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What does a school nurse do?

Q. What is the role of school nurse?A."Professional responsibilities have not changed overall," said Carolyn Duff, president of the National Association of School Nurses. "What has changed is the increasing number of students with chronic health conditions, including asthma, diabetes and severe allergies. All of these conditions have the potential for life-threatening emergencies. What this means for school nurses is an increasing need to train and maintain a competent team of unlicensed school personnel to prevent, recognize and respond to emergencies.”School nurses' duties expand with changing timesMaria SonnenbergBeyond sniffles and sneezes, they must manage complex conditions and chronic illnesses.(Photo: Tim Shortt, Florida Today)STORY HIGHLIGHTSSome nurses are assigned to several schools during a workweekNational Association of School Nurses recommends a 1-to-750 ratio of nurses to well studentsSchool nurses also go beyond the traditional boundaries of kindergarten to high school students to provide Head Start screenings and physicalsThe Boy Scout motto of "be prepared" equally applies to today's school nurses, who not only deal with the typical bruises and tummy aches that have always been part of school life, but must now contend with a student population that is increasingly more medically fragile.As school systems face budget cuts, nurses must also adapt to a "migrant" lifestyle as they are assigned to several schools during a workweek."There have been a lot of changes in the last 20 years," said Pamelia Hamilton, community health nurse consultant and school health coordinator for the Brevard Department of Health, which supervises the 160 nurses and health technicians who serve public schools in Brevard County.According to the National Association of School Nurses, a third of all school districts reduced nursing staff in the past year because of the recession, and a quarter of all school districts in the nation don't have nurses. In these districts, medical emergencies are typically handled by a school's front office staff, the way they were in Brevard until the late 1980s, when nurses were first introduced to local schools.Brevard's ratio of nurse to students — about 1 per 450 — is exemplary, when considering that Florida, with a nurse-to-student ratio of 1 to 2,537, is at the bottom of the list in the number of nurses in schools. Only Utah, North Dakota and Michigan are worse off in numbers. Vermont, on the other hand, has a ratio of 1 nurse per 396 students.The National Association of School Nurses recommends a 1-to-750 ratio for well students and 1 to 125 in student populations with complex health care needs."People who live here think our nursing program is the norm everywhere, but when they move out, they are in for a shock," Hamilton said."What we do is so extraordinary that we've been recognized with several awards."The health department hires, trains and pays the school district's nurses. In turn, the district reimburses the health department for most costs incurred in running the program.New responsibilitiesThe foremost duty of a school nurse is to keep kids learning as long as possible. These days, that can take the form of fixing an accidentally stapled finger or a nasty cold, as it did years ago, but it can also entail helping a pregnant teen stay in school and teaching them to become a good mother. Brevard's Teen Parent Program, for example, assists about 250 pregnant girls at Palm Bay, Eau Gallie, Titusville and Cocoa high schools.Nursing supervisor Travia Williams Torey McGhee in the Head Start classroom in Cocoa High School in Brevard County, Fla. (Photo: Tim Shortt, Florida Today)"We explain to them what is happening to their bodies and train them to care for their babies," Hamilton said.School nurses today also go beyond the traditional boundaries of kindergarten to high school students. Nurse Travia Williams and her team of technicians travel through the county's Head Start program sites to provide the screening, physicals and related services necessary for the little ones to be better prepared when their school days start.Other nurses are devoted to one-on-one care with medically needy students who otherwise would not be able to attend school.School nurses are also tasked with managing children's increasingly complex medical conditions and chronic illnesses. A child may have a tracheotomy or require nasal gastric tube feeds by an experienced nurse. Nurses may be required to monitor students' insulin pumps and keep track of inhalers and EpiPens. In some instances, Medicaid pays for a private duty nurse to be with the student one-on-one throughout the school day."Professional responsibilities have not changed overall," said Carolyn Duff, president of the National Association of School Nurses. "What has changed is the increasing number of students with chronic health conditions, including asthma, diabetes and severe allergies. All of these conditions have the potential for life-threatening emergencies. What this means for school nurses is an increasing need to train and maintain a competent team of unlicensed school personnel to prevent, recognize and respond to emergencies."Another change is a welcome change," Duff said. "There is now a greater emphasis on prevention and wellness in health care.""School nurses are identifying students at risk for both health and learning problems at an early age and are able to initiate early referrals for intervention and treatment."The National Association of School Nurses lists data that underscores why school nurses' duties are so varied these days. Among students ages 12 to 19, pre-diabetes and diabetes has increased from 9 percent in 1999 to 23 percent in 2008, and 32 percent of children ages 2 to 19 are obese. More than 10 million children suffer from asthma. The prevalence of food allergies among children younger than 18 increased 19 percent from 1997 to 2007.Mental health issues among students are on the rise. School nurses estimate they spent about a third of their time providing mental health services.Overall, 15 percent to 18 percent of children and adolescents have a chronic health condition, nearly half of whom could be considered disabling.ACA's impactThe enactment of the Affordable Care Act could provide an opportunity to strengthen a nurse program that serves the nation's 52 million school-age children. For many of these students, the school nurse is the sole provider of access to health care.Health care reform's emphasis on wellness dovetails with the goals of school nurses, who provide continuity of care and promote healthy lifestyles for students during their most critical developmental years. They perform early intervention services such as periodic assessments for vision, hearing and dental problems with the goal of removing barriers to learning.States are testing different health care models for high value rather than high cost and high volume. School nurses are included in the plan."Health care reform will lead to greater opportunity for school nurses to successfully connect students from low-income families to medical homes, because more students will be insured," Duff said."More widespread access to medical homes will provide greater opportunity for school health services to focus on prevention and wellness and tighter management of students with chronic disease."National Association of School NursesThe Roles & Responsibilities of School Health Nursingby Beth GreenwoodWhen the first school nurse was hired in New York City in 1902, her primary goal, according to the National Association of School Nurses, was to reduce student absences from communicable diseases. In the years since Lina Rogers first implemented the practice of school nursing, the role has expanded, but the goal has not changed. School nurses continue to perform valuable services to schools, individual students and the community.Children's Health NeedsThe rationale for placing nurses in school is based on the concept that a child with unmet health needs will have difficulty learning. School nurses are ideally placed to assess physical, emotional, mental and social health needs of the school children for whom they care. Chronic medical conditions such as asthma, epilepsy, Type I diabetes and mental health problems can increase absenteeism and affect learning. The school nurse can help manage the medical care of students who have chronic diseases, and promote education from the primary to the high school level.Health Education and ManagementThe National Association of School Nurses sees the school nurse as taking a lead role in the school community to oversee school health policies and programs. In addition to providing direct services, the school nurse is ideally placed to promote health education and to integrate health-care solutions into the school setting. As the number of children with increasingly complex medical problems has risen, school nurses have taken the primary role in issues such as the management of medical equipment and complicated treatments while the child is at school.Screening and ReferralsA school nurse may perform a wide variety of direct care tasks such as screening students for scoliosis, vision or hearing problems. When a problem is identified, the nurse will make referrals to the appropriate specialist or work with the primary care doctor to assure the child’s needs are met. The school nurse collaborates with parents or other family members and serves as the liaison between school personnel, family, health-care providers and the community at large.Emergency and Public Health FunctionsAs a nursing professional, prepared at the baccalaureate level, the school nurse often practices independently. In addition to routine care such as medication management and screenings, she may act as the first responder in health emergencies for both students and school staffers. School nurses also perform public health functions such as disease surveillance, to increase the opportunity to recognize a communicable disease outbreak and intervene early. A school nurse also helps to assure immunization compliance and promotes overall student health.Performance ExpectationsThe National Association of School Nurses has a number of expectations for school nurse performance. These include such responsibilities as facilitating normal development, providing leadership in the promotion of health and safety, acting as a case manager and intervening in both actual and potential health problems. The school nurse is an essential component of school educational teams such as committees for special education or individual educational plan teams, which must take health issues into account in their decision-making processes.

As a parent, what did your child's school do that made you say "you can't be serious…"?

This is going to be long because it is alot to explain, I apologize ahead of time.The very first day of 6th grade, at a new school, my 12 year old son had to miss almost the whole day of new classes with new teachers because the school nurse felt that he needed to be in her office the majority of the day to learn about diabetes. It is probably now that I should tell you, he was diagnosed as a type one diabetic 7 years earlier, at 5 years old, before kindergarten had even started. Suffice it to say, he knew more than she did, so he was upset at the implication that he needed to be taught how to deal with himself, so he called me, and I came to the school to see what the deal was, why was she “teaching” him what he already knew?I walked into her office and immediately recognized her as the school nurse from my elementary school 25 years prior. All those years ago, I had moved to a new school in the middle of the year, where I was the new kid and knew no one. My first day, she had come to the classroom to talk to my teacher and saw that I had a scab on my face. It was just a pimple that I had popped and then kept scratching and picking at, but she thought it was an indication that I had chicken pox. She made me stand in front of the class full of students that I didn't know, the ones that already thought I was weird, and lift my shirt so she could see my stomach and back to make sure. You know, because in 4th grade, there is no way it could be a pimple, and absolutely not possible that I was old enough to know if that was what it was or not. I was going through puberty (before the rest of my classmates, I might add) and had pimples on my back that she carefully inspected in front of everyone, making sure to comment on how big and disgusting they were amist the laughter of my classmates. That was only the first of many times that she would prove to me, even as a young girl, that she was a horrible nurse, but it was by far the most embarrassing. So that part of my story is just so you can understand the animosity already building tension between myself and the nurse. I hated her because from my perspective, she was the reason that the kids all called my poxy for years. Of course, she did not remember me.Anyway back to the original point. For weeks after that first day of school, she would pull my son out of class to quiz him on carb counting, and calculating insulin, or berate him for not having a pump, or the “right” doctor. She would call me and try to direct me to financial help, (We didn't need it, we just didn't WANT a pump) or to teach me about giving him insulin. One time she took his juice and fast acting sugars from his classroom and bus and replaced it with what she thought was more appropriate. (In reality, the only real difference was the dollar amount spent, and the name brands) The nurse and I had gone the rounds several times over this, various other things she did or things she said, and how she was so condescending to both me and my son. To be clear, there was absolutely no reason for her to think we didn’t know what we were doing, or that we needed further education on diabetes, he was well controlled and as far as she knew, she had never met us prior to that first day of school. She had no records of him, except the doctor’s order that I sent the school the week before school started. She knew nothing about us! Several times she made comments about it getting easier the longer he had it, and other comments sounding like she thought he was recently diagnosed. At one point, she did tell me that she had never seen a sliding scale like his, (How much insulin he gets depends on what he is eating and what his blood sugar is at, just like every other type one I've ever met) leading me to believe that she is the one that had no idea what she was doing, but also that she doesn't listen.So, now to the day my answer is actually about, the day that made me say “You can’t be serious!” My son called me about an hour after school had started, he was upset, telling me that he was high and she wanted to correct him. (For the non-diabetics here, correction means that you are at this level, but you need to be at this level, so we will give you insulin to get you where you need to be) He had told her no, that is not how this works, we can not correct because I had breakfast less than two hours ago. (we only correct at meals because the ‘fast acting' insulin can sometimes take up to 3 hours to fully affect you. So if you correct in beteeen or after a meal, it will stack on top of itself and all the insulin will hit you all at once, making you dangerously low) She would not listen to him, because again, he knew nothing about his own diabetes, therefore he just didn't know what he was talking about. I told him to put her on the phone, and I repeated what he had already told her, DO NOT GIVE HIM INSULIN UNTIL LUNCHTIME. I was very clear about this, I did not care how high he was, don't do it, you can correct him in 3 hours for lunch. She argued with me, I remember at one point asking her if she thought I was stupid and her laughing. Finally, she agreed that I am his mother, and what I say trumps what she thinks, and plus she did not have the orders from a doctor to do so anyway. (Which she legally needs to do anything)We get off the phone, and I go about my day, fully believing that she listened to us about his treatment. Maybe an hour and a half later, I am in the shower getting ready for work, when I hear my phone ring. I just let the voicemail get it and would check it later. I continue getting ready and decide to check the message while I'm getting dressed. It was my son “Mommy, can you come get me, I don't feel well, I'm light heaeeeeeeee” BANG! I hear shuffling around, and then the nurse yells “I need some help in here!” by this point I am running out the door while putting my pants on in a panic as I run to my car. I hear the secretary on the voicemail say “oh she must be on her way, no one is on the phone.” I get to the school in about 4 minutes, (normally it takes at least 8) no shoes, looking disheveled, pissed, and scared to death. My son has come to by now, he is sitting on the bed in the nurses office drinking a sprite, confused and pale. He has a huge knot on his forehead and can barely talk, but he is able to tell me that he feels a lot better now. I am too pissed and worried to say anything to anyone, so I just pick up him and carry him to my car.So a few things here: the nurse absolutely lied to me on the phone, after telling her to not give him insulin and her agreeing, she hung up the phone and made him give himself a shot. He is not the kind of person to argue with authority figures, and he was also unaware that I had told her no, just as he had, so he hesitantly gave himself a shot, and went back to class. She blatantly disregarded what both of us had told her, forced him to do something he knew he shouldn't, and then sent him back to class. Thank God his teacher is excellent and had been paying attention to him. He saw that he was acting strange and sent him with a buddy back to the office. This could have happened in the classroom, or in the hallway alone without enough time to get him glucagon, ending in a tragedy. Once he got to the office, she had him call me instead of testing himself, so there is no way of knowing exactly how low he was. I do know that by time I got him to the hospital, he was at 87, and that was at least 40 minutes after the fact, after drinking a sprite and getting a one ML shot of basically pure sugar. He was probably in the 30s, if not lower. He was disoriented and weak, she should have tested him herself first, not have him call me. While on the phone with my voice mail, he had dropped the phone, hit his head on her desk, and had a seizure. The insulin she gave him, and the insulin from breakfast hit him at the same time and made him drop way too low. Exactly as we told her it would. Once that happened, she did do everything right and acted quickly, probably saving his life, but it should not have happened in the first place. Not only that, but they never called me back. They just assumed that I was on the phone with him when it happened, they assumed that I knew what was going on. Even after it had been almost 30 minutes and I wasnt there, they still didn’t call me! Had I not decided to listen to my voice mail right then, I have to wonder when they would have actually called me.My husband and I went to the principal and the superintendent the next day, but the nurse still couldn't or wouldn't see how this was the fault of her ego and ignorance. She worked in the district for at least 30 years and I know we weren't the only people that had problems with her. We were told that over the years there have been many, many complaints about her attitude and people skills toward other students and parents. Which makes me wonder why on earth they kept her on as a nurse being so rude and condesending to people. I don’t know of anything of this caliber happening before this, but I do know it was the last time. That is as much as I can say about that…. This incident helped us make sure that several policies and rules were changed as far as diabetics carrying supplies like meters, glucagon, and snacks with them instead of making them keep it in the office, or in their classrooms, but also making it clear that only the parents or doctor can make any changes to a treatment plan. (As it already was, thisbjust made it clearer)Edit to clarify: We met with the superintendent and principal, and then later on with the school board, the police, and lawyers to make absolutely sure that she would never be able to disregard another student or parent’s wishes again. But also so that she understands how a family that has lived with a disease every single day for 7 years can know more about it than a nurse that took a class years ago and only has experience with it every few years when there is child that is afflicted by the disease coming to her office once a day that she has to help. She was forced into early retirement, and was charged with medical neglect. We are still very much in the process of seeing this as far as we can take it, my son could have died at her hands, and you can bet your ass that I am taking this way farther than it needs to go. The law moves slowly, but I have every faith in the world, that justice will prevail, but that is what I meant but that is all I can say about that.

As a doctor, what's the worst illness you've ever had? Did it make you feel more empathy for your patients who suffered the same?

I was a burn patient. My scars have reinforced for me not to judge others by appearance.I am an orthopaedic surgeon. I’ve had broken bones. Some required surgery; some only needed cast treatment. My experience reinforced my previously held belief that opioids (narcotics) were needed only minimally or not all and that pain fades quickly with compliance of a plan like ice, elevation, rest, over the counter medication, early mobilization, etc. I never took any opioids, even with surgery.My wife had a pelvic tumor which escaped two medical professionals’ evaluations; one Gynecologist and one Internal Medicine Nurse Practioner. It reinforced for me that one must be an advocate for one’s own healthcare.My father-in-law is losing his battle with non-alcohol cirrhosis. Most of his home health nurses have been true angels. Only one was a buffoon. It reinforced for me that one cannot accept mediocrity when it relates to your end-of-life care.I have served as a team physician for two professional sports teams, one junior college and three high schools. That 30+ year experience has reinforced for me that team care is year-round and encompasses much more than episodic injury care. It includes education on hygiene, nutrition, carbohydrate loading, hydration, conditioning, cross training, injury prevention, etc. Additionally, parents require the same education to be consistent with expectations of the athletes, if the athlete is still in school.I have served, unwillingly, as the family go-to question answerer for all things medical, even if it’s out of my field. I always defer to the proper medical professional (diabetes care, pulmonologist, gastroenterologist, etc.). I only reinforce what the appropriate provider has recommended and can teach the relative why compliance is crucial 24/7. I never act as the treating physician outside of my field, but it makes relatives feel more secure hearing the plan re-echoed by me. I don’t treat in-laws; but I empathize a lot.I served as a military physician in some third-world areas. It reinforced for me how darn lucky we are in the U.S. to have clean water virtually everywhere, not have to teach our kids where the mine fields are, not have to take anti-malaria and parasite medicine on a regular basis.I serve as treating physician for other health care professionals who request me to be their doctor. It’s an honor when another doctor wants you to be their doctor. It reinforces for me that the brightest, most educated people revert to about 8th grade level of mental function when they are facing their own personal medical issue.In addition to being a doctor, I also do medical research. It has reinforced for me that everything in healthcare needs to be evidence based.I was the healthcare surrogate and older brother for a brain-injured sister who succumbed to stage 4 cancer. It reinforced for me that a living will and careful thought about end-of-life choices need to be considered before the decisions are forced by circumstance.I’ve helped patients with terminal illness decisions. It reinforced for me that personal dignity takes many forms and means different things to different people at different stages of life and illness.Doctors are people, too. At some point in our lives we all are patients, just as our family members will be. I strive to treat my patients just like I would as if they were family. That perspective has always served well.

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