More Than Band-Aids

There was a point in Meri Jackson's life when she was embarrassed to say she was a school nurse. Rubbing elbows with neonatal nurse practitioners and emergency-room nurses who worked with cutting-edge medicine and lifesaving procedures, Jackson felt her nine-months-a-year battles with tummyaches paled by comparison. When she started her career in school nursing in 1976, she wasn't even allowed to administer immunizations.

Today it's a different story. Like most school nurses across the country, Jackson has seen her responsibilities grow dramatically in number and complexity. School nurses are managing care for more children with chronic conditions such as asthma and Type 2 diabetes. At the same time they are doling out more and more psychotropic drugs, such as Ritalin and Prozac, and performing involved medical procedures for students with severe disabilities--a population newly mainstreamed into the public schools by force of federal antidiscrimination laws. "We're not sitting in our offices waiting to clean off a skinned knee anymore," says Jackson, a school nurse in San Diego. "School nurses are out there on the front lines of health care."

What is worrisome, however, is that they are few and far between. The National Association of School Nurses recommends a student-to-nurse ratio of 750 to 1; most of NASN's members, however, serve 1,000 to 2,500 students. To help alleviate the shortage, a growing number of states--including California, Virginia and Florida--are considering investing money from tobacco-lawsuit settlements in hiring nurses. The hope is that with more nurses, school districts will be able to see successes like those at a 3,000-pupil district in McComb, Miss.

In McComb, where 90% of students are poor enough to qualify for a free lunch, the schools enjoy a comparatively low student-to-nurse ratio of 500 to 1. "You can have all the bells and whistles as far as technology and facilities go," says superintendent Pat Cooper. "But if at the beginning of the day you start with an unhealthy child, there isn't a lot of learning that can go on." McComb health coordinator Norma Krapac and her staff sought to deal with a growing asthma problem in the district by teaching students about what triggers their attacks and placing nebulizers in every school. As a result, absenteeism among asthmatics has fallen. School disciplinary referrals have also dropped since a plan to put a nurse in every school was implemented. "When a child skips class or misbehaves, there's usually a lot more to it than meets the eye," says Krapac. "Maybe that child is avoiding a bully, for example. Nurses are in a position to notice those things." Krapac and her staff perform many tasks school nurses would never have considered their responsibility just five years ago--haggling with health insurers, counseling kids with mental illness, transporting children to dental appointments and even teaching them basic skills like hand washing.

As demanding as this swarm of unofficial chores is in McComb, it is far tougher in districts where one nurse is responsible for up to several thousand students, sometimes spread throughout as many as 10 buildings. That kind of work load is typical in Illinois, where the state school-nursing association lobbied unsuccessfully for tobacco-settlement money to go toward hiring nurses. In such cases schools rely on lunchroom supervisors and secretarial staff for basic first aid and call 911 for anything more complicated, says Phyllis Pelt, director of the school-nurse certification program at the University of Illinois at Chicago. "Something as simple as a ring being stuck on a child's finger and it getting swollen--schools will call 911 for that if the nurse is out of the building," says Pelt. "It's a tremendous waste of resources, but how can you blame them?"

Pelt has introduced new topics into her curriculum, such as how to give presentations and interpret school demographic data. "Today school nurses need to be marketers in some ways," Pelt says. Nurses must know how to communicate with administrators on the need to hire a health aide, for example, or how to lobby a principal to fix water fountains so kids can get a drink from somewhere besides the soda machine.

Most school nurses are pleased to be tackling the new challenges, Pelt believes. But she is nostalgic for the days when children's needs weren't so great: "The problems we're seeing today can't be helped with a Band-Aid. We wish, for the kids' sake, that they could."