School Health Services Staffing
MN Statute 121A.21 School Health Services requires:
(a) Every school board must provide services to promote the health of its pupils.
(b) The board of a district with 1,000 pupils or more in average daily membership in early childhood family education, preschool disabled, elementary, and secondary programs must comply with the requirements of this paragraph. It may use one or a combination of the following methods:
(1) employ personnel, including at least one full-time equivalent licensed school nurse;
(2) contract with a public or private health organization or another public agency for personnel during the regular school year, determined appropriate by the board, who are currently licensed under chapter 148 and who are certified public health nurses; or
(3) enter into another arrangement approved by the commissioner (of Education).
- Minnesota Department of Education’s State School Nurse Consultant is available to discuss school nurse staffing options that meet statutory requirements. If needing additional consultation, contact mde.healthyyouth@state.mn.us.
This statute, which has not been updated since 1988, does not consider the varying health needs of students and intensity or severity of those needs, equity measures (i.e., poverty impacting health access, health outcomes and health risk, and the legal scope of nursing practice for the various level of licensed nurses). Current best practice recommendations from The National Association of School Nurses (NASN) and The American Academy of Pediatrics (AAP) support a professional nurse access for every student every school day.
The National Association of School Nurses (NASN) and the American Academy of Pediatrics (AAP) no longer support a recommended ratio based on student population. The NASN Position Statement, School Nurse Workload: Staffing for Safe Care states that “all students need access to a school nurse every day. In addition to the number of students covered, staffing for school nursing coverage must include acuity, social needs of students, community/school infrastructure, and characteristics of nursing staff.”
The American Academy of Pediatrics (AAP) Council on School Health addresses this in their recommendations Role of the School Nurse in Providing School Health Services stating “Pediatricians can advocate for a minimum of one full-time professional school nurse in every school with medical oversight from a school physician in every school district as the optimal staffing to ensure the health and safety of students during the school day.”
Schools can provide health services to students through a variety of methods. Staffing models should be determined not only by the size of the district, but several other factors should be considered to meet the health needs of students. These factors include:
- The number and the complexity of student health conditions (e.g., diabetes, seizures, anaphylaxis, asthma) seen in the general student population. The medical complexity and technology used to manage these health conditions can vary widely between students.
- The social determinants of health (SDOH) impacting access to community health services and the need for coordinating care with community providers. Schools often use the percentage of students who qualify for free-reduced price lunch, English language learners, student homelessness, and the community refugee / immigrant population as SDOH indicators. SDOH is discussed further in the Health and Educational Equity section.
- The number and complexity of students with complex medicals needs such as g-tube feedings, suctioning, and urinary catheterization.
Assessing School Health Services describes assessment tools can help nurses and district leadership make decisions about how to meet the health needs of students, staff recruitment, and staffing models.
MN Statute 121A.21 provides a minimal guide for staffing decisions made at the local level which has resulted in a wide variety staffing models throughout the state. School’s staffing structure decisions can be challenging and often complicated by funding resources and misperceptions or understanding of the complexity of student health needs, professional nursing standards and licensure requirements by which nursing practice is held accountable to. In addition, there are nursing workforce issues including the availability of nurses within the community, competition and compensation with community healthcare organizations, and the complexity of the specialty practice of school nursing.
School districts often employ nurses with a variety of levels of nurse licensure. It is important that school leaders, school human resource personnel, school employees, parents, and nurses themselves have clear understanding of legal scope of nursing practice as defined by Minnesota Board of Nursing. Job descriptions and titles should be in alignment with the type of nurse licensure and corresponding scope of practice. Regardless of the staffing model, access to education, student health and safety are the primary concerns.
School Nurse Administrator: Licensed School Nurses who have a collaborative, managerial, and leadership role within the district. They are part of the district administrative and leadership team. School Nurse Administrators provide operational management and strategic leadership to nursing staff and other health service staff in the educational organization.
Licensed School Nurse (LSN): Licensed by Minnesota Professional Educator Licensing and Standards Board (PELSB) as a school nurse (Minnesota Rules, 8710.6100), which requires current professional registered nurse license (RN) and registration as a Public Health Nurse (PHN) from the MN Board of Nursing and have a bachelor degree or higher in nursing education.
- To use the title “school nurse” the person should be licensed as a school nurse per MN Administrative Rule 8710.6100.
Public Health Nurse (PHN): Registration as a PHN requires a licensed as professional registered nurse (RN), have a baccalaureate or higher degree with a major in nursing, and have completed course work which included theory and clinical practice in public health nursing (Details are available in MN Rule part 6316.0100 subpart 4).
Registered Nurse (RN): To be licensed as a professional RN by the Minnesota Board of Nursing (Minnesota Statutes, 148.171, subdivisions 15 and 22), the person must have a minimum of an associated degree (2 year) in nursing or higher (bachelors, masters, doctorate degree) from an accredited nursing program.
Nursing Specialty Certifications
Certification is a process indicating an individual has met predetermined standards that recognize a specialized body of knowledge, skills, and experience. Many nursing specialty areas have professional organizations that provide certification to individual practitioners.
To make sure that certification maintains the highest standards, national associations control the process and development of certification examinations conducted by their specialty interest groups. There are many certifications available to professional nurses (RN). Two of the more common for nurses in schools include:
The National Board for Certification of School Nurses (NBCSN) advances the quality of school health services through the practice of certification for the specialty of school nursing. Nurses with this specialty certification use NCSN (National Certified School Nurse) credential.
The Pediatric Nurse Certification Board (PNCB) provides certification as Certified Pediatric Nurse (CPN), Certified Pediatric Nurse Practitioner (CPNP) in acute and primary care and Pediatric Primary Care Mental Health Specialist (PMHS).
Licensed Practical Nurse (LPN): To be licensed as (LPN) by the Minnesota Board of Nursing license (Minnesota Statutes, 148.171, subdivisions 8 and 14) the person must have completed an accredited nursing program (usually 12-18 months) most often from a technical college.
- Only licensed nurses (RNs and LPNs) may use any abbreviation or other designation such as nurse which implies licensure. (Who Needs a Minnesota Nursing License).
Unlicensed Assistive Personnel (UAP): The Minnesota Board of Nursing (Minnesota Statutes 148.717 Subd. 24) defines “Unlicensed assistive personnel” (UAP) as any unlicensed person to whom nursing tasks or activities may be delegated or assigned, as approved by the board.” There is no minimal level of education or training required to be a UAP in the schools, however First Aid, Cardiopulmonary Resuscitation (CPR), and medication administration are basic recommendations.
In the school system, the UAP is most often a paraprofessional role, often called a health assistant, health clerk, or health aide. Teachers, administrators, and any other school staff that provide health services at the direction of the LSN, RN, or PHN are also considered UAPs because they do not have a nursing license.
Schools may hire UAPs that are Certified Nurse Assistant (CNA), Certified Medical Assistant (CMA), Certified Emergency Medical Technicians (CEMT) or Paramedics because of their training or education but each of these certifications and licensure (if applicable) have a defined scope of practice and practicing outside that scope may have consequences for the individual’s certification or licensure.
What is the difference between an RN and LPN?
A RN and LPN have distinct scope of practices as defined in the Minnesota Nurse Practice Act. We have highlighted a few, not all the differences, between the scope of practices. The Minnesota Board of Nursing Provides details in the RN and LPN Scope of Practice Chart (PDF).
| Registered Nurse (RN) | Licensed Practical Nurse (LPN) | What it means in school health. |
|---|---|---|
| The "practice of professional nursing" means the performance, with or without compensation of those services that incorporates caring for all patients in all settings through nursing standards recognized by the board…” | The "practice of practical nursing" means the performance, with or without compensation of those services that incorporates caring for individual patients in all settings through nursing standards recognized by the board at the direction of a registered nurse, advanced practice registered nurse, or other licensed health care provider …” | RNs can practice independently within their scope of practice. LPNs working in school health need to be working at the direction of RN, advanced practice registered nurse, or other health care provider such as a physician or physician assistant. LPN as the “sole” nurse within a school, without direction as described above can be practicing nursing outside their legal scope of practice. |
| “providing a comprehensive assessment of the health status of a patient through the collection, analysis, and synthesis of data… | “conducting a focused assessment of health status…and reporting changes and responses to interventions in an ongoing manner to a registered nurse…” | RNs conduct comprehensive assessments to plan care which meets the health needs of students The LPN provides an assessment that is targeted to a specific condition as part of the on-going plan of care developed by the RN or by the medical provider. |
| “collaborating with the health care team to develop and coordinate an integrated plan of care; developing nursing interventions to be integrated with the plan of care…” | “participating with other health care providers in the development and modification of a plan of care; determining and implementing appropriate interventions within a nursing plan of care or when delegated or assigned by a registered nurse…” | RNs can independently develop care plans to meet student health needs, such as the Individual Health Plan (IHP), Emergency Care Plan (ECP), nursing accommodations in a 504 plan or Individual Educational Plan (IEP). LPNs cannot develop care plans to meet student health needs. LPNs can provide valuable information to the RN who writes the care plan. Both the RN and LPN can implement an Asthma Action Plan, Diabetes Management Plan, Seizure Action Plan or Anaphylaxis/Allergy Action Plan developed by a licensed health care provider. |
What is the difference between and LSN and RN who is not an LSN?
The LSN by virtue of licensure through PELSB can carry the title of “school nurse”. The baccalaureate or higher nurse education prepares the school nurse for complex decision making, and skills to assess the school population as a community as well as assessing individual health. School and special education administrators should consult with Minnesota Department of Education Special Education for nursing as “related services”. More information can be also found in School Health Services Laws and Rules (PDF).
What is nursing delegation? Who can delegate?
Nursing Delegation is covered extensively in the Nursing Delegation for the School Setting. But for the purpose of staffing models, only the RN can delegate nursing activities to UAP. The Minnesota Board of Nursing in Minnesota Statute 148.171 subd. 7a defines "Delegation" as the transfer of authority to another nurse or competent, unlicensed assistive person to perform a specific nursing task or activity in a specific situation. With that authority to delegate comes the responsibility for the education, training, supervision, and monitoring of the those to whom tasks are being delegated. The nurse is accountable to make these determinations to provide for the health and safety of the students. Therefore, the LSN, PHN, RN workload is greatly impacted by the volume, multiple school locations, and the complexity of the cares being delegated.
- Hired directly by the school – Nursing staff LSN, PHN, RN, LPN or UAP are hired directly as school staff.
- Contracted by the school - The school or district may contract with an outside agency. This is often local public health but may also be another agency such as a nursing staffing agency, local clinics, etc. Contract nursing services include “general” or “day to day” nursing services for the entire school/district population or for specific situations in which the health needs of a student are complex and 1:1 nursing care is needed to provide for safe learning environment.
- Consulting agency - To meet the minimal standards, some schools elect to enter into a consultation agreement with an outside nursing agency. Nursing consultation and contracted nursing are very different. In general, nursing consultants help schools understand legal requirements, develop policy and procedures, and provide some generalized training related to emergency recognition (i.e., anaphylaxis) and emergency response. This training is not student specific to the student’s specific plan of care from the health care provider. Nursing consultants do not delegate, train, supervise, or monitor nursing activities performed by a UAP.
- Telehealth School Nursing: School nursing services provided via telehealth is a newer option for schools. As with contracted or consultant nursing, schools should understand what and when nursing services are provided and by whom.
Regardless of school district size, staff recruitment, or staffing model, every district needs to must provide services to promote the health of its pupils as mentioned in the introduction required by MN Statute 121A.21. Districts also need to have some arrangement to provide for safe medication administration to student which includes safe procedures, training, and documentation. Look for detailed information in Minnesota Guidelines for Medication Administration in Schools.
Minnesota Statute 121A.22 Administration of Drugs and Medicine Subd. 4 Administration states: Drugs and medicine subject to this section must be administered in a manner consistent with instructions on the label. Drugs and medicine subject to this section must be administered, to the extent possible, according to school board procedures that must be developed in consultation:
(1) with a school nurse, in a district that employs a school nurse;
(2) with a licensed school nurse, in a district that employs a licensed school nurse;
(3) with a public or private health or health-related organization, in a district that contracts with a public or private health or health-related organization, according to section 121A.21; or
(4) with the appropriate party, in a district that has an arrangement approved by the commissioner of education, according to section 121A.21.
A comprehensive school-based health center is a safety net health care delivery model located in or near a school facility and that offers comprehensive medical care, including preventive and behavioral health services. These services are provided by licensed and qualified health professionals in accordance with federal, state, and local law, to all students and youth within a school or district regardless of ability to pay, insurance coverage, or immigration status.
SBHCs are an excellent complement to school nursing services but do not replace school nursing services. They function differently and each have their own set of standards and requirements. The Joint Statement from National Association of School Nurses and School-Based Health Alliance – School Nursing & School-Based Health Centers in the United States: Working Together for Student Success (PDF) describes how services complement and care for student health needs.