Community involvement in health in schools was a major thrust in the 1970s and 1980s. Counseling and mental health services were added to the responsibilities of school nurses, who began to directly teach children concepts of health. Children were no longer just being screened for illnesses (Vessey and McGowan, 2006). Because of federal laws that required schools to make accommodations for handicapped children, medically fragile children were attending schools, often for the first time. One of these laws, PL 93-112 Section 504 of the Rehabilitation Act of 1973, was an important step in helping all children enjoy a normal educational experience (Robert Wood Johnson Foundation, 2010). This law was followed by PL 94-142 Education for All Handicapped Children Act, which required that children with disabilities have services provided for them in the schools.

Following the passage of the Americans with Disabilities Act in 1992, PL 105-17 Individuals with Disabilities Education Act (IDEA) passed in 1997. Both of these laws required that more children be allowed to attend schools. Schools had to make allowances for their special needs, which included ensuring that their school experience was in balance with their health care needs by developing individualized education plans (IEPs) and individualized health plans (IHPs). That meant that more children with human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), chronic illnesses, or mental health problems were in the classrooms and needed more attention from the school nurse (Robert Wood Johnson Foundation, 2010). The No Child Left Behind Act of 2001 requires a healthy environment in the schools, which also affects children who have health problems (Adler, 2009). Table 42-1 summarizes the effects of these laws on school nurses and schoolchildren.

Also during the 1990s, the responsibilities of the school nurse were extended to include the development of complete clinics and health care agency centers within or attached to the schools (Vessey and McGowan, 2006). These school-based clinics will be discussed later in this chapter. By 2002, some school nurses were responsible for several schools, and they provided care under a variety of nursing roles. To address obesity and to promote healthy eating and physical activity through changes in school environments, Congress passed the Child Nutrition and WIC Reauthorization Act of 2004 (PL 108.265 Section 204). This act designated that each local education agency (LEA) participating in federal school meal programs, such as the National School Lunch or Breakfast Program, must establish a local school wellness policy. Table 42-2 gives the highlights of school nursing history over the last century.

The federal government, through the coordination of the Centers for Disease Control and Prevention, has developed a plan that school health programs should follow (CDC, 2008) (Figure 42-1).

Then, in 1998, the government expanded the program again to include a more complete school health education program that included the parents and the community in the children’s care. By 2009, 22 states had been funded for their school health programs by the CDC (CDC, 2009b). The funding has paid for the development of health education plans of study, or curricula, that include policies, guidelines, and training for these health programs. The states then use these courses to teach the children. The schools are actively involved in helping the children practice problem solving, communication, and other life skills so they can reduce their risk factors.

According to the CDC, two states in particular have been very successful with these programs. West Virginia has developed a program called the Instructional Goals and Objectives for Health Education and Physical Education, which increased the ability of the children to pass the President’s Physical Fitness Test. In Michigan, the Governor’s Council on Physical Fitness, Health, and Sports developed an Exemplary Physical Education Curriculum project that made up educational materials and plans for children to achieve high physical fitness scores. All of these programs were paid for by the federal school health program funding (CDC, 2009b).

After the CDC began funding educational programs about prevention of HIV in the schools in 1987, there was clearly a need to expand these programs. By 1992 the CDC began giving money to fund other school health programs that taught students about heart disease, cancer, stroke, diabetes, and substance abuse prevention (Kann, Brener, and Wechsler, 2007). These programs have been evaluated by the School Health Policies and Programs Study 2006 (CDC, 2006), which looked at all eight parts of the school health program in all 50 states and the District of Columbia. The study found that only half of the states had the recommended 1 school nurse for every 750 students that was discussed earlier in this chapter. It also found that most school health programs had access to mental health counselors, but that the food in the schools’ cafeteria tended to be high in salt and fat. Most schools had rules forbidding weapons on the school grounds or use of tobacco. Parental involvement in the school health programs was only about 50% and, to make a difference in a child’s health, parents are encouraged to be involved (Kann, Brener, and Wechsler, 2007).

Because many schoolchildren may not receive health care services other than screening and first aid care from the school nurse, the U.S. government began funding school-based health centers (SBHCs) during the 1990s. These are family-centered, community-based clinics run within the schools. These clinics give expanded health services, including mental health and dental care, as well as the more traditional health care services (Brown and Bolen, 2008). The SBHCs can range in size from small to large; some school clinics are open to the community only during the school year and others are open 24 hours a day all year round. An example of the more limited clinic is the SBHC in Worchester, MA, where six clinics are run in the schools (elementary through high school) by the Family Health Center of Worchester, Inc during the school year months of August through May (Family Health Center, 2010).

Another example of a clinic is the school-linked program, which is coordinated by the school but has community ties (Brown, 2008). An example of this is the Collaborative Model for School Health in Pitts County, North Carolina. The nurses employed by the local hospital in that area provide health care for children in kindergarten through fifth grade. There is collaboration between the county health department, the local university’s nursing school, and other private health care providers to give primary, secondary, and tertiary nursing care. An evaluation of the program has shown that the children’s school attendance and learning has increased as a result of the presence of more complete school health services (Trapp, 2010).

At a center in Texas, an urban SBHC is located in a school district where many of the children lack health insurance. The school nurses there are assisted by three part-time nurse practitioners and one public health nurse. The school nurse is responsible for the record keeping on the children’s immunizations, does the screening, and gives first aid to injured children. Then the school nurse refers children who need additional health care to the SBHC in the school. Parents like the program because they trust the school nurse. They also like its location inside the school because everyone can receive health care without having to travel far to get to a clinic (Texas Association of School-Based Health Centers, 2010).