Today marked a professional and personal highlight for me, one I will always cherish. I was a panelist for the Future of Nursing 2030 Town Hall in Philadelphia. I am sharing my statement to the committee in this blog post. For those who supported me, coached me, listened to me practice and helped me navigate this high stakes event, thank you, thank you, thank you. A special appreciation to Dr. Susan Hassmiller for her invitation to participate and for always championing the work of school nurses.
A 4-year-old preschool girl is stuffing her school lunch into her pants pockets instead of eating it at school. This same little girl refuses to eat her breakfast or afternoon snack because she is "saving her food for home." Her family escaped a dangerous Central American country and traveled for more than a year, mostly on foot, to seek asylum. The school administrator asked: "how can we help this family?" I thought how can we help a traumatized family assimilate into a foreign country with nothing but what they could carry on their backs? It is a big question, one that repeats itself in my school community and many others across the country.
I am a school nurse, a relentless one because that is what it takes to care for students and families with complex health, emotional and social needs. September will begin my 19th year serving the families of Camden, New Jersey. This urban school district is 13 miles from my house, but a world away with 37% of families living below the poverty level, and a 10-year gap in life expectancy. The two zip codes between where I live and where I work tell a story of the impact of privilege vs poverty.
School nurses are “population health gold” because we are at the epi-center of the concerns that children bring to school every day. From increasing gun violence in schools and communities, threats to undocumented families, the opioid crisis, homelessness, hunger, racism, transportation barriers, chronic absenteeism, mental health crises, adverse childhood experiences and I have not even mentioned one health issue, we function in a hidden healthcare system that has been widely misunderstood. Being relentless is our only choice.
Dr. Erin Maughan, Director of Research for NASN, published an article entitled: School Nurses: An Investment in Student Achievement. “With nearly 20% of students entering school with a chronic health condition, such as asthma, life-threatening allergies, diabetes, and seizure disorders (U.S. Health Resources and Services Administration, 2016), school nurses provide direct care (checking blood glucose, providing treatments) to students with these needs; empower students to manage their own chronic conditions; and work with students’ healthcare providers, school staff, and the community to coordinate students’ needs. At the same time, school nurses can detect illness early, prevent its spread, and identify students at risk, while also advocating for the well-being of the entire community.” The Return on Investment is at least 2:1, it could actually be much higher, but additional funding for research is needed.
One of my personal and professional goals has been to amplify the voice of school nursing and elevate the profile of our profession. I do this through a weekly blog called, what else, but The Relentless School Nurse. I spotlight the work of school nurses around the country and leverage the power of social media, specifically Twitter sharing these important stories that illustrate the impact of school nursing on children, families, and communities.
But we cannot work in isolation, although school nursing can feel isolating at times. The overwhelming needs of the students and families I serve, coupled with my niece surviving the 2018 school shooting at her Parkland, Fl hight school, turned me into a school nurse activist. My outrage fuels my actions and I now sit on the advisory board of AFFIRM Research, a national a-political gun violence prevention research organization where I am, but should not be, the only nurse.
There is a saying in public health that you can’t boil the ocean, but YOU can boil your part of the ocean. To continue the metaphor, here was one of the flames that got the temperature of my part of the ocean rising. In 2015, I became a Johnson & Johnson School Health Leadership Fellow, a member of an interdisciplinary team that included 3 school nurses and two community partners to look at overuse of the ED by Camden families for non-emergent care.
We introduced Community Cafes, an evidence-based program, and asked what was working and what was not working with your child’s healthcare experiences? We asked the experts, parents, and caregivers, and their answers were inspiring. The biggest takeaway message was that parents want to feel connected to their child’s healthcare provider. If they could not see the provider that they had a relationship with, they would go to the ED because they would be speaking to a stranger anyway. Not one parent mentioned convenience, the answers highlighted either the presence or absence of relationships.
Moving outside of the four walls of my health office allowed me to work with community-based organizations. The work has evolved over the past 5 years and now includes a collaboration with The Camden Coalition of Healthcare Providers and the NJ Chapter of American Academy of Pediatrics. Our group is called the Healthy Spaces Community Collaborative of Camden, with a focus on ACEs, Trauma-Informed Care & Violence Prevention.
In 2016 the Rutgers-Camden SON’s school nurse certificate program, where I am on faculty, received a grant by the New Jersey Nursing Initiative to redesign our program to infuse population health and leadership. Rutgers Camden Nursing was the first program in the nation to build the school nursing curriculum on NASNs newly introduced Framework for 21st Century School Nursing Practice. Based on the revision, our program moved from a post-Baccalaureate to a graduate-level certificate and infused population health and leadership into the coursework. The second cohort of school nursing students are completing their rigorous program and now have an option to pursue an MSN in school health services. They will begin their practice with foundational knowledge that being embedded in community is one of the principles of school nursing.
School nursing is a specialty practice with a National Certification designation. There are states where school nurses are certified by the Department of Education, like NJ or the Department of Health, but there is no Universal School Nurse. The title of “school nurse” varies from state to state based on regulations that exist. Some states employ Unlicensed assistive personnel (UAP). While UAPs provide important care, they are no substitute for a registered nurse. Fewer than 40% of US schools have a full-time school nurse. 35% employ a part-time nurse and 25% of schools have no school nurse.
The Philadelphia school district eliminated 100 school nurse positions due to budgetary concerns. Two students died within 8 months of each other, and in both cases, a school nurse was not present. One of the students became ill at her Philadelphia elementary school and died later that night from respiratory failure secondary to asthma. A nurse was assigned to her school just twice a week. The day that she died there was no nurse present.
School nurses are first responders to all emergencies, including school shootings. Since 2018 there have been 38 school shootings reported nationally. This slide reflects 2018 data, but so far in 2019, there have been 14 additional school shootings. It is no surprise then that, students and teachers feel unsafe at school and families live in fear that their school will be next. Active shooter drills are now part of the fabric of school, another challenge for school nurses to expertly manage. We need research to guide our practice, including the efficacy of emergency preparedness programs like active shooter drills, and teaching Stop the bleed training to students and staff.
Every Student Counts, NASN’s new data Initiative is designed to encourage a robust national school health data set that will:
- Influence local, state, and national student health policy;
- Identify best practices in school health; and
- Better understand child health.
This design will lead to policies that better support the needs of students, increase evidence-based school nursing practice, and better youth health outcomes.
As Dr. Erin Maughan wrote: “Data helps build bridges that connect school nursing to the rest of the healthcare system. This initiative provides the support and structure for the collection and use of data by every school nurse, but needs funding.”
School nurses are responsible for students from preschool to high school, ages 3 to 21, and have an incredibly diverse practice. Youth and adolescents may come to school with a variety of somatic complaints like headaches or stomach pains, or come in need of accommodations for chronic health conditions and special needs. Students coping with crippling anxiety that is interfering with their ability to learn are also evaluated in the school nurse’s office. We have access to our nation’s 55 million children and see 95% of them on a regular basis. We use our expert assessment skills, but have few tools, limited resources, truncated technology and often work with unrealistic school nurse to student ratios.
School nurses spend up to 35% of their time addressing mental health issues in children and adolescents because up to 20% of students suffer from bullying, anxiety, stress, depression, and similar concerns (Bohnenkemp, Stephan, & Bobo, 2015; Perou et al., 2013).
On July 12, 2019, Massachusetts Representative Ayanna Pressley spearheaded groundbreaking Congressional testimony for the Oversight Committee on "Identifying, Preventing, and Treating Childhood Trauma” credited a school nurse for saving her by recognizing the signs and symptoms of trauma and abuse she had exhibited, when she was a quiet, silent, but deeply troubled student.
Daily aspects of our practice charge us with identifying health conditions that impact learning. Annually we screen students for height, weight, blood pressure, hearing, vision, oral health and in some states, scoliosis. We refer students who need further testing through our screening process, develop emergency health plans and coordinate care.
As the Chief Wellness Officers of our schools, we also provide health promotion for our students, families, and staff. Ask a school nurse “What Happened in School Today?” the next chance you get!
School nurses are experts with immunization compliance and parent education. We have been boots on the ground in the midst of this current measles outbreak. In April of 2009, a NY school nurse alerted the health department that a large number of students presented with a fever. This trend was identified as the swine flu, the H1N1 virus that spread widely and predominated in most parts of the country.
Nurse Practitioner-led school-based health centers in urban districts are part of the solution to increasing access to primary care and urgent care. Telehealth is another emerging model, especially in rural America. School nurses should be collaborating partners in these centers. School nurses have worked in the hidden healthcare system of school health for more than 100 years.
The first school nurse Lina Rogers was placed in the NYC school system in October 1902 as a great experiment through the innovative idea of Lillian Wald. There is no better place to share the impact of her work than here today as the Future of Nursing 2030 includes school nursing in this important conversation.
This is what we need in order to be able to practice at the top of our licenses and best serve children, families, and communities
- First, we need to be in every school. We cannot make a difference if we are not present. As a recommendation by NASN, CDC, AAP, there should be a full-time school nurse present in every school building.
- Better evidence is needed to guide our practice. Funding for population-based and community-based nursing practice that includes funding for research.
- Prioritize school nursing services in developing collaborative healthcare delivery models between school health services and clinical and community health providers,
- We need to strengthen our collaboration with pediatric providers by maximizing technology. Bi-directional communication by sharing health information electronically would be a logical next step. This is happening on a limited basis in states like DE & CO, but what about the rest of the country?
- A national immunization registry would track our students as they move from state to state.
- School nurses need to be life-long learners and have open access to evidence-based research to guide their practice to keep students safe, healthy and ready to learn.
Let me end with a message from a former student who I had not heard from in 15 years:
Yesterday my son was sent home from school with a project to do on their superhero, so I thought I should tell you that you are mine. I never told you but in the 4th grade, your kind words and warm hugs saved me, one morning you allowed me to sit down in your office because you knew I wasn't having a good day. The night before that was a very bad day for me. The day we talked was the same day I planned to commit suicide, but thanks to your loving and warm felt words and hugs I'm able to be here for my sons and move forward with life. Thank You Soooo Much! I kept this story in for a long time, I just wanted you to know that you matter.
I can't help but imagine what would have happened had a school nurse not been there for this student...
References:
Wang, L.Y., Vernon-Smiley, M., Gapinski, M.A., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of school nursing services. JAMA Pediatrics, 168 (7), 642.
Willgerodt, M.A., Brock D., & Maughan, E. ( 2018). School nurses in the US: The National School Nurse Workforce Study. Journal of School Nursing.
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