A Contemporary Framework Update for Today’s School Nursing Landscape: Introducing the School Nursing Practice Framework™

Abstract

School nursing is a unique nursing specialty that benefits from a practice framework that aids school nurses in explaining and accomplishing their role. In 2016, the NASN debuted its Framework for 21st Century School Nursing Practice™, which has shaped school nursing practice as well as education, leadership, research, and collaboration with stakeholders. However, practice frameworks are not meant to remain the same indefinitely. Therefore, NASN evaluated and updated the Framework to ensure its continued alignment with the education and healthcare landscape. The purpose of this article is to share the history of the Framework for 21st Century School Nursing Practice™ development, provide the rationale for the update, and discuss the strategic process NASN used to update its Framework now entitled the School Nursing Practice Framework™.

Introduction

School nursing is like no other nursing specialty. There are elements of pediatric, emergency, mental health, and community/public health nursing intertwined in the fabric of school nursing, but the activities, environment, and desired outcomes of school nursing practice are unique to this specialty. Therefore, the practice of school nursing must be examined through a unique lens that promulgates the critical, yet complex, work of school nurses, made challenging by addressing student health in an education environment. Since 2016, the National Association of School Nurses (NASN) Framework for 21st Century School Nursing Practice™ (often referred to as the Framework) has provided school nurses with a mindset for how they consider, explain, and carry out their school nursing practice with a distinctive environmental context and skill set. The Framework has supported school nurses in their professional journey. This article details the history of the Framework for 21st Century School Nursing Practice™ development, the rationale for updating the Framework, and the outcomes of a robust process for updating the Framework.

Building Upon the Success of the Framework for 21st Century School Nursing Practice

The Framework for 21st Century School Nursing Practice™ was introduced to school nurses in 2015. In the first publication about its inception, NASN explained the importance of a framework as “a set of concepts that are linked together in a distinctive way to provide guidance for achieving an overall goal” (Maughan et al., 2015). In 2015, NASN expressed an obligation to school nurses and the people they serve to develop a framework reflecting professional school nursing practice. The goal was a framework that reflected the importance of evidence-based best practice and offered guidance toward priority school nursing activities. NASN desired a framework that guided school nurses in promoting student health and academic success through fostering a healthy and safe school environment. To that end, NASN staff reviewed existing literature regarding school nursing practice, needs assessment data, common healthcare topics for school-aged children, healthcare climate, and critical skills necessary to meet child health problems. The NASN team consulted with an expert in conceptual framework development and sought expertise from the NASN Board of Directors. NASN also constructed an advisory committee of practicing school nurses and school nurse leaders across the United States to support the process. The result of these activities was a visual depiction and series of NASN School Nurse articles describing five principles (labels for categories that bring like activities together) and their components (actions that exemplify each principle). At the end of this inaugural debut of a framework draft, NASN gave readers the opportunity to give feedback on the Framework’s accuracy, utility, consistency, and clarity. Based on this feedback, NASN (2016) revised the Framework and presented it to its members.

Since its formal debut in 2016, the Framework for 21st Century School Nursing Practice has been lauded for its usefulness in guiding professional development, new school nurse orientations, presentations to school administrators and personnel, and annual goal setting and more direct care activities, such as screening processes, data collection and utilization, and complex care problem-solving (Maughan et al., 2016). Over the past 7 years, references to the Framework have grown to include categorizing school nurse interventions (Best et al., 2018), school nurse responsibilities in job descriptions (Reising & Cygan, 2022), workload indicators (Jameson et al., 2022), and school nurse activities related to mental health (Hoskote et al., 2023).

Rationale and Process for Updating the Framework

Practice frameworks are not intended to remain the same forever, just as evidence and standards of care change over time. For school nurses, a practice framework exists to align with the education and healthcare landscape. Since the creation of the Framework, our education and healthcare systems have been affected by the COVID-19 pandemic, a mental health crisis, school violence, federal and state legislation impacting school nursing practice, advances in technology, evidence regarding school nursing practice, and an increased focus on issues such as environmental concerns and nurse self-care. Because the world in which school nurses practice has changed, the framework reflecting and guiding that practice must also change, but not without a well-informed and strategic process. This process included multiple points of review and input from engaged parties including brainstorming sessions among NASN staff, survey creation and dissemination, focus groups, stakeholder meetings, accuracy checks, and a final review by NASN leadership and staff.

Review and Survey

First, NASN formed a multidisciplinary team to discuss the potential need for updating the Framework. This team discussed the education and healthcare system changes, especially as a result of the COVID-19 pandemic, and their potential impact on Framework appropriateness. This team devised a plan to gather data from school nurses regarding awareness, utilization, and appropriateness of the Framework.

Second, NASN designed a 25-question survey to ascertain school nurses’ knowledge, attitudes, and practices surrounding the Framework. NASN strategically shared the survey through a tiered process in the following order: (1) NASN Board of Directors, (2) NASN state affiliate leaders, (3) NASN members, and (4) non-NASN members via state school nurse consultants. A modified version of the survey was disseminated to Overseas School Nurse Association conference attendees. Results of these efforts indicated that more than 20% of the 877 survey responders had not previously heard of the Framework. For those familiar with the Framework, the most common uses of it were to (1) inform the school nurse job description, (2) inform (or educate) school administrators about the school nurse’s role, and (3) orient new school nurses to their role. Every participant was given an opportunity to review the current Framework and then report on what was most confusing and what might be missing. Resounding feedback reflected a need for greater emphasis on mental health, school violence and other emergency preparedness, self-care, as well as a clarification on the relationship between the Standards of Practice principle and the more practice-oriented, or activity-driven, principles (Care Coordination, Quality Improvement, Leadership, and Community/Public Health). More details about this survey and findings will be shared in a future publication.

Focus Groups

Third, NASN organized a series of focus groups with practicing school nurses as well as school nurse educators, leaders/consultants, and researchers. NASN gathered these school nurse expert groups to discuss the survey findings and gather the unique perspectives of school nurses who engage with the Framework in different ways (using the Framework to guide practice, educate school nurses who will use the Framework to guide practice, lead school nurses to practice in alignment with the Framework, and research school nurse practice and outcomes that result from practicing in alignment with the Framework). The feedback suggested the five existing principles remained appropriate in describing the work of school nurses. The feedback from these school nurse focus groups and their discussions regarding the survey findings were submitted in a summary report to a visual graphics designer to inform an updated Framework image incorporating the existing five principles.

Component Format Change

Fourth, upon the recommendation of school nurse focus group members and feedback from the survey, the bulleted components underwent a thorough review, change in format, and analysis in the context of School Nursing: Scope and Standards of Practice, 4th ed. (NASN, 2022). Many school nurses struggled to articulate the difference between Framework components that exemplify principles and competencies that are evidence of complying with standards. Because the standards of school nursing practice described in School Nursing: Scope and Standards of Practice, 4th ed. (NASN, 2022) are the professional expectations of school nurse behavior and their competencies are evidence of compliance with the standards, the components of the Framework were rewritten to reflect the format of the competencies. In fact, a table was created to demonstrate how competencies from all standards align with the five principles of the Framework and will be made available on the NASN website. In addition, school nurses wrestled with how to operationalize the components written as single word or phrase statements, such as education reform or outreach. Consequently, the reformatting of components as statements with action verbs clarifies what school nurse activities are characteristic of each principle. School nurses also grappled with how the Standards of Practice principle related to the other more practice-oriented principles—Care Coordination, Quality Improvement, Leadership, and Community/Public Health. This echoing challenge was the impetus for a conceptual shift in how NASN will describe the relationship between the Standards of Practice principle and the four practice principles moving forward.

Framework Graphic Update and Approval

Fifth, the graphics designer created a draft of the Framework with the visual depiction and components. Several key stakeholder meetings were held with national school health and education leader associations to reflect upon the updated Framework. Stakeholders reviewed the draft and provided feedback about their perceptions of school nursing based on the Framework and alignment between their role and the role of school nurses. Stakeholders expressed great appreciation for the complex role of the school nurse, with more than one stakeholder stating, “School nurses do a LOT!” Stakeholders expressed a need for a component that firmly expressed the necessity for school nurses to be “at the table” where decisions about student health and well-being are made, and the collaboration that occurs between school nurses, families, and students’ medical homes. Refinements to the Framework resulted based on this stakeholder input.

Sixth and finally, the Framework draft with updates was presented to a select group of current and past NASN staff familiar with the original Framework to ensure key aspects critical to the original were not lost in the update. The updated Framework was then presented to all NASN staff members by the project’s lead nurse to inform them of the changes, confirm accuracy, and ensure feedback was appropriately incorporated. The NASN leadership team and Board of Directors Executive Committee met and discussed methods to introduce and promote the updated Framework.

Results of the Framework Update Process

Based on the feedback from the Framework update process, NASN made several notable changes. First, survey and focus group participants commented on the title, with most expressing that its reference to the 21st century was now outdated. While the title’s inclusion of the phrase 21st century helped education stakeholders recognize alignment between the school nursing Framework and education initiatives, such as the United States Department of Education’s 21st Century Community Learning Center Program, an almost unanimous response was to remove this dated reference. Furthermore, NASN changed the order of words in the title so that school nursing appears first (School Nursing Practice Framework), marking the importance of those doing the work of school nursing practice. Discussion regarding the word practice revealed the importance of ensuring school nurses and stakeholders are aware that the Framework reflects the activities and foundational standards that guide the practice of the specialty of school nursing. While school nurse educators, leaders, and researchers use the Framework in their roles, they should do so keeping in mind that they use the Framework in work that equips, supports, elevates, and champions those practicing school nursing. Those practicing school nursing and those who support school nurses do so for the attainment of health and education goals of the students, families, and school communities they serve.

It is also important to note the expected outcomes of school nursing practice that align with the Framework. What once appeared in the center of the Framework depiction now appears as a tagline below the title: “Supporting Students to be Healthy, Safe, and Ready to Learn.” When school nurses practice to the fullest extent of their education, training, and licensure, and in a manner consistent with the principle of Standards of Practice, and with a mindset that includes the four practice principles (Care Coordination, Quality Improvement, Leadership, and Community/Public Health), positive student outcomes result. Students will be healthier, safer, and more ready to learn when a school nurse is providing quality care, monitoring the impact of that care through data-driven methods, leading initiatives that advance student health and equitable access to education, and promoting student health through activities consistent with community and public health tenets.

In addition to some nuanced word changes, updating the Framework resulted in a refreshed visual depiction of the Framework (see full-page graphic at the beginning of the article). The updated color palette purposefully compliments the NASN logo color scheme. The design highlights the overlapping nature of the principles, signifying the complexity of school nursing practice and the myriad activities that school nurses perform. Specifically, the overlapping nature of practice principles and the Standards of Practice principle signifies that one school nurse activity may reflect several different principles. The color palette also aids the portrayal of the layers of support school nursing practice provides students, families, and school communities.

The layers of support are a key divergence from the original Framework (see Figure 1). Instead of the Standards of Practice principle depicted as a ring surrounding the other practice principles, the Standards of Practice principle is now depicted as the foundational layer of practice and performance standards necessary to provide legally sound, evidence-based, clinically competent, quality care (see letter A in Figure 1). The next layer of support depicted in the Framework is the school nurse. Resounding feedback regarding the Framework included this question: “Where is the school nurse?” Now the School Nurse is visible in the Framework, depicted with an aerial view of the school nurse. (Imagine flying over a school nurse and looking down to see the top of the school nurse’s head and arms outstretched. See letter B in Figure 1.) The school nurse stands upon the Standards of Practice foundational principle while holding responsibility for and influence over the four overlapping practice principles.

Figure 1.

Layers of Support

The four overlapping practice principles make up the next layer of support within the Framework (see letter C in Figure 1). The four overlapping practice principles remain the same principles included in the original Framework. However, all four principles now overlap with one another, rather than only those adjacent to one another overlapping. The overlapping nature of the four practice principles cannot be overemphasized, as most school nursing activities are complex and reflect aspects of multiple principles.

While the practice principles may be separated to discuss each in greater detail, when possible, consider them as a unified layer of support for students, families, and school communities. When discussed separately, keep the following definitions and key updates of the practice principles in mind:

• Care Coordination: “the label used for the principle that brings student-centered like activities together that are purposeful and deliberate in the delivery of health services over time” (NASN, 2020, p. 226). This principle now puts a greater emphasis on the school nurse’s role in mental health and collaborative care with school-based professionals, the family, and the medical home.

• Leadership: the label used for activities related to “the mind-set of leadership, not a position” (NASN, 2020, p. 228). NASN has updated the components to include the school nurse’s role in sharing expertise, engaging in decision-making, preparing for emergency/disaster, and self-care.

• Quality Improvement: the label used for activities related to data collection and its use for consistent practice improvement and measurable outcomes for the student, school community, and the school nurse.

• Community/Public Health: the label used for activities related to delivering “proactive nursing services within and across school populations” (NASN, 2020, p. 227). This principle includes activities that address cultural sensitivity, social determinants of health, and education for health promotion and disease prevention.

The layers of support, including the foundational layer of Standards of Practice, the School Nurse practicing upon that foundation, and the layers of support the school nurse provides when practicing with a mindset of the four overlapping practice principles provides the ultimate supportive environment for the utmost layer—Students, Family and School Community (see letter D in Figure 1). Students remain the center focus of the Framework, which aligns the Framework with the Whole School, Whole Community, Whole Child Model (Centers for Disease Control and Prevention, 2023). The Framework also emphasizes the importance of the student’s family and school community being considered and included in school nursing practice.

Updated Framework Implementation Plan

NASN has several activities planned for a phased rollout of the School Nursing Practice Framework. Coinciding with the publication of this article is a “First Look” virtual event for the school nurses and stakeholders who volunteered their time to review and provide feedback regarding the Framework. Next, NASN will be creating brief informational videos targeting several key school nurse groups, including new school nurses, experienced school nurses, leaders, educators, and researchers. NASN will also be partnering with key stakeholders to share the updated Framework and key talking points specific to healthcare and to education.

Publications

NASN will publish additional articles in NASN School Nurse to illuminate school nurses’ complex, holistic practice that affects students, families, and school communities through Care Coordination, Quality Improvement, Leadership, and Community/Public Health activities in line with Standards of Practice. NASN also encourages school nurses to consider authoring and submitting their own articles that exemplify using the Framework in day-to-day practice, prioritization, planning, and personal development.

Presentations

In addition to publications, NASN is developing various presentations to inform school nurses and stakeholders of the Framework updates and their relevance to the changing landscape of school nursing practice. NASN is incorporating the updated Framework into annual conference presentations and presentations offered by NASN staff and board members. Moreover, because surveyed school nurses shared the importance of the Framework in articulating their role to others, NASN will create a presentation slide deck that school nurses can use to spotlight their role and key activities to school administrators as well as other school personnel.

Educational Offerings

Known as Focus on the Framework, NASN has partnered with instructional design experts to develop a self-paced educational opportunity for school nurses. This training is intended for novice to experienced school nurses. When available, the training will guide school nurses through each principle and its practice components, with microbursts of learning about many activities or concepts integral to safe, effective, student centered, legally compliant, and evidence-based care. Learners will see the Framework in action through case studies and self-reflection activities in an accompanying workbook.

Member Videos

NASN looks forward to capturing the incredible work school nurses do that epitomizes Care Coordination, Quality Improvement, Leadership, and Community/Public Health in alignment with Standards of Practice. These quick glimpses into the day-to-day activities of school nurses will be invaluable in bringing the Framework to life for school nurses new to the role, new to practicing school nursing with a Framework mindset, or interested in enhancing their practice while aligning activities with Framework principles.

Podcast

NASN School Nurse hosts several podcasts each year, and one of those podcasts will highlight the updated Framework. During this episode, listeners will hear about the many steps involved in the Framework update process, the lessons learned from this process, and what the updates and dissemination efforts mean for school nurses.

Monitoring and Evaluation

Just as school nurses assess their students’ needs, develop a plan to address their needs, implement the plan, and evaluate the difference made by their actions, NASN will use a similar strategy. During the recent Framework survey, NASN learned that 20% of responders to the survey had not heard of the original Framework. NASN is interested in monitoring uptake of the School Nursing Practice Framework™ and evaluating the difference practicing with a Framework mindset makes in the outcomes of student health, safety, and readiness to learn.

Continuous Improvement Feedback Loop

No monitoring and evaluation process is complete without a process for implementing feedback. Therefore, NASN intends to use knowledge from monitoring Framework update website visits and evaluating dissemination processes to improve and enhance opportunities for school nurses to learn about, interact with, and grow from the Framework.

Ways to Promote the Framework Mindset Now

School nurses need not wait for the activities previously mentioned to begin spreading the word about the updated Framework. The following are just a few suggestions to consider:

• Tear-out: Accompanying this article is a full-page tear out of the School Nursing Practice Framework™. School nurses can hang this tear-out on an office bulletin board. Doing so may prompt conversations about the Framework and the many activities school nurses perform to support student health, safety, and readiness to learn.

• Newsletter: The Framework is a great topic for a school newsletter. Featuring the Framework and the role of the school nurse in a newsletter is a terrific way to make parents and other school personnel aware of the vast and vital role of school nurses in student health and success.

• Incorporate into staff presentations: No one can explain the value and impact of school nursing practice better than school nurses. In the school setting, other school personnel may not understand the role of the school nurse or why it is so important for students and the school community to have access to a school nurse. Interdisciplinary staff meetings may be an ideal opportunity for school nurses to succinctly describe the role school nurses play in student, school, and community health. The Framework helps tell that story in an organized and compelling way that school personnel can understand and appreciate.

• Plan for next school year: It is never too early to set goals for the next school year and develop strategies for reaching those goals. Some school nurses may choose to focus on one principle at a time. This might include making a concerted effort to operationalize the principle of Standards of Practice throughout the next school year. Goals could include becoming more familiar with and incorporating local, state, and federal policies and regulations or starting a journal club with other school nurses to purposefully engage with evidence. Conversely, school nurses may take a comprehensive approach and set one small goal for each principle. Goals might include the following: (1) review all school board–approved policies pertaining to health services (Standards of Practice), (2) identify a student who should have an individualized healthcare plan and develop the plan (Care Coordination), (3) choose one data point and submit data for that datapoint to the National School Health Dataset: Every Student Counts! (Quality Improvement), (4) make recommendations for a policy update based on what is learned from the review of board-approved policies (Leadership), and (5) identify one potential community partner and set up a “get to know each other” meeting (Community/Public Health).

• Professional development: Similar to planning for the care of students for the next school year, school nurses can plan for their own growth and development using the Framework as a guide. Considering each principle and each component, school nurses can identify topics that are unfamiliar or activities where they could grow in confidence or competence. School nurses can seek NASN educational offerings that will enhance their knowledge and skills in these areas.

Conclusion

The Framework for 21st Century School Nursing Practice™ successfully advanced the practice of school nursing by giving school nurses a common language and visual depiction of the complex relationships among the many activities school nurses perform. These student-centered activities, done in alignment with one’s standards of practice, have resulted in the support of students, families, and school communities in forward momentum toward health, safety, and readiness to learn. The rigorous process of evaluating school nurses’ use of the original Framework and appropriateness of the Framework during a changing health and education landscape has resulted in an updated framework, the School Nursing Practice Framework™. With an updated title, a new look, and action-oriented components to help school nurses put the Framework principles into practice, NASN is poised to continue advancing the practice of school nursing.