Why School Nurses?
For "aaacn Viewpoint," Goldberg, E., 1996. (v.1/96) The American Academy of Ambulatory Care Nursing
"Help! We are in danger of losing our school nurse!" wrote two PTA presidents who joined forces to fight budget cuts targeting school nurses.
In their Massachusetts town, one secretary with no medical training was responsible for first aid and medications for sixty-six students with medical problems that included diabetes, seizure disorders, bee sting allergies, severe asthma, and multiple handicaps.
In New Hampshire, Barbara Westmoreland, RN, co-chair of a statewide asthma information and support network and a substitute school nurse, launched a letter writing campaign to legislators and news editors when the state board of education proposed lowering state standards that would lead to cuts in school nurses.
"As the parent of children with asthma, I would be devastated. I would truly fear for my children's lives," she wrote. "...I beg you to consider carefully the implications of this proposed change."
As a health care provider, you too can help reduce unnecessary risk, illness, and school absences for your patients by supporting school nurses as a vital part of a community support system that includes all care providers. By actively promoting school nursing you can help create schools that are safer and healthier environments for all children.
Never has the need for a full time professional school nurse been greater. People who are not involved in the day-to-day operation of a school may not see the increasing numbers and variety of health needs of today's students or understand the need for a school nurse who functions not only as a care provider to an average of 40 to 50 students a day, but as the liaison between the school, home, community, and primary health care provider.
According to the 1988 National Health Interview Survey on Child Health, 30.8 percent of children and 31.5 percent of adolescents had one or more chronic health conditions. Among all children with a chronic health condition, 10 percent have severe conditions which have a daily impact on the child's life. There are increasing numbers of students with chronic health conditions and special needs in our schools, more working and single parents, and more children at risk. More parents are relying on school nurses for the initial assessment of injuries and health complaints, referrals and problem management.
When students attend schools without nurses, students have unnecessary symptoms, excessive absences, lower achievement and lower self esteem. Where school health services are inadequate, all children are underserved and students with disabilities and chronic conditions may be subjected to hazardous and even life threatening situations. Teachers do not understand the effects of a health problem or medication on learning or behavior. Absences and poor performance may be blamed on the child or the family rather than on the lack of a school nurse to provide necessary supports.
Effective advocacy for your patients means advocacy for school nurses. In their book, Building the Healing Partnership, authors Patricia Taner Leff and Elaine Walizer emphasize the importance of a health care provider becoming a resource and ally to families and that advocacy enhances a provider's relationships with families.
As a health care professional, you can follow the lead of experienced advocates who emphasize that "First, families should believe absolutely that their children have a right to attend school and to do so in a safe and healthy environment."
Don't encourage parents to accept standards that disadvantage their child or a situation that doesn't meet their child's needs. Help parents understand and exercise their rights when inadequate health services put a child's health and education at risk.
Clarify the common misunderstanding that schools are not required to provide nursing services and other health supports to children. Under Section 504 of the Rehabilitation Act of 1973, the federal law that prohibits discrimination in education on the basis of disability, schools are obligated to provide necessary services, aides and accommodations so that students with health problems can attend school safely and successfully.
Federal courts have distinguished between school nursing services and medical services defining "medical services" as those diagnostic procedures or treatments that must be performed by a licensed physician.
School health services, especially for students with special health needs, are considered to be "related services." They are defined as supportive procedures or therapies, (for example, receiving medications, nebulizer treatments, peak flow or glucose monitoring, ingredient substitutions in school menus, special feedings, catheterization, or suctioning) that enable a child to attend school and that can be performed by a qualified professional other than a physician, which most state medical practice laws define as a licensed nurse. Some state laws provide for delegation of specific tasks to a non-licensed lay person but only if there are appropriate procedures, training and professional nursing supervision to ensure "safe" delegation.
In addition, the U.S. Department of Education Office for Civil Rights has ruled that students must have reliable access to their prescribed medications and be able to depend on the help and understanding of knowledgeable school staff.
Whether students need antibiotics to cure ear or sinus infections, monitoring and medication to control variable conditions such as seizures, asthma or diabetes, or cast care or pain control, students need school nurses to get the continuity of care their conditions require.
Without a nurse, large numbers of school children are at daily risk because the school cannot provide the proper management of routine chronic health conditions nor the timely assessment of acute injuries and illnesses. And, many opportunities for cost effective prevention, early intervention and referral are missed, especially for school children at highest risk because of economic or social conditions.
Too often, parents feel alone in their desire for safe schools. Each contact with your patient's families and school is an opportunity to share a vision of safe, continuous, reliable, coordinated care that a professional school nurse provides.
Help make that vision become a reality by providing comprehensive documentation of your patient's health needs and treatment goals that emphasize the team approach to care. Written patient information to schools should specify the need for monitoring, assistance or supervision that the child's treatment or rehabilitation plan requires.
Also share that vision with community health and education organizations. Promote support for quality school health services such as the following statement passed unanimously November 30, 1995 at the board meeting of the New England Chapter of the Asthma and Allergy Foundation of America.
Recognizing that asthma and allergies are two of the most common chronic health conditions among school-age children and the leading causes of school absences; and Recognizing that students with asthma and allergies face daily challenges to managing their condition, which requires the safe, reliable and effective administration of medication and the implementation of precautions, environmental safeguards, and emergency plans; and Recognizing that the professional school nurse is the only school professional qualified by training and experience and defined by law to be responsible for the daily assessments, decisions, and interventions that enable students to manage their conditions and that reduce health-related risks and barriers to their education; AAFA-New England Chapter recommends that every elementary and secondary school should have at least one full-time registered nurse to ensure that every student can attend school safely and successfully.
Talk to your families. Become familiar with the health services at your patients' schools. Ask,
- Who administers medication?
- Is there a school nurse?
- Is the school nurse always there?
- Do parents and school staff meet to share health information about a student?
- Is there a written health service and coordinated care plan for your patient?
- Do policies allow for assisted, supervised or independent self-care of inhalers and other routine medication?
Talk with school nurses. Few nurses have the time to do the outreach and public relations that makes their work visible. Find out what you can do to increase awareness of their services and accomplishments as well as their needs and wish lists.
Numbers count.
The 1995 Massachusetts Department of Public Health Comprehensive School Health Manual states "The number of registered nurses responsible for the school health services program should be determined by a needs assessment of the health status of the student population and community."
National standards recommended by the American Nurses Association include one registered nurse for every 750 students in the general school populations, one registered nurse per 225 student in mainstreamed ["inclusion"] populations ... Other factors to consider are the number of children with special health care needs, numbers of buildings and distance and/or travel times between buildings."
Ask the school district for the number of students with asthma and other health conditions and special needs. Use the numbers to increase your community's appreciation of school nursing services or to raise awareness in professional and community groups of unmet needs and unacceptable conditions for students at school.
Don't wait for an emergency.
In many understaffed school districts nurses drive a circuit of schools each day in order to administer medications to students in different schools forcing secretaries, teachers and principals to take on nursing responsibilities and perform nursing tasks on a daily basis at the most risky time of day -- lunch/recess.
One mother wrote to her town paper describing the impact of having only a part-time nurse. "Last year [my son] missed a lot of school and I missed a lot of work because, as a mother, I worried, "What if the nurse isn't on schedule today? Will he be properly attended to? What is he has to go out to recess and like any normal kid runs around even though I begged him not to in the morning, returns and can't breathe? ...so subsequently I kept Kurt home and consequently he fell behind in school..."
The danger of inadequate staffing was illustrated recently in one Massachusetts elementary school. The nurse was administering a nebulizer treatment to a child with asthma in one school while a student with diabetes went into a coma at another school in another part of town as frantic staff called the nurse and the mother for help. When the nurse finally arrived, she administered glucagon to the child and called the rescue squad. The parents have taken legal action against the school and the school is re-evaluating its budget and staffing patterns.
Keep informed about your town and school budget. Help town and school leaders understand the impact of decisions that impact the quality of health services, especially when students needs are neglected or where "delegation by default" improperly burdens teachers and secretaries with nursing tasks.
Let school boards and legislatures know how the lack of school nurses hurts your patients, putting them at risk for unnecessary illness or disability, and increasing the cost of health care to the family and the community.
Promote the benefits of school nursing. Emphasize reduced incidents of illness and disability, reduced risk and fewer restrictions, reduced diagnostic and treatment costs, fewer disruptions and lost school/work days to students and parents, fewer emergencies and hospitalizations, and reduced insurance costs.
Use National School Nurse's day every January as an opportunity to let your legislators know the wisdom of using tax dollars to strengthen school nursing and health service programs in your community.
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