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Nurses work in various clinical settings, including schools. School nurses (SNs) have a multifaceted role, and they are the key personnel in the health care system. However, SNs' roles and responsibilities are not fully understood. Therefore, the purpose of this article is to explore perceptions of SNs' roles by the school community (teachers, parents, and school administrators) and address SNs' roles in the school community as explained by the National Association of School Nurses (NASN) Framework™. An understanding of the NASN Framework will guide SNs in integrating their roles into their daily activities and help the community understand their varied roles so members of the community will seek SNs' expertise, and collaborate to improve students' well-being and academic performance.
Nurses work in various clinical settings, including schools. School nurses (SNs) have a multifaceted role, and they are the key personnel in the health care system. However, SNs' roles and responsibilities are not fully understood. Therefore, the purpose of this article is to explore perceptions of SNs' roles by the school community (teachers, parents, and school administrators) and address SNs' roles in the school community as explained by the National Association of School Nurses (NASN) Framework™. An understanding of the NASN Framework will guide SNs in integrating their roles into their daily activities and help the community understand their varied roles so members of the community will seek SNs' expertise, and collaborate to improve students' well-being and academic performance.
Keywords: School nurse, NASN Framework, student health, roles, responsibilities.
urses work in various clinical settings, including schools. Schools have an important role in improving students' health and learning by supporting opportunities to learn and practice healthy behaviors, providing school health services, creating safe and positive school environments, and engaging families and communities (New Jersey State School Nurses Association [NJSSNA], 2023). According to the American Community Survey in 2021, 54.2 million students were enrolled in kindergarten through 12th grade (Fabina et al., 2023). Students spend a considerable amount of time in school. A National School Nurse Workforce Study estimated 78,869 full-time equivalents of publicschool nurses in the United States, including 65,052 registered nurses (RN) and 13,817 licensed practical/vocational nurses (LPN/LVN) (Willgerodt et al., 2024). SNs have daily access to students and are key personnel in the school health system; thus, they can help students improve their school performance by assisting them in adhering to healthy practices and addressing health problems. Health and education are closely linked, whereby they each have a direct effect on the other (Denke & Winkleblack, 2020). The goal of New Jersey's SNs is to improve health and educational outcomes for children and youth by promoting school and community wellness, and providing highquality health care in the school setting
(NJSSNA, 2023). Research shows that SNs decrease absenteeism, increase compliance with vaccinations, improve chronic disease management, and assist with the identification and management of mental health conditions, allowing students to remain in school and improve their academic performance (Maughan et al., 2018). The Centers for Disease Control and Prevention (CDC, 2024b) indicate that children who are in a good state of health demonstrate better academic performance than students who are unhealthy.
The SN is the link between the school, students, families, health care, and other community partners. SNs have multifaceted roles; thus, they are instrumental in assisting children, parents, teachers, administrations, and the community in maintaining and coordinating students' health and improving academic performance. However,
the SN's multiple roles are not clearly understood by the school community. Therefore, the purpose of this article is to explore parents", teachers', and school administrators' perceptions of the roles of SNs, and describe their roles in the school community as explained by the National Association of School Nurses (NASN) Framework™. The NASN Framework will help SNs integrate their responsibilities into daily tasks and enable the school community (parents, teachers, school administrators) to understand the potential impact of their role, fostering collaboration to enhance students' health and academic outcomes.
Literature Review
Studies conducted and published in the United States between 2010 and 2024 were included in the study. A thorough electronic search
was conducted with the PubMed and CINAHL databases, which yielded six articles. Inclusion criteria focused on the terms school nurse, roles, perceptions, parents, teachers, administrators, and students. Exclusion criteria included studies conducted outside the United States. A limited number of studies have explored the community's (including parents, teachers, administrators, and students) perceptions of SNs' roles. Three studies reported that parents perceived SNs' important roles to be providing first aid and emergency care, communicating with parents, examining students' health annually, preventing infectious disease, educating students, screening, and monitoring immunization records (Gillooly et al., 2020; Helal et al., 2015; Maughan « Adams, 2011).
The literature search yielded only four studies that investigated teachers' perception of SNs' roles. The most important roles of SNs as perceived by teachers were administering medication, providing first aid, and communicating with parents regarding health problems (Mahat et al, 2022; Maughan & Adams, 2011). Other identified SN roles included improving overall school health, addressing medical concerns of chronically ill students, improving immunization rates, maintaining student health records, and improving attendance and academic performance (Baisch et al., 2011; Biag et al., 2015). The literature search yielded no studies conducted in the United States to ascertain administrator, principal, and student perceptions of the SN's role. There is sparse literature that examines the perception of SNs' roles by the community. Although SNs have many roles and responsibilities in the school health system, research findings indicate inadequate knowledge of SNs' roles among community members.
Failing to understand the diverse roles of SNs can resultin their undervaluation and misuse. SNs need to demonstrate their roles in daily tasks and ensure others recognize their contributions. The complexities of roles also necessitate that SNs are flexible and able to adapt to the evolving needs of students, schools,and communities (Jordan et al, 2021). The NASN Framework" should be used to guide SNs' practice and enhance student-centered activities to support student health and assist in student academic success. Integrating their roles into daily activities and connecting with students will increase community awareness of their roles. They should also use the NASN Framework" in discussions With school administrators to advocate for the expansion of their role in the school setting. In addition, job descriptions should be reviewed and revised regularly to ensure they align with best practices within a school setting (Reising & Cygan, 2020). If there is a lack of formal school nurse leadership, the school should partner with universities or professional organizations With expertise in the field of school nursing.
Integrating the NASN Framework" into Practice
In 2015, the NASN developed the Framework" for 21st Century School Nursing Practice to reflect current school nurse practice. The Framework guides practicing SNs in providing a healthy and safe school environment that enhances student well-being and academic success (NASN, 2024). Twenty-first-century school nursing practice is studentcentered, surrounded by the family and school community (see Figure 1). In the student-centered approach, the focus is on identifying an individual student's needs while collaborating with families, school staff members, and health care providers to optimize their health and academic achievement. The NASN Framework?" contains four key nonhierarchical, overlapping principles: 1) care coordination, 2) community/public health, 3) leadership, and 4) quality improvement. The fifth principle encompasses these principles and standards of practice, which are considered foundational for evidencebased and clinically competent quality care. Each of these principles has a specific set of practice components. For instance, care coordination includes direct care and collaborative communication;
community/public health nursing includes disease prevention and access to care; leadership includes advocacy and professionalism; and quality improvement includes data collection and evaluation. (NASN, 2024). Based on the NASN FrameWork", the SN should address all principles in their daily activities.
Care Coordination
In the United States, more than 40% of school-aged children and teens have at least one chronic health condition, like asthma, diabetes, seizure disorders, or food allergies (CDC, 2024a). Children spend a considerable amount of time in school. Therefore, SNs arein a unique position to coordinate the care of students with chronic health conditions. They should coordinate students' care among teachers, parents, and health care providers. Care coordination by SNs decreases costs associated with chronic conditions (Maughan et al., 2018).
More children with chronic health problems are attending school; thus, they may be absent from school more often than healthier children. Absenteeism could reduce the amount of time students can engage in instructional practices, leading to lower levels of academic achievement (Keppens, 2023). According to the American Academy of Pediatrics (AAP, 2016), SNs play a significant role in managing disease, working closely with children and their parents to reinforce primary care providers' recommendations and provide treatment(s) during the school day. SNs should follow up with students who miss class, help students and families in managing their children's chronic health problems by educating and coordinating care with health care providers, and provide children with the chance to reach their academic potential (Yoder, 2020). They should also guide students and families in developing a medical absence action plan as directed by state agencies.
School nurses, in collaboration With primary care providers, are tasked with assisting parents of children with chronic health problems in developing an individualized health care plan (IHP) to help con-
trol the illness. SNs should check With the child and parents regularly to ensure the action plan is beneficial. Managing a child with a chronic illness is an overwhelming task for parents, and can result in families feeling overwhelmed and confused about available services. SNs should explain and refer parents to available community resources based on their health needs. SNs have the capacity to be a valuable resource to families and serve as the liaison to coordinate various aspects of health care services to improve the health and well-being of the child, which will, in turn, improve their academic potential.
Children are also increasingly exposed to violence and trauma at high rates. Studies have demonstrated that children who experience adverse childhood experiences are more likely to exhibit negative behaviors, decline in attendance and grade, and exhibit difficulties concentrating and learning at school (Bethell et al., 2014; Cohen et al., 2017). Therefore, SNs should collaborate with school personnel and mental health care providers to support children affected by childhood trauma by creating traumainformed care environments. A trauma-informed environment will support students' physical and
mental health, which will assist in students' achieving academic success. SNs should also collaborate With school personnel to develop policies and practices for traumainformed care.
Community/Public Health
The practice of school nursing is grounded in community/public health. This principle indicates that SNs not only help promote the individual student's health and wellbeing, but also the well-being of the school community and public. SNs should promote healthy behaviors and disease prevention through health education and awareness
campaigns targeted at students, staff, and families. They should also be involved in school district events, supporting the school community through continuous surveillance of student and staffconditions to prevent and control the spread of communicable diseases (NASN, 2024).
School nurses can play a key role in promoting health equity among children by ensuring all students have equal access to health care services within the school setting, addressing health disparities, and collaborating with health care providers and community partners, which are aligned with the NASN Framework™. SNs should collaborate with local public health agencies and community organizations to address health disparities and develop programs and activities that will improve access to health care services and enhance health outcomes within schools and communities. SNs should conduct culturally sensitive health screenings, provide health education based on community needs, and support health equity policies, such as culturally appropriate health education, school nutrition programs, and mental health support services. SNs are a vital component of the health of communities; thus, they should make their contributions visible to the public by collaborating with various leaders and agencies in the community and educating them about their functions.
Leadership
The NASN Framework™ highlights leadership as a key principle for SNs, who have skills and expertise to serve as leaders in developing and implementing school health policies, programs, and procedures for the provision of health services (NASN, 2024). Some policies and programs they could develop and implement in collaboration with other school health personnel and health providers are student health screening and immunization plans, managing chronic health problems, emergency response plan for anaphylaxis shock, and procedures for reporting communicable diseases.
School nurses may demonstrate leadership by advocating for stuschool dents' educational and health needs, participating in school board meetings to emphasize their services, and guiding health care practices, procedures, and programs within school settings. It is helpful to include the leadership principle in their job description so SNs will carry out leadership responsibilities and make this aspect of their job more visible to the school community. SNs should demonstrate to policy makers the impact of school nursing on the health and academic success of students by maintaining data on their daily activities (NASN, 2024)
Quality Improvement
Quality improvement focuses on using data and evidence to enhance school nursing services (NASN, 2020). SNs can improve quality care by screening and identifying health issues early, continuously monitoring and evaluating students' health, and using technology to manage data, eventually enhancing student health to support their academic success. SNs have access to students daily, and therefore, can monitor students' health, analyze progress, identify health issues, and report on immunization trends. These activities will have the highest impact on the health of the school community. SNs can also incorporate re - search findings and evidence-based practices to improve quality of care, and conduct research studies to generate new evidence for practice (NASN, 2020). Conducting surveillance for trends in health care issues within their community and implementing quality improvement stra - tegies can improve the health of students within the community. Dissemination of research and/or quality improvement programs that have been successful can have a farreaching impact on overall health of students within a region.
Conclusion
Over the past century, the SN role has expanded. It is essential SNs are familiar with their roles, as identified by the NASN Framework™, integrate them into their daily practice, and communicate their functions and responsibilities to the stuschool community (parents, teachers, staff, administrators) to en - hance improved utilization of their skills. To keep up with current practice, SNs should visit NASN's website to review current position documents, and be aware of current standards of practice, state regulations, and district policies. SNs are a vital component of the health of communities, and it is essential their contributions are visible to the public.
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