Individualized Healthcare Plans and Emergency Care Plans

Individualized Healthcare Plans:
The Role of the School Nurse

Position Statement

Summary

It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse), in collaboration with the student, family and healthcare providers, shall meet nursing regulatory requirements and professional standards by developing an Individualized Healthcare Plan (IHP) for students whose healthcare needs affect or have the potential to affect safe and optimal school attendance and academic performance. Because health conditions can be complex and unfamiliar to school staff and the student’s requirement for nursing care can be frequent and sometimes emergent, accurate and adequate documentation of chronic medical conditions and individual needs is critical (Lyon, 2012). Development of IHPs is a nursing responsibility, based on standards of care regulated by state nurse practice acts and cannot be delegated to unlicensed individuals (National Council of State Boards of Nursing [NCSBN], 2005). It is the responsibility of the school nurse to implement and evaluate the IHP at least yearly and as changes in health status occur to determine the need for revision and evidence of desired student outcomes.

Background

The IHP is a document based on the nursing process.  Since emerging in the 1970s, the nursing process is the cornerstone of nursing practice, using a scientific approach in the identification and solution of health problems in nursing practice (Hermann, 2005).  The American Nurses Association (ANA) and NASN define the nursing process as a “circular, continuous and dynamic critical‐thinking process comprised of six steps and that is client‐centered, interpersonal, collaborative, and universally applicable” (American Nurses Association [ANA] & NASN, 2011, p. 76).  Documentation of these steps for individual students who have healthcare issues results in the development of an IHP, a variation of the nursing care plan.  The term IHP refers to all care plans developed by the school nurse, especially those for students who require complex health services on a daily basis or have an illness that could result in a health crisis. These students may also have an Individualized Education Plan (IEP), a 504 Student Accommodation Plan to ensure school nursing services and access to the learning environment, or an Emergency Care Plan (ECP) for staff caring for these students (Hermann, 2005).

Rationale

Development of the IHP by the school nurse provides a framework for meeting clinical and administrative needs:

Demonstrates Standard of School Nursing Practice
Development and implementation of the IHP is documentation of professional performance in accordance with standards of school nursing practice, the professional expectations that guide the practice of school nursing (ANA & NASN, 2011).  The Standards of School Nursing Practice are “authoritative statements of the duties that school nurses, regardless of role, population, or specialty within school nursing are expected to competently perform” (ANA & NASN 2011, p. 4).  These standards “describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process” (ANA & NASN, 2011, p. 12).

Documents the Nursing Process
Creation of the IHP incorporates and documents the nursing process in student care in accordance with state nurse practice acts.  The nursing process provides a framework for the nurse’s responsibility and accountability.

School Nursing: Scope and Standards of Practice (ANA & NASN, 2011) outlines how implementation of each step of the nursing process strengthens and facilitates educational outcomes for students.  These steps parallel components of a well‐developed IHP.

Standard 1.  Assessment: The school nurse collects comprehensive data pertinent to the healthcare consumer’s health and/or situation. 

Standard 2.  Nursing Diagnosis: The school nurse analyzes the assessment data to determine the diagnoses or issues.

Standard 3.  Outcome Identification: The school nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.

Standard 4.  Planning: The school nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.

Standard 5.  Implementation: The school nurse implements the identified plan.

Standard 6.  Evaluation: The school nurse evaluates progress toward attainment of outcomes.

Provides Legal Documentation
A school nurse plans safe care for students and demonstrates an appropriate standard of professional care when the IHP is used as the foundation for student health interventions.  “Judicious use of the IHP as a vehicle to ensure safe nursing services and continuity of care for students with special (health) needs is a standard of care against which a school nurse’s conduct can be judged in a legal proceeding” (Hootman, Schwab, Gelfman, Gregory,  & Pohlman, 2005, p. 190).  Along with applicable laws including state nurse practice acts, expert testimony, organizational policies and procedures, the standard of care is a significant factor used by courts in professional liability cases (Pohlman, 2005).

Clarifies Clinical Practice
The IHP’s clinical purposes include clarifying and consolidating meaningful health information, establishing the priority set of nursing diagnoses for a student, providing communication to direct the nursing care of a student, documenting nursing practice, ensuring consistency and continuity of care as students move within and outside school districts, directing specific interventions, identifying (safe and appropriate) delegation of care, and providing  methods to review and evaluate nursing goals and student outcomes (Hermann, 2005).  It is important to note that student‐centered outcomes are developed early in the IHP process to guide interventions and provide a basis for evaluation to take place.  The IHP is the document that combines all of the student’s healthcare needs into one document for management in the school setting (Zimmerman, 2013).

Provides Administrative Information
The IHP serves administrative purposes, which include defining the focus of nursing; validating the nurse’s role in the school; facilitating management of health conditions to optimize learning; differentiating accountability of the nurse from others in the school; providing criteria for reviewing and evaluating care (quality assurance); providing data for statistical reports, research, third‐party reimbursement and legal evidence; and creating a safer process for delegation of care in the school setting (Hermann, 2005).

Serves as the Foundation for Health Portion of Other Educational Plans and Emergency Plans
The IHP provides the health information and activities that can be incorporated into the health portion of other school‐educational plans to foster student academic success and to meet state and federal laws and regulations.  These include the Individualized Education Plan (IEP) in accordance with the Individuals with Disabilities Education

Improvement Act (P.L. 108‐446, 2004) and a 504/ADA plan in accordance with Section 504 of the Rehabilitation Act (P.L. 102‐569, 1992) and the Americans with Disabilities Act (P.L. 110‐325, 2008).

The student Emergency Care Plan (ECP) is an emergency plan developed by the registered professional school nurse and is based on the IHP or is sometimes used instead of an IHP.  The ECP is written in clear action steps using succinct terminology that can be understood by school faculty and staff who are charged with recognizing a health crisis and intervening appropriately (Zimmerman, 2013).   The ECP is distributed to these individuals with the expectation that the information will be treated with confidentiality.  The names of the individuals who have a copy of the ECP should be listed at the bottom (Zimmerman, 2013).

Conclusion

It is the responsibility of the registered professional school nurse to develop an IHP and ECP for students with healthcare needs that affect or have the potential to affect safe and optimal school attendance and academic performance. The IHP is developed by the school nurse using the nursing process in collaboration with the student, family and healthcare providers. The school nurse utilizes the IHP to provide care coordination, to facilitate the management of the student’s health condition in the school setting, to inform school‐educational plans, and to promote academic success. The ECP, written by the school nurse, is for support staff with an individual plan for emergency care for the student. These plans are kept confidential yet accessible to appropriate staff.

References

  • American Nurses Association & National Association of School Nurses.  (2011). School nursing: Scope and standards of practice (2nd ed.).  Silver Spring MD: Nursesbooks.org.
  • American Nurses Association & National Council of State Boards of Nursing. (2019). Joint statement on delegation.
  • Americans with Disabilities Act of 1990 as Amended. (2008).  Publ Law 110‐325.
  • Hermann, D. (2005).  Individualized healthcare plans.  In C. Silkworth, M. Arnold, J., Harrigan, & D.  Zaiger, (Eds.), Individualized healthcare plans for the school nurse: Concepts, framework, issues and applications for school nursing practice (pp. 1‐4).  North Branch, MN: Sunrise River Press.
  • Hootman, J., Schwab, N.C., Gelfman, M.H.B., Gregory, E.K. & Pohlman, K. J. (2005). School nursing practice: Clinical performance issues.  In N. C. Schwab, & M. H. B. Gelfman, (Eds.), Legal issues in school health services (pp. 167‐230).  North Branch, MN: Sunrise River Press.
  • Individuals with Disabilities Education Act.  (2004). 20 U.S.C. 1400, § 602 (26) [Definitions].  Code Federal Regulations (CFR), part 300.
  • Lyon, L.  (2012). School assessment form for students with special health care needs. NASN School Nurse, 27 (6), 288. doi: 10.1177/1942602X12446752
  • National Council of State Boards of Nursing (NCSBN).  (2005). Working with others: A position paper.
  • Pohlman, K. J. (2005). Legal framework and financial accountability for school nursing practice. In N. C. Schwab, & M. H. B. Gelfman, (Eds.), Legal issues in school health services (pp. 95‐121).  North Branch, MN: Sunrise River Press.
  • Section 504 of Rehabilitation Act of 1973 (P.L. 102‐569. 199229 U.S.C.A – 794; 34 C.F. R., Part 104).  U.S. Department of Labor.
  • Zimmerman, B. (2013).  Student health and education plans.  In J. Selekman (Ed.), School nursing: A comprehensive text, 2nd ed.(pp. 284‐314).  Philadelphia, PA: FA Davis Company.


Acknowledgment of Authors: 
Bernadette Moran McDowell, MEd, BSN, RN
Sue A. Buswell, MSN, RN, NCSN
Cheryl Mattern, MEd, BSN, RN
Georgene Westendorf, MPH, BSN, RN, NCSN, CHES Sandra Clark, ADN, RN

Acknowledgment of 2013 Authors: 
Janet Bryner, BSN, RN, NCSN
Sue A. Buswell, MSN, RN, NCSN
Sandra Clark, ADN, RN
Cheryl Mattern, MEd, BSN
Bernadette Moran McDowell, MEd, BSN, RN Georgene Westendorf, MPH, BSN, RN, NCSN, CHES Susan Will, MPH, BS, RN, NCSN, FNASN

Adopted: June, 1998
Revised:  November 2003, March 2008, June 2008, June 2013, January 2015