For some children, the arrival of September means a visit with the school nurse. I can still recall my grammar school nurse, who checked our vision, our height and weight, and the straightness of our spines. She was the one who wrote to my parents to inform them that I was nearsighted and needed to see an eye doctor to get glasses. I don't remember her name; she only came in one day a week.
In most school districts, school nurse salaries and costs are part of the education budget—and when budgets are tight, many boards look to the school nurse position as a place to save money. They may cut the nurse's hours to part time, or abolish the position altogether, in which case teachers, secretaries, and other personnel often assume health care responsibilities. In a national survey of nearly 7,000 school nurses, conducted in 2013 by the National Association of School Nurses (NASN), 16% of respondents reported that school nurse positions in their areas were threatened. More than 5% said they'd been told that such positions would be filled by LPNs or aides.
The NASN recommends a nurse-to-student ratio of 1:750 and has made this issue a legislative priority. Yet, according to the 2013 NASN survey, almost half (49%) of the respondents reported caring for far more students. Indeed, many indicated that they covered multiple school buildings or were responsible for an entire school district serving thousands of children.
While vision screening and treating upset stomachs and playground battle wounds remain part of the job, these tasks represent a tiny fraction of what school nurses do today. As NASN president Carolyn Duff recently told me, “The school nurse role has drastically changed in the last 15 years. The student population is different. There are more immigrant students, more children living in poverty, more children likely to have food insecurity and poor health because of lack of access. And there are more students with chronic conditions who need support to manage their illness so they can stay in school. Schools can't afford not to have a school nurse.”
According to the National Center for Education Statistics, in 2010, 95% of children with disabilities were in regular schools. This includes children with chronic health conditions and serious illnesses requiring ongoing monitoring and support. And according to a recent article in JAMA Pediatrics, a study of school health services provided by full-time RNs in Massachusetts found that the top five procedures performed monthly by school nurses were blood glucose testing, lung auscultation, carbohydrate insulin calculation, insulin pump care, and IV infusion care. These nurses also performed catheter and ostomy care, peak flow monitoring, and myriad other required interventions. Having school nurses was deemed cost-effective when weighed against the lost productivity of teachers and parents in their absence and the costs of having these procedures done elsewhere.
Moreover, school nurses are the first responders in on-site emergencies. Delayed access to care can have tragic consequences. For example, in Philadelphia two students recently died at school: last September a sixth-grader had a fatal asthma attack, and in May a first-grader collapsed and could not be revived. At both schools, no nurse was on duty on those days, because budget cuts had changed the position to part time. While it's impossible to know whether the presence of a school nurse would have made a difference, people are wondering.
School nurses are also instrumental in health education and prevention programs, covering subjects as diverse as bullying and food allergies. In this issue, we offer an article by M. Kathleen Murphy, who, as health services director for the Milwaukee Public Schools, helped to develop and implement a protocol for the emergency management of anaphylaxis after two students died following anaphylactic reactions (see “Emergency Anaphylaxis at School”). And it was a New York City school nurse, Mary Pappas, whose recognition that something unusual was happening alerted health officials to the beginning of the 2009 H1N1 flu pandemic.
The needs of students have changed dramatically since Lillian Wald first placed Henry Street Settlement nurse Lina L. Rogers in a school on Manhattan's Lower East Side (see this month's From the AJN Archives for Rogers's 1903 report). But, as a recent NASN resolution affirms, the primary goal of school health services and school nurses remains the same: “to promote health and prevent disease within the school setting.” Today, school nurses are needed more than ever.