Should Administer School Nursing Services? Who
CHARLES W. HUMES, Jr., EdD
The issue of administration and supervision of school nurses is discussed.
Introduction The administration and management of school nursing services presents a dilemma to those education professionals who are charged with the responsibility for coordinating the various supportive services. These supportive services, which are usually designated as Pupil Personnel Services (PPS), encompass such disciplines as guidance, school psychology, school social work, speech therapy, and school nursing. Although the role and function of the supportive services differ from place to place, these services all usually have one thing in common (with the exception of school nursing), and that is a unity promoted by prevailing educational administrative structure. In most school districts the axis of professional direction flows from the Board of Education through the Superintendent of Schools to the office of the Director of Pupil Personnel Services, primarily because these professionals are essentially supportive, specialized personnel. However, the authority structure for the school nurse is uncertain because even though she qualifies as supportive personnel, the line of control in a given district or school is frequently blurred. The question of who should administer a school nursing program must search for its answer in two different subquestions: (1) Should the board of health or the board of education have jurisdiction over school nurses? and (2) Who should have supervisory direction over the school nurse while she is functioning in the school setting?
The Issues As one approaches the question there is the overriding concern of direction. In the broadest framework there first is the philosophical question: Is school nursing a generalDr. Humes is Director of Pupil Personnel Services in the Greenwich (Connecticut) Public Schools. 394 AJPH APRIL, 1975, Vol. 65, No. 4
ized or specialized activity? Specifically, the question becomes a jurisdictional matter, i.e., whether direction should flow through boards of education or health. Dithridge,1 in a review of the literature, found this to be a perennial issue. She states that administrative jurisdiction has been discussed since the turn of the century. In the beginning, health services tended to be placed under educational control as health departments were frequently overwhelmed with critical community health needs. In recent times, however, boards of health have become concerned with the questionable specialization of the school nurse and have often assumed a position that there exists currently no basis for differentiation. The generalized or specialized controversy was explored earlier by Richie.2 She presents much evidence to suggest that school nursing is a generalized function and belongs within the framework of public health nursing. Thus, the nurse can serve the needs of the community as a whole, of which the school is but a part. On the other side, there is the official position of the American School Health Association,3 which insists that it is a specialized function. Despite the fact that school nursing has grown proportionately faster than public health nursing,2 it is difficult to make a case for school nursing as a unique service separate from generic nursing. If one accepts school nursing as a generalized activity related to a broader public health role, it seems to follow that school nurses should not be under educational supervision for if administrative control practices are to be standardized it is essential to have one professional identification. The logical supervisor in such a model is the supervising nurse or school physician and not the school principal or PPS director. It also follows that the line of authority should come from the board of health or similar regional agency. In a large enough district the supervising nurse or physician would, in turn, be responsible for receiving administrative coordination from the Director of PPS.
School Nursing Role Problems The problem of supervision in the school setting then flows from jurisdiction and is vital in the delineation of the school nursing role. Role problems have plagued the school nurse4 and will continue to do so as long as educational management continues to be the dominant force. Unfortunately, part of the problem is that there is not a clearly delineated job entity. Hawkins sees it as a hodgepodge. He says that ". . . early stress on the school nurse's disciplinary authority and educative responsibility . . . influenced the gradual evolution of a hybrid-the school nurse of today...." 4 The role of the present school nurse, then, is essentially a mixture, the origin of which extends back to the late 19th and early 20th centuries when she was responsible for sanitation and the teaching of health habits to students and parents. Although she usually continues to perform direct nursing services, the modern school nurse apparently prefers to be also engaged heavily in educational services. The school nurse, as herein defined, should be considered in a separate category from that of the school nurse-teacher who has a primary instructional responsibility and must be certifiable from state departments of education. On the other hand, the typical school principal sees the school nurse in a rather narrow context. He cherishes her availability for administering first aid, transporting sick children, and being present for emergencies. Rarely does his role definition involve the breadth of responsibilities set forth in the Guidelines for School Nursing,3 particularly as they relate to education and counseling. The discrepancy between role expectations may be helped by the accountability movement and the writing of behavioral objectives,5 but even here education management will establish priorities according to perceived need so that this favorable development will tend to have minimal impact.
Advantages in This Model The advantages in a supervisory and organizational arrangement that have been herein described are many and varied. Some of the more obvious ones are as follows:
Supervision Most school nurses despair over the fact that educators are always convinced that they know what the nurse's function should be. Practically every teacher and principal is prepared to describe the school nurse's function. There is usually an inordinate emphasis on emergency care and clinical service. Although the Guidelines for School Nursing3 describe in detail an expanded role for the school nurse, the advocated position for educational management seems to compound the problem. Paradoxically, these guidelines also call for professional leadership from within the discipline. There is need for such supervision in order to improve the quality of performance but it would appear
that the best hope for professional direction rests with the health or allied areas rather than with education.
Identification Role clarification attempts must be accompanied by an identification with nursing as a professional discipline with reinforcement through provision for in-kind supervision. Although many school nurses are itinerant, in terms of delivery of services, they usually spend enough time in a school on a regular basis to be considered "resident." When one is a building resident, i.e., assigned to a building, in the public schools then it is standard practice to be under the authority of the building principal. Building principals, as general administrators, tend to view even the function of noninstructional specialties in a limited fashion and characteristically they are regarded as simply building staff members. Thus, role problems are created when the solution of problems is rarely on the side of the specialist.6 In such a climate there can be but limited professional identification. Clearly, the school principal should not have supervisory responsibility for the professional endeavors of the school nurse but obviously may be charged with the responsibility for attendance and time reports.
Staffing The question of staffing reform is directly related to role delineation for if there are a multiplicity of nursingrelated assignments in a given school building they should be handled through differentiated staffing patterns. Unfortunately, much of the public feels that professional overstaffing tends to occur in the schools. When a problem is presented in most public schools the usual solution, unless there is a system of accountability and the generation of alternatives, is to add a staff member. As applied to school nursing one often sees an adequate supply of nurses but poor utilization of professional capabilities. Thus, in many school situations one sees nurses performing jobs that should be delegated to aides or technicians. This is less likely to occur where there is in-kind management of the specialty. When educational management prevails, there is a point of view that the only person one can trust in health matters is the registered nurse. It is unlikely that a reordering of responsibilities through differentiated staffi'ng will ever take place where educators are called on to make the decisions.
Articulation If school nursing is basically a health specialty that operates in a school setting then it appears that what transpires therein should be related in a direct way to what is happening health-wise elsewhere in the community. It frequently happens that a child who requires nursing service in school comes from a family that also requires some kind of health assistance. A school nurse who is under educational management will often find it difficult, if not frowned upon, to render such total family assistance SCHOOL NURSING
395
inasmuch as it will take time away from her direct school services. A public health nurse working in the schools tends to have more of a working knowledge of the general health needs of the community. With this kind of background information she is better able to view student health problems in a community context. Certainly the contact with preschool children and their families speaks for itself in terms of later problem solving. Obviously, if one subscribes to a more restricted school nursing role then such articulation is not likely to happen.
Salary
School nurses employed by boards of education are the highest paid members of the nursing profession.' Such a wage differential has not necessarily come about through increases in responsibility or training (although many school nurses possess the baccalaureate degree) but has been due to their placement on teacher salary schedules. Some school nurses deserve more salary than other nurses but this should be deternined by job analysis. Under in-kind management such job differentiation becomes a real possibility because there is expertise within that discipline to deal with the issue while educational management is not equipped to do so. School nurses under boards of education who cry for professional role development are then faced with a dilemma. Should they accept a more equitable salary based on a professional role delineation? In the strategy required to win professional recognition it is sometimes necessary to yield on some immediate points to make gains on the thornier problems. It is quite likely that job differentiation over the long term will result in more opportunities for salary growth in all aspects of nursing.
program should come from health services. This means, fi'rst, that the preferred jurisdiction emanates from the board of health and, secondly, that the actual management and supervision of school nursing practice falls to someone from the health community, i.e., a supervising school nurse or a school physician. In such an arrangement there will tend to be less domination by educational managers, specifically, school principals. While it would be naive to assume that the school principal will ever cease to be a major factor in the determination of the school nursing role, the opportunities for intervention and direction will be considerably less in the proposed administrative arrangement. Naturally, a more health-oriented system of administration will not cause a more enlightened role to develop, for there are other problems to be resolved as well.4 However, role tends always to be ultimately determined not by job description but by job functioning. Perhaps the final answer to the total problem will be eventually settled through the subtleties of collective negotiations or the realities of behavioral objectives.
References 1. Dithridge, E. H. Administration of School Health Services: A Review. Nurs. Outlook 14:50-53, 1966. 2. Richie, J. School Nursing: A Generalized or a
3. 4.
Concluding Remarks
5.
The answer to the question posed by the article is quite clear. Administration and supervision of the school nursing
6.
396 AJPH APRIL, 1975, Vol. 65, No. 4
Specialized Service? Am. J. Public Health 9:1251-1259, 1961. American School Health Association. The Nurse in the School Health Program. J. School Health 37:1-40, 1967. Hawkins, N. G. Is There a School Nurse Role? Am. J. Nurs. 71:744-751,1971. Dickinson, D. J. School Nursing Becomes Accountable in Education through Behavioral Objectives. J. School Health 41:533-537, 1971. Cromwell, G. E. The Nurse in the School Health Program. W. B. Saunders Company, Philadelphia, 1963.
CHARLES W. HUMES, Jr., EdD
The issue of administration and supervision of school nurses is discussed.
Introduction The administration and management of school nursing services presents a dilemma to those education professionals who are charged with the responsibility for coordinating the various supportive services. These supportive services, which are usually designated as Pupil Personnel Services (PPS), encompass such disciplines as guidance, school psychology, school social work, speech therapy, and school nursing. Although the role and function of the supportive services differ from place to place, these services all usually have one thing in common (with the exception of school nursing), and that is a unity promoted by prevailing educational administrative structure. In most school districts the axis of professional direction flows from the Board of Education through the Superintendent of Schools to the office of the Director of Pupil Personnel Services, primarily because these professionals are essentially supportive, specialized personnel. However, the authority structure for the school nurse is uncertain because even though she qualifies as supportive personnel, the line of control in a given district or school is frequently blurred. The question of who should administer a school nursing program must search for its answer in two different subquestions: (1) Should the board of health or the board of education have jurisdiction over school nurses? and (2) Who should have supervisory direction over the school nurse while she is functioning in the school setting?
The Issues As one approaches the question there is the overriding concern of direction. In the broadest framework there first is the philosophical question: Is school nursing a generalDr. Humes is Director of Pupil Personnel Services in the Greenwich (Connecticut) Public Schools. 394 AJPH APRIL, 1975, Vol. 65, No. 4
ized or specialized activity? Specifically, the question becomes a jurisdictional matter, i.e., whether direction should flow through boards of education or health. Dithridge,1 in a review of the literature, found this to be a perennial issue. She states that administrative jurisdiction has been discussed since the turn of the century. In the beginning, health services tended to be placed under educational control as health departments were frequently overwhelmed with critical community health needs. In recent times, however, boards of health have become concerned with the questionable specialization of the school nurse and have often assumed a position that there exists currently no basis for differentiation. The generalized or specialized controversy was explored earlier by Richie.2 She presents much evidence to suggest that school nursing is a generalized function and belongs within the framework of public health nursing. Thus, the nurse can serve the needs of the community as a whole, of which the school is but a part. On the other side, there is the official position of the American School Health Association,3 which insists that it is a specialized function. Despite the fact that school nursing has grown proportionately faster than public health nursing,2 it is difficult to make a case for school nursing as a unique service separate from generic nursing. If one accepts school nursing as a generalized activity related to a broader public health role, it seems to follow that school nurses should not be under educational supervision for if administrative control practices are to be standardized it is essential to have one professional identification. The logical supervisor in such a model is the supervising nurse or school physician and not the school principal or PPS director. It also follows that the line of authority should come from the board of health or similar regional agency. In a large enough district the supervising nurse or physician would, in turn, be responsible for receiving administrative coordination from the Director of PPS.
School Nursing Role Problems The problem of supervision in the school setting then flows from jurisdiction and is vital in the delineation of the school nursing role. Role problems have plagued the school nurse4 and will continue to do so as long as educational management continues to be the dominant force. Unfortunately, part of the problem is that there is not a clearly delineated job entity. Hawkins sees it as a hodgepodge. He says that ". . . early stress on the school nurse's disciplinary authority and educative responsibility . . . influenced the gradual evolution of a hybrid-the school nurse of today...." 4 The role of the present school nurse, then, is essentially a mixture, the origin of which extends back to the late 19th and early 20th centuries when she was responsible for sanitation and the teaching of health habits to students and parents. Although she usually continues to perform direct nursing services, the modern school nurse apparently prefers to be also engaged heavily in educational services. The school nurse, as herein defined, should be considered in a separate category from that of the school nurse-teacher who has a primary instructional responsibility and must be certifiable from state departments of education. On the other hand, the typical school principal sees the school nurse in a rather narrow context. He cherishes her availability for administering first aid, transporting sick children, and being present for emergencies. Rarely does his role definition involve the breadth of responsibilities set forth in the Guidelines for School Nursing,3 particularly as they relate to education and counseling. The discrepancy between role expectations may be helped by the accountability movement and the writing of behavioral objectives,5 but even here education management will establish priorities according to perceived need so that this favorable development will tend to have minimal impact.
Advantages in This Model The advantages in a supervisory and organizational arrangement that have been herein described are many and varied. Some of the more obvious ones are as follows:
Supervision Most school nurses despair over the fact that educators are always convinced that they know what the nurse's function should be. Practically every teacher and principal is prepared to describe the school nurse's function. There is usually an inordinate emphasis on emergency care and clinical service. Although the Guidelines for School Nursing3 describe in detail an expanded role for the school nurse, the advocated position for educational management seems to compound the problem. Paradoxically, these guidelines also call for professional leadership from within the discipline. There is need for such supervision in order to improve the quality of performance but it would appear
that the best hope for professional direction rests with the health or allied areas rather than with education.
Identification Role clarification attempts must be accompanied by an identification with nursing as a professional discipline with reinforcement through provision for in-kind supervision. Although many school nurses are itinerant, in terms of delivery of services, they usually spend enough time in a school on a regular basis to be considered "resident." When one is a building resident, i.e., assigned to a building, in the public schools then it is standard practice to be under the authority of the building principal. Building principals, as general administrators, tend to view even the function of noninstructional specialties in a limited fashion and characteristically they are regarded as simply building staff members. Thus, role problems are created when the solution of problems is rarely on the side of the specialist.6 In such a climate there can be but limited professional identification. Clearly, the school principal should not have supervisory responsibility for the professional endeavors of the school nurse but obviously may be charged with the responsibility for attendance and time reports.
Staffing The question of staffing reform is directly related to role delineation for if there are a multiplicity of nursingrelated assignments in a given school building they should be handled through differentiated staffing patterns. Unfortunately, much of the public feels that professional overstaffing tends to occur in the schools. When a problem is presented in most public schools the usual solution, unless there is a system of accountability and the generation of alternatives, is to add a staff member. As applied to school nursing one often sees an adequate supply of nurses but poor utilization of professional capabilities. Thus, in many school situations one sees nurses performing jobs that should be delegated to aides or technicians. This is less likely to occur where there is in-kind management of the specialty. When educational management prevails, there is a point of view that the only person one can trust in health matters is the registered nurse. It is unlikely that a reordering of responsibilities through differentiated staffi'ng will ever take place where educators are called on to make the decisions.
Articulation If school nursing is basically a health specialty that operates in a school setting then it appears that what transpires therein should be related in a direct way to what is happening health-wise elsewhere in the community. It frequently happens that a child who requires nursing service in school comes from a family that also requires some kind of health assistance. A school nurse who is under educational management will often find it difficult, if not frowned upon, to render such total family assistance SCHOOL NURSING
395
inasmuch as it will take time away from her direct school services. A public health nurse working in the schools tends to have more of a working knowledge of the general health needs of the community. With this kind of background information she is better able to view student health problems in a community context. Certainly the contact with preschool children and their families speaks for itself in terms of later problem solving. Obviously, if one subscribes to a more restricted school nursing role then such articulation is not likely to happen.
Salary
School nurses employed by boards of education are the highest paid members of the nursing profession.' Such a wage differential has not necessarily come about through increases in responsibility or training (although many school nurses possess the baccalaureate degree) but has been due to their placement on teacher salary schedules. Some school nurses deserve more salary than other nurses but this should be deternined by job analysis. Under in-kind management such job differentiation becomes a real possibility because there is expertise within that discipline to deal with the issue while educational management is not equipped to do so. School nurses under boards of education who cry for professional role development are then faced with a dilemma. Should they accept a more equitable salary based on a professional role delineation? In the strategy required to win professional recognition it is sometimes necessary to yield on some immediate points to make gains on the thornier problems. It is quite likely that job differentiation over the long term will result in more opportunities for salary growth in all aspects of nursing.
program should come from health services. This means, fi'rst, that the preferred jurisdiction emanates from the board of health and, secondly, that the actual management and supervision of school nursing practice falls to someone from the health community, i.e., a supervising school nurse or a school physician. In such an arrangement there will tend to be less domination by educational managers, specifically, school principals. While it would be naive to assume that the school principal will ever cease to be a major factor in the determination of the school nursing role, the opportunities for intervention and direction will be considerably less in the proposed administrative arrangement. Naturally, a more health-oriented system of administration will not cause a more enlightened role to develop, for there are other problems to be resolved as well.4 However, role tends always to be ultimately determined not by job description but by job functioning. Perhaps the final answer to the total problem will be eventually settled through the subtleties of collective negotiations or the realities of behavioral objectives.
References 1. Dithridge, E. H. Administration of School Health Services: A Review. Nurs. Outlook 14:50-53, 1966. 2. Richie, J. School Nursing: A Generalized or a
3. 4.
Concluding Remarks
5.
The answer to the question posed by the article is quite clear. Administration and supervision of the school nursing
6.
396 AJPH APRIL, 1975, Vol. 65, No. 4
Specialized Service? Am. J. Public Health 9:1251-1259, 1961. American School Health Association. The Nurse in the School Health Program. J. School Health 37:1-40, 1967. Hawkins, N. G. Is There a School Nurse Role? Am. J. Nurs. 71:744-751,1971. Dickinson, D. J. School Nursing Becomes Accountable in Education through Behavioral Objectives. J. School Health 41:533-537, 1971. Cromwell, G. E. The Nurse in the School Health Program. W. B. Saunders Company, Philadelphia, 1963.
