Nursing the Whole Child

A couple of years ago, I sat with a high school student at a school-based clinic as she waited for the results of a pregnancy test. When the test came back positive, our conversation was not about whether she would have to drop out of school — it was about how the school district would support her throughout her pregnancy and beyond.

The student continued to attend classes and, with the support of the registered nurse practitioner and the school nurse, received on-campus prenatal health care and education about pregnancy and childbirth. After delivery, she attended the parenting class provided by the health center.

Last year, sitting on a panel that included Washington’s governor, a state legislator and district administrators, the student spoke eloquently about the support she received from the nursing staff before, during and after her pregnancy and shared her aspiration to attend college and become a nurse.

Health Care’s Evolution

School nurses and school-based health centers do make a difference in the lives of students, which is one reason I take such pride in the career path I chose 17 years ago. Every day, as coordinator of nursing services for the 27,000-student Kent School District in Washington, I have an opportunity to support students on their path to graduation, college and career.

Nurses have been a part of the school setting since the late 1800s. They were first employed by the New York City schools to work with students and parents to fight the spread of communicable diseases that prevented students from attending school.

These interventions proved wildly successful, and the schools experienced a dramatic uptick in student attendance. The role of the school nurse was expanded to include not only providing care but also teaching students how to stay healthy.

Today, school nurses provide episodic care and manage a broad range of acute and chronic health issues. They track communicable diseases such as Influenza A, mumps and measles and handle emergency procedures such as anaphylaxis. They work with parents, medical providers and insurance companies to keep students healthy and attending school. According to the National Center for Education Statistics, they serve nearly 50 million students in approximately 98,300 public elementary and secondary schools.

Chronic conditions such as asthma, epilepsy, Type 1 diabetes, anaphylaxis, obesity and mental health concerns may affect students’ ability to be in school and their capacity to learn. These students require emergency care plans to keep them safe in the classroom. Students who once would have been homebound due to complex illness now are educated alongside their peers.

Medical equipment such as cardiac monitors, ventilators, insulin pumps, gastrostomy tubes and urinary catheters have become common devices to support students in school settings as school nurses strive to integrate students into general education classrooms in accordance with Section 504 of the Rehabilitation Act of 1973, which guarantees students with special needs the same education rights as their peers.

Nurses also respond to the toll poverty and homelessness exact on students. Low-income and homeless students are more prone to poor nutrition, exposure to environmental toxins and domestic abuse. Learning in school is not high on the agenda when students are hungry or do not know where they will spend the night. Nurses work with the larger community to meet these students’ needs by coordinating a weekend food backpack program or finding shelters for students so they don’t have to spend the night on the street.

The Critical Link

A few years ago, I heard that a 6th-grade student had missed 55 percent of the school year. During a home visit with the school nurse and school counselor, we learned the student had asthma and stayed home to share his inhaler with his mother and little brother. The school nurse was able to get the family on state insurance so each person in the family could have their own inhaler. The student was able to return to school and move on to 7th grade.

In Kent, we recognize the critical link between wellness and student success. Our 42-school public education system operates 42 health rooms covered by registered school nurses. Working with the parent/guardian, the student and the student’s health care provider, the nurses develop individual health plans and emergency action plans and provide training for the staff around those plans.

The school nurses work collaboratively with educators on implementing best practices for students with medical conditions, sometimes working one-to-one with the teachers to help them understand how the particular health condition can affect learning.

For example, if a diabetic student’s blood sugar levels are not within normal limits, the student is unable to concentrate on the concepts being taught. This has enormous implications for an elementary school learner who is just beginning to understand reading and math. In addition, the teacher must recognize the signs and symptoms of uncontrolled blood sugar levels and the need for medical intervention.

Emotions also can trigger health concerns such as asthma, a chronic condition prevalent in school-aged children. High-stakes tests, including collegiate entrance exams, can lead to students’ stress-induced asthma, which can be alleviated by medication to dilate their airways to help them breathe. Working with teachers, the nurse should be aware of the students’ testing dates and attempt to schedule asthma treatments prior to examinations.

At the beginning of each school year, our school district’s nurses meet with classroom teachers and administrators to address these potentially life-threatening conditions. They teach staff how to administer medication, protect from blood-borne pathogens and use an epinephrine auto-injector.

We also are sensitive to the dangers of food allergies. Lunch menus clearly indicate foods prepared with allergen-causing substances such as nuts, and school nurses help students, teachers and parents understand how to read food labels.

Allergies go beyond the cafeteria. One family reported that their son was allergic to frogs. While the district’s nutrition services department does not have frog on the lunch menu, the early-year discussions with teachers turned up a discovery that the classroom science kits contained frogs for dissection.

Keeping students safe means establishing a collaborative relationship among the school nurse, all teachers and administrative staff. Communication is key to safety both in the classroom, school house and before- and after-school activities.

Operating Costs

The Teen Health Center, located at Kent Phoenix Academy, one of the district’s alternative high schools, is a critical aspect of our comprehensive plan to support students at risk of failure so they can reach their graduation day. This clinic, which was launched in 2007, was conceived through a fellowship with the Robert Wood Johnson Foundation and is underwritten in part by a grant from the Washington state health department.

In addition, families’ health insurance covers a small part of billable services of the operating costs. Added funding comes from Medicaid billing and state-assisted insurance. There is no charge to the student.

During the school’s planning stage, a district team compiled a list of 15 risks factors for dropping out and subsequently determined that the Teen Health Center successfully addressed 13 of the factors.

Last year, about 88 percent of the school’s 300 students used the Teen Health Center at least once during the year. It is staffed by a part-time nurse practitioner and a full-time mental health therapist. Most of these students are seen regularly for treatment of chronic conditions, such as asthma, diabetes and emotional-mental health disorders. The clinic also offers care for illnesses, immunizations, testing for sexually transmitted diseases and confidential reproductive health care.

We have diagnosed anxiety disorders, helped students obtain their first set of eyeglasses and worked with students who had suicidal thoughts.

While I was visiting an elementary school last month, a kindergarten student proudly showed me how his school nurse taught him to check and measure his blood sugar level. I asked him what the monitor said his blood sugar level was and he told me 275, adding that he would probably need some insulin. I told him I was proud that he could read and do math.

Then he said he had a tummy ache and needed to go home. I went in search of a thermometer and found a new infrared thermometer that I was not familiar with. He showed me how to use the device, took his temperature and then took mine. This is a student who likes to work with his nurse and to take care of the visiting nurse.

Many of our students have developed supportive relationships with their nurse and stop by the clinic and the health room to tell the nurses that they finally passed that difficult math exam or found a place to live, and most importantly, to invite them to their graduation.

Central Connection

The school represents the second most influential component in a student’s life after the student’s home. Teachers, administrators and parents know that a student who arrives at school fed, rested and healthy is in a condition to learn.

Support, care and compassion are integral parts of this profession, and we take a holistic approach to serving our students. Working alongside teachers and school administrators, the school nurses promote healthy behaviors; provide health education to all staff and students in the school; address physical, mental, emotional and social health needs of students; and, in doing so, support student achievement in the classroom.

School nursing is a specialty practice and critical to the health and safety of students. In Kent, we work as partners to keep students healthy, attending school and ready to learn and strive for academic success. Student health is key to student success and academic achievement.