The COVID-19 pandemic has elevated the vital role of the school nurse. Despite this recent attention, misconceptions about school nurses persist. Because school nurses bridge the medical and education fields, their role is often misunderstood. Unfortunately, school nurses often enter the position lacking sufficient preparation for the specialized environment of schools, and this inadequate training is further exacerbated by their lack of knowledge about the legal issues related to their work. However, school nurses navigate multiple legal issues every day. They must know federal, state, and local rules, policies, regulations, and laws that apply to schools. A survey conducted by the National Association of School Nurses (NASN) reports that school nurses are eager to learn more about legal matters and how these issues affect them.
School administrators should better understand the legal decisions that nurses must navigate. If leaders fail to understand the scope and standards of the nursing profession, it can lead to miscommunication and negatively impact students’ health and academic success.
The Role of the School Nurse
At the center of the multifaceted role of the school nurse is the student. Care and support are rendered through five key principles.
- Care Coordination: This task includes performing nursing assessments, identifying diagnoses, developing plans, implementing nursing interventions, and evaluating effectiveness. Care coordination also encompasses nurses’ collaboration with other health care professionals, school personnel, and students’ families to address chronic health concerns.
- Public Health: This task involves monitoring (such as during an outbreak of E. coli) and preventing diseases (such as teaching about nutrition to prevent Type 2 diabetes).
- Quality Improvement: Nurses collect and utilize health data for improvement purposes related to students’ health, gathering innumerable data points (such as the number of health office visits) to help drive future care.
- Leadership: Leading efforts in student advocacy, nurses act as change agents for school health initiatives and serve as the health experts to support school leaders.
- Standards of Practice: Nurses provide evidence-based, competent care within their state Nurse Practice Act and provide scope and standards of practice.
Range of Training
Part of the confusion surrounding the role of school nurses is related to the many entry points into the profession—nurses’ level of education can impact their knowledge of legal issues as well. School nurses can carry the title of “nurse” after receiving any of the following degrees:
- Licensed Practical/Vocation Nurse (one year of education)
- Associates Degree/Diploma in Nursing (two years of education)
- Bachelor of Science in Nursing (BSN) (four years of education)
Only the BSN school nurses receive specialized training in pediatrics, which is why the NASN recommends that they have a minimum of a bachelor’s degree. Because even BSN-prepared school nurses may not receive sufficient preparation, some states require school nurses to obtain state certification during their first few years of practice.
Need for Legal Literacy
Like other school personnel, school nurses are responsible for carrying out their duties while protecting the legal rights of the students. School nurses must have the legal literacy necessary to interpret and implement the laws and regulations for nursing within an educational setting.
In particular, school nurses play an important role in identifying students who may have a disability under Section 504 of the IDEA. A student’s health history or frequent visits to the health office may be indicators of a student with an undetected disability warranting further investigation. Evaluation teams should include school nurses to ensure both academic and developmental aspects are considered and that all areas of potential disability are evaluated. School nurses’ contributions to the evaluation process can be invaluable, especially if the student has a medical condition affecting the student’s ability to attend school, see clearly, remain focused, or learn effectively.
School nurses also play a critical role in the provision of related services. In the case of Irving Independent School District v. Tatro in 1979, the U.S. Supreme Court clarified that schools must provide nursing services that may include urinary catheterizations, tracheotomy care, gastrostomy feedings, and medication administration. School nurses may also train other school personnel to deliver certain medical tasks necessary for students to remain at school, based on their state’s rules. When a service animal is deemed appropriate for a student, school nurses are ideal for integrating the service animal into the school while meeting all students’ health and safety needs.
In addition to supporting school nurses in developing an understanding of disability law, school leaders should ensure nurses are legally literate on a wide range of other topics. For example, they require an understanding of student privacy, including the Family Educational Rights and Privacy Act. The Health Insurance Portability and Accountability Act provides other protections for student health records. Nurses must also be aware of students’ Fourth Amendment protections related to search and seizure because school leaders may seek their school nurses’ assistance in strip searches, making schools legally vulnerable. For example, in Safford Unified School District v. Redding, the U.S. Supreme Court decided in favor of a student who was subjected to a search involving a nurse. Additionally, school nurses are often involved in issues related to abuse and neglect. School nurses are considered mandatory reporters because they are in a position to both detect and to prevent cases of abuse and neglect.
Finally, nurses should be aware of constitutional limits surrounding their own expression and religion. For example, nurses cannot display religious posters in school offices and should be cautious about what they share on their personal social media. Thus, in addition to the legal knowledge specific to nurses, they need to be legally literate on the same topics as other educators.
Recommendations for School Leaders
School nurses must understand the intersection of relevant expectations and laws related to both education and health care provisions. Well-meaning but unknowing school leaders may make requests of school nurses that directly contradict the Nurse Practice Act, such as mandating a school nurse to reinsert a gastrostomy tube without having a health care provider order or allowing an untrained instructional assistant to administer medication in the school nurse’s absence. Thus, leaders should foster a collaborative relationship and open communication with their school nurses. In addition to this general suggestion, school leaders should also:
- Recognize and appreciate the many roles and responsibilities of school nurses.
- Identify the type of training their school nurses receive and support their continued participation in state and national nursing associations.
- Ensure school nurses are provided the professional development necessary to keep students and the surrounding communities safe—which includes legal training.
Andrea Tanner is a nationally certified school nurse with a Certificate in Education Law from Indiana University in Bloomington, IN. She is the immediate past president of the Indiana Association of School Nurses and a Robert Wood Johnson Foundation Breakthrough Leader in Nursing. Janet R. Decker teaches school law courses at Indiana University and is a co-author of Legal Rights of School Leaders, Teachers, and Students. Suzanne E. Eckes is a professor at Indiana University, a co-author of Principals Avoiding Lawsuits, and a past president of the Education Law Association.
Irving Indep. Sch. Dist. v. Tatro, 468 U.S. 883 (1984).
Magnus Health (Apr. 17, 2014). School nurse liability: 7 must-know legal facts. Retrieved from https://magnushealth.com/insights-7-must-know-legal-facts-for-school-nurses.
National Association of School Nurses. (2016a). Education, licensure, and certification of school nurses (position statement). Retrieved from www.nasn.org/nasn/advocacy/professional-practice-documents/position-statements/ps-education.
National Association of School Nurses. (2016a) Framework for 21st century school nursing practice. Retrieved from www.nasn.org/nasn/nasn-resources/professional-topics/framework.
Ratterman, M. J., Angelov, A., Reddicks, T., Monk, J., & Tanner, A. (2021) Advancing health equity by addressing social determinants of health: Using health data to improve educational outcomes. PLoS ONE 16(3): e0247909. https://doi.org/10.1371/journal.pone.0247909
Safford Unified School District v. Redding, 557 U.S. 364 (2009).