must continue to refine the BIS concept, so that it remains current for continued use as an ethical standard by leading authority organizations, such as the NASN. At the practice level, training is required to apply the BIS under different scenarios and with varying resources. For example, school nurses need to be aware that the procedure for accessing the ethics committee varies by state (e.g., a review of the procedure to access the ethics committee as this varies by state; Brent, 2013; NASN, 2016; New Jersey Department of Education, 2020). At the education level, the BIS may be incorporated into ethics-focused education specific to school nursing. This ethics-focused education should be a part of the curriculum for nurses training to become school nurses, as well as part of continuing education and/or annual competency reviews. Promoting ethical competency in school health decision-making may also contribute to increased job satisfaction for school nurses, particularly if this competency can be objectively assessed (Jeon et al., 2020). The BIS may lead to future work developing an ethical school nurse competency scale. Finally, opportunities for research include further exploration on how individual contextual factors could affect the BIS by using different pediatric age groups, illnesses, geographic locations, family structures (nuclear versus extended), or theoretical frameworks to guide studies.
According to Wilson, questions of concept may not have one single answer (Wilson, 1969). Additionally, this concept analysis cannot provide absolute verification the BIS is the only concept to use when making school health care decisions, for mental health or otherwise. Furthermore, analyzing the pediatric ethical concept of the BIS is a limitation unto itself as it is not simple or straight forward. An evaluation of the BIS within the context of school health should be validated. Even though limitations exist, the prescriptive and easy to use Wilsonian method allowed for (1) clarification of the BIS, (2) different uses of the concept, (3) the identification of who may use it in practical scenarios, (4) examples of BIS cases, and (5) more specifically how it can be applied to school situations where teenagers are in need of SBMHS.
The BIS for making school health decisions is complex, but this concept analysis explicates it further by defining and outlining the core elements as well as its importance in the context of school nursing. The long-standing ethical concept of the BIS has been used for more than a century and remains relevant to this day when making a difficult school health care decision, especially during times of challenge such as the current COVID-19 pandemic. More than ever, the role and responsibilities of the school nurse align with the application of the BIS concept or optimally protecting and promoting the subjective and objective welfare interests and well-being of a child, all things considered.
Laura Grunin and Susan Malone 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.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Laura Grunin, RN, MSN https://orcid.org/0000-0001-5854-1131
Susan Malone, RN, MSN, PhD https://orcid.org/0000-0001-6861-9377
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Laura Grunin, RN, MSN is a PhD candidate at NYU Rory Meyers College of Nursing in New York, NY, USA.
Susan Malone, PhD, MSN, RN is an Assistant Professor at NYU Rory Meyers College of Nursing in New York, NY, USA.
1 NYU Rory Meyers College of Nursing, NY, USA
Corresponding Author:Laura Grunin, RN, MSN, NYU Rory Meyers College of Nursing, 433 First Avenue New York, NY 10010, USA.Email: lg2980@nyu.edu
