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Objectives: Youth suicide is an urgent public health problem. Gatekeeper training aims to prevent suicide by training people to identify warning signs and make referrals to appropriate services. Many states in the United States have enacted gatekeeper training laws (GTLs) to train school staff in suicide prevention. The objectives of this study were to describe the development of a dataset on GTLs and use the dataset to summarize trends in uptake of GTLs from 2002 through 2022 as well as differences in characteristics (eg, frequency and duration of training) of GTLs., Methods: We used publicly available legal databases from all 50 states and the District of Columbia to conduct a policy surveillance assessment of GTLs. We cross-checked data with the American Foundation for Suicide Prevention's 2022 Suicide Prevention in Schools (K-12) issue brief and used Westlaw Edge to conduct a sensitivity analysis. We included the following data in the full dataset: type of laws (encouraged, mandatory, or conditional mandatory), date passed, effective date, frequency of training, and length of training., Results: In 2022, 49 states and the District of Columbia had GTLs, 31 of which were mandatory laws. In 2002, only 6 states had such laws, and none were mandatory., Conclusion: The growing proliferation of laws on suicide prevention training for school staff warrants evaluation of the laws' effectiveness. Our policy surveillance data may be used to better understand the role of these laws in a school-based approach to youth suicide prevention., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This article is part of Legal Issues 101, a series of topics addressing some common questions and misconceptions about the law and school health. School nurse job responsibilities differ regarding monitoring student attendance and assisting school administrators with required truancy reporting. However, all school nurses support student attendance with a focus on students being safe, healthy, and ready to learn. In this article, the authors address frequently asked questions on topics surrounding student attendance including excused and unexcused absences, truancy, parent/guardian engagement, and related laws.

Appropriate management by schools of all students with a concussion, regardless of the cause, has not received the same attention as sports-related concussions. Focus groups conducted with Massachusetts School Nurses in 2015 found that some had applied protocols required in the state's sports concussion regulations to all students with concussion, not just student athletes. We surveyed high school nurses in Massachusetts to examine (1) the extent of this practice and (2) the extent to which protocols for all students with concussion are included in school policies. Of 168 (74%) responding, 94% applied the return-to-learn and play, and medical clearance requirements to all students with concussion, regardless of how or where the concussion occurred and 77% reported their school's policy required these protocols for all students with concussion. A significant association (odds ratio: 13.3, 95% confidence interval [2.4, 72.8], p <.01) existed between the two measures. These findings have important clinical and academic implications.

Diabetes affects tens of thousands of school-aged children in the United States. The ability to appropriately manage their diabetes is essential to preventing life-threatening health complications if occurring during the school day. The purpose of this study was to assess school personnel's knowledge of diabetes (types 1 and 2) and perceived self-competence in performing diabetes management skills. A non-probability sample of elementary school personnel ( N = 809) from five different school districts in Georgia completed a diabetes knowledge and competence questionnaire. Descriptive statistics, one-way analysis of variance, and principal component analysis were performed to analyze the data. School personnel reported limited knowledge of diabetes basics and an overall low perceived self-competence in performing many of the diabetic management skills. Despite state legislation enacted to assist children with diabetes in school and available training for school districts, the study found that school personnel are not well trained and lack confidence in performing diabetes management.

Background: Sport-related concussion (SRC) has been associated with cognitive impairment, depression, and chronic traumatic encephalopathy. American football is the most popular sport among males in the United States and has one of the highest concussion rates among high school sports. Measured head impacts and concussions are approximately 4 times more common in contact practices compared with noncontact practices. The Wisconsin Interscholastic Athletic Association passed new rules defining and limiting contact during practice before the 2014 football season., Purpose: To determine if the SRC rate is lower after a rule change that limited the amount and duration of full-contact activities during high school football practice sessions., Study Design: Cohort study; Level of evidence, 2., Methods: A total of 2081 high school football athletes enrolled and participated in the study in 2012-2013 (before the rule change), and 945 players participated in the study in 2014 (after the rule change). Players self-reported previous concussion and demographic information. Athletic trainers recorded athlete exposures (AEs), concussion incidence, and days lost for each SRC. Chi-square tests were used to compare the incidence of SRC in prerule 2012-2013 seasons with the incidence in the postrule 2014 season. Wilcoxon rank sum tests were used to determine differences in days lost because of SRC., Results: A total of 67 players (7.1%) sustained 70 SRCs in 2014. The overall rate of SRC per 1000 AEs was 1.28 in 2014 as compared with 1.58 in 2012-2013 ( P = .139). The rate of SRC sustained overall in practice was significantly lower ( P = .003) after the rule change in 2014 (15 SRCs, 0.33 per 1000 AEs) as compared with prerule 2012-2013 (86 SRCs, 0.76 per 1000 AEs). There was no difference ( P = .999) in the rate of SRC sustained in games before (5.81 per 1000 AEs) and after (5.74 per 1000 AEs) the rule change. There was no difference ( P = .967) in days lost from SRC before (13 days lost [interquartile range, 10-18]) and after (14 days lost [interquartile range, 10-16]) the rule change., Conclusion: The rate of SRC sustained in high school football practice decreased by 57% after a rule change limiting the amount and duration of full-contact activities, with no change in competition concussion rate. Limitations on contact during high school football practice may be one effective measure to reduce the incidence of SRC.

The most recent legislative attempts to curb violence in schools have been school-based dating violence prevention laws. In the previous decade, there was an increase in legislation designed to prevent bullying in schools; these laws now exist in 50 states. However, most anti-bullying laws provide an expansive definition of bullying that includes any type of peer aggression, harassment, or teen dating violence (TDV). Having several different state and federal laws aimed at curtailing multiple forms of aggression may produce confusion about appropriate intervention and disciplinary responses, requiring school districts to develop parallel sets of policies, educational curricula, intervention approaches, and reporting requirements for overlapping behaviors that can be simultaneously peer aggression, bullying, harassment, and TDV. We conducted a systematic search of applicable laws and systematically coded those we identified for relevant content (i.e., definitions, covered locales, protected groups, and personnel, procedural, preventive, and disclosure elements). Anti-bullying laws were typically more detailed than dating violence laws. TDV laws were more likely to target TDV and control intimate behavior and to provide for education about healthy relationships. Both types of laws often mandated trainings; specified reportable behaviors; discussed sanctions, recommendations, and interventions; and mentioned counseling, specially trained staff persons, or designated specialists. Both anti-bullying and TDV laws also sometimes directed reporting of aggregate incident rates and impacts of prevention efforts. Neither type of law tended to specify school and community resources or prevention approaches. Results inform discussion of the merits of different approaches to school-based violence prevention laws.

In 2015, the Massachusetts Department of Public Health conducted focus groups with school nurses (SNs) and athletic trainers (ATs) from Massachusetts middle and high schools to assess implementation of legislated regulations relative to the management of students' head injuries incurred during extracurricular sports. Four tape-recorded focus groups were conducted by experienced facilitators. Lists of themes were synthesized by investigators for each focus group. Participating SNs and ATs supported the sports concussion legislation, felt that implementation had gone well, indicated that the law empowered them in managing return-to-school/play for students with concussion, and experienced support from their school administrators. Some SNs reported that they had applied relevant procedures to all students with head injuries, regardless of how or where the injury occurred. Challenges identified included protocols for away games, inconsistent concussion care by physicians, and a need for teacher education. Further research is required to quantify these findings.

The Massachusetts Teachers Association's Environmental Health and Safety Committee is using a number of approaches to evaluate and improve the enforcement of the U.S. Asbestos Hazard Emergency Response Act legislation intended to ensure the proper management of asbestos in public buildings, including schools. The committee first approached state regulators directly concerning enforcement concerns, with limited success. Next, the Massachusetts Teachers Association developed an organizing strategy and a curriculum focusing on the requirements of the Asbestos Hazard Emergency Response Act and on building a membership-run health and safety committee infrastructure in local unions. Five trainings took place throughout Massachusetts over a 2-month period in 2015. The committee implemented follow-up procedures and support for locals to continue to engage in this ongoing effort. This work illustrates that the passage of the Asbestos Hazard Emergency Response Act in 1986 was insufficient action to remediate school asbestos exposures. It is necessary for unions representing school employees to systematically hold regulators and school districts accountable for enforcement and compliance., (© The Author(s) 2015.)

This article provides a multipart analysis of the public schools' responsibility for students with concussions. The first part provides the prevailing diagnostic definitions of concussions and postconcussive syndrome. The second and central part provides (a) the legal framework of the two overlapping federal laws--the Individuals with Disabilities Education Act and Section 504 of the Rehabilitation Act and the varying state laws or local policies for individual health plans and (b) a summary of the developing body of hearing officer decisions, court decisions, and Office for Civil Rights rulings that have applied this framework to K-12 students with concussions. The final part offers recommendations for proactive return to school policies, with the school nurse playing a central supporting role., (© The Author(s) 2014.)

Competitive foods in schools have historically been scrutinized for their ubiquity and poor nutritional quality, leading many states to enact legislation limiting the availability and accessibility of these items. Evaluations of these policy approaches show their promise in improving the healthfulness of school food environments, considered an important strategy for reducing childhood obesity. Yet little is known about the decision-making processes by which such legislation is formed and adopted. Using a comparative case study design, this study describes and analyzes the policy formation processes surrounding five state-level competitive food bills introduced in 2009-2010. Data for each case were drawn from multiple key informant interviews and document reviews. Case studies were conducted, analyzed, and written independently using a standard protocol and were subsequently compared for recurring and unique themes. Abbreviated case studies and summary tables are provided. Results indicate that bill cost is a major barrier to achieving strong, health-promoting policy change. Additionally, findings reveal that supporters of stronger competitive food policies often concede to changes that weaken a bill in order to neutralize opposition and achieve stakeholder buy-in. These challenges suggest that continued research on the development, implementation, and evaluation of public health policies can contribute to the advancement of new strategies for effective health promotion., (© 2015 Society for Public Health Education.)

Delegation of nursing procedures and medication in school is fraught with legal and ethical concerns for the school nurse. Because nurses may be responsible for coordinating care for several school buildings, delegation of nursing care and medication administration has occurred out of necessity. Nurse Practice Acts in some states, but not all, allow for delegation of medication to unlicensed assistive personnel. This article explores Glucagon(®) delegation laws in the United States and presents an argument against such delegation in states where Nurse Practice Acts do not allow for delegation of medication to unlicensed assistive personnel.

Arguably, the most important school-based intervention to increase physical activity was Title IX of the Education Amendments of 1972, which led to a 600% increase in girls' sports participation between 1972 and 1978. We studied the effect of this increase in sports participation and athletic opportunities while young on the physical activity and weight of adult women some 20-25 years later. Our results indicate that adult women who were affected by Title IX and had greater opportunity to participate in athletics while young had lower body mass index (BMI) and lower rates of obesity and reported being more physically active than women who were not afforded these opportunities. However, effect sizes were quite modest.

Children spend many hours each week in and around school buildings. Their short- and long-term health outcomes and ability to learn are affected by numerous environmental factors related to the school buildings, the school grounds, the school transportation system, and the use of various products and materials in and around the school. Many school buildings are old, and they-and even newer buildings-can contain multiple environmental health hazards. While some districts self-report they have environmental health policies in place, no independent verification of these policies or their quality exists. Teachers and other staff, but not children who are more vulnerable to hazards than adults, are afforded some protections from hazards by Occupational Safety and Health Administration (OSHA) regulations, by their employment contracts, or through adult occupational health services. Major environmental problems include: indoor air quality, lighting, pests and pesticides, heavy metals and chemical management issues, renovation of occupied buildings, noise, and cleaning processes and products. No agency at the federal or state levels is charged with ensuring children's health and safety in and around school buildings. No systematic means exists for collecting data about exposures which occur in the school setting. Recommendations are made for dealing with issues of data collection, federal actions, state and local actions, and for building the capacity of the Environmental Protection Agency and the Centers for Disease Control and Prevention-designated and funded Pediatric Environmental Health Specialty Units (PEHSU) in responding to and evaluating risks to children's environmental health in schools.

This study examines prevention practices and perceptions in U.S. schools since passage of federal No Child Left Behind (NCLB) legislation, using survey data from state education agencies (SEA) and a population-based sample of school districts. Only one third of U.S. public school districts rely on evidence-based prevention curriculum in middle schools. Funding from other sources and large size were positively associated with using evidence-based curricula. States and districts differed on their perceptions of high-priority activities, and neither supported the federal priority on student drug testing. The findings suggest that there is a disconnect between what NCLB says and what is funded.

As a result of various health concerns, children are receiving an increased number of medications while at school. In Pennsylvania, the School Code mandates a ratio of 1 certified school nurse to 1,500 students, which may mean that 1 school nurse is covering 3-5 buildings. This implies that unlicensed personnel are administering medications, a violation of licensing laws in Pennsylvania. The purpose of this study was to determine the policies and practices that Pennsylvania public schools have in place regarding medication administration. The sample consisted of 314 state-certified school nurses who returned a 71-question survey. Findings indicated that school nurses are very concerned about issues related to medication administration. Additional findings identified the lack of standing orders to administer over-the-counter medications, the increase in medication errors when the school nurse had responsibility for multiple buildings, and the lack of understanding of the ramifications of the Nurse Practice Act on school nursing practice in regard to delegation. Recommendations for practice include development of detailed policies and procedures and collaboration among all stakeholders in the development of policies that address legal issues.

While 31 million Americans have been diagnosed with asthma, children are most severely affected. Asthma also is common among teachers, indicating that the school building environment may be associated with asthma prevalence among occupants. Children are sensitive to environmental pollutants, which are more concentrated in indoor air environments. Schools are a significant source of indoor air pollutants. Yet little research has addressed the causal relationship between asthma and specific levels of indoor pollutants. Indoor air quality is seldom controlled in schools in a way that minimizes such exposures. While few laws limit indoor air pollutants in schools, some laws outline or mandate practices that can control exposures. This report presents recommendations for laws and regulations that control and, ideally, prevent indoor air quality problems and aims to reduce or mitigate such disease.

Companion articles explore random drug testing programs in schools. The first article addresses random drug testing of students from a legal perspective. It describes legal issues and current case law regarding drug testing programs in schools and commonly asked questions regarding these programs. The second article addresses random drug testing of students from a practice perspective. It explores arguments for and against random drug testing programs and the role of the school nurse in policy and procedure development.

This article addresses practice issues related to school health records and school nursing documentation. Because the issues have been posed by practicing school nurses, the article is in Question and Answer (Q and A) format. Specifically, the questions addressed concern the following: ownership and storage location of student health records when the school nurse is contracted from a community health agency rather than employed by the school district; documentation of sensitive health information on students' health records including pregnancy, drug and alcohol abuse, mental illness, history of suicide attempt, and HIV status; inclusion of medical diagnoses and current medications on a student's Individual Educational Program (IEP); and Health Insurance Portability and Accountability Act (HIPAA)-permitted communications between school nurses and health care providers related to students' immunization status, regarding a student's treatment needs in school, and via facsimile (e.g., records of immunizations, completed physical examination forms, and medical orders). HIPAA, the Family Educational Records and Privacy Act (FERPA), and other laws are addressed as appropriate, and resources for obtaining further information are included.

Student discipline has become a subject of increasing concern at local, state, and national levels. This article is a discussion of current federal, state, and local school district legal requirements for student discipline in public schools with examples that illustrate several issues that could or should involve a school nurse. A brief history of the legal developments in school discipline includes key U.S. Supreme Court decisions and Acts of Congress. School district options in policy development and disciplinary procedures are discussed. Some of the discipline incidents include issues of nurse-patient confidentiality.