School Nursing Past and Present

The "A Day in the Life: A Photo Essay of the Wisconsin School Nurses and the COVID-19 Pandemic" project began with a desire to validate and honor the work of Wisconsin school nurses as well as to create a historical photographic record of this moment in time. There is no doubt that the COVID-19 Pandemic has impacted public health, healthcare systems, and school nurses. The role of the school nurses had to change during the pandemic to address the health crisis impacting students and the public's health. Although this time has been remarkable, it is not surprising that school nurses performed the way that they did, with grace, professionalism, and an unwavering desire to protect the health of children, has always been at the heart of school nursing. As Lina Rogers Struthers wrote in her book, The School Nurse: A Survey of the Duties and Responsibilities of the Nurse in the Maintenance of Health and Physical Perfection and the Prevention of Disease Among School Children, “School nursing is still in its infancy, and many changes in methods are to be expected, but the underlying essentials, child love and preservation of child health—will exist as long as child life” (Rogers Struthers, 1917, vii)       

School nursing began in the United States in the early 1900's to improve student attendance. At the time, school physicians were responsible for completing daily classroom inspections to identify students with communicable diseases such as measles, scarlet fever, and diphtheria. Students diagnosed with these conditions were excluded from school and instructed to receive treatment. Many families failed to receive the necessary treatment and the child would subsequently not return to school.

Lina Rogers Struthers was hired as the first school nurse upon the recommendation of Lilian Wald. Ms. Wald,  a public health nurse and founder of the Henry Street Settlement, (Schumacher, 2002) an organization that provided home visiting nursing services to the immigrant poor on the Lower East Side of New York (Houlahan, 2018) was approached by the New York City (NYC) Board of Health and the NYC Board of Education to embark on a one-month experiment to determine if placing a nurse in a school, to supplement the medical inspections being conducted, could help to decrease the number of students who missed school after being excluded because they had a contagious disease (Schumacher, 2002). 

In the early years of school nursing, the school nurse and physician worked together conducting classroom inspections. After ill and infectious children were sent home, the school nurse would visit the student’s home to provide education and make community referrals to assist the family in accessing the necessary medical care. As the medical inspection process evolved, the school nurse role expanded. Instead of sending the student with a health concern home, when possible the physician kept the student in school and had the school nurse examine and treat them, eliminating the student’s absence from school. Seeing the value of early detection provided, school nurses expanded their assessments to include examining students for physical defects and making community referrals for treatment to decrease the impact of the disability (Zaiger, 2000, Zaiger, 2009).

In the 1930s and 1940s the school nurse responsibilities included not only student health assessments and classroom inspections, but the school nurse was also viewed as an advisor and health educator. In a speech, at the 1935 American Public Health Association conference, given by Elma Wood, a registered nurse who oversaw health education for the Tennessee Valley Authority, Elma stated,

As the school grows in its awareness that health is associated with all phases of its program, the nurse becomes increasingly an adviser on the health aspects of such activities as the school lunch, swimming pool, picnics, field trips, excursions, hikes, and contributes to the educational phases of these whenever possible (Rood, 1935).

Initially, school nurses developed brief educational presentations on topics such as proper rest and sleep, cleanliness, and dental health. Later, school nurses developed health education curriculum that could be taught by the classroom teacher (Zaiger, 2006). School nurses also began providing education to teachers. As nurses were being recruited for the war efforts and the number of school nurses working in schools decreased, school staff were required to perform some of the health services. Teachers were expected to provide first aid and illness management along with monitoring for signs of contagious diseases (Zaiger, 2006).

In addition to providing education, school nurses reviewed and interpreted student health data for teachers, parents, and the student to assist in understanding how a child’s health concern might impact their educational attainment. If a concern was identified, the school nurse assisted the family with referrals to community resources. School nurses continued to make home visits to provide education to children and their families (Zaiger, 2000).

Research on school health services was also occurring during this time and numerous reports on topics such as “staffing patterns for school health services, effective strategies for referral and follow-up of students with positive screening results, and the beneficial impact of nursing services on school attendance” (Institute of Medicine, 1997, p. 40-41).

During the 1950s and 1960s school health was seen more broadly as a program that was led by the school nurse. Although school nurses continued to provide direct nursing care to students, their role extended far beyond the walls of the school nurse office. School nurses completed environmental assessments of the school building, looking for potential hazards and provided recommendations for improvement. They became involved in the development and review of school policies related to student health and educated school staff on emergency care of students. They provided health education to students, emphasizing nutrition and mental health. With the development of new vaccines for diseases such as polio and measles, the school nurse also administered immunizations at school (Functions and Qualifications for the School Nurses, 1961).

Leading up to this time, there had been a decline in the diagnostic and treatment aspect of school health services, with an emphasis being placed on accessing healthcare services through physicians in private practice. During the late 1960’s a new role, the School Nurse Practitioner, emerged. With the introduction of School Nurse Practitioners, students had greater and easier access to primary care and health care concerns were more easily addressed (Institute of Medicine, 1997).

Significant legislative changes-- including Head Start, Medicaid, the Elementary and Secondary Education Act, the Community Health Center Program, the Education for All Handicapped Children Act, and the Child Nutrition Act-- during this time that impacted public education settings occurred in the 1970s. Public Law 94-142 amended the Education of the Handicapped Act to provide educational assistance to all handicapped children. (The law has since been re-enacted, with certain modifications, as the Individuals with Disabilities Education Act (IDEA)). Section 504 of the 1973 Rehabilitation Act expanded the definition for disability and offered protection for a greater number of individuals with disabilities. These acts require schools to provide services and accommodations to a more expansive number of students (Dang, 2010, Mattey, 2019.)

In addition to the expanding educational right of individuals with disabilities, advancements in the treatment of diabetes, including shorter hospitalizations and the inventions of the glucometer and the insulin pumps required schools to have the necessary personnel to provide diabetes management in school, such as education, nutrition management, and medication administration, including injectable insulin (Mattey, 2019). Due to the increase of students with complex health needs, the clinical functions of school nurses were expanded to include primary care services with the nurses working in close collaboration with physicians.

The concept of a comprehensive school health program (CSHP) was introduced in the 1980s. CSHPs were developed to address "’new social morbidities’— injuries, violence, substance abuse, risky sexual behaviors, psychological and emotional disorders, and problems due to poverty—and many students' lack of access to reliable health information and health care” Institute of Medicine, 1997, p.20). CSHPs were thought to have the ability to improve health and educational outcomes for students and reduce overall health care costs by emphasizing prevention and easy access to care by providing health education, health promotion and disease prevention, and access to health-related services at the school site.

It appears school nursing has come full circle, school nurses are again being sought after to assist with the prevention and mitigation of contagious disease, specifically COVID-19. Although many schools have had school nursing positions for decades, the COVID-19 pandemic resulted in some schools hiring their first school nurse. School leaders realized how value a school nurse could offer as they navigated the challenges created by the pandemic. School nurses assisting in creating the infrastructure that allowed schools to remain open. School nurses stepped up and took the lead in interpreting public health guidance and surveillance data. They developed, reviewed, revised, and implemented policies, procedures, and protocols aimed at keeping students, staff, and the larger community healthy and safe. School nurses connected with families, offering education, guidance, and support. They used their voices to advocate for the health needs of the students, staff, and the community. As Catherine McDonald (2020) said of this time,

…like school nurses do every day, they will continue to assess the data available, integrate it into prior knowledge about infection control, capitalize on emergency preparedness planning, advocate for equitable distribution of services, access evidenced-based resources, plan for interventions in the schools, and constantly evaluate outcomes to improve approaches.