School Days
Although budget cutbacks are restricting hiring in some states,
America's school districts are facing an unprecedented need for school
nurses who can provide care to students with a diverse range of cultural
and medical needs.
By Sally Parker
Little Joey (not his real name) was blue-literally. Born with a heart
defect that left him breathless, he couldn't climb the stairs or run
around the playground at his Dallas school with the other children.
But a team of professionals, led by the school nurse, had a plan to
remove the barriers created by the preschooler's condition. School medical
and social workers, his teacher and the hospital where Joey received
treatment showed staff and other teachers how to adapt activities for
him. They educated his classmates. They worked with his parents, fine-tuning
solutions perfectly suited to his personality and physical needs.
Surrounded by people who cared, Joey excelled academically and became
popular among his classmates.
"We had to be sure that normal school activities could be adapted
to his physical condition," recalls Suzanne Medrano-Kubelka, RN,
MSN, APRN, BC, director of health services for the Dallas Independent
School District. "He's in the second grade right now."
Much has changed in the specialty field of school health since Lina
Rogers-generally acknowledged to be America's first school nurse-was
placed in a New York City school more than 100 years ago. Given a month
to make a difference in the absentee rate of children (New York was
one of the first cities in the world to mandate attendance), Rogers
was successful, and on November 4, 1902, she had a permanent job.
But one thing hasn't changed: The goal of school nurses is still to
advance the well-being, academic success and lifelong achievement of
students.
If you love children, enjoy being a health resource in a non-medical
setting and work well both on your own and in a team, school nursing
could be the ideal career for you. While hiring prospects vary widely
among school districts, depending on budget allocations, never has there
been a greater need.
"The biggest [reason why nurses choose this specialty] is the
kids. Working with them, you know you make a difference," says
Judith Robinson, RN, PhD, FAAN, executive director of the National Association
of School Nurses (NASN). "You're giving kids the ability to do
their best."
Cultural Competence Goes to School
Thirty years ago, a child like Joey probably would not have been in
school at all. But when Congress passed the Individuals with Disabilities
Education Act (IDEA) in 1975, students with severe medical conditions
became mainstreamed into standard classrooms.
These days a school nurse is as likely to insert a urinary catheter
as to check a temperature. Children who once required hospitalization
or 24-hour institutional care now come to school. They have a variety
of conditions that require monitoring, including bone and muscular diseases
(such as spina bifida), seizures, heart disease, diabetes, asthma and
other chronic illnesses. They need tube feedings, insulin shots and
nebulizers.
The medications and procedures that school nurses can administer vary
according to the laws of each state. But "anything you ever saw
in a hospital you now see in a school," Robinson says.
Naturally, school nurses provide life-saving care during emergencies
and a place to rest for students who are feeling feverish. But they
also screen for diseases, including a burgeoning number of asthma and
diabetes cases, especially in racial and ethnic minority children.
"We have a significant number of children with asthma [in the
nation's schools]," Robinson reports. "And we've seen a significant
increase in the number of children with type 2 diabetes and excessive
weight gain early in life." Type 2 diabetes, which used to occur
primarily in adults, is linked to poor eating habits, excess weight,
inactivity and a predisposition to the disease.
According to the American Diabetes Association, 15% of American Indians
and Alaska Natives and nearly 11% of Hispanics are now thought to have
type 2 diabetes, compared to roughly 6.2% of the nation overall.
Students in low-income urban and rural areas are especially prone to
the insufficient nutrition and sleep that lead to poor health. As a
result, health education is a major priority for school nurses in these
communities. It is the school nurse who educates students and teachers
about health issues. One-on-one and in front of a class, nurses guide
students to take responsibility for their own wellness. They also show
teachers and staff how to handle medical emergencies and meet the special
needs of mainstreamed students with serious medical conditions.
School nurses also perform a community service role, advocating for
children who are experiencing family or social problems and assessing
students' mental health. Because this kind of work requires the nurse
to build a relationship of trust with the student and family, nurses
who share the same ethnic or cultural background as a minority student
are often in a better position to establish such trust. At the very
least, they are more likely to be aware of potential cultural barriers
that can keep students from reaching out.
"School nurses need to be sensitive to the cultural and social
differences among students," says Medrano-Kubelka, who is Hispanic.
"Each culture brings with it some differences." In her Texas
school district, students speak more than 57 different languages. The
area has a large Hispanic population and a grow-ing number of Asian
Americans.
School nurse Olivia Hernandez, RN, who speaks Spanish "mas o menos"
("more or less"), worked in a doctor's office and a hospital
coronary care unit before settling comfortably into what she calls her
niche 29 years ago. "I knew [school nursing was right for me] the
minute I came in," she remembers. "I feel like I touch a lot
of children's lives, and their parents' as well."
Hernandez, who works at Urban Park Elementary School in East Dallas,
Texas, sees her role not only as that of a health care provider but
also as an open-door health educator and community resource. Her clinic
walls are covered with brightly colored posters that teach health lessons,
like handwashing and asthma care. She helps families track down insurance
coverage, fill out forms, find doctors and dentists.
She also enjoys being a role model for the school's largely Hispanic
population. Posters in her clinic proclaim "I want to be a doctor"
and "I want to be a nurse," prompting questions from curious
students. She tells them she went to nursing school and had training
to do her job, and that they, too, can find a rewarding career in the
health care field.
Reaching Out to Troubled Teens
Other school nurses agree that being an advocate and role model for
students is a vitally important part of their job. In fact, their work
often has just as much to do with keeping a student on track as dealing
with the medical issues he or she may have.
For example, Sharon Gooden, RN, was teaching a student newly diagnosed
with diabetes how to live with his disease when she noticed other problems
that needed addressing. The teenager was coming to school on an empty
stomach and without taking his insulin. The health issue became a social
one when she realized his family wasn't caring for him properly. Gooden
enlisted the help of a social worker and doctor to get the whole family
on board to treat the student's illness.
"You're an advocate, definitely," says Gooden, an African-American
school nurse who works on temporary assignments through Comprehensive
Resources, Inc., a staffing agency that provides nurses and other health
professionals to schools in New York City. "In many cases, a school
nurse may be the first to pick up on these kinds of issues."
Her goal now is to teach the student to manage his diabetes, because
he'll have it all his life. For teenagers wrestling with the challenges
of puberty, this can be a tricky proposition. Learning to manage a chronic
medical condition on top of everything else can seem overwhelming to
them. School nurses can help not just by teaching but also by applying
their negotiating skills.
"Sometimes there's a lot of resistance and denial [in teens],"
Gooden explains. "Sometimes we actually have to physically go look
for them because they will not come into the clinic on their own, either
because of denial or because they don't see the importance. But other
times, I lay back and keep silent so that I leave an entrance for them
to come back in my door."
For Gooden, who has been an RN since 1968, school nursing offers an
ideal setting to help prepare teenagers for the responsibilities-health-related
and otherwise-of adulthood. She particularly enjoys talking with girls
about careers and self-esteem.
"We have a lot of students who really just come by because they
need nurturing," she says. "If you are approachable, they'll
start telling you about other issues you can help them with."
A Great Career-But Are There Any Jobs?
Many specialty areas of nursing have been hit particularly hard by
the current RN shortage, and school nursing is no exception. The U.S.
Department of Health and Human Services recommends a ratio of one school
nurse for every 750 students. Yet in some parts of the country, such
as Virginia and Oregon, nurses are actually facing nurse-to-student
ratios of one-to-2,000 or even higher.
Unfortunately, a lack of nurses is only part of the problem. While
many of the nation's hospitals are going to unprecedented lengths to
recruit more nurses, the school nursing shortage is a more complicated
situation. Ironically, even though school nurses are urgently needed
all over the country, some school districts aren't hiring-because they
can't afford it.
Education budgets are tight these days, and educators have a sharp
eye on the bottom line. Unless a school has special health issues or
needs, nursing can be one of the last priorities for funding. Most school
nurse salaries are paid by federal and state education dollars-money
that educators are likely to funnel elsewhere, especially in cash-strapped
districts where there aren't enough textbooks to go around.
Sometimes schools are not even aware that they are allowed to allocate
government-provided education funds to health care. When the federal
Elementary and Secondary Education Act, also known as the No Child Left
Behind Act, came up for renewal last year, the NASN successfully lobbied
for language changes that included school nursing services. The goal,
says Robinson, was to let schools know without a doubt that they can
use those education dollars to hire and retain nurses.
In passing IDEA, the federal government ensured that all students,
including those with disabilities, would have access to education. But
how a school district addresses students' health needs is an entirely
local decision.
As a result, some school districts aren't recruiting nurses-but many
are, driven by local and state mandates for reasonable nurse-student
ratios. One of the best examples is Vermont, where state law requires
that a school nurse be available for every 500 students and that every
school have a nurse. On the other hand, one of the most challenging
job markets is Colorado, where the ratio at some districts is one nurse
to 8,000 or 9,000 students.
The severe shortage of nurses in many school settings often means unqualified
people, such as teachers, are performing nursing procedures out of necessity
for the students who need them-essentially practicing nursing without
a license, which is against the law. But budget constraints prevent
many schools from filling those roles with qualified nurses.
To bridge the gap, some districts around the country hire LVNs and
LPNs as school nurses. Others, like Vermont, continue to insist that
a school's primary nurse be an RN.
Fortunately, many inner city schools have survived health staffing
cutbacks because budget officials are aware that school nurses provide
essential services to students who are more likely to have limited or
no access to other health providers, Robinson notes. On the other hand,
some rural districts in the South would love to find nurses but have
been unsuccessful, in part because they cannot afford to pay a competitive
wage.
But despite the difficulties of the current job market, school nurses
have one of the highest rates of job satisfaction in the nursing profession,
according to a survey by the Health Resources and Services Administration's
Bureau of Health Professions, Division of Nursing.
"What we find is that most people who get into school nursing
either leave within a year if it's not a good fit for them, or else
they stay for the rest of their career," Robinson says.
As for school nurse salaries, a recent NASN member survey found that
most respondents earned between $20,000 and $49,000 a year. (Information
on hours worked was not asked.) Sixty-eight percent are paid on a teacher
salary scale, and roughly 26% earn less than teachers. Nurses on a teacher
pay scale usually work 180 days a year, earning a starting salary of
$20,000 to $28,000.
Some school nurses supplement their income during the summer by covering
for vacationing hospital nurses or working as summer camp nurses.
The Dallas Independent School District is in the midst of beefing up
its nursing ranks, Medrano-Kubelka says. Two years ago, when the district's
ratio had increased to one nurse for every 1,300 students, the board
of education approved a measure to lower the ratio to 500 students per
nurse. With about 165 nurses in 216 schools, the ratio is improving,
but the district is continuing to hire more nurses.
According to Medrano-Kubelka, the district is looking for RNs with
a bachelor's degree in nursing and experience in a number of areas,
including ICU, emergency and community health. Depending on previous
school nursing experience, the beginning salary is approximately $35,000.
"We are always willing to consider an applicant," she adds.
"If we're not hiring just then, we'll always get back to them.
The potential to be hired is good."
To attract more candidates, the district offers a mentoring program
which pairs new school nurses with experienced leaders during their
first two years. The mentors and mentees meet every two weeks or so
to go over competencies in key areas.
Getting Your Foot in the Schoolhouse Door
Some school nurses, like Gooden, find that working for a staffing agency
is a good option. These agencies contract with school districts to fill
gaps in nursing coverage. For instance, Comprehensive Resources has
a contract with New York City public and other schools to provide nurses
for a variety of assignments. The nurses can work in a wellness setting
or choose to assist children with special medical needs. And they can
pick the age group they prefer.
"It's important for the agency to make the right fit," says
Lynette Lewis, MBA, MLS, Comprehensive's director of nursing services.
"The nurses have to suit the students and the school has to suit
the nurse. Some nurses may want to do more wellness work, while others
might want to focus on medically fragile children."
School health is unique among nursing jobs in one important way, Robinson
notes: The culture is different. The education field has a rhythm distinct
from that of a hospital or other acute-care setting. While there's plenty
to keep nurses busy, the pace is less frenetic, the emergencies fewer.
Here the emphasis is on promoting health and preventing disease.
Robinson advises nursing students who are considering this specialty
to do a pediatric rotation in a school to get a feel for the job. Training
or experience in pediatrics and community or public health is the ideal
background for a school nurse. Some nursing schools even offer degree
programs in school nursing. One of the best known is the Advanced Practice
in Primary Health Care: School Nurse Practitioner MSN program at Seton
Hall University College of Nursing (South Orange, N.J.), one of only
five such programs in the U.S. listed in the National Directory of Nurse
Practitioner Programs.
Gooden doesn't hesitate to recommend her chosen specialty to other
minority nurses. "Hospital nursing is not the only thing out there,"
she emphasizes. "You have other choices. And school nursing is
an excellent one."
Sally Parker is a free-lance writer living in Rochester, N.Y.
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