• for nurse practitioners only, the provision of primary care, including prescribing medications when allowed under the State Nurse Practice Act.

The traditional model for school nursing provides for a school nurse, typically in an office or health room, with or without an aide. The National Association of School Nurses and other organizations in the National Nursing Coalition for School Health have prepared and distributed standards of nursing practice that guide the services nurses deliver in schools (Proctor et al., 1993). A single nurse may also be shared among several schools. In School Health: Policy and Practice, the American Academy of Pediatrics has analyzed the various nurse staffing patterns which are listed in Table 4-3.

Personnel. The professional training required for school nurses varies, depending on location and changing economic conditions. The American Academy of Pediatrics (1993) reported in 1993 that only 38 states required school nurses to be registered nurses, and only 19 required the attainment of specific school nurse certification. SHPPS found that although only 8 percent of all states required school nurses to be certified through the American Nurses Association or the National Association of School Nurses, 62 percent of states offered their own certification for school nurses. Of those states offering certification, 66 percent required it for employment as a school nurse. Health aides are employed in 76 percent of states, but only 8 percent of these states required prior technical training for health aides (Small et al., 1995). The Closer Look investigation reports similar findings.

In some school districts, school nurses are employees of the school system; in others, school nurses are provided by the local health department or another agency. The National Association of School Nurses recommends a ratio of one school nurse per 750 students. In recent years, there has been interest in expanding the school nursing function through the use of nurse practitioners, nurses with additional training (generally at the master's level) who are certified by state laws to provide a range of primary care services. School-based nurse practitioners can perform physical examinations, prescribe certain medications with physician protocols, and frequently serve as the anchor provider in school-based clinics. The drive for independence from physicians has characterized the nurse practitioner movement (Clawson and Osterweis, 1993); however, school-based nurse practitioners usually have a backup relationship with a licensed physician in the community. Other graduate programs prepare school nurses for administrative and management roles, as well as for mental health positions in schools.

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