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Beyond boo-boos

As school nurses say over and over, their job consists of much more than bandages and boo-boos. "The reality is, that is a very small part of what the professional nurse does in the school setting," said Marilyn Morgan, RN, a school nurse with the Flagstaff (Ariz.) Unified School District.

As a result of a 1975 law mandating that children with special health care needs be included in regular school populations, children with increasingly complex health conditions have been attending U.S. schools, according to the National Association of School Nurses.

About 1.7 per 1,000 children younger than age 20 have Type 1 diabetes and increasing numbers of children are being diagnosed with Type 2 diabetes. Many of these children must take insulin. An increasing number of students and school workers have life-threatening allergies, which, if triggered, require an injection of epinephrine. Students with severe asthma who require nebulizer treatments also are increasing.

Nurses report regularly seeing children with feeding tubes, tracheal tubes, catheters and ventilators. They have students with heart defects, muscular dystrophy, cancer and cerebral palsy. They must draw up individual health plans for these students, explaining their care, how to give them the best educational experience and what to do in an emergency.

In most states, they train nonmedical assistants, sometimes health clerks, sometimes secretaries and instructional aides, in how to give medications in their absence.

School nurses also are responsible for state-mandated screenings, keeping students up-to-date on immunizations and creating preventive health programs. As school counseling services are cut, they often are responsible for counseling and mental health programs. They also may teach health classes and help students learn healthy habits.

In some areas, the school nurse is the first or only contact a family has with the health system. Morgan recently saw a student with a possible case of strep throat whose parents waited over the three-day weekend so she could see the school nurse. "Her mom and dad just couldn't afford to take her to the doctor over the weekend," she said. "That's what we're here for, to make sure the kids get seen, to help reduce those barriers to receiving medical services."

Becky Rendon, MSN, RN, president of the Texas Association of School Nurses, has treated teachers, cafeteria workers and bus drivers, as well as students at the middle school in San Antonio where she works.

School nurses say they value the hands-on time they spend with students, school workers and community members. Some teach health classes, develop prevention programs and do counseling. But in a growing number of school districts, nurses have little time for anything but drawing up individual health plans, conducting mandatory screenings and training people to give medications, said Janis Hootman, Ph.D., RN, president-elect of the National Association of School Nurses and nursing supervisor for the Multnomah Education Service District in Portland, Ore.

The National Association of School Nurses recommends one school health nurse to no more than 750 students in the general school population, one nurse to no more than 225 students in schools that include children with special medical needs, and one nurse to no more than 125 students in schools that have large numbers of severely chronically ill or developmentally disabled students. For medically fragile students, the ratio should be based on individual needs.

Few states come close to meeting these guidelines, and some are light-years away. In California, one of the states hardest hit by the economic crisis, schools average one nurse per 2,517 students, said Linda Davis-Alldritt, MA, RN, PHN, school nurse consultant for the California Department of Education in Sacramento. Only 5 percent of California schools have a full-time nurse; one-quarter have no nurse at all, Spradling said. The other 70 percent have a part-time nurse who may visit one day a week or a few hours a month, she said.

"And those numbers are getting worse," she said.

For the children

One district, which has two nurses for 8,000 students in 11 schools, recently voted to cut one of the nurses. The nurse, Susan van Ouwerkerk, RN, health services specialist for Moorpark Unified School District in California's Ventura County, requested a hearing through her union and eventually got her job back.