There is similarity, however, in the types of services offered from one school system to the next, which is likely the result of several factors. A majority of states have state school nurse consultants, many of whom have distributed sample policy and procedure manuals from their state department of health or education or both, to guide the development and delivery of health services in local settings. The National Association of School Nurses has defined roles and standards for school nurses (Proctor et al., 1993) and provides a system for disseminating information and training to nurses who practice in schools. The American School Food Service Association has recently released standards for school foodservice and nutrition practices (American School Food Service Association, 1995). Similarly, organizations such as the National Association of School Psychologists, the American School Counselor Association, and the National Association of Social Workers have published position statements and standards for their professions. The American School Health Association (ASHA), through its interdisciplinary committees, has studied the advantages and disadvantages of different services, the organization and delivery of services, and the roles of various school health service providers. Subsequently, ASHA publications have brought this information to the attention of state and local health and education agencies. The American Academy of Pediatrics, working closely with national representatives of the school health services sector as well as the community health system, periodically updates a school health manual, School Health: Policy and Practice , that serves both as another unifying force and as an informal mechanism for ensuring local program quality (American Academy of Pediatrics, 1993). Within this document are the following seven goals of a school health program:
In some school districts, school nurses are employees of the school system; in others, school nurses are provided by the local health department or another agency. The National Association of School Nurses recommends a ratio of one school nurse per 750 students. In recent years, there has been interest in expanding the school nursing function through the use of nurse practitioners, nurses with additional training (generally at the master's level) who are certified by state laws to provide a range of primary care services. School-based nurse practitioners can perform physical examinations, prescribe certain medications with physician protocols, and frequently serve as the anchor provider in school-based clinics. The drive for independence from physicians has characterized the nurse practitioner movement (Clawson and Osterweis, 1993); however, school-based nurse practitioners usually have a backup relationship with a licensed physician in the community. Other graduate programs prepare school nurses for administrative and management roles, as well as for mental health positions in schools.
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Burdens and responsibilities of school nurses are expanding as the increasing numbers of students with special needs and students without adequate health care and health insurance increase. School nurses must keep up with changing practices and procedures, but sometimes education in the specialty of school nursing is not readily available. In 1995, the Southern Council on Collegiate Education for Nursing, an affiliate of the Southern Regional Education Board (SREB), conducted a survey of 450 institutions with college-based nursing programs in SREB states4 to examine the programs of study available for school nursing. Less than 5 percent of respondents offered such programs, and less than 1 percent of faculty have school nurse practitioner credentials (Strickland, 1995).
Another issue of importance to school nursing is the linkage of nursing services to other school health providers in order to form an integrated services team. Continued examination is also needed of the relative value of such primary prevention efforts as appropriate screenings for vision, hearing, growth, and eating disorders; early identification of individual students at risk for physical and mental health problems; development and implementation of safety programs; and case management of students with chronic diseases. Finally, of special concern to school nurses is the tailoring of school health services to local community needs through the formation of school or community planning councils and the use of needs assessments to guide planning efforts. These concerns and other priority issues were the topic of an invitational conference on school nursing in 1994, which called for more appropriate and greater access to educational opportunities for school nurses, the support of additional outcomes-based research, and the need for further policy development regarding the role of the school nurse in supervising unlicensed assistive personnel in the care of students (National Nursing Coalition for School Health, 1995).
Services Provided. While the number and role of "school physicians," per se have declined over the years, physicians have increasingly been assuming roles as consultants and advocates. Physicians are involved in schools and school health programs from many vantage points, including serving as public health officials to university teachers and researchers and as generalist and specialist providers of direct patient services. The services they provide include consultation on health policy, health curricula, and evaluation of programs and services; direct consultation regarding individual patients or groups of patients; and participation in provision of health services at the school site. Asthma specialists have set up asthma education programs, orthopedic surgeons have set up scoliosis screening and sports medicine programs, and pediatricians have advocated for and helped to develop sexuality education and health education programs. With the recent emphasis on education for all students with disabilities, the diagnosis of conditions and review of programs for these students have become additional responsibilities. Community primary care physicians (pediatricians and family physicians) frequently interact with the schools' health programs as linkages to ancillary services for their patients' medical, learning, and behavioral problems. They also assist with assessing community health needs and resources and devising mechanisms to coordinate school and community services.
A 1992 survey of 87 school districts selected as exemplary models for school health programs, conducted by the National School Boards Association, revealed that about one-half provided some type of dental services (Poehlman and Manager, 1992). A follow-up survey (with a 35 percent response rate) showed that most of the activity was located in elementary schools. Three-fourths of the schools with dental services provided screening at the school, about one-fourth also offered teeth cleaning, and one in ten gave fluoride rinses or sealants for the prevention of tooth decay. Actual treatment was provided in more than one-third of the schools with dental programs, while education for dental health was offered in two-thirds. In some schools, toothbrushes and toothpaste were distributed. In others, local dentists gave presentations, contributed their services at schools, or accepted referrals with low or no fee. In some communities, a local service club was active in providing funds for school dental services.
In 1975, Congress enacted the landmark Education of the Handicapped Act, which in 1990 was renamed the Individuals with Disabilities Education Act (IDEA). The act requires free and appropriate education for all children with disabilities, including those with physical or mental disorders, in the least restrictive setting from birth through age 21.
Federal law holds all state and local education agencies responsible for formulating Individualized Education Plans for all students with disabilities and for providing the special education and related services they require. These services include everything from physical and speech therapy and psychological services to intensive nursing care and case management. Congress annually appropriates funds to help state and local education agencies carry out this mandate, but many of the costs for special education services must be financed from state and local government revenues.
An issue of general concern in special services is the lack of trained professionals who are interested in working in the schools, for often case loads are greater and salaries lower than in other health care settings. As a result, these services sometimes are provided by paraprofessionals and assistants, under the supervision of a professional. Another issue is that eligibility of students for these services is determined by the state and/or local school system, based on recommendations of a team that may or may not include professionals in the special services fields. Further, although the special education law appears to be an entitlement, in fact, not all students with disabilities are served. Those with emotional disturbances are neglected; among those identified, less than one-third received social work, psychological, or other counseling services. Knitzer (1989) estimated that only 19 percent of students with serious emotional problems are being served.
Important Issues. School psychology has long been perceived as a marginal, special education assessment service rather than as a full system of mental health or education services for the mainstream, although this situation appears to be changing. Policymakers are beginning to recognize that education reform requires attention to the social-emotional barriers to learning. School psychologists maintain that increased expertise is necessary to deal with greater cultural diversity and educational demands of a technological workplace, as well as interdisciplinary teamwork. However, retraining and professional development are often supported inadequately within state and local budgets. Although gains have been made in the understanding and practice of school psychology, there is currently no office or program within the U.S. Department of Education, or any other federal agency, to support ongoing research in this area. Much remains to be learned about the relationship between psychological and other student-related services and student academic performance or other outcomes. ff782bc1db
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