The Journal of School Nursing2021, Vol. 37(5) 374–386© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519880605journals.sagepub.com/home/jsn
A gap analysis was used to examine the scope of school nursing practice in the United States. An investigator-developed 39-item self-assessment survey of scope of school nursing practice was modified from an existing validated tool, organized around the five principles of the National Association of School Nurses’ Framework: Standards of Practice, Quality Improvement, Care Coordination, Community/Public Health, and Leadership and also explored barriers to practice. The survey was sent to a national convenience sample of practicing school nurses. The survey was completed by 3,108 practicing school nurses. Gaps were identified for all principles and were greatest for Quality Improvement and Community/Public Health practice. All practice items were rated more important than the ability to practice that item (p < .001). Self-identified barriers including workload, school/district expectations, and state regulations accounted for significant variances in practice across four of five principles (p < .05, p < .001). Recommendations include support for population-focused evidence–based school nursing practice.
scope of practice, role promotion/development, standards of care, evidence-based practice, school nurse knowledge/perceptions/self-efficacy, school nurse characteristics
School nurses play a vital role in the health and academic readiness for the nation’s 74 million youth under the age of 18 (National Center for Education Statistics, 2018). Keeping children healthy and ready to learn has been the goal of school nursing since 1902 (Johnson, 2017). Twenty-first century changes in health care include shifts away from hospital-based acute care to community-based prevention and care of chronic illness. School nurses are uniquely positioned in the community to address student health needs related to chronic illness management, mental health, wellness, and prevention, thereby promoting school attendance and academic achievement (Maughan et al., 2017). On the front lines of community-based health care, school nurses have been called to be “catalysts for change” in addressing the declining health of our nation (Storfjell, Winslow, & Saunders, 2017, p. 1).
Significant variances in the scope of school nursing practice across states and school districts persist (Praeger & Zimmerman, 2009; Willgerodt, Brock, & Maughan, 2018). These variances in scope of school nursing practice represent a potential practice gap that impacts the health, wellness, and safety of children in the United States (American Academy of Pediatrics [AAP], 2016; Maughan et al., 2017; National Association of School Nurses [NASN], 2016b). Nurses practicing to full scope—to the full extent of their education and training—have the potential to play a key role in health reform, creating a safer, more patient-centered system of care to meet the changing needs of a diverse population (Cowell, 2012; Institute of Medicine [IOM], 2011).
There are an estimated 132,300 practicing school nurses in public and private schools in the United States. However, there is a gap in workforce data describing how school nurses practice, an understanding of which is crucial in determining needed resources to meet 21st-century challenges (Willgerodt et al., 2018). An analysis of the scope of school nursing practice and existing barriers to full scope of practice will provide an understanding of the gaps in practice and point to potential avenues to expand school nursing practice to full scope, thereby addressing student health needs.
The first recommendation of the Institute of Medicine Report, The Future of Nursing: Leading Change, Advancing Health (2011), is that nurses practice to the full extent of their education and training. However, this scope of practice as it pertains to school nurses, and other nonadvanced practice nurses, is not well explored (Benton, Cusak, Jabbour, & Penney, 2017). The American Nurses Association (ANA, 2015) outlines a model of nursing scope of practice pertaining to all levels of practice, wherein professionally defined scope and standards of practice form the foundation of practice, which is then limited by state regulations, institutional policies and procedures, and the practicing nurse’s selfdetermination. Dery, D’Amour, Blais, and Clarke (2015) explicate the concept of enacted scope of practice, reflecting the actual practices carried out by nurses and not the full range of activities for which nurses are educated, which is referred to as optimal or full scope of practice. For school nurses, the ANA and NASN (2017) define the scope and standards of school nursing practice and acknowledge that the full depth and breadth of school nursing practice are impacted by several factors: the school nurse’s educational preparation, licensure, and experience and factors in the work environment such as role definition, workload and work environment, and the population served.
The purpose of this study was to explore the scope of school nursing practice in the United States, identify potential practice gaps and barriers to practice, and make recommendations to address identified gaps. The gap analysis framework described by the Agency for Healthcare Research and Quality (AHRQ, 2018) was utilized. This gap analysis framework describes the following steps: (a) identify a practice standard, (b) examine current practice, (c) detect barriers to practice, (d) analyze the gap between current practice standards and actual practice in light of those barriers, and (e) determine recommendations to address identified gaps (AHRQ, 2018; Davis-Ajami, Costa, & Kulik, 2014). Gap analysis has been used to address gaps between nursing education and practice (Beauvais et al., 2017) and between standards of practice and actual practice in a health system (Golden, Hager, Gould, Mathioudakis, & Pronovost, 2017). In these studies, gaps are identified for a comprehensive array of standards, recommendations are made based on an analysis of the gaps identified, and workgroups successfully implement the recommended changes.
To measure the gap between actual and full scope of practice, only one validated measure for examining the scope of nursing practice was found in the literature, the Actual Scope of Practice Questionnaire (D’Amour et al., 2012). However, this instrument was not specific to school nursing practice. To measure the unique practice of school nursing, the development of an instrument utilizing school nursing practice standards was warranted. The Framework for 21st Century School Nursing Practice (hereafter Framework; NASN, 2016a) exemplifies the school nursing practice standards as defined in the School Nursing: Scope and Standards of Practice (ANA & NASN, 2017) and is associated with positive health and education outcomes for students and school communities (Best, Oppewal, & Travers, 2018).
A cross-sectional exploratory survey design, framed by gap analysis, was used to examine the current scope of school nursing practice in the United States and barriers to full scope of school nursing practice. Current school nursing practice and barriers to achieving full scope of school nursing practice were defined through items on a researcher-designed survey. Surveys were deployed electronically using a university-approved e-Survey platform. The study received Georgetown University Institutional Review Board approval and was determined to be exempt. All participants provided informed consent on first page of the electronic survey.
The sample was drawn from the more than 17,000 school nurses who were members of NASN at the time of survey deployment through the NASN weekly e-digest. This weekly e-digest is available to school nurses, school nursing leaders, and others interested in school health. NASN members and state-affiliate leaders were encouraged to forward the e-mail invitation with survey link to school nurses who may not have received it. Thus, the study used both convenience and snowball sampling strategies (Polit & Beck, 2017). The decision to include both NASN members and nonmembers was intentional and helped mitigate sampling bias.
Inclusion criteria for participation were self-identification as a currently practicing frontline school nurse, able to read English, and access to a computer or mobile device with stable Internet connectivity. Exclusion criteria were non-frontline school nurses (i.e., those working in school-based health centers, school nurse administrators, school nurse retirees, researchers, and educators who did not have a frontline school nurse role). Nurses practicing in an advanced practice role were also excluded as their scope of practice is different from frontline school nurses. Based on response rates of prior surveys deployed by NASN (Mangena & Maughan, 2015; Willgerodt et al., 2018), the anticipated number of respondents for this study was approximately 5,000.
After extensive literature review and consultation with school nursing experts, no instrument was found that captured school nurses’ perceptions regarding their scope of practice utilizing the Framework. Therefore, a researcher-designed survey instrument entitled Scope of School Nursing Practice Survey™ (SSNP) was developed to ascertain school nurse perceptions of their current practice. The SSNP survey was informed by the Actual Scope of Practice Questionnaire (ASCOP), a validated instrument designed to study scope of nursing practice (D’Amour et al., 2012) that used a 6-point Likert-type scale. Permission was granted to use the ASCOP as a guide for SSNP development. Items on the instrument reflect competencies for school nursing practice developed by the ANA and NASN, as published in the Third Edition of the School Nursing: Scope and Standards for Practice (ANA & NASN, 2017). The Framework was used to organize the School Nursing Standards of Practice into the familiar language and principles of school nursing practice that it exemplifies. A crosswalk was created to ensure the six Standards of Practice for School Nursing and the 12 Standards of Professional Performance that comprise the School Nursing Standards for Practice were adequately reflected in the SSNP items.
The SSNP survey was intentionally and rigorously designed. A three-step process was used to generate survey items. First, a competency document developed by the NASN Framework designers was used to generate selfassessment practice descriptors. Second, the NASN Framework descriptors were placed alongside the ASCOP items (D’Amour et al., 2012). The goal of this step was to ascertain similarities and differences and to provide a broad range of items that describe the breadth and depth of school nursing practice using the established ASCOP tool as a formatting guide. Third, items were honed to ensure they represented clearly just one element of school nursing practice described by the Framework.
Survey format was chosen to be a 6-point Likert-type scale (DeVellis, 2017). Participants first self-reported the frequency with which they practiced each item (ranging from 1 = never to 6 = always) and then reported perceived importance of each item to school nursing practice (ranging from 1 = not at all important to 6 = absolutely imperative). Frequency of practice items and importance to practice items were phrased identically (Table 1). Decisions about the order of the two sets of items (frequency then importance) were made purposefully by the project team to reduce social desirability bias (DeVellis, 2017; Polit & Beck, 2017).
In addition to the Likert-type items on the SSNP survey, participants were asked: Overall, which of the following impact your ability to practice school nursing as you would like?—Select all that apply. Potential barriers enumerated were based on the literature and expert consultation and included items such as workload, laws, policies, other’s expectations of the school nurse’s role, and inadequate resources (ANA & NASN, 2017; Mangena & Maughan, 2015; Willgerodt et al., 2018).
Steps were taken to ensure the SSNP survey was content and face valid. Expert content review was provided by eight doctorally prepared school nurse researchers. Content validity indices were examined (DeVellis, 2017). Modifications were made to the SSNP survey based on expert review. Items were entered into the e-Survey platform. Subsequently, eight frontline school nurses tested the platform user interface, completed the e-Survey, and provided feedback on ease of completion and usability. No modifications were made following frontline school nurse review. The final survey consisted of 39 items with the number of items per principle as follows: Care Coordination: 12; Community/Public Health: 8; Quality Improvement: 8; Leadership: 8; and Standards of Practice: 3.
Recruitment was conducted through two personalized emails sent at 2 weeks and 1 week prior to deployment of the survey to all NASN members and all e-digest subscribers. At Week 3, an electronic invitation with an embedded survey link was sent to these same groups. The data collection period continued for 4 weeks, and two reminder e-mails were sent. The survey was then closed. Data were collected during spring 2018.
The participants included in the study were frontline practicing school nurses, a subset of the larger group who received the invitation and survey link. The survey was opened by 5,214 people. The first question asked whether the respondent was a frontline school nurse; 495 respondents were not and exited the survey, leaving 4,719 potential participants. Of these, 1,611 did not complete the entire survey. The sample size of completed surveys was 3,108. A response rate cannot be calculated because there is an unknown number of frontline practicing school nurses who received the survey link. However, of those who opened the survey and were eligible, 65.9% completed the survey.
The sample and school characteristics are described in Table 2. The average age of respondents was 51.9 years. Nearly half of respondents (48.6%) identified their highest education level as a bachelor of science in nursing (BSN). Either national or state school nurse certification was reported by almost half (49.4%) of the practicing school nurses. Most school nurses worked in public schools (85.6%) and reported to a non-RN supervisor (65.8%). Almost half of all school nurses worked in one school building (49.7%) though some worked in as many as 10 buildings (3.5%). There was a wide range of students served, from 125 or fewer (2.9%) to more than 5,000 (2.6%). The most frequent model of practice was one nurse providing direct care in one building without assistance (43.6%).
To answer the first research question, participants were asked to indicate the frequency of performing each practice item in their current practice and then to rate the importance of each item to school nursing practice. Gaps were identified in the practice of all Framework principles (Care Coordination, Community/Public Health, Quality Improvement, Leadership, and Standards of Practice), with the largest gap in Quality Improvement practice and the smallest gap in Standards of Practice. Cronbach’s α was computed for the practice items on the SSNP survey using the sample for this study, α = .936. Overwhelmingly, across all five principles, the respondents rated the importance of the item higher than the frequency with which they practiced it (Table 3).
To answer the second research question, school nurses were asked to identify the top three factors that impact their ability to practice school nursing as they would like (Table 4). The top three barriers identified were time–workload–caseload, school’s/district’s expectations of your role, and state laws and policies.
Relationship of barriers to practice. To determine the effects of these identified barriers on practice, mean ratings for current practice in all five of the Framework components (Care Coordination, Community/Public Health, Quality Improvement, Leadership, and Standards of Practice) were compared between those who selected a specific barrier and those who did not, using independent samples t tests. A number of barriers were found to be statistically significantly related to practice, although all had small effect sizes (Table 5).
Open-ended responses. An open-ended response format was provided for respondents to add comments related to their scope of school nursing practice and 141 responses were obtained. The responses were compiled into common themes, categorized by topic, and counted (Table 6).
Demographics: Impact on practice. Simultaneous linear regression analyses were used to predict practice frequencies for each of the five Framework principle domains (Care Coordination, Community/Public Health, Quality Improvement, Leadership, and Standards of Practice) from the following six independent variables: years as a nurse, number of students served, number of buildings served, model of practice, certification, and free and reduced-price lunch (Table 7). The predictor variables were selected because they are often identified within the literature as having an impact on school nursing practice.
Years as a nurse increased the frequency of practice for Care Coordination, Community/Public Health, Quality Improvement, and Leadership. Holding national school nurse certification or multiple other certifications increased the frequency of practice on all five Framework principles compared to having no certification. Holding state certification as a school nurse conveyed significance only in the Leadership principle. The number of buildings covered by a school nurse also impacted scope of practice but only for the principle of Leadership. For each additional building (up to 10), there was an increase in the frequency of Leadership practice (p < .05). There were no clear trends in number of students served. Leadership practices were significantly lower if there were more than 75% of students receiving free and reduced-price lunch but there was no other relationship for that construct. Model of Practice (number and type of ancillary supports and number of buildings a school nurse covers) had the most significant effects in the Quality Improvement and Public Health principles. However, there was no clear trend indicating a particular model of practice increased scope of practice.
Regional differences. Analysis of variance was computed to determine regional differences in practice frequency and importance to practice ratings for all Framework principles. Regions were defined by the U.S. Department of Health and Human Services Regions and grouped into four areas: (1) Northeast and Mid-Atlantic, (2) South/South Central, (3) Midwest, and (4) West (Figure 1). There were significant differences in school nurses’ reported frequency of practice of the Framework principles by region for all Framework principles (Table 8). The greatest differences in practice were seen in Community/Public Health (p < .001, η2 = .04) and Quality Improvement (p < .001, η2 = .04) practices, indicating that the region accounts for 4% of the variance in those ratings. School nurses in the Northeast/Mid-Atlantic and the South/South Central regions reported more frequent practice of the Framework principles than school nurses in the Midwest and West regions (Figure 2). Significant regional differences were also found in importance ratings for all Framework principles. Notably, Community/Public Health differences were significant at the p <.001 level.
This gap analysis and study is the first of its kind and provides insight into the scope of school nursing practice across the United States. In this gap analysis, full scope of practice (NASN’s Framework and Scope and Standards of Practice) is compared with current practice. Once the gap is identified, barriers that impact the gap are addressed.
The largest gap between actual school nursing practice and full scope of school nursing practice identified in this study was in the Quality Improvement principle. The less frequent engagement in Quality Improvement practice found in this study describes a known gap in school nursing practice (Bergren et al., 2017; Maughan, Johnson, & Bergren, 2018; Maughan et al., 2014). Current initiatives to address this gap are aimed at culture change, education, and practical data collection processes (Bergren et al., 2017; Maughan et al., 2018; Maughan & Yonkaitis, 2017).
There was a range of practice frequencies within the Quality Improvement principle. The highest frequency Quality Improvement practice was documenting care provided. This is a foundational nursing responsibility and the first step in data collection for Quality Improvement. However, school nursing documentation is often nonstandardized and does not allow for comparisons across time and across the practices of other school nurses at the local, state, and national levels (Bergren et al., 2017; Maughan et al., 2014). It is not surprising, then, that the lowest frequency Quality Improvement practices were related to aggregating and benchmarking data. Several participants acknowledged, in the open-ended responses, the lack of external data for benchmarking on the local, state, or national level. These findings lend support for the NASN data initiative, National School Health Data Set: Every Student Counts! (Maughan et al., 2018). Differences in Quality Improvement practice by region indicate a need to explore local barriers that may inhibit this necessary component of 21st-century school nursing practice.
After Quality Improvement, the least frequent practices were in the Community/Public Health principle. This practice gap is concerning in light of the national shift to community-based care and the school nurse’s foundational role in public health (Bergren, 2017b; IOM, 2011; Storfjell et al., 2017). There was a range of frequencies reported for Community/Public Health activities. Activities practiced frequently to almost always within the Community/Public Health principle related to working with students within the school. Activities practiced only sometimes to frequently within the Community/Public Health principle were related to school and community outreach. This pattern of more frequent practice with students and less frequent practice with the school or community is consistent across four of the five Framework principles and points to a gap related to a population-focused practice.
Self-identified barriers to Community/Public Health practice were time–workload–caseload and inadequate resources. Higher frequency practice within the Care Coordination principle may indicate that school nurses with limited resources attend to Care Coordination practice before engaging in Community/Public Health practice. Additionally, open-ended responses indicated school nurse’s roles were often determined by others, such as the school principal, or that their role was limited to direct care.
Lower frequency practice and importance ratings for practice items within the Community/Public Health principle are consistent with reports in the literature of inadequate preparation in public health concepts for currently practicing school nurses (Allen-Johnson, 2017; Cogan, Conway, & Atkins, 2017). The fact that only half of school nurses have a BSN degree may contribute to lack of preparation for Community/Public Health practice. BSN preparation, recommended by NASN (ANA & NASN, 2017), includes Public Health content and skills (American Association of Colleges of Nursing, 2008) that may not be included in RN or LPN programs.
Significant differences in Community/Public Health practice by region indicate the need to explore local community factors that may impact this crucial element of 21st-century school nursing practice. These include social health determinants such as poverty and state health care law, as well as the impacts of state education mandates and the state Nurse Practice Acts on school nursing scope of practice. There is a role for national organizations to provide guidance and advocacy to enable school nurses to practice to full scope to better address the health needs of the students in their schools.
On average, school nurses indicated they frequently to almost always engaged in Leadership practice items. However, both the highest overall frequency item in the survey, “I hold myself accountable for my school nursing practice” and the lowest overall frequency item in the survey, “I seek out new funding or models that will financially support my school nursing practice” are within the Leadership principle. The highest frequency item is related to standards of practice and the lowest frequency item is related to system level work involving community outreach, which is consistent with trends across four of the five principles.
Barriers that significantly impacted school nurses’ abilities to engage in Leadership practice items were the school/district’s expectations of the role and the state Nurse Practice Act. The impact of the interplay between the education system (school/district and state) and the health system (Nurse Practice Act) has been implicated in lack of BSN readiness for school nursing practice (Newell, 2013), moral distress in school nurses (Savage, 2017) and variances in school nursing practice across states (Praeger & Zimmerman, 2009; Willgerodt et al., 2018).
School nurses who served greater than 75% of students receiving free and reduced-price lunch were less engaged in Leadership practices. Free and reduced-price lunch is an economic measure; poverty is related to an increased use of nursing services (Fleming, 2011) and poorer health (Bor, Cohen, & Galea, 2017). It is possible that engagement in greater amounts of episodic direct care for these students minimizes the time and energy for school nurses to engage in Leadership practices. Within the Leadership principle, however, is the practice component of advocacy. This finding, therefore, is a major concern.
The number of buildings the school nurse covered predicted an increase in frequency of Leadership practices. It is possible that school nurses who cover more buildings do not spend as much of their time providing direct care and can therefore attend to Leadership practices, which require time away from direct care.
The majority of activities practiced most often were in the Care Coordination principle, which is not surprising, as these activities are considered traditional school nursing responsibilities (Bergren, 2017b). However, within the Care Coordination principle, working with others, communication, and training others on emergency health care occurred more frequently than the actual practice of coordination of care to meet the health needs of students and families. Coordination of care is an important role that the school nurse is uniquely qualified to fill (McClanahan & Weismuller, 2015). It is not surprising that inadequate resources were the most significant self-identified barrier to engaging in Care Coordination practices. McClanahan and Weismuller (2015) linked effective case management with having adequate time and fiscal resources, noting in their integrative review, that many authors concluded that effective case management could not be done as a regular part of school nursing duties but instead required dedicated time and personnel.
Interestingly, less than 8% of school nurses indicated the lack of an electronic health record (EHR) in their top three barriers to practice. However, the lack of an EHR had the second largest effect size on Care Coordination practices, after inadequate resources. Lack of access to an EHR in the school health office hinders essential documentation for the coordination of patient care, the ability to standardize and aggregate health data to improve care and inhibits communication between school nurse and provider (AAP, 2016; Fleming & Willgerodt, 2017; Maughan et al., 2014; Nadeau & Toronto, 2016). Promoting the use of an EHR may enhance capabilities for all Framework practices.
School nurses in this study rated their frequency of practice the highest on items related to standards of practice and reflective of ethical principles, such as advocating for students even if others disagree, holding themselves accountable, and utilizing clinical guidelines and strong evidence to plan nursing interventions. Barriers, including time–workload–caseload and inadequate resources, had smaller effects on the Standards of Practice principle. Standards of Practice can be seen as a workforce strength.
Nearly two thirds of the respondents identified time–workload–caseload in their top three impacts on their ability to practice as they would like, and many of the open-ended responses discussed time and workload issues. School/districts’ expectations of the school nurse role and state laws and policies together account for more than 80% of the responses. Many open-ended responses identified education system practices, policies, and interprofessional interactions at the root of nursing practice determinations. Findings from this study strongly indicate a need to strengthen school nursing practice in the context of school nurse’s employment within the educational system. Navigating the complexities of the school nurse role requires education and mentoring that inconsistently occurs across states and school districts (Davis, 2018; Newell, 2013; Yonkaitis, 2018).
Several demographic impacts on practice occurred across Framework principles. Both experience as a nurse or school nurse and national school nurse certification were related to increased scope of practice. Nursing experience was positively correlated with practice in four of the Framework principles, whereas educational preparation was not. Years of experience may provide on-the-job training in navigating educational system policies and expectations and better understanding of the role, thereby enabling the school nurse to more frequently engage in Framework practices. This underscores the need for specialized training, education, and mentoring for the complex role of the school nurse. This also highlights the concern that the aging school nursing population is nearing retirement. Focused plans for mentoring incoming school nurses are critical.
Similarly, national school nurse certification, or having multiple certifications, increased the frequency of practice in all five Framework principles compared to having no certification. State certification as a school nurse conveyed significance only in the Leadership principle. These findings point to the importance of national practice standards that are evidence-based, and not state determined, and the potential for national certification to reduce variances in practice across states and school districts. There is a need for local advocacy for evidence-based policies and practices that determine the school nurse role (Willgerodt et al., 2018).
School nurses rated the importance of each Framework practice higher than their frequency of performing of that activity. Believing that an activity is important may provide incentive to engage in that activity, as described in the self-determination aspect of nursing practice regulation model (ANA, 2015). The gap between what the school nurse believes is important to do, and what the school nurse can realistically accomplish, can lead to significant moral distress (Savage, 2017). School nurses can experience significant moral distress in relation to not having enough time and resources to deliver care, especially to children with chronic illnesses (Powell, Engelke, & Swanson, 2017). Savage (2017) also found moral distress in school nurses in response to the competing demands of health care and educational policies. Interestingly, these three impacts on moral distress were the top three barriers to practice identified in this study. Addressing the root causes of moral distress, including the self-identified barriers to practice, and educating school nurses on ways to alleviate moral distress (Savage, 2017) may contribute to increases in scope of practice in other areas of the Framework.
Several limitations of the study exist. Although the survey was reviewed by experts and had acceptable internal consistency (>.7; Polit & Beck, 2017), the tool used in this survey was new. The use of convenience and snowball sampling may not be reflective of the population of practicing school nurses in the United States, though demographic data obtained in the survey were consistent with other U.S. school nursing workforce studies (Mangena & Maughan, 2015; Willgerodt et al., 2018).
Findings from this study highlight areas of focus for school nursing with implications for practice, education, research, and advocacy. First, the study found the largest gap in Quality Improvement practice and a relatively low valuation of its importance to school nurses. Data school nurses gather must have salience for both improving the practice of school nursing and demonstrating school nurse practice outcomes on measures that are linked to students’ health and academic performance such as attendance (Bergren et al., 2017). Linking school nurse efforts to academic goals is crucial in advocating for the role of the school nurse within educational settings. The NASN National School Health Data Set: Every Student Counts! provides a structure for the school nurse to begin the standardized documentation that will facilitate the school nurses’ more frequent engagement in Quality Improvement practices (Maughan et al., 2018).
Second, the low valuation and engagement in Community/Public Health activities points to a great need to increase the population health focus of current school nursing practice. A population health focus supports the key role of the school nurse in ameliorating inequities (Canales, Drevdahl, & Kneipp, 2019) and is congruent with health care shifts from hospital to community-based health care and from volume to value (Bergren, 2017b; IOM, 2011; Maughan & Davis, 2019; Porter & Kaplan, 2016). The shift will require a national effort of education, research, policy development, advocacy, and mentoring of school nurses to implement Community/Public Health nursing practice (Storfjell et al., 2017). Education and mentoring of school nurses should address public health concepts and skills, navigation of the complexities of organizations, interprofessional relationships, and state/school district regulations.
Third, the gap within the Care Coordination principle regarding the practice of coordination is concerning and must be examined further. School nurses take the lead in coordination of the care of youth with chronic health care needs attending school. Elements of the school nurse’s role in Care Coordination have been described (McClanahan & Weismuller, 2015), and the process for effective coordination of care utilizing school nurse case management has been explicated (Engelke, Swanson, & Guttu, 2014; NASN, 2019). NASN (2019) recently published a white paper regarding the central role of the school nurse in care coordination in the school setting. School nurses need to reach out beyond the areas under their direct control and influence and coordinate the work of others. Barriers such as the school/district’s expectations of the school nurse role must be addressed through policy development and advocacy both on the national and local levels. Consideration must be given to resource issues. The school nurse may not be able to provide effective coordination of care for children with chronic illnesses if there is not dedicated time to do so.
School nurses must address the barriers to full scope of practice at the national and local levels. This will require clear articulation of their full scope of practice tied to the positive health and education outcomes related to full scope of practice and the necessary resources to achieve full scope of practice. National standards and evidence-based practice guidelines are needed for school nurses to utilize in local advocacy regarding the school nurse role. School nurses in this study indicated that they recognized the constraint placed on their practices from state and school district policies and their state Nurse Practice Act. School nurses must take the lead and see these constraining policies as something they can influence and change (Bergren, 2017a). On the national level, outreach to organizations such as the Association of School Superintendents, the National Association of Local School-Boards, and School Principal organizations can provide education system leadership with an understanding of the role of the school nurse and the connection between school nursing and positive health and education outcomes for students and school communities. Within the school district, school nurses can advocate for job descriptions and a performance evaluation process that utilizes the Framework and includes a school nurse supervisor or peer in the process. Performance appraisals that consider school nursing practice standards and school district policies and include both nursing and school administrator review help to educate the nonnursing supervisor on the role of the school nurse (Haffke, Damm, & Cross, 2014; Southall et al., 2017). Other local advocacy efforts can take place at the school board or state legislative level (Bergren, 2017a).
School nurse’s moral distress must be explored and addressed. Gaps between practice and importance found in this study, and the school nurse’s open-ended responses indicate a vulnerability to moral distress. Advocacy at the national and local levels to remove barriers and attain resources that support full scope of practice is needed.
There are several recommendations for further research. First, results from this study demonstrate that there is no particular practice model (i.e., number and type of ancillary supports and number of buildings a school nurse covers) with clear advantages to increase the scope of school nursing practice. Research that provides evidence linking effective staffing and resources to student health and education outcomes is needed.
Second, this study has identified regional differences accounting for practice variance across all Framework principles, with the greatest differences in two of the least practiced principles, Quality Improvement and Community/Public Health. Regional practice differences and associated barriers to practice must be clearly analyzed to identify regionally targeted intervention to increase the scope of school nursing practice in those regions.
The Scope of School Nursing Practice survey provided a self-assessment tool for school nurses to view their scope of practice and barriers to full scope of practice through the lens of the Framework for 21st Century School Nursing Practice. Gaps in practice and barriers to practice were identified and explored. To address the 21st-century needs of students and school communities, school nurses will need to fully embrace a population focused, evidence-based practice with the school nurse as the leader in coordinating care for children with chronic illness. The Framework for 21st Century School Nursing Practice provides a blueprint for both a national agenda and local assessment focused on the vital role of the school nurse in the health and academic outcomes of students and school communities.
The authors wish to thank Nancy Crowell, PhD, for her statistical analysis.
Diane Davis, Erin D. Maughan, and Krista A. White were involved in the conception of the article while the draft was prepared by Diane Davis. All authors contributed to acquisition and analysis of the data, were involved in the revisions, 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.
Diane Davis, DNP, RN, PMHCNS-BC, CNL https://orcid.org/0000-0002-2403-6724
Erin D. Maughan, PhD, MS, RN, PHNA-BC, FNASN, FAAN https://orcid.org/0000-0002-0176-1499
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Diane Davis, DNP, RN, PMHCNS, is an assistant professor at the School of Nursing and Health Studies, Georgetown University.
Erin D. Maughan, PhD, MS, RN, PHNA-BC, FNASN, FAAN, is the director of research at the National Association of School Nurses and an adjunct associate professor at the School of Nursing and Health Studies, Georgetown University.
Krista A. White, PhD, RN, CCRN-K, CNE, is an associate professor at the School of Nursing and Health Studies, Georgetown University.
Margaret Slota, DNP, RN, FAAN, is the director of the DNP Studies, PM-DNP Program and an associate professor at the School of Nursing and Health Studies, Georgetown University.
1 School of Nursing and Health Studies, Georgetown University, Washington, DC, USA
Corresponding Author:Diane Davis, DNP, RN, PMHCNS-BC, CNL, School of Nursing and Health Studies, Georgetown University, 3700 Reservoir Rd NW, Washington, DC 20057, USA.Email: diane.davis@georgetown.edu
