School nursing.

School nursing has been in a process of transition since its inception. This role evolution parallels the growing complexity of the health, education, and social needs of America's youth. The workplace within which school nurses practice is equally complicated because health and education administrators often hold differing philosophies of management, and school health programs are ill-defined. Fortunately, there is growing support for an integrated services approach and the development of school health systems with nurses joining an interdisciplinary team rather than continuing to function as "boundary dwellers." The roles of the school nurse as primary care provider, school health coordinator, case manager, and epidemiologist are emerging and replacing outdated nursing functions. As the role of the school nurse shifts and expands, it produces a cascade effect. The role of the school health assistant to aid the nurse surfaces as the next logical step in planning. Numerous model school health programs exist today. The emphasis, and rightfully so, is preventive in nature and should be targeted at the preparation of a new generation of health consumers who are more self-reliant than their predecessors. Unfortunately, all these programs are plagued with financing problems that could be alleviated with the right plan for health care reform, such as an expansion of maternal and child health funds (Title V) to health departments and the introduction of school nursing leadership into the DASH office at the Centers for Disease Control and Prevention, a health education unit largely run by health educators, to reallocate some of these resources to the clinical preventive services needed in schools to reduce health risk behaviors. Finally, total quality management is the next issue on the horizon for this nursing specialty; benchmarking would be the place to start. In summary, systems development in the school health field is now underway, and it will not be easy, but this sort of work never has been simply. It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new system. For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders of those who would gain by the new ones.