Rx for School Nursing

Some districts are trying creative approaches to fill critical nursing needs by RACHEL SMOLKIN

When Sandy Murray became a principal 15 years ago, she never thought she’d need to know so much about ringworm, fever, pinkeye and chicken pox.

Murray had no regular nurse at Plantation Elementary School in Plantation, Fla., near Fort Lauderdale. The Broward County School District provides a nurse only for emergencies, and even then getting a nurse out to the school can take some time. Many days, Murray made a best-guess diagnosis and then decided whether to send a child home.

“Chicken pox is the worst,” says Murray, 52, who contracted the disease from her students two years ago. “We can have 15 kids in the office with bumps on them, and we have to stop what we’re doing, and then we have to try to contact the parents. That’s something the nurse would do.”

But by forging some creative partnerships, Murray, who left the principalship in October to become a personnel administrator for the district, alleviated at least some of the burden on her and other school administrators. Plantation General Hospital sends volunteers twice a week to bandage boo-boos or help make phone calls to parents and guardians. The nursing club at South Plantation High School periodically visits the elementary school to chart students’ heights and weights. And medical students at Nova Southeastern University volunteer time to staff the school clinic and explain symptoms to concerned parents.

Solutions Emerge
Plantation Elementary is just one of many schools around the country trying innovative ways of attending to student and faculty health needs. Strained budgets, insufficient numbers of nurses and increasingly complex student health problems are forcing schools and districts to embark on community partnerships, demand additional services from existing staff and explore supplementary sources of dollars to finance nurses or other health workers.

Retirements and shrinking numbers of nursing school graduates during the late 1990s have severely tested the availability of nurses. Many schools are facing state and county budget cuts even as new standardized testing requirements take effect. And students once deemed too sick to leave a hospital now attend school regularly. In the absence of regular nurses, school officials must find ways to administer Ritalin and other prescription drugs, help students use asthma inhalers, monitor diabetics’ sugar intake, identify depression or other mental health problems and care for children who have no health insurance.

“To have teachers and principals attempt to grapple with those issues on top of standards-based reform is very problematic,” says Peg Portscheller, executive director of the Colorado Association of School Executives and a former superintendent. “Districts are finding it necessary to get real, real creative” in meeting the needs of not only students, but also adults.

Solutions to improving health care vary widely according to districts’ obligations and resources. Some schools have sought training for administrators to give out medicines or have increased their reliance on health assistants who lack a nursing license. Principals have lured retired nurses back to school part-time and have solicited volunteer services from local medical students. Building administrators have juggled staff positions to squeeze a nurse’s salary from a burdened budget or have sought grants from local and federal agencies.

Hospitals, local health agencies and national health organizations also have stepped up efforts to assist schools. Health agencies are supplying medical experts who serve as advisers on school health councils. Hospitals are providing doctors who periodically visit schools to perform checkups. Some national organizations, such as the American Cancer Society, have launched training programs to educate administrators about strengthening and coordinating school health services despite budget limitations.

Turf Fights
At times, the partnerships between schools and outside organizations and agencies can create some friction over control and staffing. But some school officials who have created formal relationships with outside groups have found them surprisingly free of logistical headaches.

“Occasionally, we’ll have a county board that wants to have a turf issue,” says Don Kussmaul, superintendent of East Dubuque, Ill., Unit School District 119. The county health agency runs a clinic at the high school so that uninsured children and community members can obtain screenings and immunizations. “But normally, if the school and the health agency can work together and leave the politics out of it, it gets solved pretty easily.”

Lucinda Mejdell-Awbrey, coordinator of student support services at the Visalia Unified School District in central California, says she helps avoid potential conflicts by preparing written agreements for partnerships. These agreements can specify rules of confidentiality and information sharing as well as insurance coverage.

“You need to clearly delineate what each partner’s going to do and have opt-out language in case somebody loses funding and needs to step out,” she says. “If another agency is placing a person in the school system to provide services, it’s important to state who’s going to supervise that person. If either partner has conditions or concerns, they need to be addressed in the agreement.”

Coordinated school health efforts appear likely to expand in the coming years. Already health organizations are framing student wellness within the context of school improvement. The No Child Left Behind Act is further straining scarce dollars, but it also could spur administrators to address student maladies that might hamper learning.

“With No Child Left Behind there are going to be additional opportunities to look at kids as far as their physical, emotional and social health to make sure they are going to be in the best possible position to achieve academically,” says Charlotte Burt, president of the American School Health Association and a former school nurse. “More than any time in my life, the situation with achieving academically is requiring choices of districts and administrators.”

Judy Robinson, executive director of the National Association of School Nurses, also invokes the new law, arguing that “students will not meet standards if they’re not healthy.” She says regular nurses can identify chronic diseases such as diabetes or asthma that untrained or periodic workers might miss. Nurses also could take a leading role in environmental health, helping to uncover why children in certain classrooms might be suffering from allergies.

Board Reluctance
While nurses can help schools launch an indoor air quality program, one superintendent used his indoor air quality program to help him hire a nurse.

Kussmaul, a member of the AASA Executive Committee, had been trying for two decades to convince the school board in East Dubuque, a 628-student district in northwestern Illinois, that he needed a full-time nurse on staff. But the board always seemed to feel the rural district’s limited dollars must be spent elsewhere.

In 1999, after learning about the Environmental Protection Agency’s Tools for Schools indoor air quality program, which is being distributed by AASA, Kussmaul launched a systematic inspection of the district’s elementary school and high school. During that inspection, Kussmaul learned that a secretary at his elementary school of 400 students had to administer 43 containers of Ritalin each day. The potential hazards made him cringe.

“The phone rings, a person’s standing there and she’s trying to answer their questions, and a child’s grabbing the cup and water to take the medicine,” he posits. What if the harried secretary, momentarily distracted, did not witness a child taking an improper dosage? Or what if the child didn’t swallow the pills at all, instead giving them to a friend?

Kussmaul presented his findings to the school board, which gave him permission to seek a grant from the county health department. The county health department agreed to finance a district nurse for one year. At the end of the year, convinced of the nurse’s value, the school board found enough money to keep the nurse on staff, and she alternates between the elementary school and high school.

“Now, with the nurse’s office and the nurse’s care, everything is supervised, as it should be,” Kussmaul says. “We could not get rid of a nurse now for anything.”

Staff Adjustments
At Nathaniel Alexander Elementary School in Charlotte, N.C., Principal Dee Saltrick shudders to imagine what she would do without a nurse. The county health department, which had provided nurses to the school district in years past, announced last summer that budget cuts had forced it to reduce the number of hours nurses could spend in each school. A nurse would come to Saltrick’s school only once a week.

But Saltrick felt a full-time presence was indispensable, not only because the nurse administered medicine and decided when to send sick children home, but also because she served on a team that analyzed why children might be struggling academically. The nurse was able to offer a health perspective, suggesting that certain children might not be eating regular meals or might be suffering from poor nutrition. She also taught older children about proper diet and exercise.

So Saltrick juggled her own budget. She decided to convert a half-time secretarial position and a half-time teacher assistant position to assign a secretary to the nursing clinic full-time. The secretary, whose health-care responsibilities will expand gradually as her knowledge and comfort level increase, will be responsible for administering medicines to students and keeping track of their dosages. She also will build a rapport with parents so they still have a health care point-person at the school.

“We know kids have to be healthy if they’re going to learn,” Saltrick says. “You just have to be creative once in a while.”

Applied Training
Recognizing that schools are coping with multiple demands, the American Cancer Society has launched a leadership development program to encourage creative approaches to health needs.

For years, the cancer group had asked schools to teach children behaviors that would help prevent cancer, such as refraining from smoking and exercising regularly. But then the society’s staff and volunteers began wondering whether they could find a better way to achieve their goals.

“There’s a lot on everyone’s plate, and then an organization comes in and says, `Please teach this,’” says Beth Stevenson, director of children and youth initiatives at the American Cancer Society. “So we talked to district administrators about how we could strengthen health programs in schools and achieve all of our goals.”

After hearing that school leaders needed more training and help finding resources, the American Cancer Society launched a nationwide leadership skills training institute for district-level school health coordinators. The district applications had to indicate that the superintendent and school board president supported a health coordinator who could assess the impact of health education classes, the quality of school food services and the adequacy of health staffing, including the number of school nurses.

The first institute, which offered nearly 30 days of training between 1999 and February 2000, helped educators strengthen community connections, such as working more closely with local hospitals. It also taught administrators skills to take advantage of programs that could improve student health, such as Medicaid reimbursements and the U.S. Department of Agriculture’s school breakfast program.

Mejdell-Awbrey of the Visalia, Calif., Unified Schools applied her training from the institute to strengthen her district’s advisory committee that coordinates school health programs. The committee includes school representatives, parents, pediatricians and county health agency representatives.

Concerned about the increasing number of unfit children in the community, the committee started a program in which the school nurses identify overweight students and refer them to the local hospital. Staff at the hospital’s rehabilitation center offer fitness and nutrition classes for the students and their parents.

“You just need those partnerships,” Mejdell-Awbrey says. “We find ways to work on these issues together so that the district is not out there alone.”

Rachel Smolkin is a free-lance writer based in Arlington, Va., specializing in health and education. E-mail: rsmolkin@erols.com