With the May 10 celebration of School Nurse Day, school nurses around the country will recognize how the role of a school nurse has changed dramatically over the decades. This recognition day helps highlight the increasingly complex medical, social, and community needs and duties school nurses are responsible for.
Bales spent several years in nursing before moving into this nursing specialty. “I had no idea about school nursing when I finished nursing school,” she says. After receiving her BSN from Tuskegee University, says her heart was set on pediatric nursing and that’s where she made her first foray into nursing. She spent many years working in pediatrics and in neonatal ICU units in Florida and Georgia.
But her path changed when her family settled in one area and her children’s school district had an opening for a school nurse. She was encouraged to apply, noting that her schedule would then mirror her children’s school times. “That was 21 years ago, and I am still here,” says Bales with a laugh. “I have the opportunity to marry my love of pediatrics with the school age group and grow in my leadership skills. It’s been quite a ride.” Bales herself has assumed increasing leadership roles.
As a school nurse, Bales has taken on roles that are diverse. She has worked as an elementary school nurse, an itinerant school nurse instructor, and a consultant nurse. In her current role as a nursing supervisor, she oversees school nurses across a county school district.
Throughout her career, Bales has worked with students of elementary, middle, and high school ages and has especially enjoyed seeing them grow. And even if she might not instantly recognize a grown adult who comes up to her and says, “Mrs. Bales, it’s me!” she’s always happy to hear about their adult lives. There are many students who remember the care and comfort their school nurse gave them, and even some who are inspired to follow a nursing path because of their school nurses. Bales recalls talking with past students who have overcome health challenges and gave Bales credit for her help. “Those are very heartwarming encounters,” she says.
As with many school nurses, being able to make connections with students and their families is what keeps the profession rewarding. There are plenty of challenges school nurses face. From the increasing complexity of health conditions to the wider family and community issues that impact school children, school nurses have to be well prepared for anything.
“Some of the biggest challenges are staff shortages,” says Bales. The pandemic has compounded nursing shortages in general, and school nursing hasn’t escaped the lack of nurses to fill roles. In addition, Bales says the staffing model can look different from state to state or even within a state, and can make school nurse staffing particularly challenging. Sometimes school nurses are paid on a teacher pay scale and sometimes they are paid using a different pay scale, so it’s difficult to lure nurses, who might otherwise be offered signing bonuses and larger salaries, to the school nurse arena, says Bales.
And school nurses must continually fight for the funding they do get. Bales says it gets tiring to have to justify the need for more funding and more school nurses to lawmakers and decision makers. A healthy school community relies on the school nurses who are able to act as a liaison between students, the community, and healthcare providers. It’s frequently said that school nurses and the school health services are the hidden health system in the country, says Bales. Helping students and staff to be engaged in the learning process, she says, requires school nurses to prioritize health and safety.
For nurses thinking of moving into a school nurse role or who may already be school nurses, Bales says she encourages them to take advantage of every single opportunity that comes to them professionally. Whether it is through mentors, preceptors, or a new opportunity for a new skill, don’t turn down a challenge, she says. Join an organization like NASN to learn from others and share your own knowledge as well.
“It warms your heart to know the significant impact you are making,” says Bales. “School nursing is truly a calling.”
In the middle of National Nurses Week, a day is designated to honor the school nurses who work in schools nationwide and address issues that range from splinters to seizures. This year’s School Nurse Day on May 11 helps recognize and celebrate this career.
School nurses take care of children who attend school and with that familiarity they build close relationships with the children they see and often their families. Like a puzzle to piece together, school nurses work with the larger school community to understand and help treat the health needs of schoolchildren.
The pandemic has put increased pressure on school nurses, who already frequently are short staffed in their school districts. As much as school nurses are expected to advocate for the children they care for, they also need to advocate for themselves and their profession to ensure the best conditions for them to do their jobs.
For 2022, NASN targets areas that have a powerful impact on the children they work with, and their families, and issues that influence how a school nurse can operate within a school. Topmost is that each child should have access to a school nurse with the passage of the Nurses for Under-Resourced Schools Everywhere (Nurse) Act. Passage of this act would make it easier for schools to fund school nurses and would have the intention of alleviating some of the financial cost to districts. With grants, schools would be more able to provide a nurse who is sometimes the only medical professional a child might see.
In a forward-looking advocacy, NASN also encourages nurses to work for passage of the Tobacco Tax Equity Act, which will impart a tax on more tobacco products, including e-cigarettes. By raising taxes, nurses would hope to address the health disparities that are linked to youth tobacco use–and that in the wider community.
Because nurses know that health equity is so essential, the passage of the Improving the Social Determinants of Health Act is another identified priority. Children can’t learn as effectively if they don’t have secure housing or a nourishing and stable food supply. These and other social factors that provide a foundation from which children can have better lives are essential.
Advocacy can take as much time as a nurse has to offer. From writing to a legislator to getting more involved with work on the local, state, or federal level, there is always something that can be done to help make the jobs of school nurses and the schoolchildren they work with better.
A school nurse is a health practitioner in the educational field and so straddles two distinct professional worlds. Their work, focused on the students and their families, must encompass health and also the wider community they may see. Despite the tensions that can sometimes arise between the two areas, school nurses find incredibly meaningful, challenging, and rewarding work in their field.
This week’s National School Nurse Day (May 12) honors the tireless and complex work of school nurses—all of whom cared for students thorough a constantly changing year that veered between in-person, remote, and a hybrid of both.
I had a wonderful community health nursing rotation within my undergraduate nursing coursework that always stuck with me. I worked on a trauma unit after earning my BSN, and often thought back to that course and the role of a public health nurse. I remember calling my high school nurse on one of my days off and asking her “what do I have to do to become a school nurse?” I made the decision to follow my passion after that phone call and haven’t looked back since.
How has your job changed in the last year and with all the ramifications from the pandemic?
School nurses have always answered the call to serve during times of crisis. What I know for sure about school nursing is that we are each demonstrating how essential the role of a school nurse is to the health, safety, and well-being of students, staff, and the communities across the state of Illinois.
School nurses were at the frontlines before stay-at-home orders went into effect last year; over the summer many of us answered the call to action and donated PPE to our colleagues, volunteered at COVID testing sites, donated blood, served on various state taskforces, and supported our students by delivering meals. We are now serving in the tremendous role as frontline healthcare providers mitigating the impact of COVID-19 in our schools by isolating, contact tracing, ensuring IDPH COVID-19 Exclusion Guidelines, and case management amongst many other things.
We continue to amplify our voices at the local, state, and national level, all the while working together to address the health inequities faced by so many of our students and families that have only magnified over these past several months.
What do you enjoy most about your job?
What I enjoy most about my career in school nursing is the continuity of care that I’m able to offer my students throughout their high school experience. I love being a school nurse, and I encourage everyone reading this to follow their passion and find your place to thrive. I also enjoy being an advocate for my profession and teaching. I’ve been teaching for over seven years now, and it fulfills my other passion of educating the next generation of nurse leaders.
School nurses’ jobs are incredibly complex and you care for kids with many health conditions. What do you wish people knew about your role?
I wish people knew how vital our role is and that we are public health experts. I have a vision that every child in the U.S. will one day have access to a full-time certified school nurse. Every child deserves that access and it should not be determined by their zip code.
Can you give us an example of your work in educating the public on issues that are relevant right now?
In partnership with the COVID Collaborative, the Ad Council launched a historic public communications effort to educate the public about the COVID-19 vaccines. I was chosen to participate in these messages for healthcare professionals nationwide! The videos featured Dr. Anthony Fauci and other healthcare experts. We explained the rollout and administration of COVID-19 vaccinations and discussed how to navigate questions and conversations with patients.
At the local level, I am leading a science-first public health campaign through IASN by calling all Illinois school nurses to share their COVID-19 vaccine photos and videos by and using the hashtag #VaxUpIL and #IASNVaxUp to show how safe and important it is to get vaccinated. This campaign will also cover topics like masking, testing, vaccinations, and will address vaccine hesitancy. I’m designing the messages with diversity and inclusion in mind to maximize their reach and effectiveness.
To ensure equitable access to COVID-19 vaccines we must consider the social determinants of health that have increased the prevalence of COVID-19 within BIPOC communities. The national vaccination effort is one of the greatest operational challenges America has ever faced, and this is with existing underfunded public health programs across the country. I’m proud to be doing my part in this effort.
Barrera serves on the legislative committee and most recently as an expert panel member of the Diversity, Equity, and Inclusion Committee of the American Nurses Association-Illinois. She holds a chair elect position within the American Public Health Association’s (APHA) Nursing Section, is an active representative of Hispanic nurses on the Nursing Collaborative on Climate Change and Health, and is an active member of the Alliance of Nurses for Healthy Environments (ANHE). Barrera has been recognized for her leadership and community work by several organizations, both locally and nationally and most recently was named a 2020 Pinnacle Nurse Leader in Illinois. She is committed to being a lifelong learner and continues her efforts in improving child health outcomes in our most vulnerable populations through her current practice, advocacy, and teaching.
The COVID-19 crisis brought an abrupt and swift end to the in-person school year for most schools across the nation. But on May 6, as the nation honors National School Nurse Day, school nurses around the country say their roles are hardly idle, even if they aren’t in a school building.
“School nurses are the only healthcare providers some school children have access to on an ongoing basis,” says Laurie Combe, MN, RN, NCSN, and president of the National Association of School Nurses (NASN). “They are really a hidden healthcare system.” As school closings remove that immediate access, school nurses currently face many unknowns about the future and the steps they can take to help keep their students as healthy as possible until they see them again.
School nurses have been thinking about the return to school virtually since the schools began closing, says Combe, so they are going to be an essential voice for next steps. “It is essential that school nurses are included on school reopening planning teams,” she says, “as they are the health experts on their campus and can ensure that evidence-based processes and protocols are established.”
While students work virtually, school nurses watch for students who may show they are struggling by not logging into class and those who become, or continue their history of being, chronically absent. They are checking in on students who have chronic conditions, returning medication and equipment, and dispensing educational materials on everything from nutrition to keeping healthy habits.
One of the things Combe says is of particular concern to school nurses right now is the uptick in the need for mental health services that could impact the entire school population. “How are schools going to support that,” she says. “This is just a difficult situation. We will need to increase capacities for that in the schools.”
Luckily, she says, school nurses aren’t the only professionals talking about mental health needs in the educational systems, and Combe advises current school nurses to reach out to the school staff they can collaborate with including school counselors, social workers, and psychologists. Each specialist brings a different professional skill to the table to help school children manage this upheaval.
And the students aren’t the only ones who will be trying to navigate a new reality while they are trying to recover from the disruption in their lives including potential loss of loved ones, job loss in families, or an unstable living situation that was made worse by the crisis. “If what we’ve talked about is true,” she says, “the stress on school nurses, teachers, and school administrators is going to be immense.”
Combe says school nurses often work quietly and behind the scenes and so many people don’t realize the enormous scope of their job duties. For the work they do, she gives them kudos, saying, “I am grateful for the school nurses who step into this space to support students, families, and staff and the larger school community.”
The Centers for Disease Control and Prevention (CDC) continues to issue the rise in the number of youths who have been diagnosed with measles. This national outbreak of the highly contagious measles virus has been recorded as 1,282 individual cases in 31 states as of December 2019 and growing. This is the greatest number of cases reported in the U.S. since 1992. More than 73% of the cases this year are linked to outbreaks in New York. Now the necessity of the school nurse has come into focus.
According to the National Association of School Nurses (NASN), about 40% of our nation’s schools only have a part-time nurse, and 25% don’t have a nurse at all. Not surprisingly, the school systems that are largely affected or at greater risk are rural and urban schools. But with the potential of measles affecting a large number of children and adolescents, school nurse practitioners in several states hurried to refresh themselves on the measles symptoms and to reach the parents of students at risk of infection while working to keep all students safe. They have become the first line of defense in protecting school communities.
The origin of the school nurse has been traced to a Canadian trained woman named Lina Rogers Struthers who is credited as the first one in America. She was assigned to work in four different lower Manhattan schools just as a month-long experiment in October 1902. Officials wanted to see whether having a nurse would improve students’ health and attendance. Despite the fact that there were 10,000 students, her presence made a huge impact on improving the health of students. In fact, in just one month the absentee rate of students in all four schools dropped dramatically. And after the six-month mark, absenteeism fell by 90%. The surprise at the numbers spoke for themselves. The officials next secured funding to employ another 27 school nurses. By the end of 1914, there were as many as 400 in New York City alone. Noticing what the impact nurses were having, other cities quickly followed suit. Los Angeles was one of the first cities to jump on the bandwagon; it hired its first school nurse in 1904.
Today, everything that has to do with school nurses and vaccines—from unequivocal conversations with parents about the science of immunization to the firsthand monitoring of student populations for diseases, have been made difficult by the underfunding of nursing services. In school systems without full-time nurses, it is not unusual for nurses to travel between three or four schools a day or week. Burdened with caseloads of up to 1,500, they try to distribute medications and treatments on time, attempting to triage the most critical cases, while also keeping on top of a mountain of paperwork, according to the National Education Association, which shares with the NASN concern for the need to ramp up the number of full-time nurses.
At a time when the nation’s health care debate is receiving fixed attention, it is indisputable that the delivery of effective and responsive health care is dependent on adequate staffing resources and much success is dependent on adequate nurse staffing levels. But there is a current and forecasted national shortage of nurses because of talent pipeline conditions. While 25% of the country’s public schools do not employ a nurse, and in many school systems there are only part-time nurses, the issue is not merely the unavailability of talent. The overarching issue here is funding.
There are no federal laws regulating school nurses. Today, there are no federal laws regarding staffing, hours of work, compensation, or caseload. But the American Academy of Pediatrics (AAP) recommends at least one full-time registered nurse in every school—a standard many districts have failed to meet or are unable to meet.
The NASN defines school nursing as a specialized practice of professional nursing that advances the well-being, academic success, and lifelong achievement of students. To that end, nurses facilitate positive student responses to normal development; promote health and safety; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy, and learning.
A recently published research article in the NASN School Nurse journal focused on one of the most difficult problems for school nurses and families: the issue of suicide. The article concluded that a knowledge gap exists in school communities regarding suicide prevention education. It highlights two interrelated topics: nurse engagement in dialogue with students’ families, and the implementation of a community-based suicide prevention educational program at a suburban public school district. Diane Cody Roberts, MPH, BSN, RN, and her coauthors provide an overview of the public health problem of suicide for students, current student challenges, the role of the school nurse in suicide prevention, and a key gap in current school nursing practice. The two overarching goals for this community-based project were to have nurses engage in productive conversations with students’ parents and families about suicidality concerns and to increase the school community’s knowledge about suicide prevention.
But as Laurie Combe, MN, RN, NCSN, president of NASN pointed out recently, when the nurse is not in the school—because they are covering multiple schools—then the nurse misses lots of opportunities to build trust with parents and with families. If they don’t see the nurse and if the nurse is simply the person telling them to comply with immunization directives, then there is the likelihood of resistance.
In May 2017, the Joint Legislative Program Evaluation Oversight Committee of the North Carolina General Assembly directed the Program Evaluation Division (PED) to analyze the need for school nurses and determine how these nurses are funded. Need is growing due to increased attendance by exceptional children and students with chronic conditions as well as laws and policies expanding the health care responsibilities of schools. The PED found that only 46 of 115 Local Education Agencies (LEAs) currently meet the school nurse-to-student ratio of 1:750 recommended by the State Board of Education in 2004. Achieving either the 1:750 ratio or providing one nurse in every school (the current recommended standard of the NASN) would cost between $45 million and $79 million annually.
The report continued that approximately 60% of all medical procedures conducted in schools are performed by school employees who are not nurses. As a result, students are vulnerable to errors and gaps in emergency medical care, and funding intended for education is being used to subsidize health care. Furthermore, unlike other school-based services such as speech therapy, few LEAs file for Medicaid reimbursement for nursing services because, under the current Medicaid State Plan, a Registered Nurse must provide the care as ordered by a physician as part of an Individual Education Plan for the student.
Lee Antoinette Moore, MSN, on the faculty of the Durham, North Carolina Technical Community College School of Nursing, is a former school nurse with experience in New York City from 2004-2006, in North Carolina 2008-2010, and in Hawaii 2012 as a cover nurse who is called when there is an unplanned nurse’s absence. Her prior experience includes that of a military nurse in Germany. Both North Carolina and New York are comparable in many ways. As a whole, with the exception of a few districts, the nursing staff are each assigned to cover more than one school. All of North Carolina’s metropolitan areas have nurses covering more than one school. At the start of the school year, nurses are assigned to engage the schools’ support staff—the administrative support on such things as insulin injection, distribution of medication, some symptom identification, temperature taking and reading, as well as when to invite emergency assistance.
In 2016, the AAP issued a policy statement recognizing the important role nurses play in promoting the health and well-being of children in the school setting. By understanding the benefits and responsibilities of school nurses working in collaboration with the school physician, pediatricians can support and promote school nurses in their own communities, thus improving the health, wellness, and safety of children and adolescents.
Because the nurse plays such an integral role in the school, they must be able to work with a variety of people. School nursing training focuses on improving communication skills, developing organizational skills, performing clinical work, making presentations, and learning the correct methods for teaching health-related lessons to students. Nurses must be self-motivated and dedicated. In addition, they must be able to commit to continuing their education throughout the course of their careers.
Moore’s experience because of her assignment as a dedicated nurse to one school on Staten Island, New York is able to compare that experience to her North Carolina experience where she rotated up to three schools each school year over the course of her tenure.
A 1995 graduate of Winston Salem University School of Nursing, Moore chose school nursing to accommodate the school schedule of her young children after many years working in a variety of hospital and clinical nursing assignments. This is often the reason nurses choose school nursing as a career.
School nurses have a grounded understanding of the significance of the role they play in school systems where the primary emphasis is providing medical skills across a variety of health conditions and in a setting where they are not regarded as just adjunct staff. Penny Rosser, RN, BSN, NCSN, the lead school nurse in Orange County, North Carolina with its upper income city of Chapel Hill, has a nurse in almost every school.
There are 13 schools served by 12 nurses. “In this job,” Rosser says, “you are truly on your own, except for your team. Continuing education and how to keep skill sets up to date are always a concern. Working in the field, alone, is quite different from working in a hospital or clinic, as you are unable to attend many educational sessions or learn the latest techniques. We are truly generalists.”
Far too often it is the students that are on their own. The death of a student in a school because of the absence of a nurse is rare, but it does occur. California and Pennsylvania have had such occurrences in the not too distant past. Are students getting sicker—i.e., are there more cases of asthma, diabetes, and chronic and communicable diseases? Rosser responds, “I think it is inevitable that school sizes will increase and along with the increased population will come increased illness. I don’t think students are sicker than ever; I believe there is more diagnosed illness and more responsibility placed on school staff. I do believe that there has been an increase in mental health needs, however.”
As public awareness and public support for services to tackle mental health concerns grow, the school nurse will be thrust into the point position in our nationwide school systems. With increased responsibility will come greater appreciation of their contribution to the health status of our communities. Possibly, one nurse for each school will take root. From Los Angeles to New York and places in between such as Chicago and Raleigh, there is a ground-swell of support. The overarching principle is simply: Healthy students improve the potential to learn.