An article in the Birmingham News (dated 4/14/08) brings to light the present-day reality of the school nurse, whose responsibilities have apparently been increasing astronomically while the rest of us have been busy looking the other way.

While school nurses traditionally soothed crying children, administered Tylenol for headaches, cleaned scrapes and contusions, and allowed children with stomach aches to rest during Phys Ed, the 21st-century school nurse sees a higher level of medical complexity than ever before. And as the picture of this new breed of school nurse is painted more fully, it looks less and less like the school nurse of my childhood.

According to the Birmingham News article, school nurses can expect to see children who need feedings through gastric tubes, intermittent catheterizations, tracheostomy care, ventilator management, as well as the management of complex medication regimens including multiple psychotropic agents. The article elucidates that new life-saving technology has substantially decreased the mortality of premature children. Therefore, these children grow to subsequently develop chronic health conditions that necessitate medical monitoring throughout their educational career. Many other advances in medical technology now allow students who would have previously been kept at home or in an institution to attend school, a factor also bringing more medically complex students into school systems around the country.

With the rise in childhood obesity, it would be easy to surmise that children who are status post bariatric surgery would certainly be frequently sitting down in the offices of school nurses across the country with a variety of complaints. Coupled with the epidemic of childhood obesity and diabetes, school nurses are also more likely to have significant numbers of diabetic children under their care, necessitating the administration of insulin and glucagon, random blood sugar testing, and symptom management. And in terms of other factors, Alabama schools have medical letters on file requesting that 9,000 students statewide have automatic external defibrillators in their schools.

In Alabama, due to increased demand for skilled school nurses, funding for these positions has increased from $6 million to $33 million in the last two years, and Alabama now has approximately 1,100 nurses working in approximately 1,500 schools throughout the state.

Meanwhile, in Mesa, Arizona, budget cuts are causing school nurse positions to be scaled back. According to an article published in the East Valley Tribune, anxious parents worry that untrained non-medical staff will not be able to assume the responsibilities usually fulfilled by nurses, and many fear that their children’s health is at stake when multiple schools share one nurse.

In terms of nurse to student ratios, an article in The Novato Advance (Novato, CA) states that The National Association of School Nurses recommends a ratio of one nurse to 750 students. In California, there are reportedly 1.8 nurses per 8,000 students, and state budget cuts may increase that ratio significantly in the next fiscal year. Per a position paper on the website of The National Association of School Nurses (NASN) vis-à-vis the management of students with chronic health conditions, Delaware is the only state in the nation that mandates a full-time nurse be assigned to every school building in the state. Their website elucidates the need for trained nurses in schools thus:

The main issues surrounding in-school health management of students with chronic health conditions are:

*Health care services must be provided for students who qualify for services under IDEA or Section 504 to meet requirements of federal laws.

*State health laws, including nurse practice acts, and education laws decide who will provide the healthcare services (Schwab, Gelfman, & Cohn, 2001), and those laws in most states do not mandate that school health services are provided by registered professional school nurses.

*Effective and safe management of chronic health conditions is complex, requires careful planning by a registered professional school nurse, and may involve delegation of nursing tasks.

*Individualized health care planning is a nursing responsibility and standard of care that is regulated by State Nurse Practice Acts and cannot be delegated to unlicensed individuals (National Council of State Boards of Nursing, 2005).

*A fulltime registered professional school nurse is essential to quality student health services.

*Dependable funding is essential to quality student health services.

For the uninitiated, school nurses might seem like just another purveyor of Band-Aids and hugs for students who scrape their knee or need a shoulder to cry on. However, just a few minutes of research reveals that the role of the school nurse has certainly changed in the last 10-15 years, and that children with chronic illnesses and multiple disabilities are now part and parcel of the mainstream educational system. And while the federal and state governments have indeed mandated such educational inclusion for students with disabilities and chronic illnesses, elected officials still do not make the connection that students also need equal access to on-site nursing care during the school day.

So, the plight of the 21st century school nurse is a difficult one. To render professional and personalized care to thousands of students must not be an easy task, and to do so at multiple sites must be agonizingly complex. School nurses, under stress and overworked, must often feel that they are putting their licenses---and students’ health---on the line every day. It seems that elected officials have not yet realized the value of having licensed professional nurses in every school (except in Delaware, that is), and it will take vocal and concentrated pressure from voting parents to elicit change.

Now that my child is an adult, I think back on the days of childhood asthma attacks and fevers, and I am grateful that my child was always well cared for, even if a nurse was not always on site. For those parents of children with more complex needs, I can only imagine the anxiety that the absence of a nurse in my child’s school would engender. It would behoove state and local officials to reexamine student-nurse ratios in every school district, and to collect data vis-à-vis the number of students with chronic illnesses in each school. We all want our children to be safe and healthy, and school nurses provide a professional safety net during the day when parents and children are naturally apart. Schools bare the responsibility for children’s safety on the playground and in the classroom, and school nurses should be an intrinsic part of that system of support.
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NurseKeith is a nurse, writer, blogger, and nurse consultant. Please feel free to visit his blog, Digital Doorway .

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