School nurses serve in a primary role as the gatekeepers and advocates for student healthcare needs, bridging both educational and healthcare requisites in the school setting. According to the National Association of School Nurses, for those schools who have access to a school nurse, these professionals should serve as key members of the school-based return to learn (RTL) concussions management team. School nurses understand the medical diagnosis of concussion, can monitor student concussion symptoms over time, and facilitate communication between the healthcare provider and school (Diaz & Wyckoff, 2009). However, Lyons et al. (2017) recently found that of 144 schools surveyed in Washington state about RTL concussion management processes, parents reported they were the parties who felt obligated to relay information between school and healthcare providers. Furthermore, the researchers discovered that an overarching barrier to RTL was communication between the parties involved in the student’s management (Lyons et al., 2017). Schools and healthcare providers are currently being inundated with skyrocketing concussion identification rates (Chen et al., 2017). Therefore, schools should implement RTL policies and procedures for managing these concussions during the school day to not only facilitate potentially faster recovery, but to ensure a comprehensive, safe return to full participation in academics, sports, physical education, and physical play at recess.
Many schools do not have RTL procedures in place to consistently manage student concussions (of both athletes and non-athletes). Established procedures would create a consistent process for easily managing student symptoms upon school notification that a concussion occurred. First, school-based RTL procedures should include an immediate school nurse facilitated written parent consent form under the Family Educational Rights and Privacy Act (FERPA). Furthermore, the school should also ask the parent to sign a Health Insurance Portability and Accountability Act (HIPAA) consent so the outside medical provider can disclose information to the school. Having these forms signed for every student who experiences a concussion would allow the school nurse to communicate and collaborate with all designated healthcare professionals involved in the student’s concussion care. Additionally, it allows them to share daily academic and symptom monitoring data with the healthcare providers to ensure decisions are made using comprehensive and current academic and symptom school day data. Physician return to play/sports clearance decisions would be better informed if they included school input about how the student is performing during the school day. A physician would not clear a student to return to school/physical activities if they were provided academic and symptom data from teachers revealing the student was still highly symptomatic while engaging in school activities.
Next, school nurses could be the designated individual responsible for ensuring the concussion date of injury and date of resolution (if recovery occurs) is noted in the student’s educational and health files. Unfortunately, these two processes do not regularly occur in all schools, but could easily resolve many issues that the authors have experienced in their respective roles. Keeping track of past concussions, and their resolution trajectories provide the backstory, should learning, attentional or behavioral issues arise later in the student’s academic career, and provide the needed evidence of a BI if the student should require school-based interventions. School nurses and administrators frequently face situations involving the privacy rights of students and must learn to effectively bridge the FERPA and HIPAA divide. According to the Joint Guidance on the Application of the FERPA and the HIPAA to Student Health Records (2008), student health records at school fall within the confines of FERPA, not the HIPAA Privacy Rule. While in most cases FERPA will require parental consent for information to be shared with an outside physician, it would permit a school official to strictly verify whether the doctor wrote an excuse or some other document, as long as other information from the student’s education records is not disclosed.
These case scenarios highlight the pivotal role played by school nurses in facilitating effective school-medical communication:
The school nurse calls the parent of a middle school student who has fallen from the bleachers in choir class, impacting the back of her head and resulting in symptoms of a concussion, including confusion, slurred speech, and headache. The school nurse monitors the student, as the parent travels to the school to take their child for medical assistance. Prior to the parent’s school arrival, the school nurse receives a call from the student’s primary care provider (PCP) who is requesting current information on the student’s status and the situation. The parent contacted the PCP immediately, and made arrangements to bring the student directly to the doctor. Is the school nurse able to share this information without a signed consent or parent permission?
The health and safety emergency exception to FERPA’s general consent requirement allows school personnel to disclose information to appropriate parties when there exists a threat to the student as clarified in the guidance document Family Educational Rights and Privacy Act (FERPA) and the Disclosure of Student Information Related to Emergencies and Disasters (June 2010). Additionally, disclosures under this provision are valid only while the threat to the student exists and does not constitute a release of the student’s information for ongoing treatment and or future care. More specific information regarding the release of student information for health and safety exceptions to FERPA may be obtained from the website.
School personnel are increasingly concerned for a high school student who sustained a concussion four weeks prior and is still exhibiting symptoms including lack of ability to concentrate, report of headaches, and is at times, irritable in the academic setting. The parent provided a letter to the school nurse from the student’s physician indicating the student was cleared from the concussion after two weeks and indicated the student could return to their normal activities in the school setting including physical education and sports. In addition, the school nurse secured a signed release of information from the parents allowing her to communicate freely with the physician for continuity of care at the time of the diagnosis.
The school nurse, concerned for the continued recovery of the student informs the parent of the on-going symptoms to which the parent replies, “We are not seeing this at home”. The school nurse calls the physician’s office to report the continued presence of concussion symptoms observed by school staff in the academic setting. Upon learning this new information, the physician immediately revokes the concussion Return to Play clearance and communicates with the parent the need for continued activity restrictions as well as continued monitoring to promote healing from the concussion. The parent informs the school that they are rescinding the original signed consent allowing the exchange of health information, accuses the school nurse of violating privacy rights of the student under HIPAA and files a complaint to the State's Board of Nursing against the nurses license.
As explained in the U. S. Departments of Education and Health and Human Services on FERPA and HIPAA, the HIPAA Privacy Rule does not apply to records that are protected by FERPA. Additionally, there is generally no distinction between a “health” record and an “academic” record at the k-12 level in FERPA.
Additionally, the nurse had a signed release of information from the parent provided at the time of diagnosis allowing the xchange of health information between the physician’s office and the school for the purposes of continuity of care. Should the nurse continue to communicate with the physician office with the parent withdrawn release, it would constitute a FERPA violation unless the communication falls within the health and safety exception in FERPA described in scenario one.
Given that the purpose of Return to Play legislation is to prevent the premature return of a student back to any sports related physical activity to minimize further risk of injury to the brain, sometimes resulting in brain damage or death, there are times when the school nurse has a moral and legal responsibility to communicate important, and/or dissenting data to a medical professional in order to keep a student safe.
The critical take away message is that all schools should establish two processes that occur immediately following the notification that a student experienced a concussion to facilitate medical to school communication. First, a FERPA release permission form should be provided to all parents/guardians granting the school permission to contact the medical provider. Second, the school should maintain open and ongoing communication and collaboration with the medical provider through the student’s recovery. The medical to school communication link is strengthened when educational institutions have school nurses on staff whose role is to connect both entities to support students with health care needs in the classroom setting.
Chen, C., Shi, J., Stanley, R. M., Sribnick, E. A., Groner, J. I., & Xiang, H. (2017). U.S. Trends of ED visits for pediatric traumatic brain injuries: Implications for clinical trials. International Journal of Environmental Research and Public Health, 14. doi:10.3390/ijerph14040414
Diaz, A., & Wyckoff, L. (2013). NASN position statement: Concussions- the role of the school nurse. NASN School Nurse, 28(2), 110–111. doi:10.1177/1942602X12473949
Lyons, V., Moore, M., Guiney, R., Ayyagari, R., Thompson, L., Rivara, F., … Vavilala, M. (2017). Strategies to address unmet needs and facilitate return to learn guideline adoption following concussion. Journal of School Health, 87, 416–426. doi:10.1111/josh.12510
McAvoy, K. & Eagan Brown, B. (2017) Get schooled on concussions. Retrieved from http://www.getschooledonconcussions.com
U.S. Department of Education, & U.S. Department of Health and Human Services. (2008, November). Joint guidance on the application of the family educational rights and privacy act (FERPA) and the health insurance portability and accountability act of 1996 (HIPAA) to student health records. Retrieved June 11, 2017, from https://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hipaa-guidance.pdf
About the Authors
Brenda Eagan Brown, MEd, CBIS has worked as a TBI educational consultant for 22 years. She is the State Program Coordinator for BrainSTEPS Brain Injury School Consulting Program in PA and an adjunct professor at the George Washington University. She is currently in a Mind-Brain doctoral program at Johns Hopkins University. Brenda is published, regularly presents at the national/international levels, and has received multiple awards in the field of TBI. She has trained over 1,300 Return to Learn Concussion School Teams, co-led the 1st National Concussion Return to Learn Consensus, and is co-creator of www.getschooledonconcussions.com. Her brother sustained a severe TBI when they were teenagers, which is where her passion for helping students began.
Suzanne Oro, MSN, RN, is a Nationally Certified School Nurse and a Fellow of the Johnson and Johnson School Health Leadership Program. She currently works as Director of Health Services for Cherry Creek Schools in Colorado and is a member of their BrainSTEPS team. Her practice focus addresses health disparities in vulnerable populations, specifically Title One elementary schools, and implementing population and community-wide health programming to promote health.
Karen McAvoy, PsyD, is dually credentialed as a clinical and school psychologist. She has been involved with the Colorado Department of Education as a Brain Injury Consultant since 2010 and was instrumental in the crafting of language leading to the stand alone special education eligibility for Traumatic Brain Injury (TBI) in the state of Colorado in 2013. Karen has 27 years in education; 20 of those years in a school district holding positions as school psychologist, coordinator of the TBI team, coordinator of mental health services and coordinator of manifestation determinations. Karen provides trainings to Colorado school districts on neuroeducational assessment and intervention, understanding the function of skill deficit in behavior and executive dysfunction and is an adjunct professor in the University of Colorado Denver School Psychology PsyD program. Karen is also the author of REAP-a community-based multi-disciplinary team approach to concussion management and is the Director of Psychology at the Rocky Mountain Hospital for Children Center for Concussion.
Brown, B. E., Oro, S., & McAvoy, K. (2017). School Nurses: Managing Student Concussions and Privacy Concerns. Brain Injury Professional, 14(3), 28-30.
From Brain Injury Professional, an official publication of the International Brain Injury Association and the North American Brain Injury Society. www.braininjuryprofessional.com Reprinted with permission.