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The week before school started in late August, the center's first-aid nurse, Amy Balding, RN, was busy checking the immunization history of 1,000 kids arriving from middle school. During the school year, she's even busier, treating Berkeley High's diverse student body of 3,500.

Balding, 45, does a lot of first aid-in fact, she makes sure to wear sensible shoes that she can run in when she responds to a medical emergency elsewhere on campus. She treats an array of sports injuries and dispenses over-the-counter drugs for menstrual cramps, headaches, colds, allergies, earaches and emergency contraception.

And sometimes she just listens.

"I have kids that are here because they broke up with their boyfriend or are having a hard time at school. They don't always want to talk to the mental health provider, so sometimes I'm Mom at school," said Balding, who, after 20 years in nursing, took a significant pay cut last year to work in school-based health care. "The kids are just great. They come up and hug me in the hallway, say, 'Yo, what up, nurse?' or 'That's my nurse. Don't be disrespectful to her.'

"We've resolved a vast array of problems on campus," Balding said. "I'll see someone who was here a week later and they'll have a smile on their face instead of tears."

School-based health care is an attractive option for many in the nursing field, said Linda Juszczak, DNS, MPH, PNP, RN, director of the Center Evaluation and Quality for the National Assembly on School-Based Health Care in New York.

"There are no barriers to providing care. The clinics provide services at little or no cost, and the systems that are set up to get the kids in have a minimal amount of paperwork. It's a very frontline experience," Juszczak said.

"Follow-up for issues is very satisfying. You don't have to depend on [patients] to return. They are captive," she added with a laugh. "You can go to class and see how an asthma patient is doing."

Hagedorn agrees. "A school-based clinic offers access to the children. We do health education classes, tobacco education. We help school nurses and health teachers. It offers a variety to the NP who likes to work with children and adolescents, an opportunity not only to see patients, but to teach and be involved with the community. It's a broader perspective than just going to a clinic and seeing a population of patients."

Because physical examinations and prescribing medications are part of school-based health care, most clinics rely on nurse practitioners to run the programs, with other health professionals offering support. Nationwide, school-based health clinics employ more than 900 nurse practitioners, 500 registered nurses and 200 licensed practical nurses, as well as mental health professionals.

Many school-based health clinics collaborate with school nurses, who typically provide basic first aid and annual health screenings, as well as track immunizations. However, because of the faltering economy, many schools have been forced to cut school nurse positions altogether or slash their hours back to a few hours per week or per month. If a school is lucky enough to have an on-site clinic, the staff there often picks up the slack. Berkeley High School, for example, has no school nurse, but Balding has taken over many of those responsibilities as part of her clinic job.

"Most of the time, school districts are really strapped and don't have a school nurse that can focus on one school," said Yvette Leung, MPH, program administrator for the Alameda County School-Based Health Center Coalition, which oversees 11 centers near San Francisco. "Triage alone is about 30 students a day, and that could really fill up your day-to-day activity. Between vision and hearing screenings, you can't place the attention on other types of services. School-based health centers can offer medical treatment and also mental health services that adolescents are seeking these days."

Controversial connection

The push for school-based health care started in the late '60s and '70s with pediatricians opening clinics at a few schools in cities such as Dallas, Minneapolis-St. Paul and Cambridge, Mass.

In the mid-1980s, the model picked up steam when a nationwide teen pregnancy crisis prompted health providers to promote family planning through school-based health programs. However, linking health care in the schools with reproductive services meant increased controversy. Parents, politicians and church officials sometimes created a firestorm of criticism at the idea of providing contraceptives, or even discussing the issue of teen sex in the schools. As a result, reproductive health services vary widely in school-based health programs, depending on community needs and tolerance.