The 2-year-old had been acting out again. Malnourished, neglected, aggressive, he had been taken away from his alcoholic mother by social workers, but the child had caused so many problems he had been removed from his foster mother, too.

A review of the boy’s medical records suggested the reason for his petulance: Massive dental decay had led to painful abscesses, the oral surgery for which he’d received without anesthetic.

"That child grew up with pain, so of course he had behavior problems. An adult couldn’t have coped with that surgery," said Theresa Reed, RN, a University of Southern California Department of Nursing graduate, who as an intern at Westside Children’s Center in Culver City, Calif., had seen the boy’s case. "Nurses need to be out there doing public health advocacy, because we can see things social workers can’t."

Reed’s experience underscores the critical skills public health nurses bring to the public health arena, said Lawren Miller Askew, PHN, RN, health services coordinator at Westside, a private, nonprofit social service agency. Students from California State University, Los Angeles, CSU Long Beach, USC and other schools are participating in internship programs with the Los Angeles County Child Health and Disability Prevention program (CHDP) in preparation for a possible public health nurse career.

Through those programs, students learn to meet the challenges of public health nursing in multiethnic and largely indigent Los Angeles County.

"You need to be prepared to take your place in a multidisciplinary team setting, right alongside social workers. To deal with indigent families, you have to have good communication skills, be bilingual, have good cultural competence. The key demographics here can change at any time," Askew said.

As an example, Askew pointed to another case in which an infant, the child of undocumented Mexican workers, developed a suspicious discomfort in her vaginal area. Public agencies, assuming sexual abuse, started procedures to remove the child from the home.

The parents, who had lost their medical coverage and spoke little English, finally managed to explain to a social worker that they had been applying tomato juice to the girl’s genitals as a folk cure for ringworm. The case was dropped, but Askew notes that an infant almost was mistakenly taken from her parents. A trained, bilingual public health nurse could have cleared up the misunderstanding sooner.

Federal and state agencies have come around to the advantages of bringing more nurses into foster health care, which provides coverage to more than 500,000 children nationwide—110,000 in California.

In December 1999, President Clinton signed the Foster Care Independence Act, which provides $500 million over five years to independent living programs and increases Medicaid coverage for young people through age 21.

Last January, California’s Health Care Program for Children in Foster Care came on line, infusing (together with federal matching funds) about $9.9 million into California counties. Much of that money goes toward hiring more nurses—as many as 86 in L.A. County’s CHDP program, said Bridget Ward, MS, PHN, RN, nursing director for the program.

"We started hiring in May. We have about 33 public health nurses on board now, and we’re hiring about 24 more in January," Ward said. "Of 86 nursing positions we hope to fill this year, 79 will be public health nurse positions."

Even with the extra staff, Ward projected that the nurse-to-case ratio in the populous county will remain at a stubborn 1-to-550 or higher, well short of the state’s 1-to-200 goal (and even worse than its projected 1-to-435).

Foster care children often suffer from the drawbacks of a system not designed to track their movements and special health needs. Their records are passed among different medical providers every time they are placed with or removed from a family, but short-staffed public health services do not always keep these records up-to-date.

As a result, foster children tend to be over- or underimmunized. They suffer disproportionately from chronic diseases, neglect, abuse and—especially in L.A. County—problems stemming from their parents’ prenatal drug use, said Janet Schneiderman, MN, PHN, RN, assistant professor of clinical nursing at the USC Department of Nursing.

About 80 percent of these children have at least one chronic medical condition, Ward said, mostly the sort that results from neglect: growth failures, parasites, asthma, gastroesophogeal problems, anemia, visual/hearing problems, congenital disorders, and an overall failure to thrive (low height, weight and mental development).

Working closely with the child’s social worker or probation officer, the public health nurse will ensure that he or she receives proper medical care, even if this means only reviewing or updating a medical record and making a referral.

"When a medical report comes in, as far as the social worker knows, everything’s OK. With no medical training, they didn’t know to follow up. But with a nurse’s knowledge, you save time by identifying the most severe conditions, doing triage," said Sharon Leahy, PHN, RN, program specialist at the L.A. County Department of Children and Family Services, which oversees the CHDP program.

The extra staff also should allow for more home visits, she added—a much-needed improvement.

"Before, because of the large caseloads, nurses simply couldn’t go to see the child in his or her own home environment. At least with a home visit, the nurse can help parents deal on the spot with the kids, not only in terms of the child’s health, but also to educate parents on the signs of developmental and other problems," Schneiderman said.

Nurses also form a critical link between the child and the medical provider. Nurses often can navigate through the health care bureaucracy better than a social worker, because they can discuss medical issues in medical language, a plus when dealing with doctors, she said.

About 48,000 children in the foster care system qualify for the Health Care Program for Children in Foster Care, and 1,686, or 3.4 percent, of these children are in the care of the Probation Department, according to CHDP figures.

Last year, CHDP received $6.4 million to fund the fledgling program. California Gov. Gray Davis has earmarked an additional $1.9 million for the program in the new fiscal year, Ward said.

"Nursing students are not being given the opportunity to deal with this. It’s the highest level of patient advocacy," said Schneiderman, whose students have participated in public health nurse internship programs.

"We need to prepare our students to work with foster kids. These kids are invisible; they constantly move around from home to home.

"Nursing education today stresses acute care, dealing with immediate needs. We don’t always emphasize how to work with people who have complex needs like the foster care population. It’s hard to get that sort of clinical experience."