Staff Models for School Health

The Washington State Staff Model for the Delivery of School Health Services is available for download from the Office of Superintendent of Public Instruction (OSPI) Web page at https://www.k12.wa.us/sites/default/files/public/healthservices/pubdocs/schhealth.pdf. The document, sponsored by OSPI and the Washington State Nursing Quality Assurance Commission (NCQAC), outlines staffing needs for nursing care in schools. It describes the different levels of staff that may provide health services because of their training, education, licensure, certification, and responsibility.

According to the Staff Model, staffing for school health services is based on registered nursing assessment of the student population to:

•identify special health care needs;
•prioritize those students with the highest need; and
•determine the levels of nursing care required for individual students.

The model is used to predict the nursing care and staff needs of individual schools and individual school districts.

The nursing assessment of the student population is an ongoing process. When students are identified with new conditions or their health conditions change, they require nursing assessment and clinical judgment that determines the level and type of nursing care required and appropriate staffing.

The model also describes the role of the certificated school nurse in the state of Washington. The knowledge and skills acquired through the certification process (WAC 181-79A-223(1)) are over and above the knowledge and skills required for licensure as a registered nurse and are generally not obtained in a bachelor’s of science in nursing (BSN) degree program. Registered nurses employed with the classification as certificated or “Educational Staff Associate” are required to have a ESA certificate through OSPI (WAC 181-86).

In Class II school districts, the statute (RCW 28A.210.300) states that a “…school district of the second class may employ a regularly licensed physician or a licensed public health nurse [...] for the purpose of protecting the health of the children in said district.”

The model describes roles and possible duties of all school staff providing health services:

•Certificated (registered) school nurses.
•Non-certificated registered nurses.
•Licensed practical nurses.
•Health room assistants.
•Clerical staff.

ESA certificated (registered) school nurses are responsible for assessing the health needs of the student population, allocating available health services resources, and managing the delivery of health services in schools.

Non-ESA certificated (registered) nurses may be responsible for those activities described above. In addition, non-ESA certificated (registered) nurses may work under the guidance and oversight of ESA certificated (registered) school nurses depending on district employee policies, procedures and contracts. As with all licensed nurses, non-ESA certificated (registered) nurses are responsible for their own practice under their own license.

Licensed practical nurses may work in any school district under the supervision and guidance of the registered nurse. Licensed practical nurses are also responsible for their own practice under their own license.

Unlicensed school staff (i.e., health room assistants and clerical staff) providing nursing tasks in a school must do so only after the delegation, training and ongoing supervision of a registered nurse. Although not specifically mentioned in the Staff Model, unlicensed staff in Washington State schools that provide health services may also include administrators, teachers, classroom paraprofessional educators, front office staff, bus drivers, coaches, and others.

The recommendation is that the school nurse and the school administrator review and discuss the Staff Model, student health needs, and plan for health services and appropriate staffing.

In the state of Washington, OSPI, and the Nursing Care Quality Assurance Commission currently recommend nurse staffing for schools as:

One school nurse to 1,500 regular education students who are not *nursing dependent, *medically fragile, or *medically complex (*see Staff Model for definitions of severity coding).  Additional licensed nursing services are recommended to meet the special needs of students with more acute conditions.

The National Association of School Nurses (NASN), in their position statement, School Nurse Workload:  Staffing for Safe Care revised 2020 states:

“NASN and the National Association of State School Nurse Consultants (NASSNC) (2012, 2014) assert that every student needs direct access to a school nurse so that all students have the opportunity to be healthy, safe, and ready to learn. In order to achieve adequate school nurse staffing, NASN recommends:

● Using a multifactorial health assessment approach that includes not only acuity and care but also social determinants of health to determine effective school nurse workloads for safe care of students.

● Developing evidence-based tools for evaluating factors that influence student health and safety and for developing staffing and workload models that support this evidence.

●Conducting research to determine the best models for school nurse leadership in school health, such as RN only, RN-led school health teams, and RNs certified in the specialty practice of school nursing.

●Increasing involvement of school nurses at national, state, and local levels in policy decisions that affect the health of students.”

When the numbers of students who are identified with serious, complex, and fragile health conditions increase, more school nurse time is required for the health and safety of those students. The number of students with critical health needs is increasing. School nurses must prioritize their time by first addressing the most critical needs to keep students safe at school.

The American Academy of Pediatrics released a 2016 Policy Statement titled Role of the School Nurse in Providing School Health Services in which they recommend that there is a minimum of one full-time professional school nurse in every school.

The Response to Intervention (RTI) model matches public health models of prevention.

•The bottom level illustrates PRIMARY PREVENTION activities, or UNIVERSAL approaches, aimed at ALL students to create a safe and supportive learning environment.
•The second level depicts EARLY INTERVENTIONS aimed at SOME students who show signs of risk for greater problems.
•The third level describes INTENSIVE, TIME-CONSUMING, AND TARGETED INTERVENTIONS aimed at students who have serious health problems.

 

The following model represents the broad scope of school nursing practice and the contributions that school nurses make in all levels of health services: Primary Prevention, Early Intervention, and Intensive, Targeted Intervention. Nursing interventions in the areas of primary prevention and early intervention are clearly associated with student academic success. However, nurses must prioritize their work, targeting the top level of students who are already in need of critical health services. School nurses value prevention and early intervention, and they strive to provide those services as much as possible within their time constraints.