In true school nurse fashion, Cynthia Samuel, R.N., M.S., Ph.D.-C, calls everyone "dear" or "sweetie." But her nurturing disposition belies a certain tenacity. She is determined to eliminate the health disparities she sees every day working in an urban elementary school in Irvington, New Jersey. "I became a nurse because I love working with children, especially underserved, underprivileged children in the urban community," Samuel says.
Samuel's students are part of the most vulnerable population suffering from health and economic disparities, so often disproportionately tied to race and ethnicity. But at school, through the nurse, they have access to potentially life-changing care and support.
Each morning, students of varying ages greet nurse Samuel at her office door. Often, their basic needs have not been met. They are hungry, tired, and they don't want to be at school. "These children are very needy," she says. And it goes beyond food and shelter. "They need love. They need encouragement."
A visit to Samuel's office may be the only professional health care some students receive, as parents choose to avoid a trip to the pediatrician they cannot afford. "They don't receive immediate health care. Oftentimes it's delayed until they see the nurse," Samuel says. And ongoing problems that do make it to a clinician, like a persistent cough, have often been ignored too long. "By the time they reach the doctor, the situation has evolved into a complex matter."
Without a doubt, school nurses are on the front line of pediatric health. The stereotype that school nurses only distribute children's aspirin, bandage schoolyard scrapes, and watch over anyone lying down with a headache is largely misguided. They provide physical and emotional health services, including acute and urgent care in response to illness and injury. They monitor chronic diseases and counsel students and parents regarding condition management. They provide health education for individuals and classrooms, health assessments (vision, hearing, height/weight, scoliosis, etc.), and referrals to primary health care providers and emergency rooms. They also communicate with school staff, parents, and health care providers related to individual student needs, explains Linda Davis- Alldritt, R.N., M.A., P.H.N., F.N.A.S.N., F.A.S.H.A., the president-elect of the National Association of School Nurses (NASN). On the administrative side, nurses review immunizations and maintain students' medical histories.
"School health is a specialty," Samuel says. "It is not the cushy, cushy job many people envision it to be." In an urban setting, where socioeconomic inequalities are most prevalent, a school nurse's practice extends beyond the school building to the community and the students' parents.
Samuel encounters the same health disparities she sees in her school working with residents in outlying neighborhoods. Among parents, she addresses health issues like hypertension, obesity, heart disease, and nutrition. "Oftentimes, what they know about health care is from what the school nurse has instilled in them," she says. And if the nurse does not talk directly to parents, children often serve as a vital link to their families at home, sharing what they have learned about health and nutrition in an unconventional position of influence.
It is an eye opener to the needs of children as well as the needs of communities that people just aren't addressing, says Susan Fletcher, R.N., M.S.N., Ed.D., an associate nursing professor at the Chamberlain College of Nursing in Downers Grove, Illinois. Before coming to Chamberlain, she worked as a school nurse at an inner city elementary school in St. Louis, Missouri.
"I would have kids coming to me with gun shot wounds and stabbings from gangs," Fletcher says. "They would come to me because they trusted me." Some of her students lived in neighborhoods where gang members assaulted children who refused to join their ranks. One boy managed to resist the constant pressure with help from his mother, grandmother, and Fletcher. The abuse escalated to the point where he eventually came to school with a broken leg and arm. But Fletcher and the boy's family maintained their support. Years later, a policeman approached her in a hospital, asking her if she recognized him. After a moment she realized it was the same boy, grateful and happy. "That's why you stay in it," Fletcher says. "That's why you do school nursing."
Often, school nurses are the sole medical expert in a notorious breeding ground for germs. "You need community health training to become aware of the demographic in which you practice," Samuel says, stressing the need for seasoned, veteran nurses. Samuel recommends hospital training; it gives school nurses the experience necessary to become an independent practitioner working under pressure.
Part of her work includes collaborating with the school's cafeteria staff to ensure the healthfulness of the childrens' food. The cafeteria workers must do more with less, she says, providing balanced meals in the midst of extreme budget cuts. She would like to see healthier school lunches in general, but it's especially important in schools like hers, where the economic gaps are widest. Lunch may be the only nutritionally sound meal—or the only meal—some children get. Parents have been known to steal food from the cafeteria as well.
"A lot of the parents don't know what fresh vegetables are, fresh fruits," Samuel says. "They've never been exposed to it," and it's not readily available to them. As a result, their children consume inordinate amounts of processed, canned food for dinner and bring in things like potato chips and blue "juice" to school for lunch. "Salt and sugar—that's all they've had," Samuel says. "We have to be change agents in the behavior." She references Michelle Obama and her focus on fresh, well-prepared foods as an example. (An initiative lead by the First Lady, sponsored by the White House Task Force on Childhood Obesity, released 70 recommendations for curbing child obesity in May of this year, including a 17-point section pertaining to healthier foods in schools. Read the full report and recommendations at www.letsmove.gov.)
However, it is possible to implement changes in the greater community as a school nurse, Fletcher says. The key to a successful health campaign is incorporating the needs of the community. In her experience, promoting an agenda the people do not support is ineffective. "We're so quick to come up with solutions that we don't really listen," she says. Instead, school nurses must talk to parents and other members of the community, gauge their interests, and integrate their ideas.
Working with young children from disenfranchised families presents another unique aspect of school nursing: it can be an emotionally draining job. School nurses must address psychosocial issues, as children recover from the trauma of homelessness, or intervene with children suffering abuse and neglect. Samuel has attended conferences with parents, child protective services, and school administration, sharing her findings and recommendations regarding children's wellness. Parents also seek her input with less severe problems at home and general child rearing issues.
Other school workers may turn to the nurse, knowing he or she can act as a child advocate. A cafeteria worker once came to Fletcher after seeing a child scrounge for food in the school garbage; his mother, a drug addict, could not feed him. Fletcher and school administrators worked with the mother, giving her food and rehab information, and the child eventually moved in with another family member. School nurses need to be able to address these situations as well. "The kids are an inspiration and the families are an inspiration," Fletcher says. "Even with all the heartache, you'll see bright spots."
"We have to reform health care in the schools," Samuel says, calling for increased research and funding, particularly promoting pediatric health in urban communities. Many schools are under funded and under staffed. "We have issues of wide disparity between states on the caseloads of school nurses," says Davis-Alldritt. "Some nurses are expected to care for thousands of students in multiple buildings." She notes that nurses practice in only 75% of U.S. schools. "School nurses will always provide a safety net, ensuring that children are ready to learn," Davis-Alldritt adds. In order for that net to be secure, a nurse must first be present and supported.
A drastic shift in the allocation of education funds during the past 15 years has also cut into the nursing budget. "Many districts respond by lowering the standards of [nursing] care, assigning procedures like catheterization, suctioning, and diabetes management to school secretaries and other personnel who are not prepared," Davis-Alldritt says. "In any other setting, this would not happen—it would be considered unsafe." While the recently passed Patient Protection and Affordable Care Act will eventually impact school nurses and their work, "it will be several years before these measures are implemented, and even then, not all children will be covered."
NASN is working to identify research priorities to determine how to best utilize school nurses. There are also plans to commit government stimulus money to create uniform electronic medical records in schools, allowing nurses to more easily share information with other local health care providers, ensuring the most accurate, up-to-date information. They are small steps on an administrative level, but Samuel cites strength in numbers.
"We need to be unified. We need to have a strong voice collectively to make elected officials aware of who we are, what we do," Samuel says. "We need to be recognized and we need to be advocated for." Samuel says she wants to fill that role, consulting on a state and national level, in addition to her work with students. "I want to be the voice for underserved, underprivileged children," she says. Samuel already campaigns for pediatric health by speaking out on the subject. Healthy children perform better academically, and Samuel says her doctoral research shows the relationship between pediatric health and increased learning readiness. It's easy to use the resources obtained as a nurse to become an advocate for the children, Samuel says. "We do make a difference by being here."
School nurses become enmeshed in the whole life of the school and surrounding community, Fletcher says. Families even came to her for a second opinion after seeing doctors at their local clinic. At times, they function as case manager, policy maker, and consultant. Unique health care challenges, socioeconomic issues, and the public health factor make school nursing a demanding, but rewarding specialty. "You have to love it," Fletcher says. "It's transformative. It changes the way you look at life."