Stereotypes of school nurses primarily dispensing aspirin, taking temperatures, and offering hugs are rooted in nostalgia.
These days, school nurses increasingly handle a growing number of students with chronic or serious health issues, provide emergency care, and connect with community partners to provide additional health services.
Despite the vital role that these health professionals fulfill for students, there is a lack of full-time public school nurses to help meet the well-being of students, especially in urban school districts. Only 30% of public schools have a full-time school nurse, according to a 2007 study by the National Association of School Nurses (NASN).
Additionally, only half of schools have a registered nurse 30 or more hours each week, according to a 2014 School Health Policies and Practices Study by the Centers for Disease Control and Prevention.
Informing the public about the expanded role of school nurses and the consequences of their absence benefits students, their families, and communities, nursing experts say.
“Because school nurses practice independently as the only health care provider in the education setting, they need the critical-thinking skills that bachelor-prepared nurses develop,” says Beth Mattey, MSN, RN, NCSN, president of NASN. To this end, NASN recommends a bachelor’s degree in nursing as the minimum preparation for a school nurse.
“Many states require ongoing education to maintain an RN license and/or a school nurse certification,” Mattey continues. “NASN provides ongoing education through resources, clinical guidelines, webinars, and other online education courses. We also sponsor hands-on learning and conferences to keep school nurses abreast of current practice.”
Evolving Role of Nurses
“When schools don’t have a school nurse, there is not a health professional to help students manage acute illness and chronic conditions in the school setting,” says Mattey. “Students don’t leave their health issues at the door, and many chronic conditions must be managed during the school day. This includes students with diabetes, asthma, life-threatening allergies, epilepsy, and sickle cell disease. Children who live in poverty are at greater risk of having a chronic condition and unmet health needs.”
The average adult thinks about his or her own education decades ago and assumes every school has a nurse and the health needs are the same, says Nina Fekaris, MS, BSN, RN, NCSN, president-elect of NASN.
“Unless you are a parent of a child with a chronic illness or a life-threatening disease, you just don’t think these things are in schools,” says Fekaris, the only nurse assigned to four schools serving 4,200 students in her suburban school district in Oregon. “They don’t understand what school nurses do and they don’t understand that kids are more fragile that are attending schools now. There’s a lot more care coordination that needs to happen in school buildings to keep kids safe.”
Fekaris, who has been a nurse for 40 years and has 30 years of experience as a school nurse, says the growing number of students with type 1 diabetes is a major health change. When she first started, there were none; now, there are about 150 diabetic students, including kindergarteners, in her school district.
Advances in medical treatment and technology have also altered the practice of school nursing. For example, one treatment device for children with seizure disorders is an implanted device under their skin that delivers an electrical pulse to a nerve in their neck. “At the sign of seizure, what we want to do is activate that device to fire an impulse to try and stop the seizure, and the way you activate that is by swiping a pretty powerful magnet across that device in their chest. Thirty years ago we didn’t have that technology,” explains Fekaris.
Greater Needs at Urban Schools
Students in high-poverty urban areas are especially vulnerable when schools lack an adequate number of nurses, says Maura McInerney, a senior attorney at the Education Law Center, an education advocacy group that champions the hiring of more nurses.
“The consequences can be devastating, and I don’t think that the average citizen recognizes the critical role school nurses play in the health, safety, and education of school children,” McInerney says.
Without access to full-time nurses, students may not receive urgent or accurate and timely treatment at prescribed intervals. And, children with special education needs may not be identified or receive nursing care, McInerney adds.
“Perhaps what is most striking is the number of children with qualifying disabilities such as diabetes and asthma, who fail to receive Section 504 Plans that are critical to supporting them to attend and be successful in school. Finally, school nurses are important teachers and counselors and are often the first people to identify a child’s need for health interventions and counseling services,” says McInerney.
There are 180 nurses for 332 Philadelphia public schools serving 200,000 students. In 2011, the district had 289 school nurses. By the 2013-14 school year, that number had dwindled to 179. In March, the district announced the number of school nurses would be increased with the goal of a nurse at every school. “At that time, 123 schools had no full-time nurse and 17 schools had a nurse one day a week or less,” McInerney says. “We hope this happens, and ELC is fighting for more funding to under-resourced schools in Philadelphia and elsewhere to make this a reality.”
Unfortunately, sometimes it takes a crisis to spotlight the need for school nurses and drive changes, says Robin Cogan, who has worked 15 years as a school nurse in Camden, New Jersey. “In Flint, there was one school nurse. They now have nine school nurses. It shouldn’t take a tragedy to get a school nurse in every building,” she argues, referring to the 2015 water crisis in Flint, Michigan, that involved lead contamination.
Mattey recalled a Philadelphia student, 12, who died from an exacerbation of her asthma two years ago. “The severity of her asthma was unrecognized on that day because the school nurse was not scheduled to be in the school. The School District of Philadelphia had been having financial difficulty and school nursing services were cut,” Mattey says.
For working parents, the presence of a nurse can help them decide to enroll their child if he or she has a chronic condition, says Cherisse Howell, RN, supervisor of staff education, school health nursing, at the Montefiore Health System, one of the largest school health programs in the nation. A school nurse “gives a parent a sense of security that I can go to work and provide for my family and still feel safe that my child is OK because there is a nurse at school,” says Howell, a nurse since 2005.
Having a nurse or school clinic gets children into the building because parents share the positive experiences of the health services, Howell says. The Montefiore Health System has clinics inside elementary, middle, and high schools and provides primary, dental, mental, and community health services to over 30,000 students at 85 schools on 23 campuses.
“We transitioned from what many thought of as the school nurse… when nurses were doing ice for injuries and Band-Aids for boo boos,” says Howell. “We’ve moved to an era where, specifically in the Bronx, we have thousands of children suffering from asthma and our diabetes cases are rising. We have children with health disparities that would otherwise keep them from school. We now have these health professionals in the educational building, and children can get the treatment they need and the instruction they need simultaneously.”
Outreach and Partnerships
The volume of students treated and the complexity of their medical care require school nurses to form health care partnerships, says Lynn Meadows, RN, MS, coordinator of student health services for the Fulton County School System in Georgia.
“We can’t just do the job in a clinic. You have to partner with a local physician or a health organization in the community because it’s a team approach now of how we take care of kids,” says Meadows, a nurse for 30 years and a school nurse for 15 years. “It’s not just a school nurse trying to manage the health care needs of kids while they are in school. Yes, they are in school…but they also go home. So that collaboration and networking with health care providers outside our clinic obviously keeps that continuity of care better for kids.”
Many school nurses seek professional development to keep up with the changing care dynamic that students require, which is why partnerships are important. School districts are looking to school nurses to be caught up on health issues that can impact the community, Meadows says.
“For instance, regarding the Zika virus, my superintendent will look at me and ask, ‘Well, what should our school district’s response be to a community health issue like Zika virus?’ So I have to be up to snuff. I have to find partners that I can work with to say, ‘What is the latest, how does this impact the community, and ultimately, how might it impact the school?’ Whatever is the hottest topic or health care issue going on in the community, school nurses have to be aware of it,” says Meadows.
School nurses arrange for mobile dental clinics to visit schools and mobile vision vans to visit and provide eye exams and glasses for students who may not have those services available, says Mattey.
School nurses also work in schools and the community to promote tobacco education and cessation programs, educate students about prescription drug abuse and other substance abuse, provide immunization services for students, encourage exercise programs, and educate about healthy eating.
School nurses not only play a key role for helping students learn, their presence assists educators. One study found teachers spend less than 20 minutes each day dealing with student health issues when a nurse was assigned to their school.
Data also showed students with asthma have improved attendance and better health outcomes when a school nurse managed asthma, says Mattey. Furthermore, immunization rates also improve when a school nurse is present.
“What administrators and school districts need to know is that not only do school nurses keep students in school by addressing health issues so they can stay in school, school nurses save money,” says Mattey. “A recent JAMA study demonstrated that for every $1.00 spent on school nurse service and resources, $2.20 was saved in societal costs. The study did not take into account reduced emergency room visits due to early intervention by the school nurse,” she adds.
“Consider the case of a child with a severe peanut allergy, and every day when your child goes off to school you hope that your child is not exposed to peanuts. A school nurse recognizes the potential emergency, works to make the environment safe for the child, and ensures that emergency plans are in place in the event of an exposure to peanuts. The school nurse will educate the staff on the signs and symptoms of an exposure and how to prevent the exposure in the first place,” says Mattey. “There are many health conditions children bring to school. The professional school nurse has the expertise to educate and work to prevent an emergency, but if an emergency occurs, the school nurse will recognize the emergent condition and take action.”
School nurses juggle an array of demands despite their salaries being among the lowest for RNs. However, in some areas, school nurses are paid on the teacher salary scale, which also includes benefits. For school nurses on the lower end of the salary scale, lack of understanding about all they do is a factor, nurses say.
“Traditionally, the profession of school nursing has been looked at as someone in the clinic just handling little boo boos,” explains Meadows. “There isn’t widespread public knowledge of what it takes to be a school nurse, or the volume of kids with chronic illness or medical issues. There is not enough information in the community or across the nation on how school nursing has evolved. Many people don’t get that.
“School nursing has changed. It’s a profession on its own. For many of our children, the first health provider many of them see is the school nurse. I tell many of my nurses, ‘You can be the person who finds out what is going on with that child and make a difference in that child’s life for the rest of his or her life,’” Meadows says.
Although school nurses affect educational settings, taxing working conditions can compromise their effectiveness in treating students. If the school lacks a nurse, or if the school nurse “has a workload that makes it difficult to adequately educate all staff and follow up with parents, there may not be adequate protection for students,” argues Mattey.
“The ANA has a saying, ‘Nurses are an investment in the future, not a cost center.’ I say the same about school nurses. School nurses are an investment in the future of our children, linking health and education. We are not a cost center,” Mattey adds.
Parents and guardians must address the importance of school nursing with administrators, Mattey says.
“Parents should ask, ‘Who is meeting the health needs of my child while in school?’ The answer should be a professional registered school nurse,” argues Mattey. “Parents assume that a nurse will be taking care of their children, but that is not always the case and parents need to ask the question. If not a school nurse then they need to find out, ‘Why not?’ Parents in Charlotte, North Carolina, advocated to make sure their children had access to a full-time school nurse, successfully increasing the number of school nurses in the schools.”
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