News
School Health Services
Volume 16, Number 3, May 2003
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Iowa Code
Immunization Changes
Governor Vilsack
signed a law containing new immunization school entry requirements for the fall
of 2003. The law requires a Varicella (chickenpox) immunization for children
entering school and enrolling in licensed childcare. Public Health is working
on the Iowa Administrative Code revisions describing the law. Expected possible
revisions include: children 18 months of age and older who are enrolled or
attempting to enroll in a licensed child-care center shall receive at least one
dose of Varicella vaccine, or have a reliable history of natural disease; and
children 4 years of age and older who are enrolled or attempting to enroll in a
public or nonpublic elementary or secondary school shall receive at least one
dose of Varicella vaccine if born on or after September 15, 1997, or have a
reliable history of natural disease. This dose shall have been received on or
after the applicant was at least 12 months of age. The proposed ‘reliable
history of natural disease’ may be a history of chickenpox from the parent(s).
The bill also authorizes nurse practitioners and physician assistants to sign
the immunization medical waiver.
These changes would
go into effect July 1, 2003, which means that Varicella immunization or a
history of disease will be required for entry into kindergarten for the 2003-04
school year. For additional information, please contact Marnell Kretschmer,
IDPH Immunization Program Manager, telephone 515-281-4917, e-mail
mkretsch@health.state.ia.us.
Homeless Children and Youth: Immunizations
The
intent of Federal and State Laws for the education of homeless children and
youth is to ‘ensure homeless students have opportunities to meet the same
challenging student academic achievement standards to which all students are
held’ [20 U.S.C. 6201, Title X Part C, Subtitle B, Sec. 721-723; Iowa Code
§256(2003); and 281 IAC 33.5]. The Iowa
Administrative Code, homeless child or
youth of school age immunization requirements for admission to public
school include:
·
Medical
exemption,
·
Religious
exemption,
·
Immunizations
have started and a provisional validated certificate of immunization,
·
Student
is a transfer student from another school, and
·
The
school district must seek immunization records, refer the school age homeless
child or youth to immunization sources, and provisionally enroll the student
per requirements [281 IAC 33.5].
Homeless
students enrolling in school meet the above requirements and the school assists
the student to meet the requirements so the student may attend school.
Briefing: Improving Academic
Achievement by Meeting Student Health Needs
The Iowa Interagency
Health Promoting Communities and Schools team compiled the Briefing: Improving Academic Achievement by Meeting Student Health
Needs. The purpose of the Briefing is to provide scientific research links between academic
achievement and health and encourage discussions on the impact of school health
programs on student success. The document is available on the DE website: http://www.state.ia.us/educate/ecese/cfcs/hpi/documents.html A
PowerPoint presentation is available.
School
Nurse Briefing: Iowa School Health Services and the Licensed Practical Nurse
Draft 3/12/03
This
draft briefing describes the role of the Licensed Practical Nurse (LPN)
providing Iowa school health services. The
briefing, developed by the Licensed Practical Nurse Workgroup (Ellen Johnson, Jean Phillips, Susie
Poulton, MaryAnn Strawhacker, Charlotte Burt, and reviewed by Lois Churchill March
2003) is intended to detail the LPN practice in the school. The Workgroup would
appreciate your suggestions.
Education and health
laws govern the delivery of safe, effective, and
accessible health services in Iowa schools. Qualified health
professionals such as nurses, physicians, dentists, allied health personnel,
education personnel (licensed educators, paraprofessionals, secretaries, and
health assistants), and health advisory committees collaborate to provide
school health services. This briefing describes the
role of the Licensed Practical Nurse (LPN) in providing Iowa school health
services. Included are LPN laws, professional standards, health service
delivery, future explorations, definitions, and
references.
LPN Laws
LPN Practice. The LPN is accountable for practicing in accordance with the
current Iowa Code and Iowa Administrative Code (IAC). Selected paraphrases
summarizing the LPN practice (complete text available at
http://www.state.ia.us/nursing) follow:
·
Understands
the legal implications of the LPN scope of practice while carrying out
supportive or restorative services under the supervision of a registered nurse
(RN) or physician [655 IAC 6.3(1)],
·
Participates
in the nursing process by assisting the RN in monitoring, observing, and
reporting reactions to therapy [655 IAC 6.3(2)],
·
Performs
activities not requiring the knowledge and skill of the RN [655 IAC 6.3(3)],
·
Practices
in the school setting under the direction of the RN or physician in the same
building [655 IAC 6.3(6)b],
·
Understands
accountability for performing only activities in the LPN scope of practice,
seeks assistance when activities are beyond the scope of the LPN preparation,
performs assigned and delegated activities informing the RN when the activities
are not executed, carrying out medical regimen prescribed by a physician, and wears
LPN identification [655 IAC 6.3(9)], and
·
Provides
supportive and restorative care to an individual student in the school
according to the student's health plan under the supervision of and as
delegated by the RN employed by the school district [655 IAC 6.6(2)].
LPN Education. The Iowa Board of Nursing
approves education programs preparing practical nurse candidates [Iowa Code
§152.5(2001)]. In Iowa there are 28 approved LPN programs and 9,431 active LPN
licensees (IBN, 2001). The LPN education is at least one academic year of basic
curriculum in nursing theory and practice leading to eligibility to apply for
the national licensure examination and LPN licensure [655 IAC 2.1(1)]. This
course of study prepares the LPN to work in structured care settings such as
long-term care facilities. The curriculum is a career ladder program.
LPN Minimum Standards of Practice
The U. S. National
Federation of Licensed Practical Nurses (NFLPN) is an LPN professional
organization. The NFLPN licensed practical nurse standards include education,
legal and ethical status, practice, continuing education, and specialized
nursing practice. The LPN practice standards describe the LPN nursing care role
to meet the health needs of people, under the direction and supervision of qualified
health professionals including:
·
Accept assigned
responsibility as an accountable member of the health care team,
·
Function within the
limits of educational preparation and experience,
·
Function with other
members of the health care team,
·
Know and use the
nursing process in planning, implementation, and evaluation,
·
Participate in the
peer review and other evaluation processes, and
·
Participate in policy
development concerning the health and care of society and the roles and
functions of the LPN (NFLPN, 2001).
LPN and Health Service
Delivery
The school
administrator [Iowa Code 271.1(1)(2001)] coordinates, supervises, and directs
the activities of the School Registered Nurse (SRN). In turn, the SRN
delegates, monitors, and evaluates health service delivery by the LPN and
reports to the administrator. The chart below differentiates the nursing
process performance of the SRN and LPN. Under the direction of the SRN, the LPN
may provide the following health services: medication administration; first
aid; immunization review and recording; completing factual information reports;
sending routine notices to parents; assist with activities such as screening,
and others.
Health Services
Delivery Model-Nursing Process-LPN and SRN Performance Comparison
|
Nursing Process |
Licensed Practical Nurse (LPN) |
School Registered Nurse (SRN) |
|
Assessment |
Initial assessment
outside scope of practice. Performs ongoing health assessment (collects,
reports, and records ongoing subjective and objective data in an accurate and
timely manner) as specified in the individualized health plan (IHP) and
emergency plan (EP). Notifies the SRN of changes in status. |
Provides the
initial assessment and oversees ongoing assessment. Conducts review of school
and medical records, interviews individuals knowledgeable about the student,
observes the student in the school setting, and conducts physical assessments
as warranted. |
|
Nursing Diagnosis |
Participates by
assisting the SRN. |
Uses information
collected through the assessment process to develop outcomes directing the
IHP and EP. |
|
Outcome
Identification |
Participates by
assisting the SRN. |
Identifies care
goals for the IHP and EP. |
|
Planning |
Provides data and
assists with identification of priorities for goal setting. |
Designs and
documents the IHP and EP care. |
|
Implementation |
Provides care to
students with health needs under the SRN direction within the laws and
standards. Documents interventions and student responses to care. |
Delivers health services using RN
knowledge and skills. Delegates and educates others in tasks not requiring
nursing skills and knowledge and retains accountability. |
|
Evaluation |
Provides the SRN
with subjective and objective data related to nursing interventions and
student responses. |
Conducts in-depth
ongoing analysis of student responses to intervention, progress on goal
attainment, and needed IHP and EP modification for attainment of optimal
student health status. |
|
IHP and EP |
Assists and
implements plan as delegated by SRN. |
Writes plans and
educates others to provide the services as appropriate. |
Adapted from: Iowa Board of Nursing, 2001; Schwab,
N. C., Hootman, J., Gelfman, M. H., Gregory, E. K., & Pohlman, K. J., 2001;
and Washington State Nursing Care Quality Assurance Commission & Washington
State Office of Superintendent of Public Instruction, 2000.
The Role of the LPN in School Health Services-Future
Proposed Explorations
Currently school
districts employ unlicensed health assistant personnel, without health
background, experience, or qualifications, to provide health services under the
supervision of the SRN. This workgroup explored the feasibility of the LPN providing these services to a select group of students as
determined, delegated, and supervised by the SRN. Continuing work on the
feasibility of this idea in Iowa will continue.
Role of the LPN in School Health: Current and
Proposed
Iowa
schools hire unlicensed health assistant personnel to provide school health
services. Often without health background, experience, or qualifications,
unlicensed health assistant personnel provide health services daily to
schoolchildren across Iowa. The most recent Iowa Department of Education data
reveals the average school nurse to building ratio is 1:3.5. Over 17% of all
districts in Iowa do not employ a school nurse. This data suggests the need to
explore means to ensure all Iowa
students have access to quality school health services. Although preferred, a
school nurse practicing in every building is not attainable given our current
economic climate. Other states have established a role for the LPN within the
delivery of school health services. The purpose of this workgroup was to begin
exploring the Iowa feasibility of the LPN providing
limited student health services to a select group of students as
determined and supervised by the SRN. The discussion included:
·
A select group of
students may be defined as:
s
students within a
building or district requiring routine special health procedures,
s
students requiring
ongoing assessment after initial assessment by the school RN,
s
students requiring first
aid.
·
Delegated tasks could
include clerical as well as student specific such as medications or procedures.
·
Accountability for
delegation would remain with the RN.
·
Complex factors must
be considered to ensure student safety when determining the ratio of RN to
LPN(s) supervised.
·
Caution must be
exercised to use the LPN within their scope of licensure and preparation.
The need to modify the IAC requirement of an RN in the same
building (proximate area).
Summary
This
paper discusses the LPN role in providing
student school health services. Currently, the
LPN may function in a school to provide supportive or
restorative care under the supervision of the SRN in the same building, provide care to a specific
student in accordance with the student’s health plan and under the supervision
of and as delegated by the SRN, and provide services not requiring the
knowledge and skill level ascribed to the SRN. The services are delegated and
supervised by the SRN. The LPN laws, professional
standards, and health service delivery will guide future explorations of the LPN role.
Definitions
Administrator. A person licensed to coordinate, supervise, or direct the
activities of other practitioners [Iowa Code §271.1(1)(2001)].
Health
Assistant. An unlicensed health individual providing school health
services, including various titles (unlicensed assistive personnel, assistive
personnel, qualified designated personnel, nurse associate, classroom
assistant, paraeducator, paraprofessional, secretary, teacher, principal, and
others) functioning in an assistive role delegated by the RN. The individual
must be instructed, competent, and supervised in providing the health
service(s) in the individual health plan and emergency plan [281 IAC 41.96(1)].
Health
Service Policy. “Health services
are part of comprehensive school improvement, assisting all students to
increase learning, achievement, and performance. Health services support
existing programs to assist each student in achievement of an optimal state of
physical, mental and social well being and facilitate continuity and linkages
between the school, home, and community” [281 IAC 12.9(11) and IASB, 2001].
Health Services. Includes, but is not limited to, service(s) for individuals whose
health status, stable or unstable, requires interpretation or intervention,
administration of health procedures and health care, or use of a health device
to compensate for the reduction or loss of a body function [281 IAC 41.96(1)].
Individualized Health
Plan (IHP) and Emergency Plan (EP). A written confidential document
detailing the desired outcomes and provision of the health service(s) in the
education program [281 IAC 41.96(1)].
Licensed Practical
Nurse (LPN). The LPN legal minimum practice is in the
Iowa Code Chapter 152 and 655 IAC §6.3-6, page one of this paper.
Nursing
Process. The decision-making method used as the organizational
framework for the practice of nursing. The school nurse uses this process when
determining the student health service plan including assessment, nursing
diagnosis, outcome identification, planning, implementation, and evaluation.
The documentation of the process, plan, and components are ongoing.
Registered
Nurse (RN). Licensed to practice nursing by a board of nursing to
formulate nursing diagnoses, conduct nursing treatment, carry out physician
instructions, supervise, teach, and evaluate the LPN in the performance of
nursing care activities, perform additional services requiring education and
training, and apply scientific principles (Iowa Code Chapter 152 and 655 IAC
6).
School Registered Nurse (SRN). Licensed to
practice in accordance with the laws, regulations, standards (NASN & ANA,
2001), and the Code of Ethics (NASN, 1999).
School Nursing
is a specialized practice of professional nursing that advances the well being,
academic success, and life-long achievement of students. School nursing takes
place primarily within local education agencies serving school-age children.
However, school nurses also provide services in alternative sites (e.g.,
juvenile justice centers, alternative treatment centers, preschools, and
residential campuses) and within the larger surrounding community, at students'
homes, vocational/occupational settings, environmental camps, field trips,
school-sanctioned competitions, and sporting events (NASN & ANA, 2001).
Standards. Authoritative statements, defining acceptable
school nursing practice, by the nursing profession describing the quality of
practice, service, or education (NASN & ANA, 2001).
Supervision.
Assessment, delegation, evaluation, and documentation under the direction of
the RN. Levels include physically present, available at the same site, and
available on call [281 IAC 41.96(1)].
References
Iowa Association of School Boards. (2001, June 26). Student
Health Services Policy Code Number 607.2, Administrative Regulations Appendix
C-R-1, Code Number 607.2-R1. Policy
Primer: Updates to Educational Standards, 14:3.
Iowa Board of Nursing. (2001). 2001 Annual Report. Retrieved October 2002 from the World Wide Web:
http://www.state.ia.us/nursing/annual%20reports.html.
Iowa Department of Education. (1998). Guide for effective paraeducator practices in Iowa. Des Moines,
Iowa: Author.
Iowa Expert School Nurse Committee. (1999). Iowa Individual Health Plan. State of
Iowa: Department of Education.
Joint Task Force for the Management of Children with Special
Health Needs. (1990). Guidelines for the
delineation of roles and responsibilities for the safe delivery of specialized
health care in the educational setting. Reston, VA: The Council for Exceptional
Children.
National Association of School Nurses. (1999). Code of Ethics for the School Nurse.
Scarborough, ME: Author.
National Association of School Nurses & American Nurses
Association. (2001). Scope and standards
of professional school nursing practice. Washington, DC: American Nurses
Publishing.
National Federation of Licensed Practical Nurses, Inc.
(2001). Nurse practice standards for the
licensed practical /vocational nurse. Garner, NC: Author.
School Nurse Delegation Workgroup. (2002). Interpretative Statement: Iowa school nurses
and delegation. State of Iowa; Department of Education.
Schwab, N. C., Hootman, J., Gelfman, M. H., Gregory, E. K.,
& Pohlman, K. J. (2001). School Nursing Practice: Professional Performance
Issues. In N. Schwab & M. Gelfman (Eds.), Legal issues in school health services (pp.149-156). North Branch,
MN: Sunrise River.
State of Iowa. (2002). Iowa Code and Iowa Administrative Code.
Des Moines, IA: State of Iowa. Retrieved October 2002 from the World Wide Web:
http://www.legis.state.ia.us/.
Iowa Code §152.1(2-6)(2001); 655 IAC 2, 3, 4.6(c), 6, 6.2(5), 6.3(1),
6.3(6), 6.6(1), 6.6(2), 7
Iowa Code §256.7(24)(2001); 281 IAC 12.3(11); 12.4(12)
Iowa Code §256B(2001); 281 IAC. 41.12(11), .96(1)
Iowa Code §271.1(1)(2001)
State of Iowa, Iowa Department of Public Health.
(2003). Iowa Board of Nursing: Iowa Code
and Iowa Administrative Code. Retrieved January 2003 from the World Wide Web:
http://www.state.ia.us/nursing/.
Tennessee Nurses Association. (2002). School health: School LPN. Nashville, TN: Tennessee Nurses
Association. Retrieved November 2002 from the World Wide Web:
http://www.tnaonline.org/school_1pn.html.
Uric, P.F. (1996). Supervisory
leadership: A training manual for school nurses working with school health
paraprofessionals. Denver, Colorado: Office of School Health.