According to the Centers for Disease Control and Prevention (CDC) (2016), the healthy development of children and adolescents is influenced by many societal institutions, and after the family, the school is the primary institution responsible for the development of young people in the United States. The school environment is also a key setting in which students’ behaviors and ideas are shaped. Just as schools are critical to preparing students academically and socially, they are also vital partners in helping young people take responsibility for their health and adopting health-enhancing attitudes and behaviors that can last a lifetime (CDC, 2017).

BOX 30.1 Youth at Risk

· • Every day nearly 3200 young people start smoking (CDC, 2015).

· • Daily participation in high school physical education classes dropped from 42% in 1991 to 27.1% in 2013 (CDC, 2017).

· • Seventy-five percent of young people do not eat the recommended number of servings of fruits and vegetables.

· • Marijuana use among young people increased from 15% in 1991 to 46% in 2015.

From National Institute on Drug Abuse: National survey of drug use and health, 2015.

Academic success and healthy children and youth are closely intertwined. It is impossible to achieve success in school without maximizing the health of the students. School-age children and adolescents face increasingly difficult challenges related to health. Many of today’s health challenges are different from those of the past and include behaviors and risks linked to the leading causes of death such as heart disease, injuries, and cancer. Examples of behaviors that often begin during youth and increase the risk for serious health problems are the use of tobacco, alcohol, and drugs; poor nutritional habits; inadequate physical activity; irresponsible sexual behavior; violence; suicide; and reckless driving (Box 30.1).

In the United States, approximately 55.6 million children attend school every day (National Center for Educational Statistics, 2016). Their presence creates a unique opportunity for school nurses to have a positive impact on the nation’s youth. The primary providers of health services in schools are school nurses, and there are approximately 73,000 registered nurses working in schools in the United States (U.S. Department of Health and Human Services [USDHHS], Health Services and Resources Administration, 2010).

School nursing is a specialized practice of professional nursing that advances the well-being, academic success, and lifelong achievement and health of students. To that end, school nurses facilitate positive student responses to normal development; promote health and safety, including a healthy environment; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy, and learning (NASN, 2017). The National Association of School Nurses (NASN) recommends one school nurse for every 750 students in the general population, one for every 225 students in mainstreamed special education populations, and one for every 125 severely chronically ill or developmentally disabled students; however, caseloads vary widely, depending on mandated functions, socioeconomic status of the community, and service delivery model (NASN, 2015).

More than 21% of the nation’s children live in poverty (National Center for Children in Poverty, 2017). Poverty is defined as an annual income below $24,339 for a family of four (U.S. Census Bureau, 2017). Decreased or inferior health care has been linked to serious health problems, resulting in an increase in absenteeism that may be correlated with failure in school. The school nurse can effectively manage many complaints and illnesses, allowing these children to return to or remain in class.

TABLE 30.1

Racial and Ethnic Breakdown of Uninsured Children in the United States in the Year 2012

Race Number Percentage
White 2.9 million 38.8
Hispanic 2.7million 38.1
Black 1.0 million 14.2
Asian and Pacific Islander 306,000 4.3

Data from Children’s Defense Fund: The state of America’s children, 2014.

Indeed, on a daily basis, school nurses see students with a variety of complaints. Increasing numbers of children are being seen in the school setting because they lack a source of regular medical care. According to the Children’s Defense Fund (2014), nearly 9.2 million U.S. children, or 1 in 11, do not have health insurance. This is a decrease from the nearly 12 million in previous years. Table 30.1 illustrates the racial and ethnic breakdown of uninsured children in the United States in the year 2012. Poor academic performance is strongly correlated with the uninsured status of youth, and conversely, acquisition of health insurance leads to an improvement in school performance. Through education, counseling, advocacy, and direct care across all levels of prevention, the nurse can improve the immediate and long-term health of this population.

There is a need for mental and physical health services for students of all ages to improve both their academic performance and their sense of well-being. This chapter provides an overview of school health and the role of the nurse in the provision of health services and health education. It also offers an in-depth look at the components of a successful school health program and the major health problems of today’s youth.


History of School Health

Before 1840, education of children in the United States was uncoordinated and sparse. In 1840, Rhode Island passed legislation that made education mandatory, and other states soon followed. In 1850, a teacher and school committee member, Lemuel Shattuck, spearheaded the legendary report that has become a public health classic. This report, known as the Shattuck Report, has had a profound impact on school health because it proposed that health education was a vital component in the prevention of disease.

Public health officials and others soon realized that schools played an important part in the prevention of communicable disease. When smallpox broke out in New York City in the 1860s, health officials were faced with trying to implement a widespread prevention program. They chose to target the schools and began vaccinating children. This experience led to the 1870 requirement that all children be vaccinated against smallpox before entering school (Allensworth et al., 1997).

At that time, schools were frequently poorly ventilated and lacked fresh air, effectively spreading diseases among the children. Late in the nineteenth century, a practice of inspecting

schools began to identify children who were ill and exclude them until it was deemed they were no longer infectious. Soon thereafter, compulsory vision examinations became a requirement to identify children who might have difficulty in school. In 1902, New York City hired the first nurses to help inspect children, educate families, and ensure follow-up treatment. Within a few years the renowned nurse Lillian Wald was able to show that the presence of school nurses could reduce absenteeism by 50%. By 1911, more than 100 cities were using school nurses, and by 1913, New York City employed 176 school nurses (Allensworth et al., 1997).

As they became more comfortable in their positions, early school nurses began to take on more active roles in the assessment of children, treatment of minor conditions, and referral for more serious problems. In addition to identification, treatment, and exclusion for communicable diseases and screening for problems that might affect learning, other issues quickly became part of school nurses’ practice. In the early part of the twentieth century the temperance movement led schools to teach children about the effects of alcohol and tobacco. Also early in the twentieth century, “gymnastics” was introduced in schools in an effort to promote physical activity. World War I was a pivotal point for school health services, and the call for a national effort to improve the health of schoolchildren emerged. In 1918 the National Education Association joined forces with the American Medical Association (AMA) to form the Joint Committee on Health Problems and publish the report Minimum Health Requirements for Rural Schools. This group also called for the coordination of health education programs, medical supervision, and physical education. By 1921 nearly every state had laws that required physical and health education in schools. Additionally, fire drills became part of safety education programs introduced during and after World War I (Allensworth et al., 1997).

Even though emphasis was placed on health services in schools, barriers still existed. Many schools and cities were unwilling to take on the task of providing primary health care for all children. The idea that schools should simply identify and refer problems to physicians was a common practice backed by the AMA. By the 1920s, medical services and preventive health services were clearly separated in the public health arena and in the schools, thereby largely supported by each state, which focused more attention on “health education.” The federal government did not get involved with school health until the passage of the National School Lunch Program in 1946. The School Breakfast Program was implemented 30 years later (Allensworth et al., 1997).

There was no impetus to change the direction of school health programs until the 1960s and 1970s. During these decades there was increasing publicity about children living in poverty and the move to mainstream children with disabilities. These two issues, along with an increase in the number of children of immigrants, contributed to changes in school health programs.

During the 1960s the first nurse practitioner training programs opened and made the inclusion of primary care services in schools possible. In 1976 the first National School Conference, supported by the Robert Wood Johnson Foundation, was held in Galveston, Texas. After this conference a variety of school health service models began to emerge with new partnerships and ideas created to provide the most comprehensive health care services for school-age children. In addition, the Education for the Handicapped Act in 1975 mandated that all children, regardless of disabilities, have access to educational services.

The 1980s and 1990s saw several measures aimed at improving the health of schoolchildren. The Drug-Free Schools and Community Act was implemented in 1986 to fight substance abuse through education and was expanded in 1994 to include violence prevention measures. During this period, the Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health, began funding state education agencies to develop and implement programs aimed at alcohol and tobacco use, physical education, and the reduction of sexually transmitted diseases (STDs) and HIV infection among the nation’s youth. Also, the federal government encouraged states to use part of their maternal and child block grant monies to fund school-based health centers.