The School Nurse Practitioner

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COMMENTARIES 641

infancy (pylonc stenosis) on subsequent learning abilities. J

Pediatr 87:8, 1975

The

School

Nurse

Practitioner

The report of the American Academy of

Pediat-rics’ Committee on School Health on the school

nurse practitioner which appears in this issue of

Pediatrics (p 665) recognizes the innovative

ap-proach that school nurse practitioners are making

to the problem of delivery of medical services to

children in underserved areas and stresses that school nurse practitioners, with supervision, can be

used appropriately and effectively in providing

im-proved health care to these children. The Commit-tee notes that utilization of school nurse

practition-ers has been associated with improved

immuniza-tion referrals and a decrease in emergency room use

by participating children, and indicates that the

presence of school nurse practitioners in school

settings permits some children to obtain care who

previously were not receiving adequate care and

services.

The Committee wisely recommends that

contin-ued research and evaluation should occur before the final value of school nurse practitioners and

their role in the delivery of primary health care are

established and before school nurse practitioner

primary care programs can be assumed suitable for

most, rather than special situation, school

pro-grams. The Committee points out the need for

children to have a “medical home” and observes

that school-based school nurse practitioner care, in itself, is acceptable only when such a “home” is not available elsewhere. The Committee also notes that

in successful school health programs that utilize the

services of school nurse practitioners, there has

been a close relationship between the school nurse

practitioner and the physician with the physician

available for supervision.

Since an appreciable number of school-age

chil-dren, particularly adolescents, never visit a doctor’s office, a clinic, or hospital except for extreme illness or in an emergency, a well trained school nurse

practitioner working with the child’s personal

phy-sician, school physician, or an alternative source of

health care can supplement and significantly im-prove the care that a child receives. Many students do not have a basic health care source and even

when personal physicians, hospital-based clinics,

neighborhood health centers, or other health

facil-ities are available, the children are not brought to

them for the care they require. Because of the lack

of early assessment and care of physical, emotional,

and learning disorders, many schoolchildren

de-velop progressively more severe problems which

may go unrecognized and adversely affect their

health and ability to lean. The school nurse

prac-titioner can be an important contributor to

im-proved health care for them.

School nurse practitioners have the competence to participate in providing a broad range of direct primary health care and services to the school-age

child.”2 For the child whose care is limited and

inadequate, the school nurse practitioner can

sig-nificantly increase and improve the health care the

child had previously received. For those children

who have a personal physician, the school nurse

practitioner can, with the physician’s approval,

mi-tiate assessment procedures and provide follow-up

and effective continuity of care. In our experience

children seen and assessed by school nurse

practi-tioners for a significant illness that needed to be

seen by a physician were more likely to be taken to

the physician than those children seen by a

“regu-lar” school nurse, since parents were more likely to

take a child to a physician if they knew that a

qualified health professional had made the referral for additional medical care.

In the decade since the first school nurse

practi-tioner program was established, it has been shown

that school nurse practitioners who have had

ade-quate formal educational preparation can, in

coop-eration and consultation with physicians, educators, and school personnel, assume initiative and respon-sibility for providing a wide variety of health care

functions and activities. They can identify health

status and learning, perceptual, and emotional

problems; utilize improved interviewing techniques;

assess physical health status; participate in

evalu-ating the physical, cognitive, social, and emotional

development of children; deal with various aspects

of parent and child relationships; employ

appropri-ate health services for emergencies and common

childhood disorders according to previously

deter-mined treatment plans; identify and assess factors

that may produce learning disorders; provide antic-ipatory guidance for children with health,

develop-mental, or educational problems; supervise

treat-ment regimens in the school; collaborate in design-ing preventive health care and screening programs;

and be involved in integrating care. An adequate

school nurse practitioner program also prepares

school nurse practitioners to participate in the

ac-tive management of many common childhood

ill-nesses. In addition, school nurse practitioners can

also provide the services that, ideally, are now the

major functions and activities of “regular” school

nurses (eg, provide comprehensive health

educa-tion; promote communication among parents,

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642 PEDIATRICS Vol. 65 No. 3 March 1980

sicians, and schools in cases where children have special health problems or learning disabilities;

counsel children and families; help in the

develop-ment and evaluation of early childhood develop-ment programs; and coordinate health care which involves the school, family, and community in the

area of general health, dental health, and mental

health).

The contribution of school nurse practitioners depends upon the health needs of the children, and the presence, absence, or deficiency of health care resources. School nurse practitioners may be called

upon to provide diagnostic and therapeutic services

for children in the school setting because health

care from other professionals is not readily available

or is essentially nonexistent. In such situations

these activities on the part of the school nurse

practitioner are appropriate. School nurse

practi-tioners routinely attempt to integrate the care they

provide with the health care otherwise available.

They refer children who have a personal physician

and provide extensive care only to those children

who do not have any other stable souce of care.

Although it might be of value to have more school

health care provided or closely supervised by school

doctors, there are probably less than 750 full-time doctors specializing in school health in the

approx-imately 88,000 schools in the United States, and it

is unlikely that the number of full-time school doc-tors will increase materially within the next few

years.

Under the overall supervision of physicians, more

extensive use of the school as a setting where health

care is provided would significantly increase the

likelihood that the health needs of school-age

chil-dren are met. Because school nurse practitioners

are skilled at assessing children with problems, they

frequently can determine that a child who

com-plains of some illness does not have to be sent

home. Without the services of a school nurse

prac-titioner, minor ifinesses that do not require

exclu-sion from school may not be assessed properly and

the children may be excluded from school

unnec-essaily. School absenteeism is also reduced when the child can be brought back to good health sooner

so that the child has an opportunity to learn more

effectively. Where health care is needed, the nurse

practitioner may provide it or make arrangements for effective referral so that the child can return to

school more quickly.

School nurse practitioners are an important

source of referral to physicians because nurse

prac-titioners can readily and skillfully determine the

problems that require a physician’s special care and

can motivate children and their families to utilize

their own physicians or other health care providers

more appropriately and on a regular basis. It has

been reported that twice as many problems

requir-ing referral are identified by school nurse practi-tioners as by “regular” school nurses.’

In its report the Committee raises the question

of cost effectiveness of school nurse practitioners. Since the presence of a child in the classroom rather

than at home increases the income that the school

receives, utilization of the school nurse practitioner could be of positive value to the school that employs

her and to the working parent who does not have

to stay home unnecessarily to be with the child.

Although the Committee suggests that it would

be desirable to show that children who have some

of their care provided by school nurse practitioners have fewer illnesses, accidents, or hospitalizations,

the Committee recognizes the difficulty of

deter-mining such outcomes. In fact, it would be difficult for almost any health professional to demonstrate conclusively that the incidence of these factors had been influenced significantly by the presence of any particular health professional in a community.

School nurse practitioners as well as other nurse

practitioners have been shown to be effective and

competent providers of health care. Sox4 recently

reviewed more than 40 studies in which the

com-petence of care given by nurse practitioners or

physician’s assistants was directly compared with

that given by physicians. Sox concluded that the

reviewed studies demonstrated that nurse

practi-tioners and physician’s assistants provided care that was, in general, equal in quality to care provided by

physicians. McAtee5 and Hilmar and McAtee6

com-pared school nurse practitioners with “regular”

school nurses and reported that school nurse

prac-titioners manage a significantly greater proportion

of the health problems of schoolchildren and are

less likely to refer pupils inappropriately to

physi-cians for consultation or care. McAtee also noted

that school nurse practitioners exclude (dismiss

from school) one half as many pupils as do regular

school nurses because nurse practitioners can

rec-ognize and manage more health problems in the

school setting.

The Committee suggests that in order for school

nurse practitioners to function most effectively, a

close relationship between the school nurse

practi-tioner and the physician must be developed. The

Committee also states that establishment of

stan-dads for school nurse practitioner training

pro-grams is essential for professional creditability. It is to be hoped that all physicians who care for children will become knowledgeable of the role of the school

nurse practitioner, will recognize the assistance

school nurse practitioners can provide to physicians

and patients, and will work with the nurse

practi-tioners in providing optimum care for children.

Whenever possible, the physician should obtain this

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COMMENTARIES 643

knowledge by firsthand observation of the school nurse practitioner in practice. (It would also be

desirable if pediatric residents in training had an opportunity to work with the school nurse

practi-tioner in the school so the residents could learn of

the potential of the school nurse practitioner as a health care provider.) In addition, representatives

of the American Academy of Pediatrics should

con-tinue to work closely with directors of school nurse

practitioner training programs and with other

school nurse practitioners in developing mutually agreeable guidelines and standards for school nurse

practitioner programs, in delineating the scope of

practice of school nurse practitioners, and in

deter-mining the degree of supervision a school nurse

practitioner needs in caring for various conditions

affecting school children. The Committee on School

Health would appear to be the one group most

qualified to work with school nurse practitioners in accomplishing these objectives.

Greater understanding of the role of the school

nurse practitioner by health professionals and

oth-ers will lead to greater acceptance of their expanded role as health care providers. It would be a disser.

vice to the children of this country if the broad

services that school nurse practitioners can provide were not fully utilized.

REFERENCES

HENRY K. SILVER, MD

Department of Pediatrics University of Colorado School of Medicine Denver

1. Silver HK, Igoe JB, McAtee PR: The school nurse practi-tioner: Providing improved health care to children.

Pediat-rics 58:580,1976

2. Silver HK, Igoe JB, McAtee PR: School nurse practitioners: A concise descriptive definition of their functions and

activ-ities. J Sch Health 47:598, 1977

3. Nader PR, Conrad J, Williamson M, et al: The high school nurse practitioner. J Sch Health 48:649, 1978

4. Sox HC Jr: Quality of patient care by nurse practitioners and physician’s assistants: A ten-year perspective. Ann Intern

Med9l:459, 1979

5. McAtee PA: Nurse practitioners in our public schools? An assessment of their expanded role as compared with school nurses. Clin Pediatr 13:360, 1974

6. Hilmar NA, McAtee PA: The school nurse practitioner and her practice: A study of traditional and expanded health care responsibilities for nurses in elementary schools. J Sch

Health 43:431, 1973

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1980;65;641

Pediatrics

Henry K. Silver