507283
research-article2013
NASXXX10.1177/1942602X13507283NASN School NurseNASN School Nurse
State School Nurse Consultants Q&A
Ethical Considerations for School Nurse Leaders Linda C. Wolfe, EdD, RN, NCSN, FNASN
Keywords: ethics; leadership; school nursing
S
chool nursing literature has many articles on how the evidence-based practice and the role of the school nurse impact children in the school setting. These frameworks create the boundaries and expectations of our practice. As leaders, we embrace these accepted constructs and they define us for the public. Yet, one foundation stands out amongst them all—ethics. One could argue that all the structures, except ethics, are more about the tasks we perform and less about the manner in which they are implemented. It seems that it is the ethics that is the essence— that is, the heart—of the school nurse. It is stories (of school nurses who change lives or save lives) that create a picture for the community of a compassionate and trusted health care provider. School Nursing: Scope and Standards of Practice (NASN, 2011) acknowledges the importance of ethics to the comprehensive nature of our practice with the inclusion of ethics. In fact, ethics is the first standard (Provision 7) listed under Standards of Professional Performance. A school nurse’s life is never dull—too many work days go well beyond when the last bell rings, too many student-tonurse ratios create unreasonable challenges, too many children have more needs than there are accessible resources, and too many school
284 NASN School Nurse | November 2013
communities lack an understanding of how the school nurse fits into the health care system. In spite of this, school nurses respond with their hearts to meet the needs of the school community. Going “above and beyond,” “out on a limb,” “at all costs,” or “the extra mile” is routine for school nurse leaders. It is our ethical responsibility. Parents and the community trust school nurses. Is this because of our skills, our ethics, or both—and what does the literature say? A current literature search on school nursing and ethics over the past 10 years yielded only 10 relevant articles. This scarcity of articles could mean that the topic is an irrelevant one to today’s practice. It could also mean that this area of school nursing continues to be an elusive part of being a school nurse leader. This is a topic that is difficult to get your arms around, let alone your head! Below is a quick snapshot of the articles. To help nurses understand the ethics inherent to the practice, the American Nurses Association (ANA) created a code of ethics (ANA, 2001) in 1950. This text was revised several times over subsequent years with the current version including nine provisions and interpretive statements. In 2012, the ANA created a task force to make recommendations on the need for revisions. NASN developed its first code of ethics statement in the 1970s (NASN, 2010). The current NASN statement was revised in 2010 and can be accessed online. It defines ethical conduct
in three areas: client care, professional competency, and professional responsibilities. Both organizations recognize the value of ethics in our practice and the need to articulate a common set of principles to shape our decisions. The challenge is always in the details. Below are challenging scenarios and dilemmas that have been shared with me by school nurse leaders. They are categorized by the framework used in NASN’s Code of Ethics. The scenarios are meant to engage the reader in an ethical discussion. How might the Code of Ethics help to shape the actions of a school nurse leader? Caution to reader—you may not agree with the author! That’s OK! That is the challenge of an ethical dialog. There is likely agreement that a fair rule of thumb is always “what’s in the best interest of the child?” but, conclusions on best interest may differ. Perhaps the Code of Ethics can help find common ground.
Scenario 1 Peter is a kindergartener who has a rare skin disorder that affects his hands. Holding an object, like a pencil, for a long period of time causes blistering on his fingers. Kindergarteners spend a lot of time learning skills that rely on fine motor skills—copying the alphabet, writing their name, drawing, etc. It seems like Peter would benefit from an accommodation plan that allows him to use a computer, perhaps even one that is voice activated. The dilemma is that advocating for a
DOI: 10.1177/1942602X13507283 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. © 2013 The Author(s)
Table 1. Ethics Articles Sorted by Topic and Country of Origin Topic
Author’s Country of Origin
Number of Articles
Counseling support
Sweden
1
Documentation
Sweden/United States
2
Obesity
United States
2
Politics
United Kingdom
1
Professional standards
United States
1
Research
United Kingdom/United States
2
School health staffing
United States
1
computer will require the school to buy a computer for Peter, and there really isn’t any money in the budget. What is the best response of a school nurse leader? A. Talk it over with the parents and encourage them to buy a computer or advocate for one. B. Leave this decision to the principal. C. Hold a bake sale to raise money for a computer. D. Bring this idea to the interdisciplinary team. Relevant Statements Within the NASN Code of Ethics Client Care, Interpretive Statement E. School nurses advocate on behalf of clients’ needs. Professional Responsibility, Interpretive Statement D. The school nurse recognizes that practice environments impact the quality of client care and is cognizant of the need to improve these environments. Answer D is the best choice as it encompasses these two interpretive statements. The interdisciplinary team should involve the parent (Answer A) and the principal (Answer B). This will allow for a rich discussion on the best way to meet the needs of this child. While the school nurse believes a computer is the answer, there may be compelling reasons for the child to learn to use a pencil—one being that the child has a strong desire to write his name!
There may also be ways to avoid skin break-down if the health care provider is engaged in the team discussion. A bake sale (Answer C) may be in the future, but the first step is the need to arrange for a meeting where the nurse can advocate for Peter and his needs.
Scenario 2 The local high school has a new school nurse, who previously worked in labor and delivery for 10 years. As basketball season approaches, the principal informs the new nurse of a new assignment, which will be to cover the basketball games. The new nurse knows that she would be more comfortable helping to deliver a baby than dealing with a cardiac arrest or compound fracture. What is the best response of a school nurse leader? A. Contact the union because covering games is outside of the current contract. B. Tell the principal that a school nurse doesn’t have the skills for this type of assignment. C. Explore with the principal about who would be best qualified for this assignment. D. Sign up for a class to enhance the necessary nursing skills needed to competently assess and care for athletic injuries. Relevant Statements Within the NASN Code of Ethics Professional Competency, Interpretive Statement B. School nurses must
evaluate their own nursing practice in relation to professional practice standards and relevant statutes, regulations and policies. Professional Competency, Interpretive Statement C. School nurses must have knowledge relevant to meet the needs of clients within the school setting. Since individual expertise varies, nurses consult with peers and other health professionals with expertise and recognized competencies in various fields of practice. When in the client’s best interest, the school nurse refers clients to other health professionals and community health practices. Answer C is the best answer because it addresses the immediate need for the school as the “basketball season approaches.” While choosing Answer A or B removes the responsibility from the nurse, it does not address the need of student athletes and doesn’t build any confidence in the principal relative to the skills of the school nurse. Further, Answer B indicates that caring for sports injuries is outside of the scope of school nursing practice, which is clearly not accurate. Answers C and D affirm that the school nurse recognizes the limitations of her current skills and ability. Answer C seeks a solution that engages others and is the best choice for today. It also recognizes that a more experienced school nurse, an athletic trainer, or an emergency medical technician may be an option for the school to consider. However, Answer D is also the right answer because it addresses the future. Almost every school has daily physical education programs where students engage in sports like basketball. The school nurse needs to be competent in handling athletic injuries that can occur in the school setting. Seeking continuing education in this area would be the prudent, and ethical, thing to do.
Scenario 3 School nursing research is important to the future of the practice. So, when a local hospital contacts the local
November 2013 | NASN School Nurse 285
elementary school nurse about partnering on a study regarding the influence of nursing care on the educational outcomes of students, this is recognized as a great opportunity for school nursing. The hospital has already received approval by their human subject review board. The school nurse researches the school’s policies and learns that there are no rules regarding research. In fact, some of the teachers have done research on their students when they were working on their postbaccalaureate degrees without notifying anyone. What is the response of a school nurse leader? A. Accept this proposal and negotiate how the research results can be published in a timely manner. B. Direct the hospital to put the proposal in writing and submit it to the school board for approval. C. Review the proposal to ensure that it protects the confidentiality of the students and that the interventions are within the scope of practice of the school nurse. D. Agree to participate in the study as the school and students will be anonymous. Relevant Statements Within the NASN Code of Ethics Client Care, Interpretive Statement D. School nurses maintain client confidentiality within the legal, regulatory, and ethical parameters of health and education.
286 NASN School Nurse | November 2013
Professional Responsibilities, Interpretive Statement D. The school nurse participates in and promotes research activities as a means of advancing school health services and the health of students. This is done as appropriate to the nurse’s education, position, and practice environment and in adherence with the ethics that govern research, specifically, 1. right to privacy and confidentiality, 2. voluntary and informed consent, and 3. awareness of and participation in the mechanisms available to ensure the rights of human subjects, particularly vulnerable populations (minors, disabled, etc.). Answer C is the best answer as it is the place to start. Although a review board has approved the proposal, the school nurse should be fully aware of all aspects of the study and comfortable that it will protect the confidentiality of her students and the school community. One component of the review will be to ensure that Answer D has been fully addressed. Once she has approved the proposal, it will be time to work through the details of Answer B and then encourage Answer A to be considered. These three scenarios provide a little insight into some types of ethical dilemmas facing school nurse leaders. In each situation, there was a need to consider the best interest and safety of the child, review legal implications of the
potential decisions, and consider the impact to school nursing practice. Making ethical choices isn’t easy, but the NASN Code of Ethics provides a framework for decision making by school nurse leaders. ■
References American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/ MainMenuCategories/EthicsStandards/ CodeofEthicsforNurses/Code-of-Ethics.pdf National Association of School Nurses. (2010). Code of ethics. Retrieved from http://www .nasn.org/RoleCareer/CodeofEthics/tabid/117/ mid/434/dnnprintmode/true/Default .aspx?SkinSrc=%5bG%5dSkins%2f_default%2f No+Skin&ContainerSrc=%5bG%5dContainers %2f_default%2fNo+Container National Association of School Nurses. (2011). School nursing: Scope and standards of practice. Retrieved from http://www .nursesbooks.org/Table-of-Contents/ Standards/School-Nursing-Scope-andStandards-of-Practice.aspx
Linda C. Wolfe, EdD, RN, NCSN, FNASN Director, School Support Services Delaware Department of Education Dover, DE Linda has been a school nurse since 1986. She is currently the Delaware State School Nurse Consultant and was previously an elementary school nurse in the Indian River School District. Linda is a pastpresident of the National Association of School Nurses.
research-article2013
NASXXX10.1177/1942602X13507283NASN School NurseNASN School Nurse
State School Nurse Consultants Q&A
Ethical Considerations for School Nurse Leaders Linda C. Wolfe, EdD, RN, NCSN, FNASN
Keywords: ethics; leadership; school nursing
S
chool nursing literature has many articles on how the evidence-based practice and the role of the school nurse impact children in the school setting. These frameworks create the boundaries and expectations of our practice. As leaders, we embrace these accepted constructs and they define us for the public. Yet, one foundation stands out amongst them all—ethics. One could argue that all the structures, except ethics, are more about the tasks we perform and less about the manner in which they are implemented. It seems that it is the ethics that is the essence— that is, the heart—of the school nurse. It is stories (of school nurses who change lives or save lives) that create a picture for the community of a compassionate and trusted health care provider. School Nursing: Scope and Standards of Practice (NASN, 2011) acknowledges the importance of ethics to the comprehensive nature of our practice with the inclusion of ethics. In fact, ethics is the first standard (Provision 7) listed under Standards of Professional Performance. A school nurse’s life is never dull—too many work days go well beyond when the last bell rings, too many student-tonurse ratios create unreasonable challenges, too many children have more needs than there are accessible resources, and too many school
284 NASN School Nurse | November 2013
communities lack an understanding of how the school nurse fits into the health care system. In spite of this, school nurses respond with their hearts to meet the needs of the school community. Going “above and beyond,” “out on a limb,” “at all costs,” or “the extra mile” is routine for school nurse leaders. It is our ethical responsibility. Parents and the community trust school nurses. Is this because of our skills, our ethics, or both—and what does the literature say? A current literature search on school nursing and ethics over the past 10 years yielded only 10 relevant articles. This scarcity of articles could mean that the topic is an irrelevant one to today’s practice. It could also mean that this area of school nursing continues to be an elusive part of being a school nurse leader. This is a topic that is difficult to get your arms around, let alone your head! Below is a quick snapshot of the articles. To help nurses understand the ethics inherent to the practice, the American Nurses Association (ANA) created a code of ethics (ANA, 2001) in 1950. This text was revised several times over subsequent years with the current version including nine provisions and interpretive statements. In 2012, the ANA created a task force to make recommendations on the need for revisions. NASN developed its first code of ethics statement in the 1970s (NASN, 2010). The current NASN statement was revised in 2010 and can be accessed online. It defines ethical conduct
in three areas: client care, professional competency, and professional responsibilities. Both organizations recognize the value of ethics in our practice and the need to articulate a common set of principles to shape our decisions. The challenge is always in the details. Below are challenging scenarios and dilemmas that have been shared with me by school nurse leaders. They are categorized by the framework used in NASN’s Code of Ethics. The scenarios are meant to engage the reader in an ethical discussion. How might the Code of Ethics help to shape the actions of a school nurse leader? Caution to reader—you may not agree with the author! That’s OK! That is the challenge of an ethical dialog. There is likely agreement that a fair rule of thumb is always “what’s in the best interest of the child?” but, conclusions on best interest may differ. Perhaps the Code of Ethics can help find common ground.
Scenario 1 Peter is a kindergartener who has a rare skin disorder that affects his hands. Holding an object, like a pencil, for a long period of time causes blistering on his fingers. Kindergarteners spend a lot of time learning skills that rely on fine motor skills—copying the alphabet, writing their name, drawing, etc. It seems like Peter would benefit from an accommodation plan that allows him to use a computer, perhaps even one that is voice activated. The dilemma is that advocating for a
DOI: 10.1177/1942602X13507283 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. © 2013 The Author(s)
Table 1. Ethics Articles Sorted by Topic and Country of Origin Topic
Author’s Country of Origin
Number of Articles
Counseling support
Sweden
1
Documentation
Sweden/United States
2
Obesity
United States
2
Politics
United Kingdom
1
Professional standards
United States
1
Research
United Kingdom/United States
2
School health staffing
United States
1
computer will require the school to buy a computer for Peter, and there really isn’t any money in the budget. What is the best response of a school nurse leader? A. Talk it over with the parents and encourage them to buy a computer or advocate for one. B. Leave this decision to the principal. C. Hold a bake sale to raise money for a computer. D. Bring this idea to the interdisciplinary team. Relevant Statements Within the NASN Code of Ethics Client Care, Interpretive Statement E. School nurses advocate on behalf of clients’ needs. Professional Responsibility, Interpretive Statement D. The school nurse recognizes that practice environments impact the quality of client care and is cognizant of the need to improve these environments. Answer D is the best choice as it encompasses these two interpretive statements. The interdisciplinary team should involve the parent (Answer A) and the principal (Answer B). This will allow for a rich discussion on the best way to meet the needs of this child. While the school nurse believes a computer is the answer, there may be compelling reasons for the child to learn to use a pencil—one being that the child has a strong desire to write his name!
There may also be ways to avoid skin break-down if the health care provider is engaged in the team discussion. A bake sale (Answer C) may be in the future, but the first step is the need to arrange for a meeting where the nurse can advocate for Peter and his needs.
Scenario 2 The local high school has a new school nurse, who previously worked in labor and delivery for 10 years. As basketball season approaches, the principal informs the new nurse of a new assignment, which will be to cover the basketball games. The new nurse knows that she would be more comfortable helping to deliver a baby than dealing with a cardiac arrest or compound fracture. What is the best response of a school nurse leader? A. Contact the union because covering games is outside of the current contract. B. Tell the principal that a school nurse doesn’t have the skills for this type of assignment. C. Explore with the principal about who would be best qualified for this assignment. D. Sign up for a class to enhance the necessary nursing skills needed to competently assess and care for athletic injuries. Relevant Statements Within the NASN Code of Ethics Professional Competency, Interpretive Statement B. School nurses must
evaluate their own nursing practice in relation to professional practice standards and relevant statutes, regulations and policies. Professional Competency, Interpretive Statement C. School nurses must have knowledge relevant to meet the needs of clients within the school setting. Since individual expertise varies, nurses consult with peers and other health professionals with expertise and recognized competencies in various fields of practice. When in the client’s best interest, the school nurse refers clients to other health professionals and community health practices. Answer C is the best answer because it addresses the immediate need for the school as the “basketball season approaches.” While choosing Answer A or B removes the responsibility from the nurse, it does not address the need of student athletes and doesn’t build any confidence in the principal relative to the skills of the school nurse. Further, Answer B indicates that caring for sports injuries is outside of the scope of school nursing practice, which is clearly not accurate. Answers C and D affirm that the school nurse recognizes the limitations of her current skills and ability. Answer C seeks a solution that engages others and is the best choice for today. It also recognizes that a more experienced school nurse, an athletic trainer, or an emergency medical technician may be an option for the school to consider. However, Answer D is also the right answer because it addresses the future. Almost every school has daily physical education programs where students engage in sports like basketball. The school nurse needs to be competent in handling athletic injuries that can occur in the school setting. Seeking continuing education in this area would be the prudent, and ethical, thing to do.
Scenario 3 School nursing research is important to the future of the practice. So, when a local hospital contacts the local
November 2013 | NASN School Nurse 285
elementary school nurse about partnering on a study regarding the influence of nursing care on the educational outcomes of students, this is recognized as a great opportunity for school nursing. The hospital has already received approval by their human subject review board. The school nurse researches the school’s policies and learns that there are no rules regarding research. In fact, some of the teachers have done research on their students when they were working on their postbaccalaureate degrees without notifying anyone. What is the response of a school nurse leader? A. Accept this proposal and negotiate how the research results can be published in a timely manner. B. Direct the hospital to put the proposal in writing and submit it to the school board for approval. C. Review the proposal to ensure that it protects the confidentiality of the students and that the interventions are within the scope of practice of the school nurse. D. Agree to participate in the study as the school and students will be anonymous. Relevant Statements Within the NASN Code of Ethics Client Care, Interpretive Statement D. School nurses maintain client confidentiality within the legal, regulatory, and ethical parameters of health and education.
286 NASN School Nurse | November 2013
Professional Responsibilities, Interpretive Statement D. The school nurse participates in and promotes research activities as a means of advancing school health services and the health of students. This is done as appropriate to the nurse’s education, position, and practice environment and in adherence with the ethics that govern research, specifically, 1. right to privacy and confidentiality, 2. voluntary and informed consent, and 3. awareness of and participation in the mechanisms available to ensure the rights of human subjects, particularly vulnerable populations (minors, disabled, etc.). Answer C is the best answer as it is the place to start. Although a review board has approved the proposal, the school nurse should be fully aware of all aspects of the study and comfortable that it will protect the confidentiality of her students and the school community. One component of the review will be to ensure that Answer D has been fully addressed. Once she has approved the proposal, it will be time to work through the details of Answer B and then encourage Answer A to be considered. These three scenarios provide a little insight into some types of ethical dilemmas facing school nurse leaders. In each situation, there was a need to consider the best interest and safety of the child, review legal implications of the
potential decisions, and consider the impact to school nursing practice. Making ethical choices isn’t easy, but the NASN Code of Ethics provides a framework for decision making by school nurse leaders. ■
References American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/ MainMenuCategories/EthicsStandards/ CodeofEthicsforNurses/Code-of-Ethics.pdf National Association of School Nurses. (2010). Code of ethics. Retrieved from http://www .nasn.org/RoleCareer/CodeofEthics/tabid/117/ mid/434/dnnprintmode/true/Default .aspx?SkinSrc=%5bG%5dSkins%2f_default%2f No+Skin&ContainerSrc=%5bG%5dContainers %2f_default%2fNo+Container National Association of School Nurses. (2011). School nursing: Scope and standards of practice. Retrieved from http://www .nursesbooks.org/Table-of-Contents/ Standards/School-Nursing-Scope-andStandards-of-Practice.aspx
Linda C. Wolfe, EdD, RN, NCSN, FNASN Director, School Support Services Delaware Department of Education Dover, DE Linda has been a school nurse since 1986. She is currently the Delaware State School Nurse Consultant and was previously an elementary school nurse in the Indian River School District. Linda is a pastpresident of the National Association of School Nurses.
