A person must give attention to the body, mind, and spirit to be healthy. In order to manage health and illness along this continuum, everyone requires skills that promote health and prevent disease. By helping promote these skills among the school staff, students, and the broader school community, the school nurse has an opportunity to contribute to the nation’s goals of health promotion, disease prevention, and decreasing disability.
Epidemiological studies provide evidence of the role modifiable risk factors play in many chronic diseases. While there is less disease in the United States due to infectious agents than there once was, there is more disease related to industrial, technological, and lifestyle changes (U.S. Department of Health and Human Services [USDHHS], 2000). The Surgeon General also estimates that perhaps 50 percent of premature death and disability is related to unhealthy behaviors (e.g., lack of physical exercise, injury and violence, lack of a healthy diet, substance abuse, lack of responsible sexual behavior). The common denominator in the leading causes of morbidity and mortality in the United States is unhealthy lifestyle behaviors, behaviors that can be modified (USDHHS, 2000; USDHHS, 2003; Bloom, Cohen, Vickerie, & Wondimu, 2003).
Unfortunately, health trends are unfavorable. Diabetes, cancer, and other chronic diseases continue to burden our health care system. Violence and abusive behaviors continue to ravage homes and communities. Mental disorders continue to be undiagnosed and therefore untreated. Obesity is up 50 percent over the last two decades. Tobacco smoking has risen among adolescents in the last ten years. Forty percent of adults have no leisure physical activity. And disproportionate rates of HIV/AIDS exist among women and communities of color (USDHHS, 2000; Bloom et al., 2003; USDHHS, 2003). Globally, the leading causes of morbidity, such as heart disease, major depression, traffic accidents, stroke, and chronic lung disease, also appear to be linked to largely preventable causes.
These chronic diseases carry direct and indirect costs. Currently, in the United States direct health care consumes around 14 percent of the gross national product. Indirect costs include losses in work productivity and absenteeism (both for school staff and students). By modifying health behaviors, many of these health problems can be prevented. The savings in direct and indirect health care costs is yet to be realized.
The school environment adds its own unique set of health risks, especially those that take a toll on the mind and spirit of staff. These risks come from a variety of sources. From within the school staff, pressures are created when conflicts arise between the demands created by standardized educational benchmarks and the personal desire to be creative and effective teachers. Staff also struggle with time constraints, trying to stay current in their fields while balancing the demands of day-to-day work and family. Within the classroom, issues of class size, workload, limited resources, student culture, and safety confound pressures felt by staff and student alike. Pressures from outside the classroom include the nurse, teacher, and counselor shortage; parents; and the public. The school environment clearly plays a role in the health risks of staff and students.
Health and wellness include several dimensions: physical, emotional, spiritual, intellectual, occupational, and social. Health can be viewed as a continuum and dynamic state that is influenced by the perception of the individual. Along this continuum, a person moves between health and illness. Health is more than the absence of disease. People can live with a medical diagnosis and still consider themselves healthy because of the way they care for their mind, spirit, and body (Edelman & Mandle, 1997; Pender, 1996). Illness is a person’s response to a disease or dysfunction. Disease is the medical diagnosis given for a defined set of signs and symptoms.
Maintaining a healthy state can occur with little effort for some people, while others have to be actively involved to achieve this state of physical, mental, and social well-being. Achieving wellness, however, always involves being actively engaged in choosing health seeking behaviors. Health promotion strategies target behavior change that reduces risk for disease and promotes movement up the health continuum. Disease prevention strategies target ways to avoid illness or disease. Choosing effective health promotion (e.g., enhancing current activity and/or dietary practices, incorporating meditation or relaxation techniques to enhance life balance) or disease prevention (e.g., regular medical exams, obtaining recommended immunizations) strategies depends on the degree of risk for an individual or group. Health risk can be determined through focused risk appraisal and/or disease screening. Health risks can also be estimated using evidence-based recommendations (U.S. Preventive Services Task Force, 1996; U.S. Preventive Services Task Force, 2002; Edelman & Mandle, 1997).
The school nurse’s role in promoting health and preventing disease at school is clearly supported by a Coordinated School Health Program approach, The Scope and Standards of Professional School Nursing Practice, and Healthy People 2010. A Coordinated School Health Program devotes one of its eight components to school-site health promotion for staff. In the other seven components of this model, promoting health and preventing disease for students and the broader school community are also clearly evident (e.g., physical education, school health services, school nutrition services, school counseling, healthy school environment, family and community involvement) (Marx & Wooley, 1998).
Healthy People 2010 (USDHHS, 2000) globally addresses goals and strategies to prevent premature death, disability and disease in this country. The leading health indicators — lack of physical activity, overweight and obesity, tobacco use, substance abuse, lack of responsible sexual behavior, mental health, injury and violence, poor environmental quality, lack of adequate immunizations, and inability to access to care — highlight major contributors to morbidity and mortality in the United States, and they provide targets for how behavior change can lead to positive health outcomes.
Many schools are taking an active role in promoting health and preventing disease. Regardless of the specific model schoolwide program model, the following components appear to be universal: needs assessment, developing partnerships within and outside the school to promote a sense of community ownership, incentives to provide motivation, creative messaging to deliver an impressionable health message, and follow-up to provide reinforcement. The school nurse can review these model programs and incorporate those components that best match the health needs and culture of their school (Marx & Wooley, 1998).
It is the position of the National Association of School Nurses that the school nurse has a role in promoting health and preventing disease in the school community he/she serves. In light of the growing prevalence of behavior-linked disease, the school nurse possesses the knowledge and skills to role model, deliver educational messages, and plan programs that focus on health promotion and disease prevention for the school community.
Supporting a healthy culture in the school environment is essential for promoting individual and organizational health and wellness. Having this supportive culture, which can be fostered by the school nurse, is critical to helping students, staff, the school community, and the school nurse who are trying to make lifestyle changes to improve health.
ROLE OF THE SCHOOL NURSE
Promoting health and preventing disease within the school community is within the scope of school nursing practice. The Scope and Standards of Professional School Nursing Practice (ANA & NASN, 2001) assists the school nurse in identifying health needs and implementing services to promote healthy behaviors and prevent disease.
The school nurse’s position in the school community affords the opportunity to serve as a source of reputable health-related information (e.g., community resources, written materials, health classes, one-on-one counseling). The school nurses possess the knowledge and skills to assist in monitoring the progress of health behavior changes by those in the school community (e.g., blood pressure measurements, height and weight measurements). Through the school nurse’s health and wellness behaviors (e.g., not smoking, daily exercise, stress management strategies), she/he role models behaviors that can be copied by those in the broader school community. School nurses possess the knowledge and skills to identify and/or develop, secure, and implement health and wellness programs for school staff, students, and the broader community.
The school nurse role first involves assessment of the health risks of the school community she/he serves. Health risks unique to the school community can be determined by conducting risk assessments and disease screenings. School-based data can also be compared with national norms for age, ethnic group and region to determine leading areas of health risk, and therefore determine the focus for health promotion and disease prevention activities for the school (Allegrante, 1998; Edelman & Mandle, 1997; Galemore, 2000).
After summarizing the health risk assessment data (for students, school staff, and/or the broader school community), the school nurse can then determine which health promotion and disease prevention strategies are most appropriate. Strategies should incorporate the various dimensions of health and wellness, target risk factor reduction, and can be designed for the individual or school. Through the development of a focused health promotion and/or disease prevention plan, steps can be taken to reduce the leading causes of morbidity and mortality for the school. Examples of health promotion/disease prevention strategies include the case finding that is accomplished during the assessment phase (e.g., risk appraisal or disease screening); health education and counseling; promoting immunizations; meditation; and eastern therapies that promote relaxation techniques; and low impact exercise. Developing schoolwide policy is also a powerful intervention strategy that can target the broad issues and greatly impact the school culture (e.g., issues of worksite safety, staff stress and employee assistance) (Allegrante, 1998; Edelman & Mandle, 1997; Galemore, 2000).
Guidance for specific steps to take in developing a school-site health promotion program is available in the literature (Marx & Wooley, 1998). Overall, the problem solving process outlined by the nursing process is key.
Promoting health in the school setting is foundational to academic success (Satcher & Bradford, 2003; California State Legislature, 2002). The school nurse serves students, school staff, and the surrounding community, each interconnected with the other. A focus on health promotion and disease prevention at school will have a ripple effect on the health and wellness of the entire school community served by the school nurse.
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