1. The Certified School Nurse: Untapped Resource
Dr. Barbara Zimmerman, RN
Associate Professor in Nursing
Coordinator School Nurse Certification Program
Millersville University

2. Untapped Resource Recognizes subtle changes of youth
Knowledge, skills and expertise to assess for and refer
Return to school plan
Follow-up
Advocate
The certified school nurse (CSN) is an untapped resource for mental health providers. The CSN has the knowledge, skills and expertise to assess for, refer and provide mental health interventions to school age youth. In addition, the CSN is a connection from the student to the family and mental health providers to promote continuity with interventions. Often the CSN is the first to recognize the red flags, many times very subtle, for mental health problems. The CSN can play a key role in the return-to-school plan, with follow-up and support in that difficult time for the student and family. Frequently, the CSN is also involved in prevention and health promotion activities related to mental health. These types of activities provide a proactive approach to mental health problems that enable the CSN to partner with mental health providers for education and support group assistance.
School nurses serve a multitude of student health needs in addition to promoting primary
health prevention activities for student/faculty well-being. Although the number of school age youth with chronic illnesses has sharply increased, as a result of asthma, allergies and diabetes, the school nurse provides care for just as many or more students with mental health problems. If it hasn’t already, the United States will reach a point where mental health/psychosocial problems and risk-taking behaviors result in a greater morbidity and mortality for school age youth than physical illnesses (Melnyk, Brown, Jones, Kreipe & Novak, 2003). Given the barriers to mental health care, fragmentation of care for school age youth is most prevalent. How can these children stop “slipping through the cracks,” obtain follow-up care or be screened for problems before they reach a crisis
A key person who could link the mental health provider, parent and student is the certified school nurse (CSN). How can we best use the CSN to help students in school and how can the CSN support the student returning to the school setting from mental health treatment? How can a partnership between CSNs and the mental health system develop to help decrease the effect of fragmented care?

3. Overview History SN Educational criteria for SN Certification
Roles of School Nurses

4. History School Nursing
1902 NYC to reduce absenteeism
Communicable disease
Chronic disease
Physical
Mental
“Specialized practice of professional nursing that advances the well being, academic success and life-long achievement of school age youth” NASN
School health is delivered in three ways across the nation. The first way is by a school nurse employed by the Department of Education and hired by the local School Board of Directors. This primarily occurs in the New England, Mid-Atlantic States to Illinois and some western states. The southeast (beginning with Maryland) and midwest tier of states provide school health services through public health nurses who are employed by the Department of Health. The third means of providing health services is for the local school board to contract care out to public health departments. Very few states (6-7) serve their students in this manner. The first two methods for providing school health are about evenly split (~22-21 states).

5. School Nurses
Facilitate positive student responses to normal development
Promote health and safety
Intervene with actual/potential problems
Provide case management services
Collaborate with others to build student and family capacity for adaptation, self management, self advocacy and learning
Mental health morbidities extend into the school and require the school nurse to be knowledgeable of these problems and trajectories, primarily as they affect learning. Often, difficulties in academic
performance or social relationships and absenteeism precede a mental health diagnosis. Many of the mental health disorders that emerge in childhood are likely to persist through adult life. With this in mind, many have concluded that the incidence of students with difficulties in school must be viewed as an educational and health crisis (DeSocio & Hootman, 2002).
School absences or frequent visits to the health office for vague, nonspecific physical health problems are often related to an underlying mental health problem (Campo, Jansen-McWilliams, Comer & Kelleher, 1999). Students frequent the health office with aches, pains, stomachaches and other unexplained physical symptoms. Somatic complaints often are seen in the school-age child with depression but adolescents can present that way as well (Lyon & Morgan-Judge, 2000). The CSN can often identify mental health problems, such as depression, drug involvement and suicidal behavior (Eggert, Thompson, Randell & Pike, 2002).
The disruptive behaviors that come with Attention Deficit Disorder and Oppositional Defiant Disorder often appear during preschool and early school age, making school transitions and social functioning difficult as well as academic success. Even though children and adolescents with depression attract less attention, their academic functioning still suffers. Being compromised by symptoms of poor concentration, distractibility, insomnia and day time sleepiness, students do not succeed academically. Anxiety disorders and Post Traumatic Stress Disorder (PTSD) are often co-morbid with depression and also contribute to school avoidance or lack of achievement.
Tiet et al. (2001) notes that events like changing schools are associated with an increase in anxiety disorder and depression. Other adverse events (abuse, violence, divorce, homelessness) in these students’ lives also put them at risk for mental health problems. These students, depressed or anxious, are often frequent health room visitors. Studies (e.g., Insel, 2003) indicate that behaviors as a result of mental health disorders affect school performance causing academic impairment.
The CSN recognizes these markers of psychosocial distress and compromised school functioning and is able to achieve prompt mental health promotion and prevention activities or referral for diagnosis and treatment.

6. PA School Nurses BSN plus additional educational content
school law with special needs- IEP and 504
educational psychology
counseling techniques
practicum in school health
Specialist I and II School Nurse
24 graduate credits and 3 years practice
Ratio: 1: 1500
Act 48

7. Roles of School Nurses Assessment Coordination Education Advocacy
Collaboration
The CSN recognizes these markers of psychosocial distress and compromised school functioning and is able to achieve prompt mental health promotion and prevention activities or referral for diagnosis and treatment. The CSN is often the individual who has the total picture of the student and can initiate referral for diagnosis and care. The CSN role in identifying a student with a mental health disorder is crucial for prompt referral and diagnosis. Since the CSN is also a member of the Student Assistance Team (SAP), this makes his or her role even more advantageous to facilitating ongoing collaboration with mental health providers

8. Assessment Role Holistic view aware of subtle changes
Physical and Mental Screening
TeenScreen – Columbia University
SAP team assessment
Individualized Educational Program
Assessment and objectives

9. Coordination SAP Team member
Connect students with mental health providers
Support groups
Monitor health status
Give information
Problem solve
Emotional support

10. Education Students Faculty Parents Health promotion and prevention
Stress reduction
Symptoms of depression or anxiety
Chronic illness management
Adherence
Crisis prevention, recognizing triggers
Faculty
Parents

11. Advocacy
Absenteeism
Support groups
Youth
Parent

12. Collaboration School community Mental Health Community SAP
Transition of students back into school
Consultants
Co-facilitators
Educators

13. Partnership for Success
Coordination of services within school
Connection to mental health providers
Collaboration
Seamless transition
Support groups
Updates of student progress-problems
Screening
Advocacy