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Today's School Nurse:
More Than Just Bandaged Knees

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The job of the school nurse has become more demanding as students with complex medical situations have entered schools and as society's expectations have changed. Education World writer Mary Daniels Brown talked with school nurses around the United States about their changing roles. Included: Online resources every school nurse should know about!

A generation ago, the school nurse cleaned and bandaged the occasional scraped knee and sent home children with stomachaches or fevers. But today's school nurse does more than that -- a lot more.

"We are getting more and more medically fragile children into the school system," Joey Van Camp, coordinating nurse for the Westminster School District in southern California, told Education World.

Gerri Harvey, creator of a Web page called School Nurse Perspectives, agrees. "Children come to school sicker and needier than ever before," said Harvey, an elementary school nurse for 12 years who is now the community liaison nurse at Community Health and Hospice in Laconia, New Hampshire.

In fact, all of the school nurses interviewed for this article confirmed that they now care for students with complex medical conditions.

MORE STUDENTS WITH DISABILITIES

"The past ten years has seen a tremendous change, but I believe the shift to more responsibility falling on schools has been an on-going trend for about 25 years," Harvey told Education World.

The Education for All Handicapped Children Act -- originally passed in 1975 and later amended and renamed the Individuals With Disability Education Act (IDEA) -- guarantees a free, appropriate education to all children in the least restrictive environment possible. As a result of that legislation, many children with severe disabilities, who previously would have been institutionalized or assigned to special education buildings, now attend public schools, a change commonly referred to as inclusion or mainstreaming.

School nurses now may care for students with intravenous tubes for medication, gastrostomy (feeding) tubes, tracheostomies, and ventilators. Those advanced technological devices require care and monitoring, Lucretia Anderson, school nurse with the Pittsburgh Board of Education, told Education World. And students in wheelchairs may be unable to use the toilet by themselves or may require the insertion of a catheter.

Students without physical disabilities are also requiring more care.

According to Harvey, "school nurses administer more medications than ever before." In addition to dispensing prescription medications, such as Ritalin, nurses help students with chronic conditions manage their health.

"Students with diabetes or asthma must have a plan of care in place," explained Anderson. It is the school nurse's responsibility to help students follow their care plans during school hours. The school nurse must be familiar with every student's treatment regimen, including any devices or medical procedures the treatment requires. Students who have diabetes monitor their blood glucose level, often several times a day, and may require insulin injections during school hours.

School nurses also help the growing number of children with asthma monitor and control their condition. For reasons that experts cannot explain, the incidence of childhood asthma has risen dramatically in recent years. According to the American Lung Association, asthma accounts for 10 million lost school days a year and is the leading cause of school absenteeism attributed to chronic conditions.

Children who have asthma often use a peak flow meter (a device that measures the amount of lung obstruction) and, when necessary, an inhaler. Severe attacks may require a nebulizer, a device that uses compressed air to deliver medication in a fine mist that is inhaled through a face mask. Use of a nebulizer involves combining the prescribed amount of medication with the appropriate amount of water. By helping students manage their asthma at school, nurses may be able to reduce the number of school days the children miss because of their condition.

SOCIETY'S CHANGING EXPECTATIONS

A recent New York Times article, For School Nurses, More Than Tummy Tending, reported that, in interviews conducted around the country, "school nurses uniformly said their jobs were changing because American life has changed." The article refers to "a growing public sense that a school is, in part, a health-care provider."

As Gerri Harvey explained to Education World: "There is definitely a shift in expectations from parents, who expect the school to assume responsibility for many aspects of a child's physical, social, and emotional well-being, things families and medical providers were once expected to provide."

"Sometimes I think I'm the only medical professional some of these children ever see," Van Camp said. "Some days there will be a line of children waiting outside of my office at school, some with their parents."

It's not unusual for parents to ask the school nurse to look at their child's ears or throat and advise whether the child needs to see a doctor. For immigrant families, particularly if the parents don't speak much English, a child's school nurse may be the point of entry into the health-care and social-services systems.

SCHOOL NURSES TRAIN OTHER SCHOOL PERSONNEL

When the nurse cannot meet all the demands she faces herself, school districts generally assign some of her responsibilities to other school personnel. (Most school nurses are women, although Martha Dewey Bergren, an experienced school nurse who is now an instructor at the University of Minnesota, told Education World that she is beginning to see some men at professional meetings.) Once the school administration has designated other personnel, usually secretaries, to perform certain tasks, it becomes the school nurse's responsibility to train those people to perform their duties.

The most commonly delegated task is dispensing medications, although state law governs which nursing tasks can be assigned to other school personnel. Many school employees who are being asked to help with medical duties feel insecure about their new responsibilities because they are already busy, Anderson explained. One school secretary recently posted this message to the discussion forum on the National Association of School Nurses Web page: "I have lost my valued reputation as a good secretary because I have refused to monitor a student's blood sugar level and to do a catheter for a student with spina bifida. The sad thing is I am a terrific secretary. What do you think of secretaries being asked/intimidated into doing medical procedures such as these? In our district/state there is no such thing as a school nurse, and the secretary has to give medication."

NO NATIONAL STAFFING STANDARDS

There is no uniform national standard for the number of students a school nurse cares for; state law usually regulates that number. Anderson, for example, is responsible for 1,500 children, a number that complies with Pennsylvania law. The National Association of School Nurses recommends these nurse-to-student ratios:
  • 1:750 in general populations
  • 1:250 in mainstreamed populations
  • 1:125 in severely handicapped populations

Along with the school nurse's expanding workload comes a large amount of paperwork. Anderson described the school nurse's job as extremely paper-intensive. "In today's litigious society, we have to document everything we do," she explained to Education World.

SCHOOL NURSES ENTER THE COMPUTER AGE

Computer literacy also figures on the growing list of skills that school nurses must have. Computers can help school nurses deal with the extensive paperwork of their job, particularly if school districts also provide clerical help so nurses don't have to enter all the data themselves. Computers also provide school nurses with two other necessities: support and information.

Bergren founded and continues to manage SCHLRN-L, an e-mail discussion list for school nurses. In 1994, at the end of its first year, the list had about 140 members. Now, about 1,600 nurses from at least 14 countries (that's the number of countries she can identify from the e-mail addresses) participate. School nurses, who are often the only health-care professionals in their building, perhaps even in their district, sometimes feel isolated. SCHLRN-L allows them to discuss issues and share information with their colleagues.

"Mostly what the members get out of the list is the virtual community, the camaraderie," Bergren told Education World.

Lacking the medical libraries available to nurses working in hospitals, school nurses also use the computer to obtain information. If a new student with an unusual medical condition enrolls, the nurse can use Internet resources to learn about the condition. She or he may also use the computer to locate community resources for families.

It's likely that the school nurse's responsibilities will continue to increase. Bergren told Education World that some school districts are beginning to ask their nurses to handle third-party billing for services such as hearing and vision screening tests. In the world of tightening budgets, school districts, which have traditionally conducted these screenings for free, are starting to seek reimbursement for services to children whose family health plans will cover the procedures. And additional questions, such as whether school nurses should be involved in drug testing, loom ahead.

A QUESTION OF FUNDING

Most school nurses today face more demands than they can meet. In general, nurses see the solution to that problem not in the delegating of responsibilities to other school personnel, but in the placement of more nurses in the school.

"The typical school nurse's office is teeming with students in need all day long, but staffing ratios have not always increased to accommodate the increased demand for the nurse's services," said Harvey. "My observation is that most schools have continued to staff for school nurses the same as they always have, even though the demands on the nurses have increased tenfold."

Darlene Huff, coordinator of the health services program for the Columbia [Missouri] School District, serves on both the board of directors and the executive committee of the National Association of School Nurses and co-chairs the association's professional development committee. She told Education World: "IDEA mandates nationally that special education children be included in the public schools. What is not mandated or funded is the support personnel, the registered professional school nurses, to care for those children. Federally, and at the state level, as legislators mandate services, they have to put the funding dollars behind those mandates for the school nurses."

TAKE THIS JOB AND LOVE IT

With all the duties and responsibilities today's school nurse faces, why would anyone want the job? Jean Tsotsonis of Hyannis, Massachusetts, who has been a school and public health nurse for ten years, believes that school nurses are underpaid in comparison to their colleagues in other areas of nursing.

Yet despite her dissatisfaction with the pay, Jean Tsotsonis loves her job. "Being with children of any age keeps me laughing," she told Education World. "I love to see them succeed and try. I love their growing up and crying and laughing and singing."

"I love school nursing, especially after all these years, because it is the story of life," she added. "Hugging an adult is awkward in an ambulatory care setting, but I can always hug a child."

ADDITIONAL ONLINE RESOURCES ABOUT THE ROLE OF THE SCHOOL NURSE

National Association of School Nurses
The nonprofit National Association of School Nurses is dedicated to improving the health and educational success of children and youth by developing and providing leadership to advance school nursing practice.

School Nurses Institute Partnership: Promoting Continuing Education in Virginia
Dedicated to the continuing professional development of school nursing personnel in Virginia, this site presents an array of reference materials. The site includes links to related Web sites, a chat room, a discussion list for nurses in Virginia, and information on a mentoring program for school nurses in the state.

The National Association of State School Nurse Consultants, Inc.
This organization's mission is "to promote the health and learning of the nation's children and youth by providing national leadership and advocacy, impacting public policy, collaborating, and proactively influencing school health programs and school nursing practice." The Web site includes information about the association's core beliefs, position statements, and an extensive list of links.

California School Nurses Organization
The CNSO provides information about school nurse educational preparation and practice in California. The site includes a list of approved credentialing programs in the state and a list of job openings.

The Association of School Nurses of Connecticut
In addition to membership information, this resource offers a job bank, a discussion list for school nurses in the state, and information about school nurse qualifications and professional development.

School Nurse Organization of Minnesota
Minnesota school nurses can check here for news stories, contact information for state and federal representatives, and links to other educational resources.

School Health Alert
This monthly newsletter for school nurses posts articles on medical topics.

American School Health Association
The ASHA is "a multidisciplinary organization of administrators, counselors, dentists, health educators, physical educators, school nurses and school physicians, [that] advocates high-quality school health instruction, health services, and a healthful school environment."

American Nurses Association
The ANA offers information on state nurses associations, nurse credentialing, international nursing, ethics and human rights, workplace issues, and legislation. Included are columns from The American Journal of Nursing, the official journal of the American Nurses Association, from 1997.

School Nurses and the Internet
Teresa Brown urges school nurses to use computers and the Internet for keeping records, finding information about health conditions and available resources, and communicating with other school nurses.

Nurse To Nurse
This searchable, browser-based forum (bulletin board) allows nurses to post questions or comments and to answer those posted by other nurses.

Article by Mary Daniels Brown
Education World®
Copyright © 2009 Education World

Originally published 02/07/2000
Last updated 10/20/2010



 

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