School Days

Little Joey (not his real name) was blue–literally. Born with a heart defect that left him breathless, he couldn’t climb the stairs or run around the playground at his Dallas school with the other children.

But a team of professionals, led by the school nurse, had a plan to remove the barriers created by the preschooler’s condition. School medical and social workers, his teacher and the hospital where Joey received treatment showed staff and other teachers how to adapt activities for him. They educated his classmates. They worked with his parents, fine-tuning solutions perfectly suited to his personality and physical needs.

Surrounded by people who cared, Joey excelled academically and became popular among his classmates.

“We had to be sure that normal school activities could be adapted to his physical condition,” recalls Suzanne Medrano-Kubelka, RN, MSN, APRN, BC, director of health services for the Dallas Independent School District. “He’s in the second grade right now.”

Much has changed in the specialty field of school health since Lina Rogers–generally acknowledged to be America’s first school nurse–was placed in a New York City school more than 100 years ago. Given a month to make a difference in the absentee rate of children (New York was one of the first cities in the world to mandate attendance), Rogers was successful, and on November 4, 1902, she had a permanent job.

But one thing hasn’t changed: The goal of school nurses is still to advance the well-being, academic success and lifelong achievement of students.

If you love children, enjoy being a health resource in a non-medical setting and work well both on your own and in a team, school nursing could be the ideal career for you. While hiring prospects vary widely among school districts, depending on budget allocations, never has there been a greater need.

“The biggest [reason why nurses choose this specialty] is the kids. Working with them, you know you make a difference,” says Judith Robinson, RN, PhD, FAAN, executive director of the National Association of School Nurses (NASN). “You’re giving kids the ability to do their best.”

Cultural Competence Goes to School

Thirty years ago, a child like Joey probably would not have been in school at all. But when Congress passed the Individuals with Disabilities Education Act (IDEA) in 1975, students with severe medical conditions became mainstreamed into standard classrooms.

These days a school nurse is as likely to insert a urinary catheter as to check a temperature. Children who once required hospitalization or 24-hour institutional care now come to school. They have a variety of conditions that require monitoring, including bone and muscular diseases (such as spina bifida), seizures, heart disease, diabetes, asthma and other chronic illnesses. They need tube feedings, insulin shots and nebulizers.

The medications and procedures that school nurses can administer vary according to the laws of each state. But “anything you ever saw in a hospital you now see in a school,” Robinson says.

Naturally, school nurses provide life-saving care during emergencies and a place to rest for students who are feeling feverish. But they also screen for diseases, including a burgeoning number of asthma and diabetes cases, especially in racial and ethnic minority children.

“We have a significant number of children with asthma [in the nation’s schools],” Robinson reports. “And we’ve seen a significant increase in the number of children with type 2 diabetes and excessive weight gain early in life.” Type 2 diabetes, which used to occur primarily in adults, is linked to poor eating habits, excess weight, inactivity and a predisposition to the disease. According to the American Diabetes Association, 15% of American Indians and Alaska Natives and nearly 11% of Hispanics are now thought to have type 2 diabetes, compared to roughly 6.2% of the nation overall.

Students in low-income urban and rural areas are especially prone to the insufficient nutrition and sleep that lead to poor health. As a result, health education is a major priority for school nurses in these communities. It is the school nurse who educates students and teachers about health issues. One-on-one and in front of a class, nurses guide students to take responsibility for their own wellness. They also show teachers and staff how to handle medical emergencies and meet the special needs of mainstreamed students with serious medical conditions.

School nurses also perform a community service role, advocating for children who are experiencing family or social problems and assessing students’ mental health. Because this kind of work requires the nurse to build a relationship of trust with the student and family, nurses who share the same ethnic or cultural background as a minority student are often in a better position to establish such trust. At the very least, they are more likely to be aware of potential cultural barriers that can keep students from reaching out.

“School nurses need to be sensitive to the cultural and social differences among students,” says Medrano-Kubelka, who is Hispanic. “Each culture brings with it some differences.” In her Texas school district, students speak more than 57 different languages. The area has a large Hispanic population and a growing number of Asian Americans.

School nurse Olivia Hernandez, RN, who speaks Spanish “mas o menos” (“more or less”), worked in a doctor’s office and a hospital coronary care unit before settling comfortably into what she calls her niche 29 years ago. “I knew [school nursing was right for me] the minute I came in,” she remembers. “I feel like I touch a lot of children’s lives, and their parents’ as well.”

Hernandez, who works at Urban Park Elementary School in East Dallas, Texas, sees her role not only as that of a health care provider but also as an open-door health educator and community resource. Her clinic walls are covered with brightly colored posters that teach health lessons, like handwashing and asthma care. She helps families track down insurance coverage, fill out forms, find doctors and dentists.

She also enjoys being a role model for the school’s largely Hispanic population. Posters in her clinic proclaim “I want to be a doctor” and “I want to be a nurse,” prompting questions from curious students. She tells them she went to nursing school and had training to do her job, and that they, too, can find a rewarding career in the health care field.

Reaching Out to Troubled Teens

Other school nurses agree that being an advocate and role model for students is a vitally important part of their job. In fact, their work often has just as much to do with keeping a student on track as dealing with the medical issues he or she may have.

For example, Sharon Gooden, RN, was teaching a student newly diagnosed with diabetes how to live with his disease when she noticed other problems that needed addressing. The teenager was coming to school on an empty stomach and without taking his insulin. The health issue became a social one when she realized his mother wasn’t caring for him properly. Gooden enlisted the help of a social worker and doctor to get the whole family on board to treat the student’s illness.

“You’re an advocate, definitely,” says Gooden, an African-American school nurse who works on temporary assignments through Comprehensive Resources, Inc., a staffing agency that provides nurses and other health professionals to schools in New York City. “In many cases, a school nurse may be the first to pick up on these kinds of issues.”

Her goal now is to teach the student to manage his diabetes, because he’ll have it all his life. For teenagers wrestling with the challenges of puberty, this can be a tricky proposition. Learning to manage a chronic medical condition on top of everything else can seem overwhelming to them. School nurses can help not just by teaching but also by applying their negotiating skills.

“Sometimes there’s a lot of resistance and denial [in teens],” Gooden explains. “Sometimes we actually have to physically go look for them because they will not come into the clinic on their own, either because of denial or because they don’t see the importance. But other times, I lay back and keep silent so that I leave an entrance for them to come back in my door.”

For Gooden, who has been an RN since 1968, school nursing offers an ideal setting to help prepare teenagers for the responsibilities—health-related and otherwise—of adulthood. She particularly enjoys talking with girls about careers and self-esteem.
“We have a lot of students who really just come by because they need nurturing,” she says. “If you are approachable, they’ll start telling you about other issues you can help them with.”

A Great Career–But Are There Any Jobs?

Many specialty areas of nursing have been hit particularly hard by the current RN shortage, and school nursing is no exception. The U.S. Department of Health and Human Services recommends a ratio of one school nurse for every 750 students. Yet in some parts of the country, such as Virginia and Oregon, nurses are actually facing nurse-to-student ratios of one-to-2,000 or even higher.

Unfortunately, a lack of nurses is only part of the problem. While many of the nation’s hospitals are going to unprecedented lengths to recruit more nurses, the school nursing shortage is a more complicated situation. Ironically, even though school nurses are urgently needed all over the country, some school districts aren’t hiring–because they can’t afford it.

Education budgets are tight these days, and educators have a sharp eye on the bottom line. Unless a school has special health issues or needs, nursing can be one of the last priorities for funding. Most school nurse salaries are paid by federal and state education dollars–money that educators are likely to funnel elsewhere, especially in cash-strapped districts where there aren’t enough textbooks to go around.

Sometimes schools are not even aware that they are allowed to allocate government-provided education funds to health care. When the federal Elementary and Secondary Education Act, also known as the No Child Left Behind Act, came up for renewal last year, the NASN successfully lobbied for language changes that included school nursing services. The goal, says Robinson, was to let schools know without a doubt that they can use those education dollars to hire and retain nurses.

In passing IDEA, the federal government ensured that all students, including those with disabilities, would have access to education. But how a school district addresses students’ health needs is an entirely local decision.

As a result, some school districts aren’t recruiting nurses–but many are, driven by local and state mandates for reasonable nurse-student ratios. One of the best examples is Vermont, where state law requires that a school nurse be available for every 500 students and that every school have a nurse. On the other hand, says Robinson, one of the most challenging job markets is Colorado, where the ratio at some districts is one nurse to 8,000 or 9,000 students.
The severe shortage of nurses in many school settings often means unqualified people, such as teachers, are performing nursing procedures out of necessity for the students who need them–essentially practicing nursing without a license, which is against the law. But budget constraints prevent many schools from filling those roles with qualified nurses.

To bridge the gap, some districts around the country hire LVNs and LPNs as school nurses. Others, like Vermont, continue to insist that a school’s primary nurse be an RN.

Fortunately, many inner city schools have survived health staffing cutbacks because budget officials are aware that school nurses provide essential services to students who are more likely to have limited or no access to other health providers, Robinson notes. On the other hand, some rural districts in the South would love to find nurses but have been unsuccessful, in part because they cannot afford to pay a competitive wage.

But despite the difficulties of the current job market, school nurses have one of the highest rates of job satisfaction in the nursing profession, according to a survey by the Health Resources and Services Administration’s Bureau of Health Professions, Division of Nursing.

“What we find is that most people who get into school nursing either leave within a year if it’s not a good fit for them, or else they stay for the rest of their career,” Robinson says.

As for school nurse salaries, a recent NASN member survey found that most respondents earned between $20,000 and $49,000 a year. (Information on hours worked was not asked.) Sixty-eight percent are paid on a teacher salary scale, and roughly 26% earn less than teachers. Nurses on a teacher pay scale usually work 180 days a year, earning a starting salary of $20,000 to $28,000. Some school nurses supplement their income during the summer by covering for vacationing hospital nurses or working as summer camp nurses.

The Dallas Independent School District is in the midst of beefing up its nursing ranks, Medrano-Kubelka says. Two years ago, when the district’s ratio had increased to one nurse for every 1,300 students, the board of education approved a measure to lower the ratio to 500 students per nurse. With about 165 nurses in 216 schools, the ratio is improving, but the district is continuing to hire more nurses.

According to Medrano-Kubelka, the district is looking for RNs with a bachelor’s degree in nursing and experience in a number of areas, including ICU, emergency and community health. Depending on previous school nursing experience, the beginning salary is approximately $35,000.

“We are always willing to consider an applicant,” she adds. “If we’re not hiring just then, we’ll always get back to them. The potential to be hired is good.”
To attract more candidates, the district offers a mentoring program which pairs new school nurses with experienced leaders during their first two years. The mentors and mentees meet every two weeks or so to go over competencies in key areas.

Getting Your Foot in the Schoolhouse Door

Some school nurses, like Gooden, find that working for a staffing agency is a good option. These agencies contract with school districts to fill gaps in nursing coverage. For instance, Comprehensive Resources has a contract with New York City public and other schools to provide nurses for a variety of assignments. The nurses can work in a wellness setting or choose to assist children with special medical needs. And they can pick the age group they prefer.

 

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“It’s important for the agency to make the right fit,” says Lynette Lewis, MBA, MLS, Comprehensive’s director of nursing services. “The nurses have to suit the students and the school has to suit the nurse. Some nurses may want to do more wellness work, while others might want to focus on medically fragile children.”

 

School health is unique among nursing jobs in one important way, Robinson notes: The culture is different. The education field has a rhythm distinct from that of a hospital or other acute-care setting. While there’s plenty to keep nurses busy, the pace is less frenetic, the emergencies fewer. Here the emphasis is on promoting health and preventing disease.

Robinson advises nursing students who are considering this specialty to do a pediatric rotation in a school to get a feel for the job. Training or experience in pediatrics and community or public health is the ideal background for a school nurse. Some nursing schools even offer degree programs in school nursing. One of the best known is the Advanced Practice in Primary Health Care: School Nurse Practitioner MSN program at Seton Hall University College of Nursing (South Orange, N.J.), one of only five such programs in the U.S. listed in the National Directory of Nurse Practitioner Programs.

Gooden doesn’t hesitate to recommend her chosen specialty to other minority nurses. “Hospital nursing is not the only thing out there,” she emphasizes. “You have other choices. And school nursing is an excellent one.”