Framework for 21st Century School Nursing Practice: An Overview.

Downloaded from nas.sagepub.com by guest on November 15, 2015

589559

research-article2015

NASXXX10.1177/1942602X15589559NASN School NurseNASN School Nurse

Feature Article

Framework for 21st Century School Nursing Practice An Overview Erin Maughan, PhD, MS, RN, APHN-BC Nichole Bobo, MSN, RN Sarah Butler, MS, RN, CDE, NCSN Shirley Schantz, EdD, ARNP, RN Sally Schoessler, MSEd, BSN, RN Keywords: role of the school nurse; heuristic framework; professional school nurse practice

S

chool nursing practice occurs along several continuums: individualized care to population health, generalist to specialist practice, and health promotion to disease prevention. Although school nursing remains rooted in its founding activities of acute care, health education, and communicable disease, school nursing has also changed over the years in order to meet the evolving health needs of students. The numbers of students and complexity of health needs for students attending school and needing nursing attention has increased, as has the number of students who are overweight and at risk for other health concerns. Social determinants such as living in poverty and lack of access to care have impacted students’ health and have also impacted school nursing practice and interventions (Viner et al., 2012). This

breadth of practice and the diversity of the school nurse role are ultimately dependent on the needs and concerns of each school nurse’s population. Additionally, health care reform has increased the focus on community-based, coordinated care and the use of technology to improve communication with family, health care providers, and local public health departments. The changes in student health needs, changes in health care during the 21st century, and the variety of activities and roles a school nurse may engage in impelled NASN to develop a visual conceptual framework that explains the key principles of school nursing and provides structure and focus to current-day evidence-based school nursing practice. A conceptual or heuristic framework (synonymous with conceptual model) is defined as a set of concepts that are linked together in a distinctive way to provide guidance for achieving an overall goal (Fawsett & Desanto-Madeya, 2013). Knowingly or not, historically, school

DOI: 10.1177/1942602X15589559 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com by guest on November 15, 2015 © 2015 National Association of School Nurses

nurses have based their practices on multiple frameworks. For example, the ecological model of health has formed the basis for coordinated school health (Lohrmann, 2008), the health belief model has been used to determine intervention strategies to change health behaviors (Hendershot, Pakulasaki, Thompson, Dowlng, & Price, 2011), and the healthy learner model has been used to align chronic condition management at school (Erickson, Splett, Mullett, & Heiman, 2006). Frameworks have been developed in the past to define school nurse practice. Christeson (2003) developed a framework to identify components that impact the school nurse’s community, such as assets and resources of the organization. Wold’s (1981) framework to help school nurses organize and focus their priorities included five overlapping concepts or areas: public health, systematic process, tools, adaptation, and helping relationships. These principles continue to be part of the practice of school nursing, but NASN determined July 2015 | NASN School Nurse 219

that a more comprehensive framework of school nursing practice is needed to reflect current trends and student needs. NASN’s Framework for 21st Century School Nursing Practice (the framework in this article and in the subsequent articles) creates an overarching structure that includes concepts integral to the complex clinical specialty practice of school nursing. The framework provides a graphic illustration of the key principles of professional school nursing practice, reflecting the organization’s stance for evidence-based best practice and providing focus to priority school nursing activities. The framework provides guidance for the practicing school nurse to reach the goal of supporting student health and academic success by contributing to a healthy and safe school environment. NASN believes it has a responsibility to its members and to the public they serve to develop a framework for professional school nursing practice.

Development of the Framework The development of the framework began with a review of the current needs and health care topics of school-age children, the health care climate, evidence-based literature, and critical skills needed to meet student health challenges. NASN nursing staff consolidated and merged the information to develop the visual framework. Outside experts in conceptual framework development were consulted to ensure that proper steps were followed as the framework progressed. The framework was reviewed by NASN’s Board of Directors and an advisory committee of practicing school nurses and school nurse leaders from across the country. The feedback advised about needed details and definition refinements. The next step in the framework process is to seek additional input from practicing school nurses and other stakeholders to ensure that the framework comprehensively reflects the practices of school nurses in the 21st century in meeting the health needs of students. Please participate by giving your input. Details on how to provide information will be provided at the end of this article. 220 NASN School Nurse | July 2015

Assumptions of the Framework Basic assumptions are made with all conceptual frameworks that provide the foundation to build the framework. NASN’s assumptions supporting the framework are: •• Assumption 1: School nursing is a specialized practice of professional nursing that advances the well-being, academic success, and lifelong achievement and health of students (American Nurses Association [ANA] & NASN, 2011). •• Assumption 2: School nursing practice is a dynamic profession that changes to meet the current health needs of students and school communities while maintaining the underlying principles of the nursing process and evidence-based practice. •• Assumption 3: School nursing is a collaborative practice, and school nurses are leaders in the transformation of school health, using their expertise in health and education. •• Assumption 4: School nurses use the critical thinking and decisionmaking model of the nursing process. •• Assumption 5: School nursing practice focuses on the “school community,” defined as the individual student, family, staff, and community at large. •• Assumption 6: School nursing practice is rooted in public health. •• Assumption 7: School nursing practice is grounded in a core set of values that reflects integrity, accountability, and responsibility for ethical practice.

Explanation of the Framework The core of the framework represents the student-centered care school nurses provide every day. Surrounding the student are five nonhierarchical key principles school nurses must include to meet the health needs of students (see introdutory figure on p. 218). The five principles include Care Coordination, Leadership, Quality Improvement, Public Health, and Standards of Practice. These principles are further defined by practice components embedded in them (listed in Table 1). The principles are connected by the Downloaded from nas.sagepub.com by guest on November 15, 2015

overarching idea that all school nursing practice is grounded in current evidence and the realization that these principles are not mutually exclusive. Additional articles describing the individual principles and respective practice components of the framework follow this overview article to provide further description and explanation.

Application of the Framework to Practice The purpose of developing the framework was to provide a visual understanding of what school nurses do, including key principles and practice components that infuse their daily activities. The framework can be a helpful tool for individuals within and outside the profession to visualize evidence-based school nursing practice in a holistic way. Practicing school nurses can use the framework to explain to educators and school board members the important role of school nurses in keeping students healthy, safe, and ready to learn. Novice school nurses can use the framework to enhance their understanding of the expectations of school nursing practice, facilitate personal professional development, and gain a vision of how daily activities fit into a higher vision of keeping students healthy, safe, and ready to learn. The key principles and components can be incorporated into school nurse job descriptions and provide guidance for annual reviews. The framework can also guide the development of continuing education and school nurse orientation programs as well as provide focus for research and evidence-based practice projects. NASN is also applying the framework to the work of the association. This framework will focus and prioritize efforts, such as the current development of a new series of online continuing education learning modules titled A Student Centered Approach to School Nursing Practice— From Developing to Exemplary School Nurse. In addition, the framework is being used by the NASN conference program committee to develop learning tracks for the NASN 2016 Conference. The framework is also being shared with current and future external partners to

Table 1. Practice Components for Each Principle in the Framework for 21st Century School Nursing Practice

Leadership

Care Coordination •• •• •• •• •• •• •• •• •• ••

Case Management Chronic Disease Management Collaborative Communication Direct Care Motivational Interviewing/ Counseling Nursing Delegation Student Care Plans Student-Centered Care Student Self-Empowerment Transition Planning

•• •• •• •• •• •• •• •• •• ••

Public Health •• •• •• •• •• •• •• •• ••

Advocacy Change Agents Education Reform Funding and Reimbursement Healthcare Reform Lifelong Learner Models of Practice Technology Professionalism Systems-Level Leadership

Quality Improvement

Access to Care Cultural Competency Health Equity Healthy People 2020 Levels of Prevention Outreach Population-Based Care Social Determinants of Health Surveillance

•• •• •• •• ••

Data Collection Evaluation Quality Improvement Cycle Research Uniform Data Set

Standards of Practice •• •• •• •• •• •• •• ••

Clinical Competence Clinical Guidelines Critical Thinking NASN Position Statements Nurse Practice Acts Evidence-Based Practice Code of Ethics Scope and Standards of Practice

highlight NASN member priorities, forming a more meaningful discussion about how partnerships can better advance the NASN mission, which is to advance school nursing practice to keep students healthy, safe, and ready to learn (NASN, n.d.). Mindful use of the Framework for 21st Century School Nursing Practice

fundamentally separates technical from professional school nursing practice, potentially leading to a shift in practice for all school nurses. As health care leaders continue to investigate ways to reform the health care system to ensure improved outcomes, it is critical school nurses are able to articulate what they do and how it


impacts students’ health. NASN welcomes reactions and feedback about the framework to ensure this represents best school nursing practice (although not meant to be a laundry list of every potential school nursing activity). Please read the articles explaining the five principles, and then go to http://www.nasn.org/framework by July 31, 2015, to provide input regarding the accuracy, utility, consistency, and clarity of the framework.

References American Nurses Association & National Association School Nurses. (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursesbooks .org. Christeson, E. P. (2003). The health of the school nurse community: A framework. Journal of School Nursing, 19(2), 73-80. doi: 10.1177/10598405030190020301 Erickson, C. D., Splett, P. L., Mullett, S. S., & Heiman, M. B. (2006). The healthy learner model for student chronic condition management—Part I. Journal of School Nursing, 22(6), 310-318. doi:10.1177/1059840 5060220060201 Fawsett, J., & Desanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). Philadelphia, PA: F.A. Davis Company. Hendershot, C., Pakulasaki, L. A., Thompson, A., Dowlng, J., & Price, J. H. (2011). School nurses’ role in identifying and referring children at risk of noise-induced hearing loss. Journal of School Nursing, 27(5), 380-389. doi:10.1177/1059840511411716 Lohrmann, D. K. (2008). A complementary ecological model of the coordinated school health program. Public Health Reports, 123(6), 695-703. National Association of School Nurses. (n.d.). About NASN. Retrieved from http://www. nasn.org/AboutNASN Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. Lancet, 379(9826), 1641-1652. Wold, S. J. (1981). School nursing: A framework for practice. North Branch, MN: Sunrise River Press.

July 2015 | NASN School Nurse 221

Framework Principle: Care Coordination

Care Coordination is one of the five principles of the proposed framework for the 21st Century School Nursing Practice. Coordination of care includes case management and care transitions, although the terms care coordination and case management are used interchangeably by some insurance companies, school nurses, and hospitals (McClanahan & Weismuller, 2015). Care coordination is a “deliberate organization of patient care activities between two or more participants . . . to facilitate” the delivery of care (ANA, 2012, p. 1). In addition to case management and care transition, the broad principle of Care Coordination incorporates many of the daily tasks school nurses perform to care for students and includes the practice components of student-centered care, direct care, chronic disease management, collaborative communication, motivational interviewing/counseling, nursing delegation, and student care plans. Student-Centered Care Student-centered care is provided at the individual or school-wide level (e.g., caring for students with special health care needs, promoting a positive school climate). School nurses work in partnership with students and their families/caregivers to facilitate decisions that include students “wants, needs and preferences” (IOM, 2001, p. 50). Student-centered care also includes the education and support students/families need to “make decisions and participate in their own care,” including health promotion and disease prevention behaviors (IOM, 2001, p. 50). Studentcentered care includes school nurses’

222 NASN School Nurse | July 2015

role in promoting student selfempowerment by respecting students’ autonomy and helping them realize their own powers and capabilities managing their conditions and making life decisions (Tengland, 2012). School nurses have a critical role in teaching and self-empowering students to manage their conditions while they are in school and in preparation for life. This overlaps the framework principle of Public Health in the practice component of levels of prevention (health promotion). Direct Care Care coordination provides for direct care needs of the student. Direct care describes the interventions that nurses and others provide to students, including routine treatments, medication administration, and responses to acute/ urgent health care needs. This overlaps with the framework principles of Standards of Care and Public Health (levels of prevention). Chronic Disease Management School nurses engage in chronic disease management activities to promote the best student health, academic, and quality of life outcomes possible, with emphasis on efficient care and student education, all leading to self-management. Case Management School nurses provide case management for students with chronic diseases and other health issues. Case management is a process in which the school nurse identifies children who are not achieving their optimal level of health or academic success because they have a chronic illness that is limiting their potential. It is based on a thorough assessment by the school nurse and involves activities that not only help the child deal with problems but also prevent and reduce their occurrence. Case management includes direct nursing care for the child and coordination and


communication with parents, teachers, and other care providers. Interventions are goal oriented based on the specific needs of the child and evaluated based on impact on the child (Engelke, Guttu, Warren, & Swanson, 2008). The process of case management overlaps with the framework principle of Quality Improvement. Transition Planning Transition planning refers to two different student transitions. In the health care arena, transition planning refers to a patient leaving one health care setting to another (Geary & Schumacher, 2012). School nurses facilitate the transitioning of students from other health care settings (i.e., hospitals or health care provider) to the school setting. The Individuals with Disabilities Education Act (Individuals with Disabilities Education Act [IDEA], 2004) refers to transition services related to preparing students with disabilities for future employment and education in postsecondary schools. The term has come to also encompass students transitioning from elementary to middle to high school, addressing their preparation for the new environment and developmental transitions for chronic disease self-management. Collaborative communication. School nurses utilize deliberate communication to enhance collaboration with the school and community health team to provide case management and care transition. Collaborative communication is clear, cooperative interaction by school nurses when working with medical home/health care providers, families, schools, specialists, and other community organizations as they partner together to meet the needs of students/families and achieve the best outcomes (NASN, 2011). Motivational Interviewing and Counseling Communication skills are essential for the school nurse to successfully provide

care coordination for students. Motivational interviewing and counseling are nursing interventions that enhance care coordination. School nurse counseling involves educating and assisting students with health needs, selfcare, and coping. Counseling is often an individual student focus, although it can be done with groups as well (Minnesota Department of Health, 2001). Motivational interviewing is a specific, well-researched, form of counseling that “elicit[s] behavior change by helping clients explore and resolve ambivalence related to an undesired behavior” (Bonde, Bentsen, & Hindhede, 2014, p. 449). Motivational interviewing takes training and practice. The focus is on empowering the student to identify their concerns and solutions instead of the nurse providing solutions. Nursing Delegation The school nurses’ coordination of care may include the delegation of nursing tasks. Nursing delegation is “the process for a nurse to direct another person to perform nursing tasks and activities” (ANA & NCSBN, 2006, p. 1). In the school setting, nursing delegation requires the registered professional school nurse (RN) to assign a specific nursing task, in a specific situation, for an individual student, to an unlicensed assistive personnel while providing ongoing supervision and evaluation of the UAP and student’s health outcomes (Bobo, 2014). Nursing delegation is further defined and regulated by state nurse practice acts. Nursing delegation overlaps with the framework principle of Standards of Practice. Student Care Plans Student educational and health care plans are integral to the process of care coordination. School nurses develop health care plans, which include the IHP and Emergency Care Plan (ECP), and also contribute to student educational plans including 504 plan and Individualized Education Programs (IEP). Student-centered documents are developed by the registered nurse, based on the nurse’s assessment and health

care provider orders, and follow the nursing process to address concerns and established goals and interventions to address those goals (NASN, 2015). IHPs may include activities related to direct care, delegation, student selfempowerment, case management, chronic disease management, and transition planning. ECPs flow from the IHP and address what to do during a health emergency/crisis situation. Care Coordination in Action In daily practice, school nurses implement some or all of the nine key components of care coordination based on an assessment of the student and family needs. For example, as school nurses provide direct care for a student, they may be carrying out a part of the student’s care plan by teaching the student to better manage his or her own condition and helping the student transition to young adult independence. The use of specific components by the school nurse is also influenced by the model of nursing care delivery in the school (i.e., working in one school or many influences if the nurse decides to delegate a task), the availability of resources, and the competency and skills of the school nurse (framework principle of Leadership). Practicing the principles of care coordination leads to improved student health outcomes and is the main reason for school nurses in schools. A study of a school nurse–led case management program for students with asthma found statistically significant relationships between outcomes and attainment of goals that fostered self-management, family support, and improved health care coordination (Engelke, Swanson, & Guttu, 2014). School nurses used motivational interviewing skills to overcome communication barriers in their daily practices involving counseling overweight children and their parents (Bonde et al., 2014). School nurses of the 21st century are challenged to effectively and efficiently provide and coordinate care while honoring the student/family preferences and needs. The goal is keeping students healthy, safe, and ready to learn.


References American Nurses Association. (2012). The value of nursing care coordination (white paper). Retrieved from http://www.nursingworld.org/ carecoordinationwhitepaper American Nurses Association & National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved from https://www.ncsbn.org/Delegation_joint_ statement_NCSBN-ANA.pdf Bobo, N. (2014). Principles for practice— Nursing delegation to unlicensed assistive personnel in the school setting. Silver Spring, MD: National Association of School Nurses. Bonde, A. H., Bentsen, P., & Hindhede, A. L. (2014). School nurses’ experiences with motivational interviewing for preventing childhood obesity. The Journal of School Nursing, 30(6), 448-455. doi:10.1177/1059840514521240 Engelke, M. K., Guttu, M., Warren, M. B., & Swanson, M. (2008). School nurse case management for children with chronic illness: Health, academic, and quality of life outcomes. The Journal of School Nursing, 24(4), 205-214. doi:10.1177/1059840508319929 Engelke, M. K., Swanson, M., & Guttu, M. (2014). Process and outcomes of school nurse case management for students with asthma. The Journal of School Nursing, 30(3), 196-205. doi:10.1177/1059840513507084 Geary, C. R., & Schumacher, K. L. (2012). Care transition: Integrating transition theory and complexity science concepts. Advances in Nursing Science, 35(3), 236-248. Individuals with Disabilities Education Act (2004), 20 U.S.C. 1400 et seq. Institute of Medicine. (2001). Envisioning the National Health Care Quality Report. Washington, DC: National Academies Press. McClanahan, R., & Weismuller, R. C. (2015). School nurses and care coordination for children with complex needs: An integrative review. The Journal of School Nursing, 31(1), 34-43. Minnesota Department of Health. (2001). Public health interventions: Applications for public health nursing practice. Retrieved from http:// www.health.state.mn.us/divs/opi/cd/phn/ docs/0301wheel_manual.pdf National Association of School Nurses. (2011). The role of the school nurse (position statement). Silver Spring, MD: NASN. National Association of School Nurses. (2015). Individualized healthcare plans: The role of the school nurse (position statement). Silver Spring, MD: NASN. Tengland, P. (2012). Behavior change or empowerment: On the ethics of healthpromotion strategies. Public Health Ethics, 5(2), 140-153. doi:10.1093/phe/ phs022


Framework Principle: Leadership

Leadership is the capacity to guide someone or something along a way, not a particular position (Merriam-Webster, 2015). School nurses are natural leaders as they are often the only health care professional employed in an educational setting and provide guidance to oversee school health policies, programs, and the provision of health services (NASN, 2011). Leadership is promoted as an important standard in the profession of school nursing and highlights the need for school nurses to engage in teamwork, direct the coordination of care, and have a clear vision for student health care and is thus included as a key principle in the framework (ANA & NASN, 2011). While a school nurse who is in the first years of his or her school nursing career may not identify with all of the roles of a leader, it is vital for the nursing professional to continually advance in the skills needed to become a well-rounded leader in his or her school and community. The roles of a leader in school nursing include practice components of change agent, advocate, lifelong learner, and systems-level leader. •• Change agent. School nurses are change agents, meaning that they play key roles in collaborating with interdisciplinary teams to identify students at risk for health concerns and resources needed to promote the safe delivery of care. In making decisions, the nurse leader relies on patient-centered, evidence-based practice and performance data (Robert Wood Johnson Foundation, 2009). This role overlaps with the


framework principle of Care Coordination. Being a change agent includes the development, application, advocacy, and evaluation of policies, plans, and protocols that address children’s health issues within the school/community setting (ANA & NASN, 2011). •• Advocate. Advocacy is the ability to successfully support a cause or interest on one’s own behalf or that of another and requires a set of skills that includes problem solving, communication, influence, and collaboration (ANA, 2012). A school nurse supports both students and the profession. As an advocate for the student, the school nurse supports individuals in the school community by providing skills and education that encourage self-management, problem solving, effective communication, and influence and collaboration with others (ANA, 2012). This principle (or role) overlaps with the framework principle of Care Coordination. As an advocate for the profession, the school nurse engages in the deliberate process of influencing those who make decisions (ANA, 2012), including school administration and local and state political leaders. This second form of advocacy ties into understanding health care and education reform. Health care and education reform may include policy and legislative efforts to promote change and develop a platform and programs that provide students in the United States with student protection, effective teaching, and school leadership that affords flexibility and support at the local and state levels (Duncan, 2014). Other health care reform movements include any activities, particularly involving policy- or system-level changes, that address gaps or concerns in current health care practice. The Affordable Care Act of 2010, the most recent national health reform effort, sought to put patients in


charge of their health care, reduce the cost of health care, and improve the health of populations (American Public Health Association [APHA], 2013b). Recent legislation that addressed education reform included the Elementary and Secondary Education Act of 1965 and subsequent reauthorizations, including No Child Left Behind in 2001. School nurses must be aware of and understand health care and education reform. Reform changes may impact school nurse responsibilities, work environment goals, and student academic and health. Understanding current reform affords opportunities for the school nurse as a change agent to advocate for changes that best serve students, articulate how school nursing fits into the reform, and validate their role so it is not lost. •• Lifelong learner. Professional growth in knowledge development and skills acquisition and remaining current with events and practice require a commitment to continual learning, advanced academic education, certification, and activities that support competent professional practice (ANA, 2012). The school nurse shows commitment for continued learning for himself or herself as well as other practitioners (ANA & NASN, 2011). For example, Anderson and Enge (2012) conducted a literature review to identify electronic resources that school nurses could use for their evidencebased practice. Staying current in nursing practice in the school setting includes embracing both medical and information technology. In school nursing, current medical technology is used to provide evidence-based, specialized health care procedures (i.e., telehealth) (NASN, 2012). Technology also encompasses computer skills and the use of web-based resources to collect/manage data (electronic health records), which overlaps with the

framework principle of Quality Improvement and the practice component of data collection. Technology also allows for new forms of evidence-based education and communication and education such as social media and apps. •• Systems-level leader. Systems-level leadership includes leading change at a health care system or education system level. School nurses, along with all public health nurses, lead efforts that align emerging systems of care for population health improvement, health promotion, risk reduction, and disease prevention efforts that are within the nucleus of a reformed health system (APHA, 2013a). This component overlaps with the framework principle of Public Health’s practice component of levels of prevention and populationbased care. System-level leaders also includes a way of thinking and understanding of the interconnection between and among organizations, policies, processes, and systems (Senge, n.d.). System-level thinkers think strategically of how systems, organizations, and people connect. For example, a school nurse must realize that changes in school health policies may impact education policies and health care provider activities. When looking at processes and activities, all potential changes/ consequences must be considered. In order to be an effective leader in any of these roles, school nurses must exhibit professional behavior, values, and style (Campbell & Taylor, n.d.). Professionalism also includes the attributes of accountability, maturity, problem solving, collaboration, proactivity, positivity, professional speech, appropriate dress, and activities that align with current, evidence-based, student-centered practice. Leaders must exhibit professionalism at all times in their practice. This gives them credibility and respect so others will listen to their ideas. In addition to the various roles and attributes of a school nurse leader,

key concepts related to systems, budget, and organizations exist that school nurse leaders must understand in order to advocate and ensure student-centered care is practiced. These include how school nursing is practiced and funding streams (including reimbursement). •• Models of practice. The delivery of school health services varies across the United States. Some school nurses oversee the students in one building; some have responsibility for students in several buildings. Some school nurses have aides or others to whom they can delegate specific tasks. Nurse Practice Acts and state guidelines may influence how nursing is practiced (overlaps with framework principle of Standards of Practice). Employment practices impact the delivery of school health services and come from a variety of sources, including school districts, health departments, hospitals, health care systems, and/ or community groups. •• Funding and reimbursement. Funding also impacts models of practice. Traditional funding depends on school district budgets funds to pay for school nursing services. Innovative methods of funding school health services include support from health care systems, public health, community organizations (including community care organizations), community clinics, or reimbursement for services, for example. Reimbursement can come from utilizing Medicaid reimbursement funds (direct services and/or administrative costs) or private insurance reimbursements. Leadership in Action School nurses are leaders every day as they advocate for their students. One school nurse presented data of current conditions in her district to school board members as she advocated for her students. She was a successful change agent, since policies changed and more school nurses were hired (Galemore & Maughan, 2014). Professional behaviors


were identified by principals, educators, and others as the most influential factor when school nurses were seen and understood as valuable members of the educational team (Maughan & Adams, 2011). Every school nurse is a leader, one with a multifaceted role in a unique practice setting (NASN, 2011). When school nurses develop the leader inside of themselves, they make a positive difference in the lives of everyone in their school and community.

References American Nurses Association. (2012) Code of ethics. Silver Spring, MD: nursesbooks.org. American Nurses Association & National Association of School Nurses. (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursesbooks.org. American Public Health Association. (2013a). The definition and practice of public health nursing. Retrieved from http://apha. org/~/media/files/pdf/membergroups/ nursingdefinition.ashx#page=3&zoom=a uto,-99,712 American Public Health Association. (2013b). The impact of the Affordable Care Act on state and local public health systems. Retrieved from https://www.apha.org/topics-and-issues/ health-reform/key-aca-resources Anderson, L. S., & Enge, K. J. (2012). Education and information for practicing school nurses: Which technologysupported resources meet their needs? The Journal of School Nursing, 28(5), 358-369. doi:10.1177/1059840512443261 Campbell, S. L., & Taylor, D. D. (n.d.) Professionalism in the workplace. Retrieved from http://www.umkc.edu/starr/Workplace_ Professionalism.pdf Duncan, A. (2014). America’s kids need a better education law. Retrieved from http://www .ed.gov/blog/2013/08/americas-kids-need-abetter-education-law/ Galemore, C. A., & Maughan, E. D. (2014). Standardized Dataset for School Health Services: Part 2 Top to bottom. NASN School Nurse, 29(4), 187-192. doi:10.1177/19426 02X14536526 Maughan, E. D., & Adams, R. (2011). Educators’ and parents’ perception of what school nurses do: The influence of school nurse/student ratios. Journal of School Nursing, 27(5), 355-363. doi:10.1177/1059840511416368


Merriam-Webster Dictionary. (2015). Definition of leadership. Retrieved from http:// www.merriam-webster.com/dictionary/ leadership National Association of School Nurses. (2011). The role of the school nurse (position statement). Silver Spring, MD: NASN.

National Association of School Nurses. (2012). The use of telehealth in the schools (position statement). Silver Spring, MD: NASN. Robert Wood Johnson Foundation. (2009). Clinical nurse leaders as agents of change. Retrieved from: http://www.rwjf.org/ en/about-rwjf/newsroom/newsroom-

content/2009/02/clinical-nurse-leaders-asagents-of-change.html Senge, P. M. (n.d.). Systems thinking. Retrieved from https://www.solonline .org/?page=SystemsThinking

Framework Principle: Public Health proactive and includes disseminating the data to those who need it to prevent or control [health] conditions (Centers for Disease Control and Prevention [CDC], n.d.). School nurses practice surveil]lance when they notice an increase in strep throat or the number of students with asthma. Surveillance and use of the data overlap with the framework principle of Quality Improvement’s practice component of data collection. The role of a school nurse is to improve students’ health, prevent injury, promote healthy lifestyles, and identify students at risk to ensure all students are healthy, safe, and ready to learn. By accomplishing this role, school nurses are practicing the very definition of Public Health (CDC Foundation, n.d.). In fact, public health provides the foundation for the specialty practice of school nursing and is thus one of the five principles of the framework (ANA & NASN, 2011; NASN, 2013). Key tenets and responsibilities of public health practiced by school nurses, such as surveillance, outreach, population-based care, levels of prevention, social determinants of health (including access to care and cultural competency), and health equity, make up the practice components of this principle and are further defined in the following. Surveillance Surveillance is closely aligned with nursing assessment and is a key school nursing and public health skill. Surveillance is the ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice. It is usually


Outreach Outreach, like surveillance, is proactive and involves identifying individuals or populations at risk to assist them to address their conditions, find services to assist them, and/or provide education to prevent the condition or complications (Minnesota Department of Health, 2001). For example, school nurses outreach to students with undiagnosed asthma who exhibit signs or symptoms such as a constant cough or not participating in physical education classes. Population-Based Care The Public Health principle of the framework expands beyond individual focus inherent to the framework principle of Care Coordination to focus on populations that possess similar health concerns or characteristics (e.g., school-age children). Interventions for populations are guided by an assessment of the group, incorporates all levels of prevention, and includes all levels of practice (i.e., student/ family, school, systems) (Minnesota Department of Health, 2001). School nurses practice population-based care when they develop health promotion activities or conduct screenings for the entire school population.


Levels of Prevention Intervention strategies for populationbased care occur at three levels: before a health issues occurs (i.e., primary prevention), when a health issue has begun but before complications and often before signs and symptoms (i.e., secondary prevention), or after the health issue has occurred (i.e., tertiary prevention). Public Health addresses all levels of prevention but places extra emphasis on primary prevention. •• Primary prevention includes strategies that promote health, protect against threats of health, and result in the prevention of health issues from occurring. Examples of primary prevention include providing health education, promoting immunizations, and advocating for strategies and policies that promote a positive school environment. The activities of primary prevention overlap with the framework principle of Leadership’s components of change agent and advocacy. •• Secondary prevention includes strategies that detect and treat problems in their early stages often before signs and symptoms appear and modify, remove, or treat them before a problem becomes serious. Examples of secondary prevention include conducting health screenings and providing referrals and follow-up care once a health issue is detected. •• Tertiary prevention includes strategies that limit further negative effects from a health problem that has occurred and promote optimal levels of functioning. For example, the school nurse implements tertiary

prevention when collaborating with a student’s health team to provide effective diabetes management at school (overlapping with the framework principle of Care Coordination). Healthy People 2020 includes guidance to all levels of prevention/ intervention by providing a comprehensive set of 10-year national goals and objectives for improving the health of all Americans. It was developed by leaders and experts in the field and includes the health priorities for the nation (USDHHS, 2010a). School nurses can look to Healthy People 2020 as a guide when establishing priority activities. Social Determinants of Health School nurses address social determinants when assessing their student/population and developing their interventions. Social determinants are factors that impact health such as income/social status, housing, transportation, employment/working conditions, social support networks, education/literacy, neighborhood safety/ physical environment, access to health services, and culture (USDHHS, 2010b). Social determinants are identified to be the cause of 80% of health concerns (Booske, Athens, Kindig, Park, & Remington, 2010). School nurses address social determinants when they address mold at home that triggers a student’s asthma. Appropriate access to care is another social determinant that school nurses address regularly (USDHHS, 2010c). Access to care is having readily available comprehensive, quality health care services. It also includes access to a school nurse, referrals to health care services, insurance coverage, adequate resources, transportation to care, and timeliness of care Culture is another social determinant and includes the customs, values, and beliefs of an individual and/or population. School nurses must continually work at obtaining cultural competency, which is a set of

behaviors, attitudes, and skills that allows effective care to be delivered in crosscultural situations (Office of Minority Health [OMH], 2013). Developing cultural competence means school nurses use strategies that respect the values and expectations of all members of the school community without diminishing the nurse’s own values and expectations (OMH, 2013). Failure to be culturally sensitive and take into account students’/ families’ beliefs and values, along with their literacy level, decreases the trust between students/families and the school nurse. Lack of trust can lead to decreases in communication, decrease in compliance/management of a condition, and adverse student health outcomes. Cultural competency overlaps with practice components of the framework’s principle of Standards of Practice and Care Coordination. Social determinants of health and health disparities (health inequity) are closely related. Limited access to health care impacts the ability for people to reach their full potential, negatively affecting quality of life. For example, children with asthma have nearly twice as many visits to the emergency department than adults (USDHHS, 2012). Children of racial minorities are more likely to have untreated asthma or to be obese than White children (USDHHS, 2012; Wang, 2011). School nurses are in a critical position to notice and address health disparities of students/families because they see the students regularly and know the environments where they live and play. School nurses must also review their own practices to ensure they are providing equitable services (health equity) and attention to all of their students, paying particular attention to students at greatest risk. Public Health in Action School nurses are the eyes and ears of public health every day. They observe trends in conditions and help in the prevention of health outbreaks. One way school nurses prevent outbreaks is by supporting immunization compliance and promoting influenza vaccination. Schools with school nurses have fewer


exemptions for immunizations (Salmon et al., 2004). Pride and colleagues (2014) used active surveillance to determine reasons for vaccination exemptions and learned how a new state law impacted exemptions. School nurses provide public health services by understanding and addressing gender and race differences as they address health concerns. Rew, Arheart, Horner, Thompson, and Johnson (2014) found distinct differences by race and gender in high school students’ health promoting activities. By knowing the differences, school nurses can be sensitive to individual and population needs. These examples are just a few of how the framework principle of Public Health is integral in the school nursing goal to keep children healthy, safe, and ready to learn.

References American Nurses Association & National Association of School Nurses. (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursesbooks.org. Booske, B., Athens, J., Kindig, D., Park, H., & Remington, P. (2010). Different perspectives for assigning weights to determinants of health (County Health Rankings Working Paper, University of Wisconsin). Retrieved from http://www.countyhealthrankings.org/ sites/default/files/ifferentPerspectivesFor AssigningWeightsToDeterminantsOfHealth.pdf CDC Foundation. (n.d.) What is public health. Retrieved from http://www.cdcfoundation. org/content/what-public-health Centers for Disease Control and Prevention. (n.d.). NIOSH activities: Surveillance. Retrieved from http://www.cdc.gov/niosh/ topics/flu/surveillance.html Minnesota Department of Health. (2001). Public health interventions: Application for public health nursing practice. St. Paul, MN: Minnesota Department of Health. Retrieved from http://222.health.state.mn.us/divs/opi/ cd/phn/docs/0301wheel_manual.pdf National Association of School Nurses. (2013). Resolution—Public health as the foundation of school nursing practice. Silver Spring, MD: NASN. Office of Minority Health. (2013). What is cultural competency? Retrieved from http:// minorityhealth.hhs.gov/templates/browse. aspx?lvl=2&lvlID=11 Pride, K., Geissler, A., Kolasa, M., Robinson, B., VanHouten, C., McClinton, R., et al. (2014). Assessment of vaccine exemptions among


Wyoming school children, 2009 and 2011. Journal of School Nursing, 30(5), 332-339. doi:10.1177/1059840513518439 Rew, L., Arheart, K. L., Horner, S. D., Thompson, S., & Johnson, K. E. (2014). Gender and ethnic differences in healthpromoting behaviors of rural adolescents. The Journal of School Nursing, 31(3), 219-232. Salmon, D., Moulton, L., Omer, S., Chace, L., Klassen, A., Talebian, P., et al. (2004). Knowledge, attitudes, and beliefs of school nurses and personnel and associations with nonmedical immunization exemptions. Pediatrics, 113(6), e552-e557.

U.S Department of Health and Human Services. National Heart, Lung, and Blood Institute. (2012). Reducing asthma disparities. Retrieved from http://www.nhlbi.nih.gov/health-pro/ resources/lung/naci/discover/disparities.htm U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010a). Healthy People 2020. Washington, DC: USDHHS. Retrieved from https://www.healthypeople.gov/ U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010b). Healthy People 2020—Determinants of health.

Washington, DC: USDHHS. Retrieved from https://www.healthypeople.gov/2020/ about/foundation-health-measures/ Determinants-of-Health U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010c). Healthy People 2020— Access to health services. Washington, DC: USDHHS. Retrieved from https://www. healthypeople.gov/2020/topics-objectives/ topic/Access-to-Health-Services Wang, Y. (2011). Disparities in pediatric obesity in the United States. Advances in Nutrition, 2(1), 23-31. doi:10.3945/an.110.000083

Framework Principle: Quality Improvement

Quality Improvement (QI) is a continuous and systematic process that leads to measurable improvements and outcomes (Health Resources and Services Administration [HRSA], n.d.). QI and measuring quality are integral parts of health care reform and are current standards of practice (Agency for Healthcare Research and Quality [AHRQ], 2011). For this reason, QI is included as one of the five principles in the framework. Some school nurses may think they have little time for the practice components of QI (i.e., data collection, QI cycle, evaluation), but if school nurses make the QI process part of their daily work, they will actually better understand which of their activities have the greatest impact on student health and outcomes and which do not. This knowledge will help school nurses to prioritize activities in very busy schedules and time demands and better explain their choices for priority activities. It is also through the presentation of data that school nurses can advocate for changes in policy and for the need for additional school nurses,


which would further reduce the workload (overlapping with the framework principle of Leadership’s practice component of change agent) and improve the quality of care. Data collection and use is also helpful to articulate the breadth and importance of school nursing services to educators and policymakers. As Hassett (1998) remarked, “If you are not in the database, you don’t exist.” Data are how we show school nurses exist and the impact of the work they do. QI begins with the nursing process in action: assessment, identification of the issue, developing a plan, implementing, and evaluating (ANA & NASN, 2011). QI is sometimes referred to as the QI cycle or Deming cycle and is often depicted using the circular Plan-Do-Check-Act (PDCA) (AHRQ, n.d.) to illustrate its continuous process. The principle of QI is critical for evidence-based practice in school nursing. QI is integral to the practice components of data collection (including the Step Up and Be Counted Uniform Data Set), data collection, evaluation, and research, as described in the following. Data Collection Data collection includes school nurse documentation of daily activities, progress of student individual care plans, and other events. Documenting daily activities is an important responsibility of all nurses. Nurses learn in nursing school that if we do not document what we do, it is not considered done. This pertains to school


nursing as well. Data are the cornerstone of QI (HRSA, n.d.). Data can be quantitative (numbers) or qualitative (words) in nature. Collecting data is critical because it “separate[s] what is thought to be happening from what is really happening” (HRSA, n.d.). Data collection is also important to illustrate the variety of roles and activities of school nurses, how their time is spent, and how school nurses are able to illustrate their impact on students’ health and readiness for school. It is critical to collect data to identify concerns and monitor progress. Data can also establish a baseline of current conditions to identify trend changes (overlapping with surveillance, a practice component of the framework principle of Public Health). Data should be reported to principals, school boards, local health departments, and other decision makers and stakeholders to articulate the role of the school nurse. Data are also used to evaluate progress toward goals and job performance. The use of electronic health records to manage data and appropriately share data is also included in this principle (overlapping with the technology practice component found in the framework principle of Leadership). Uniform Data Set. Data collection also includes data points defined in the uniform data set. Step Up and Be Counted (http://nasn.org/ stepupbecounted) is a joint initiative between NASN and the National Association of State School Nurse

Consultants to identify and define data points that all school nurses across the country are collecting in the same way (Maughan et al., 2014). The ability to combine data from school nurses across the country will allow researchers to determine which school nurse interventions are most effective and better understand models of school nursing practice and workforce models and their impacts on student health. QI is about using the aforementioned with the best evidence and standards of practice for better health outcomes (overlapping with the framework principle of Standards of Practice). Evaluation Evaluation is the sixth step of the nursing process and sixth standard of school nursing practice (ANA & NASN, 2011). Generally speaking, evaluation is the assessment of the attainment of outcomes. For school nurses, evaluation includes determining student outcomes and impacts of school nurse actions and whether the processes used were appropriate. Evaluation should occur for the components of the health plans; school nursing interventions, including individual student counseling, health education classes, and nursing treatments related to student Individualized Healthcare Plan (IHPs; which are practice components of the framework principle of Care Coordination); and school nurses’ own work performance. Research Research is included in the framework principle of QI because many of the concepts of research and QI overlap, yet QI and research are different. QI determines if evidence-based practice standards are effective. Research is a more formal process for testing an intervention to gain new knowledge that is hopefully generalizable beyond the given situation (AHRQ, 2011; IOM, 2001; U.S. Department of Health and Human Services [USDHHS], 2009). Formal school nursing research is needed to ensure that

school nurse practice is based on the best evidence and that as events and techniques change, we obtain evidence about effectiveness. Data from research are also needed by school nurses as they advocate and illustrate how they impact student health outcomes (overlapping with the framework principle of Leadership and the practice component of change agent and advocate). School nurses can and should be involved in research in several ways, such as helping to identify a research question, completing research surveys, collecting data for research projects, or assisting expertly trained researchers to design studies appropriate for school settings and students. School nursing research is critically necessary to advance school nursing practice. Understanding current evidence-based practice is critical to participation in research as well as QI. QI in Action School nurses may not realize that they use the principle of QI in everyday practices. Celik (2013) used a business QI model called Lean Six to address medication documentation errors by unlicensed assistive personnel (UAPs). She first identified the problem by collecting data via monthly audits. Celik then reviewed the process to identify the reason for the errors. Her team developed standards of practice for documentation, which were implemented. The process was reviewed, and documentation errors decreased from 68% to 35%. Quality was improved. Garmy, Jakobsson, Carlsson, Berg, and Clausson (2014) formally evaluated (i.e., researched) an educational intervention to determine if student participation in a course decreased symptoms of depression. The results indicated that there was a decrease in the number of depression symptoms of participants after the course that persisted even after a year (for females). The team also evaluated the process and found students and tutors were satisfied with the course.


It should be noted in both examples that teams were utilized. QI is often a team process (HRSA, n.d.), just as school nurses are often part of teams addressing a school health concern. The principle of QI (including data collection, evaluation, and research) is critical for school nurses as we strive to ensure students are healthy, safe, and ready to learn.

References Agency for Healthcare Research and Quality. (n.d.). Plan-do-check-act cycle. Retrieved from http://healthit.ahrq.gov/health-ittools-and-resources/workflow-assessmenthealth-it-toolkit/all-workflow-tools/ plan-do-check-act-cycle Agency for Healthcare Research and Quality. (2011). National strategy for quality improvement in health care. Retrieved from http://www.ahrq.gov/workingforquality/ American Nurses Association & National Association School Nurses. (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursesbooks .org. Celik, L. A. (2013). Learning and applying new quality improvement methods to the school health setting. NASN School Nurse, 28(6), 3063011. doi:10.1177/1942602X13496121 Garmy, P., Jakobsson, U., Carlsson, K. S., Berg, A., & Clausson, E. K. (2014). Evaluation of a school-base program aimed at preventing depressive symptoms in adolescents. Journal of School Nursing, 31(2), 117-125. doi:10.1177/1059840514523296 Hassett, M. (1998). Message posted to NRSING-L Nursing Informatics Listserv electronic mailing list. Retrieved from http://mailman.amia.org/ mailman/private/nrsing-l/ Health Resources and Services Administration. (n.d.). Quality improvement. Retrieved from http://www.hrsa.gov/quality/toolbox/ methodology/qualityimprovement/ Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Maughan, E. D., Johnson, K. H., Bergren, M. D., Wolfe, L. C., Cole, M., Pontius, D. J., et al. (2014). Standardized data set for school health services: Part 1—getting to big data. NASN School Nurse, 29(4), 182-186. doi: 10.1177/1942602X14538414 U.S. Department of Health and Human Services. (2009). Code of federal regulations. Retrieved from http://www.hhs.gov/ohrp/ humansubjects/guidance/45cfr46.html


Framework Principle: Standards of Practice other framework principles (Public Health, Quality Improvement, Leadership, and Care Coordination).

Specialized knowledge, skills, decision making, and standards for practice are required to provide the best possible nursing care with the best possible outcomes. For this reason, Standards of Practice, defined as a competent level of nursing practice and professional performance common to and expected of all school nurses, is included as a principle in the framework. Included within this principle are integral practice components that underlie school nurses’ daily activities and include the scope and standards of nursing practice, code of ethics, nurse practice acts, position statements, evidence– based practice, clinical guidelines, clinical competence, and critical thinking. The Scope and Standards of Practice School Nursing: Scope and Standards of Practice encompasses a broad range of nursing practice that describes the duties that schools nurses are expected to perform competently, regardless of the role, the population served, or specialty within school nursing (ANA & NASN, 2011). They “reaffirm for the school nurse the essence of [the specialty of] school nursing and the scope of school nursing practice” and define the level of competence that school nurses should attain (ANA & NASN, 2011, p. xi). The standards include details related to the steps of the nursing process that each school nurse should use in practice and contains components from each of the


Code of Ethics A code of ethics “informs every aspect of the nurse’s life” (ANA, 2015, p. vii). “School nurses conduct themselves with honesty and integrity based on NASN core values and according to the Scope and Standards of School Nursing Practice” (ANA & NASN, 2011, p. 7). School nurses provide care, advocate for families, outreach to those at risk, provide surveillance, and collect data in a compassionate, respectful manner that protects the dignity, autonomy, rights, and client confidentiality, all within the legal constraints of the health and educational systems (ANA & NASN, 2011). This overlaps with each of the other framework principles: Public Health, Quality Improvement, Leadership, and Care Coordination. Nurse practice acts (NPAs) are laws that guide and govern nursing practice in each state and protect the public’s health and welfare by overseeing and ensuring safe practice of nursing (National Council of State Boards of Nursing [NCSBN], n.d.). NPAs determine the lawful scope of nursing practice. Boards of Nursing, established in each state and territory, have the authority to develop additional rules and regulations to clarify or make the NPA law more specific and provide more guidance for the nursing profession (NCBSN, n.d.). Boards of Nursing are responsible for issuing licenses to practice nursing. All nurses must follow the regulations, rules, and laws of the NPAs of their states as well as make legal and ethical judgments based on their particular circumstances. School nurses must understand and follow their state NPAs and guidelines as they perform nursing duties. It is NPAs and state guidelines that determine if nursing delegation can occur and greatly impacts the framework’s principle of Care Coordination.


Position Statements Position statements are evidence-based documents that provide the official position of the NASN board of directors. These statements summarize “the historical, political, and/or scientific aspects regarding a topic related to school nursing, school health services . . . that can be shared with members, community media, and legislators” (NASN, 2012, p. 2). Position statements can be used when advocating for student care needs and policy change, which overlaps with the framework principles Leadership and Care Coordination. Evidence-Based Practice Evidence-based practice incorporates the best available research, scientific evidence, availability of resources, and capacity of workers to inform clinical decision making to promote optimal outcomes (Jacobs, Jones, Gabella, Spring, Ross, & Brownson, 2012). The 21st Century School Nurse recognizes that evidence-based practice replaces empirical- or knowledge/ authority-based care (Bultas & McLaughlin, 2013) and has become the standard of health care practice (Adams & McCarthy, 2007). Evidence-based principles directly lead the school nurse to integrate evidence and research findings and should be the basis for all nursing practice (Bultas & McLaughlin, 2013). This directly relates to the framework principle of Quality Improvement. Clinical Guidelines Clinical guidelines “assist health care providers to ensure best practices” (Maughan & Schantz, 2014, p. 221). Clinical guidelines for nursing practice use the current best evidence to make clear recommendations for care and improve health care decisions to optimize patient care and improve practice outcomes. Clinical guidelines are developed by a systematic review of the evidence that determines the best care options (Institute of Medicine [IOM], 2011). School nurses advance professionalism and collegiality

among other health care professionals by recognizing, promoting, and practicing evidence-based clinical guidelines. NASN recently published their first clinical guideline related specifically to care of students with asthma.

Health. Critical thinking is also used when evaluating activities (framework principle of Quality Improvement) and advocating for needed changes (framework principle of Leadership).

Clinical Competence Clinical guidelines assist school nurses to provide clinically competent care. Clinical competence means the school nurse successfully performs at an expected professional level that integrates knowledge, skills, abilities, and judgment (ANA & NASN, 2011). This high level of competency is maintained “by enhancing professional knowledge and skills, and by collaborating with peers, other health professionals and community agencies while adhering to the standards of school nursing practice” (ANA & NASN, 2011, p. 15). The general public, students, parents, and the school community have the expectation that school nurses practice at their best possible ability to provide quality care. The school nurse is obligated to take individual responsibility and accountability for maintaining professional competence. The school nurse is also responsible for evaluating his or her care that would encourage optimal outcomes (which overlaps with framework’s principle of Quality Improvement). Nurses must constantly be learning and updating their knowledge, skills, and practice to main clinical competency, which overlaps with lifelong learning found in the framework principle of Leadership).

Standards of Practice in Action Standards of practice are underlying principles of everyday practice. Standards of practice and ethics are used in legal and evaluative disputes to judge the reasonable expectations of a nurse. Some school nurses have used the standards of practice and clinical competencies when developing school nurses’ job performance evaluations (McDaniel, Overman, Buttu, & Engelke, 2013). This reinforces standards of care and offers a regular review of practice and nursing needs. “Our students and families stand to benefit when all nurses practice to the full extent of their skills and education” (Delack, 2011, p. 133). When each of these components is considered and practiced together, the client, in this case the student, has the best possible prospect for a positive health outcome.

Critical Thinking Critical thinking is an integral part of every step in the nursing and decisionmaking process. Critical thinking is a dynamic, continuing process that uses intellect to develop and maintain competent use of reasoning skills to make sound clinical judgments that influence all practice (ANA & NASN, 2011; Weismuller, Willgerodt, McClanahan, & Helm-Remund, in press). School nurses must make decisions that are clear, rational, and open minded to provide care that is expected and is in the best interest of the clients served within the school setting. Critical thinking overlaps with the framework principles of Care Coordination and Public

References Adams, S., & McCarthy, A. M. (2007). Evidencebased practice guidelines and school nursing. Journal of School Nursing, 23(3), 128-136. doi: 10.1177/10598405070230030201 American Nurses Association & National Association of School Nurses. (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursesbooks.org. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Retrieved from http://www.nursingworld.org/ codeofethics Bultas, M. W., & McLaughlin, L. (2013). Using evidenced-based practice in the school health room. NASN School Nurse, 28(1), 34-40. doi: 10.1177/1942602X12465964 Delack, S. (2011). Vision, voice, and visibility: The tipping point. NASN School Nurse, 26(3), 133-134. doi:10.1177/1942602X11399770

doi:http://dx.doi.org/10.5888/pcd9.110324. Retrieved from http://www.cdc.gov/pcd/ issues/2012/11_0324.htm#The%20Need%20 for%20Evidence-Based%20Public%20Health Maughan, E. D., & Schantz, S. (2014). NASN’s first evidence-based clinical guidelines: Asthma. NASN School Nurse, 29(5), 221-223. doi:10.1177/1942602X14545227 McDaniel, K. H., Overman, M., Buttu, M., & Engelke, M. K. (2013). School nurse evaluations: Making the process meaningful and motivational. The Journal of School Nursing, 29(1), 19-30. doi:10.1177/1059840512469407 National Association of School Nurses. (2012). NASN board handbook: NASN governing documents overview. Silver Spring, MD: NASN. National Council of State Boards of Nursing. (n.d.). Nurse practice acts guide and govern nursing practice. Retrieved from https:// www.ncsbn.org/nurse-practice-act.htm Weismuller, P. C., Willgerodt, M. A., McClanahan, R., & Helm-Remund, T. (in press). Sailing the “seven C’s” of leadership. NASN School Nurse. doi:10.1177/19426 02X15577678

Authors’ Note Now that you have read the series of articles, go to http://www.nasn.org/framework by July 31, 2015 to provide input regarding the accuracy, utility, consistency, and clarity of the Framework.

On behalf of the National Association of School Nurses: Erin Maughan, PhD, MS, RN, APHN-BC Nichole Bobo, MSN, RN Sarah Butler, MS, RN, CDE, NCSN Shirley Schantz, EdD, ARNP, RN Sally Schoessler, MSEd, BSN, RN (suggested reference: National Association of School Nurses. (2015). Framework for 21st century school nursing practice. NASN School Nurse, 30(4), 218-231. doi:10.1177/1942602X15589559)

Institute of Medicine. (2011). Clinical practice guidelines we can trust. Retrieved from http:// www.iom.edu/Reports/2011/Clinical-PracticeGuidelines-We-Can-Trust.aspx Jacobs, J. A., Jones, E., Gabella, B. A., Spring, B., Ross, C., & Brownson, R. C. (2012). Tools for implementing an evidencebased approach in public health practice. Preventing Chronic Disease, 9, 110324.



Nursing knowledge for the 21st century: an international commitment.

Nursing in the 21st century: perfect practice, imperfect practitioners.

Nursing theory: the 21st century.

Nursing theories for the 21st century.

A 21st-century medical school.

Overview of nursing research and relevance to school nursing practice.

A 21st-century medical school - Authors' reply.

Addressing 21st-century nursing ethics: implications for critical care nurses.

Directions for nursing theory development in the 21st century.

What is nursing in the 21st century and what does the 21st century health system require of nursing?

21st Century Cell Culture for 21st Century Toxicology.

Epigenetics: An Emerging Framework for Advanced Practice Psychiatric Nursing.

Nursing in the 21st century: is there a place for nursing philosophy?

21st century exposure: an opposing view.

Training for the 21st century?

Coming of age: pharmacy practice in the 21st century.

Informing 21st-Century Risk Assessments with 21st-Century Science.

Public Health Nursing in the 21st Century: Challenges and Opportunities for Women and Children's Health.

21st century rhinology.

A 21st century truism.

21st century telemetry.

Editorial: Antibacterial targets for the 21st century.

Statistical thinking for 21st century scientists.

GeneMill: A 21st century platform for innovation.