The school nurse as part of community care in the school system: a narrative literature review

After home, school represents the second most influential environment in a child's life. As more and more children enter preschools and schools with somatic or mental problems, we are faced with the challenge of providing them with medical/nursing care right in the school.

The idea of ​​implementing the position of a school nurse has appeared in the Slovak Republic for several decades, but it did not meet with the political will and support of those who could put it into practice.

In the 1970s and 1980s, the children's field nurse regularly visited elementary schools for diagnostic, dispensary, and preventive purposes, and her main tasks included determining weight, height, orientation examination of vision, urine, regular dental fluoridation, etc. If the nurse found any anomalies, the child was invited for further examination by a pediatrician or sent to a specialized workplace. The present brings the need to re-implement the proven and successful work of nurses in schools (Popovičová, 2021).

During the search and familiarization with the issue in domestic and foreign sources, we came to the opinion that school nurses are health professionals, have a wide range of clinical, social and educational competences, combine nursing experience and trustworthiness, presence, discretion, act as defenders of children's health rights. Compared to teachers, nurses do not evaluate academic results, so they can demonstrate a higher degree of empathy, care and "non-critical acceptance", which has a positive effect on the information-seeking behavior of children and adolescents. School nurses connect children of different age groups with their families and teachers on the one hand and health care and public health services on the other.

Amendment to the School Act and SR Act No. 576/2004 Coll. on health care, services related to the provision of health care and on the amendment of some laws, as of September 2022, brought the possibility of school nurses working in kindergartens, primary and secondary schools, but also in special, combined schools or vocational schools. This pilot project will be implemented over two years, and a financial amount of EUR 3.4 million from the Renewal Plan is allocated for the new posts, and schools can draw from it in the period from September 1, 2022 to the end of August 2024. The starting salary is EUR 1,100 and the nurses are interested in the position. The school nurse will assess the health status of children, the physical and mental development of children and pupils, administer medicines, evaluate the epidemiological situation, treat children with diabetes, epilepsy and disabilities, will perform screening to identify health problems in children, but can also implement preventive and advisory activities in the field of healthy lifestyle. The role of the school nurse will also be educational, it should help in the prevention of oncological diseases, obesity and tooth decay. It is also supposed to keep statistics on injuries to children and pupils. The parent must agree to the school nurse's care (MŠ SR, 2022).

Health care at school is regulated by § 10b of the amendment to Act of the Slovak Republic no. 576/2004 Coll. on health care services related to the provision of health care and on the amendment of certain laws: "A school in which health care is provided is obliged a) provide health care correctly in accordance with standard diagnostic and therapeutic procedures, b) keep medical documentation to the extent according to § 19 par. 2, c) ensure minimum material and technical equipment in the provision of health care."

Methodology

We searched literary sources and studies in the bibliographic databases PubMed, Scopus, Web of Science, Questia with Full text according to keywords in the English language. 37 literary sources were analyzed for the needs of the work. While getting to know the sources more deeply, we kept finding new sources of information and uncovering other connections and researched issues and topics. We conducted a critical content analysis of 22 published articles, studies, book and electronic resources according to PRISMA recommendations published mainly in the National Association of School Nurses, The Journal of School Nursing and the American Academy of Pediatrics, Council on School Health. Studies were searched for in the period 2008-2020. The literary review is based on the published results of international research, national action strategies, national plans. The studies listed in tab. 1 were included in the file for the analysis of studies and research papers that deal with the topic of school nursing, school nurses. The file contains a total of twenty-two studies published mainly in English, some in Polish, German and Slovak. When searching and analyzing the available sources on the topic of school nurses, we first familiarized ourselves with the primary sources that we used for the theoretical framework. School nurse is an "old" term in sources in the Slovak language, we did not find a large number of published outputs, with the exception of the contributions of doc. Boledovičová and colleagues working at the Faculty of Social Sciences and Health Sciences of the University of Konstantin Filozof in Nitra. We drew primary literary sources from publications in the English language.

Table no. 1 Literary review

COMMUNITY NURSING CARE IN SCHOOLS

School health care was already introduced in the USA at the beginning of the 20th century. The first school nurse, Lina Rogers, was appointed in 1902 and provided care for 8,671 students in four separate schools in New York. Her successes in reducing student absenteeism led to the hiring of 12 additional nurses (American Academy of Pediatrics, Council on School Health, 2016). There were 132,300 full-time or part-time school nurses in the US (Selekman, 2013).

In Finland or Poland, a school nurse has been commonplace for several years. Poland introduced school nurses between 1992 and 2002, creating a model of school health care. Thus, Polish nurses significantly influenced the quality of programs within the Schools Supporting Health project. In 2000, the country adopted eight national standards to improve and unify the activities of nurses: "School nurse practice standard" (Boledovičová et al., 2009; Popovičová, 2021).

Especially in Anglo-American and Scandinavian countries, school nurses work, supervising children and teenagers in all matters related to health. Through a systematic search of literary sources, we focused on identifying a general description of the tasks of school nurses. Central areas of responsibilities include: direct nursing care in case of accidents, emergencies, acute or chronic illnesses; care for children with special needs; prevention, health promotion and health education; assessment of health problems and needs, creation of a healthy and safe school environment; communication, cooperation and mediation; support of teachers and other school employees; documentation and research (Schmitts, Görres, 2012).

It can be concluded that the areas of responsibility of school nurses are largely identical across countries. Many researches significantly show a reduction in absenteeism in schools where school nurses and school health care work. Nurses gained independence, historically there was a shift in roles to a significant expansion of the range of activities (Schmitts, Görres, 2012).

The school nurse has a decisive role in providing complex health services to children of specific age groups. The number of children who come to educational institutions with chronic health problems requiring health monitoring and care during the school day is growing (Murray, 2008).

The National Association of School Nurses in the USA defines school nursing as: "the specialized practice of professional nursing that enhances the well-being, academic success, and lifelong success of students. To this end, school nurses promote the health and safety of students; they provide interventions related to their actual or potential health problems" (Murray, 2008). This definition was adopted by the Board of Directors of the US National Association of School Nurses in 1999.

School nurses provide interventions and care for acute and chronic illnesses, injuries and emergencies, communicable diseases, obesity, substance use and abuse, teenage pregnancy, mental health, nutrition, and sexually transmitted infections (Murray, 2008).

The proposal for the introduction of school nurses in the Slovak Republic was submitted to the parliament in 2017 by Zuzana Zimenová, a non-affiliated member of the National Council of the Slovak Republic, in a draft amendment to the Education Act. According to Zimenová, teachers do not have the necessary competences to carry out health care services, which must be carried out during the day for students with various chronic diseases, sometimes even during the lesson (SK SaPA, 2017). Until 1989, the Slovak Republic had a School Health Service, which was provided by pediatricians and children's nurses. They carried out vaccinations, annual examinations of pupils, evaluated the mental development and behavior of pupils, monitored the morbidity of children, monitored the hygiene of the school environment and the level of school meals (Boledovičová et al., 2006; Popovičová, 2021). Boledovičová et al. in their research, which they carried out in Nitra and Prešov in 2006, they found that up to 89% of respondents expressed the need to implement the position of school nurses, and also 89% of respondents were satisfied with the proposal for the job description of a school nurse that they presented to the respondents.

The incidence of chronic diseases is increasing not only among adults, but also among children and youth. In 2010, 215,000 people under the age of twenty were diagnosed with diabetes in the US. The prevalence of food allergies in children under the age of eighteen increased from 3.4% in 1997-1999 to 5.1% in 2009-2011. On average, one in ten school-aged children has asthma, contributing to more than thirteen million missed school days each year. With the growing number of children with chronic diseases, the need for health care at school has increased. The increase in the number of children with special health needs increases the need for school nurses and school health services. Rising obesity rates over the past few decades pose an alarming risk to the current and future health of children and adolescents. The percentage of children aged six to eleven with obesity has increased from 7% in 1980 to almost 18% in 2012, with more than a third of children overweight. A serious problem is the increase in the number of students with mental or behavioral health problems. One in five adolescents between the ages of fourteen and seventeen have mental health problems (Jameson et al., 2020).

The role demands of the school nurse have changed considerably over time in response to social, cultural and political influences (Moorse et al., 2020). In the 120 years of their existence in school health systems, especially abroad, they meet the increasingly complex health needs of children and students, solving their physical and emotional needs comprehensively.

The goals of community care for children are health promotion, prevention and education. Long-term care for a child with a serious illness or disability is demanding not only psychologically and financially, but is a frequent cause of the breakup of many families (Krištofová et al., 2009).

There is no legislative framework for community nursing in the Slovak Republic. Of the surrounding countries, except for Poland, community nursing is defined in the legislation of the Czech Republic: Concept of nursing. 2004. Journal of the Ministry of Health of the Czech Republic, 2004, amount 9, p. 2-8 and decree of the Ministry of Health of the Czech Republic no. 391/2017 Coll. on the activities of healthcare workers and other professional workers, as amended.

COMMUNITY CARE PROVIDED BY THE SCHOOL NURSE

The basic goals of school health care include protecting and supporting the health of children and youth. They must be provided with the most favorable conditions for education and development (Schmitts, Görres, 2012). The place of work of a school nurse is a preschool and a school. In cooperation with children and their families, he participates in protection, support, restoration of health, prevention of diseases and effective rehabilitation. It supports students' ability to help themselves, informs about health care, provides and adapts nursing care to disabled and chronically ill children. It creates specific conditions for them, monitors the effects of treatment, rehabilitation, organizes the administration of medicines. Nursing interventions are implemented according to norms and standards (area of ​​quality management) and principles of Evidence Based Practice and Evidence Based Nursing. Uses theoretical knowledge from health psychology, communication, respects compliance with legal, ethical and professional standards when providing community nursing care.

The frequency of health disorders increases with the age of children. The predominant health problems of primary and secondary school students are disorders and diseases of locomotor organs, allergic diseases, accidents and injuries. From the epidemiological study by Kock et al. (2018) showed that health problems were diagnosed in 44.3% of primary school students and 50.6% of secondary school students. Excess body weight, endocrine disorders and eye diseases were significantly more frequent among high school students, while younger children were diagnosed with hearing and speech disorders and an increased incidence of injuries.

In addition, changing socio-economic and environmental factors contribute to an increase in civilization diseases diagnosed in children and adolescents, to an increase in the risk of metabolic disorders of carbohydrates, lipids and allergic diseases. This is confirmed by Szymborské's analysis of the health status of children and adolescents, where in the population of 0-14 years (n = 5,783) almost 31% of children had at least one chronic disease or medical condition (Kocka et al., 2018). Of the chronic diseases diagnosed in children and adolescents, allergies were the most common. Improving the health of children and adolescents should therefore be a priority of the state's health policy based on thorough scientific research.

Diagnostics of the actual health status of children and adolescents is the basis for setting health care priorities and implementing coordinated and planned preventive measures. In the school environment, the school nurse provides comprehensive nursing care. Her responsibilities include the systematic execution and interpretation of screening tests that enable early diagnosis of health disorders. Analysis of the health problems of primary and secondary school students will enable targeted preventive and promotional activities to be carried out in the school environment (Kocka et al., 2018).

The most common health problems in the group of chronic diseases diagnosed in high school and elementary school students were disorders and diseases of locomotor organs, the most common posture error in children was scoliosis; consequently, respiratory tract diseases prevailed, especially allergies and respiratory diseases – bronchial asthma. Schools and school nurses have a fundamental role in solving health disorders, behavioral disorders, promoting mental health and social emotional competences, strengthening protective factors. Student behavior disorders include attention deficit hyperactivity disorder, mood disorders, depression, bipolar disorders, anxiety disorders, panic disorders, eating disorders, psychotic disorders, and substance use (Spring et al., 2018). Mental health disorders and substance use in childhood lead to poorer school results and often persist into adulthood. These disorders are associated with many risk factors throughout life such as reduced employment opportunities, earlier mortality and financial burden. School nurses have a unique position, they can be active in mental health promotion, screening and help in managing the ongoing treatment of mental health and substance use disorders in the school environment (Spring et al., 2018).

The results of the research conducted by Raková (2015) showed that parents expect the school nurse to provide first aid, accompany children during school trips, provide health education for children, supervise hygiene at school and provide care for chronically ill children. Parents would welcome the introduction of the position of school nurse in schools, parents of children in the first grade of primary schools had a more positive attitude.

The number of adolescents actively participating in activities supporting their own health is low (Vatehová, Čipáková, 2015). In their research, the authors found that adolescents (as a sensitive age group) trust the nurse as a subject in the field of counseling regarding diet, diseases, stress, use of contraception, venereal diseases and alcohol consumption.

TASKS OF THE SCHOOL NURSE

The duties of the school nurse include health and educational goals. School nurses fulfill critical roles within the school health program by addressing children's major health problems, providing preventive and screening services, health education, health decision support, and immunizations. Part of the work of a school nurse is also the detection of abused and neglected children. Children at all developmental stages are exposed to family crises, poverty and violence, which increase the need for physical and mental health. Studies on school nursing demonstrate, in addition to reducing the number of days of absence due to health reasons, also benefits for children with chronic diseases, a high level of satisfaction of teachers and parents with the services of school nurses (Schmitts, Görres, 2012).

The main areas of interest for school health include the hygienic and epidemiological level of the school environment (exterior and interior of the school, classrooms and workshops, microclimate of the school, cleaning, ventilation...), personal hygiene of pupils as prevention of infectious diseases, hygiene of nutrition and eating regime (equipment of the kitchen and canteen, level of food serving and dining culture), epidemiological indicators (vaccination of children, health examinations), harmful effects, their manifestations and consequences as drug addiction, alcoholism, nicotine addiction; school education on parenting, marriage, sexual life, venereal diseases, basics of first aid, life management.

One of the main tasks of the school nurse is to support and monitor children with special health care needs. This primarily includes a group of chronically ill children and adolescents, to whom he provides nursing care according to an individually developed plan in terms of case management. These children represent a particularly vulnerable group whose health and well-being must be ensured in the school environment. School nurses support children with complex health needs to integrate into the classroom, including by educating teachers and classmates about the illness and how they can help a disabled child in a possible emergency situation. In addition, special needs can result from psychological problems, social disadvantage or difficulties in the family environment and lead to behavioral and learning disorders. The task of the school nurse is to identify pupils with such a risk and provide them with appropriate help (Schmitts, Görres, 2012).

SCOPE OF ACTIVITIES OF THE SCHOOL NURSE

From the point of view of the historical development of school nursing, the scope of activities of school nurses has changed over the decades. New competencies and tasks were added to the nurses, they gradually took over the responsibilities and activities that were previously mainly performed by doctors. The present brings characteristic features resulting from this development, which include the growing importance of primary health care, the expansion of counseling and offers in the field of mental health, and the greater involvement of schools in community care. The basic scope of a school nurse's activities includes:

• support of normal growth and development of children and youth;
• health protection, prevention of health problems, complications and deterioration of the health status of children and youth;
• supporting the child in treatment, care and adaptation to a chronic condition;
• dispensary care;
• safety of children, prevention of accidents;
• assessment of factors of the social environment that may adversely affect the child's health;
• assessment of lifestyle factors and child care by parents and child's behavior at school;
• assessment of parents' knowledge in caring for a child during illness at home;
• vaccination;
• dental care;
• education, health education (Hanzlíková, 2006).

THE ROLE OF THE SCHOOL NURSE

A school nurse fulfills several roles in her profession: provider of nursing care, educator, manager, advisor, consultant, advocate for the rights of children and youth, communicator, researcher, bringer of change. As a provider of nursing care, the school nurse provides high-quality nursing care according to the latest scientific knowledge, urgent care not only for children, but also for school staff; satisfies the bio-psycho-social needs of pupils and students, applies a holistic approach. In the role of a communicator, she uses all components of verbal and non-verbal communication, knows how to actively listen and knows the principles of effective communication. As a manager and case manager, the school nurse organizes, manages and controls activities aimed at achieving the goal, cooperates with the student's parents, plans check-ups with doctors and specialists. The role of the advisor is also important. For children and young people, she is a confidant, an authority, helps them adopt new attitudes, alternative solutions, advises them on health and lifestyle issues. Children and adolescents need advice, guidance in various situations, confiding, discussing health and personal problems. The school nurse can thus help eliminate inappropriate behavior and habits in children and youth. In the role of consultant, the school nurse cooperates with the school staff. As a researcher, she knows the research process and its terminology, actively participates in research, applies research results in practice. The role of the educator is very important. We present a suitable range of topics for education and health education in schools:

• basic knowledge of school work hygiene, environmental hygiene and home preparation (biorhythms, routine of the day, personal hygiene, dental care, primary and secondary loads acting on the student in the school environment and during home preparation);
• basic knowledge about the quality, rules and hygiene of healthy food, nutritional value of food, energy needs of the body, alternative nutritional directions, principles of rational nutrition, drinking regime, health risks of fast food, advertising in the context of nutritional recommendations of experts;
• basic knowledge about the movement regime, the importance of movement for health, movement and psychorelaxation, principles of fair play and safety in movement activities;
• basic practical skills and behaviors related to health care, appearance and fitness;
• accident prevention, the most common causes of accidents, possible injuries in winter and summer (eg swimming, skiing, skating), accidents related to transport;
• basic knowledge about the primary prevention of socio-pathological phenomena, primary prevention of drug problems (causes of drug problems and drug addiction, negative consequences of the use of addictive substances on a person's personality, effects and mechanism of action of addictive substances);
• rational use of free time;
• the influence of the family environment on the development of the personality of children and youth;
• learning the principles of communication, behavior and decision-making in situations related to active health, communication with adults and peers;
• socialization, involvement and active adaptation in relation to society, creating the ability to maintain relationships between people, behavioral models;
• understanding the contexts of the integration of handicapped children into regular schools, preference for consideration, responsibility and cooperation;
• the area of ​​sexual behavior, contraception, ethical attitudes towards sexuality, education for partnership, marriage and parenthood, the importance of mutual communication and understanding in the family, understanding of friendship, partner relationships;
• safe behavior, behavior in crisis situations, responsibility for one's own safety and that of others, first aid in the event of a health threat (Liba, 2016).

The position of school nurse did not exist in the system of primary and secondary schools in the Slovak Republic, with the exception of some private schools, e.g. the combined school for the blind in Levoča or the British International School in Bratislava, which employ school nurses. Abroad, on the contrary, it is a standard that has been operating for several decades. We can draw on experience in Poland, Finland, England, Australia, France, USA.

Due to the increasing complexity of the health needs of children and youth, the role of the school nurse has changed significantly over the past 25 years. The number of children suffering from chronic diseases has increased sharply. New problem areas such as immigration, poverty in families, various addictions associated with modern technologies, integration of children with special needs, violence, which represent huge challenges for school nurses, have also appeared.

During the period of the most intense physical and mental development, children spend ten years of their lives in school. It is the duty of the state to protect children's health even during school attendance. The increasing number of children with chronic diseases accentuates the need for medical supervision and care directly in schools.

FINANCING

From the analyzed foreign studies, we came to the conclusion that the salary of a school nurse depends on the number of students in the school where she works. Raková (2015) states that a monthly capitation rate applies to each student. The Organization for Economic Co-operation and Development (OECD), which collects data on national health expenditure, does not provide data on school health expenditure because in some countries the expenditure is covered by health budgets and in others by education budgets, and in many countries also by local government budgets. From the data from foreign sources, which we present in the list of cited sources, the expenditure on school health care ranged from 43,000 euros in Estonia and Iceland, 56,000 euros in Austria, 85,000 euros in Finland to 195,300 euros in Norway per 1,000 pupils. The mentioned states reported staffing standards for school nurses at an average of 1.4 school nurses per 1,000 pupils. Schools with a high percentage of pupils or students with special medical needs would require more intensive ratios of nurses to students and also a method of financing depending on the demanding scope of activities of school nurses. The American Pediatric Society advocated a ratio of one school nurse to 225 pupils or students. However, the use of a ratio to determine workload in school nursing is insufficient to meet the increasingly complex health needs of children and youth (van der Pol et al., 2020). The National Association of School Nurses in the USA recommends a ratio of school nurses to pupils of 1:750, in a population where there are more chronically ill or disabled children, this ratio should be 1:125 (Popovičová, 2021).

The financing of the costs associated with the implementation of school nurses in the system of primary and secondary schools in the Slovak Republic will be influenced by many aspects: budgets of ministries, demographic trends, numbers of children and students in schools, their health status, personnel standards for school nurses, the number of schools, regional differences. International experience shows that the ratio of pupils to school nurses is not based on evidence-based research. There is also a tool for objective measurement and assessment of school nurses' workload.

The financing of school nurses, that is, the financing of quality nursing care that is provided to our children, should not be the subject of political arguments. The budget must be adapted to the needs of the schools, not the school's budget. Children are our future, we invest in them and give them what they need. Children's health must not be a subject of political struggle and economic calculation, because society is only prospective if it invests prospectively in its children.

DISCUSSION AND RESULTS

Nursing, as an integral part of the healthcare system, also deals with health promotion, health education, and disease prevention. Community nursing is an applied field of nursing that applies to the lives of people in the community to achieve and maintain health. School nursing and the reintroduction of the position of school nurses clearly belong to the development trends of community nursing and primary care in Slovakia. The school community is one of the basic attributes of community nursing based on the historical context. The competencies and roles of nurses in the community are expanding, they can apply their theoretical and practical skills in practice, the community environment provides them with the possibility of professional growth, the development of research in nursing, and autonomy.

The change from hospital to community health care provision is inevitable, and decades of experience confirm this to us. Political will is needed to fully utilize the potential of community and therefore school nursing.

The organizational structure of school nursing varies from country to country. According to data from the National School Nurses Association (2016) in the US, 45% of school nurses have a bachelor's degree in nursing, 60% of school nurses in the US have an average age of 55, and one school nurse provides care to 250-500 students. School nurses abroad must have a university degree. The National Association of School Nurses in the USA requires that school nurses be registered, have at least a bachelor's degree, special certification for nursing care provided in the school community, and experience in a pediatric hospital. School nurses are united by a professional organization, nurses carry out research, publish professional periodicals, publish, organize conventions and conferences and are constantly educated in their field (American Academy of Pediatrics, 2016; National Association of School Nurses, 2016, Popovičová, 2021).

From the results of surveys carried out by the authors Boledovičová et al. (2009) and Raková (2015) showed that parents, but also school principals, were interested in introducing the position of school nurse in schools. In her survey, Popovičová (2021) found that parents (49.1%) were statistically significantly more interested in the presence of school nurses in schools compared to teachers (26.8%) and also parents perceived the need for school nurses in schools more than teachers. 60.4% of parents perceive the establishment of the position of school nurse as necessary, 28.3% even as very necessary. But up to 49.2% of respondents did not have any information about the work of a school nurse, which we consider to be a very important finding on which activities need to be focused.

We draw attention to the fact that nurses will enter the practice of school nursing from different areas of health/nursing care and will not be aware of the autonomous role and unique roles in the practice of community nursing in the school environment. Another important factor for which nurses need to be prepared is that there are many different types of schools and related to this also different work duties, different in primary schools, different in secondary schools, different health and other problems of children and adolescents. Nurses also need to be prepared for the fact that they will spend a lot of time interacting with children and adolescents. According to the National Association of School Nurses (2016), contact with the school nurse is sometimes a child's first interaction with health services. The reason for introducing school nurses into practice, as stated by many authors, is the increasing number of chronically ill pupils and students (Jamesom et al., 2009; Kocka et al., 2018; Spring et al., 2018). Pupils' health is directly related to their ability to learn. Children with unsatisfied health needs find it difficult to participate in the educational process. The school nurse focuses on the physical, mental, emotional and social health needs of students and supports their success in the learning process. A national survey of children with special health care needs found that 11.2 million children in the US are at risk for chronic physical, developmental, behavioral, or emotional conditions (National Association of School Nurses, 2016). School nurses also focus on the social determinants of health, which cause 80% of health problems. In the US, nearly a quarter of children attending school live in households below the federal poverty level. Children from lower-income families have more difficult access to treatment for chronic diseases (Moorse et al., 2018). The situation in many Slovak families corresponds to the findings of the author's team. According to the findings of the Statistical Office of the Slovak Republic (2020), a total of 11.9% of the population in Slovakia was at risk of income poverty in 2019, which represents approximately 640,000 people, while the increase in poverty continued in single-parent families with more children or in households where children lived with only one parent.

Based on familiarization with the topic and after analyzing the studies, we tried to propose seven priority areas for the implementation of the position of school nurse in primary and secondary schools in the Slovak Republic after the end of the two-year pilot project. We assume that the application practice of this project will gradually bring and reveal a number of problems that will need to be solved mainly legislatively and economically.

Proposal of priority areas for the implementation of the position of school nurse in primary and secondary schools in the Slovak Republic after the end of the pilot project

Priority areas:

1. School nurse - profile, occupational performance criteria, education
2. School nurse as a provider of community nursing care in schools
3. Health education, education, prevention
4. Healthy school environment
5. Financing
6. Participation in research
7. Cooperation

Due to the extensiveness of the issue, we present proposals for the basic framework of the first two priority areas.

School nurse - profile, occupational performance criteria, education

Problems related to the health of school children and high school students include physical, social, behavioral, emotional, psychological areas and require comprehensive individual care. Such care should be provided by a nurse with a second-level university education, experience in pediatric and community nursing, she should have knowledge of health education, public health, prevention, protection and health promotion. The basic professional and qualification requirements for the position of a school nurse require completion of a course in cardiopulmonary resuscitation, control of an automated external defibrillator (AED), computer skills necessary for working with text and entering data into software platforms, and at least five years of experience.

Basic framework of activities of the school nurse

1. The school nurse provides pupils and students with direct nursing care for acute illnesses, injuries, accidents, children with special health needs and disabilities of varying degrees of severity. He applies the prescribed treatment. For students with chronic conditions, he develops an individualized nursing care plan and a plan for managing potential emergency events in the school environment (e.g. diabetes, asthma).
2. Assesses the health status of children, keeps medical documentation and records on the health status of pupils.
3. The school nurse performs screening, early identification of children with possible health problems and sends them for medical examinations as needed. Screening includes assessment of vision, hearing and BMI, among others.
4. The school nurse supports a healthy school environment. Monitors immunization, incidence of infectious and communicable diseases, environmental safety, participates in environmental safety monitoring (children's playgrounds, indoor air quality and potential risks), implementation of a plan for prevention and management of school violence, bullying, disasters and terrorist events. If the school tests pupils and students for the presence of drugs, it implements and continuously evaluates the testing program.
5. The school nurse participates in health education by providing health information to individual students and groups of students. Health education topics include nutrition, exercise, smoking prevention and cessation, oral health, prevention of sexually transmitted infections and other infectious diseases, use and abuse of addictive substances, immunization, teenage pregnancy prevention, parenting, and more.
6. The school nurse has a leading role in health policies and programs, in the creation and evaluation of school health policies. These policies include health promotion and protection, chronic disease management, coordinated school health programs, school wellness policy, crisis/disaster management, emergency management, mental health protection and intervention, acute disease management, and infectious disease prevention and treatment.
7. The school nurse fulfills the role of coordinator, intermediary between the school staff, the family, health workers and the community. Communicates with parents of children and students. Identifies the special educational needs of children and students. As a case manager for pupils and students with health problems, the school nurse ensures adequate communication and cooperation between the family, school and health care providers. It ensures consistent and coordinated care.

School nurse as a provider of community nursing care in schools

Providing nursing care includes assessment - gathering information, nursing diagnosis, planning, interventions and evaluation. The nurse collects and collects up-to-date data on the health status of pupils (course of growth and development, examination results, nutritional status, resilience, cultural differences). Identifies existing and potential health problems that can be addressed. Comprehensively evaluates the health of pupils. Creates a nursing care plan, sets goals and plans interventions. In the implementation, he cooperates with pupils, families, medical facilities and teachers. The plan is individual for the student's needs. The nurse uses alternative solutions, preventive procedures, updates the plan and evaluates the success of solving the nursing problems of children and students, suggests other procedures, recommendations.

The health status of pupils and students affects their ability to learn and educate. In cooperation with pupils and students, their families, he participates in protection, support, restoration of health, prevention of diseases and effective rehabilitation. It supports students' ability to help themselves, informs about the current state of health care. At the same time, it ensures and adapts nursing care to disabled, chronically ill children, creates specific conditions for them, monitors treatment, rehabilitation, and organizes the administration of medicines.

The changes that occurred in the health care system in Slovakia after 1989 brought many changes: privatization of primary health care, the possibility of free choice of doctor, but also the abolition of the school health service. Pediatricians and nurses stopped performing health supervision at schools, a functioning system beneficial for the healthy development of future generations was abolished. The present brings evidence of the negative impact of this state decision on the quality of life of children and youth. After more than thirty years, we note an increase in diseases caused by an incorrect lifestyle and other determinants that create health and habits already in childhood. At younger school age, respiratory diseases (angina, acute bronchitis, rhinitis, laryngitis), diseases of the digestive system, nutritional disorders, metabolic diseases, type 1 diabetes mellitus, allergic diseases, oncological diseases and injuries are most common. One in ten school-aged children has asthma. Other serious problems include psychological and social. In older school age and adolescents, we encounter drug addiction, sexual problems, and suicide attempts.

Teachers do not have the competences, possibilities within the educational process and even adequate knowledge to carry out and implement health education in schools, parents have to solve mainly existential problems, and therefore the implementation of the school nurse profession becomes a necessity. Schools also have to respond to changes in the economy, to new trends and knowledge in science and technology, social conditions, demographic trends, but also trends in healthcare and the health status of the population.

Community nursing care for school-aged children

1. Assessment of pupils' health status, administration of medicines and care for children with special medical needs.
2. Management of chronic health problems and special needs of students, which have an impact on the educational process and study results.
3. Direct nursing care, supervision of compliance with the child's prescribed regime, care of children in case of injuries, acute illnesses and conditions.
4. Screening, immunization, mandatory reporting of infectious diseases.
5. Emergency and emergency management system.
6. Health education of children, education about a healthy lifestyle, counseling for obesity, drug abuse, alcohol, sexuality, mental health.
7. Prevention and health screening.
8. Monitoring of the school environment - classrooms, canteen, playground; ensures a safe environment at school.
9. Management of medical documentation and records, including personal data protection, statistical reports.
10. Caring for children during extracurricular activities: school trips, excursions, ski courses, summer camps.
11. Cooperation and communication with parents, the child's general practitioner, health care providers, RUVZ, public and state administration.
12. Responsibility for the condition of first-aid kits, purchase of medicines and medical supplies.

Conclusion

Currently, in the era of rapid political, epidemiological, social, economic, cultural changes and changes in the health system, the health of children and adolescents presents several challenges for health professionals. The integration of health care into schools can significantly contribute to the reduction of morbidity and mortality due to chronic diseases. School nurses have a special position that can help them in the development of children. Children need adults in their lives. While their teachers change every year, the school nurse may be the only adult they have contact with throughout their schooling. The school nurse plays an important role as a team member in providing prevention, early identification of problems, interventions and referrals to promote health. As Popovičová (2021, p. 56) states, "Children's health is one of the highest priorities... elementary school is a specific community that is essential for children's healthy development."

School nursing, as a specific field of community nursing practice, positively affects the health of school-aged children. We find positive examples in the work of school nurses in Poland, France, Finland, England and other countries. The implementation of the position of a school nurse concerns healthcare, education, but also the social field. In the Slovak Republic, it would fill a gap in the childcare system, because parents, teachers and school nurses have the same goal - the healthy development of the child.

Authors: doc. PhDr. Viera Hulková, PhD., MPH Alexander Dubček University of Trenčín, Faculty of Health Sciences, Department of Nursing, prof. PhDr. Mária Kilíková, PhD., MPH VŠZ and SP St. Elizabeth Bratislava, n. o.

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