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The School Nurse: Her Role Has Changed With Changing Time

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At one Montgomery County, Md., high school, the school nurse is called "Grandma," a nickname that has nothing to do with age.

Like loving, and nowadays often absent, grandparents, she and her colleagues are the first adults to whom students turn for help with a long list of psychological as well as physical difficulties. School nurses, like grandmothers, keep secrets and provide sup port along with remedies. They also manage to withhold judgment when faced with situa tions in which a mother probably could not avoid assigning guilt.

She--most school nurses are female-- knows who is diabetic or allergic to bee stings. She deals with the handicapped children who have come into the student body in the past decade, and with their parents.

She's also among the first to know who is pregnant, who is being beaten or abused, why certain students hang around after school. The one place an adolescent boy can go to cry is in the nurse's office.

School nurses are welcomed into homes and told things that even social workers never hear, because, according to Fay S. Cleary, a school nurse in Des Moines, Iowa, "We have no clout. We don't give grades; we can't take anything away. We are not threatening and are thought of as people who help."

Nurses Feel Threatened

Although school nurses may not threaten, it was apparent during the Washington conven tion of the American School Health Associ ation (asha) last week that many feel threatened by cuts in federal, state, and local education budgets.

"Budget restrictions are making boards of6education review whole programs and some times they look at school nursing as a frill," said Georgia Macdonough of Phoenix, who, like Ms. Cleary, attended the asha conven tion. Both are members of the National Asso ciation of State School Nurse Consultants.

School nurses find themselves isolated in the system and without political power. "Only the parents of kids who have been helped have any idea of what the school nurse does," ac cording to Ms. Macdonough; Ms. Cleary notes that parents of handicapped youngsters are usually the school nurse's strongest sup porters.

Paula Johnson of Baton Rouge, La., is a former hospital nurse who turned to school nursing when her children were small and she needed better hours. She, too, worries about the fu ture. "School nurses have been told, 'You were the last to come and you're gonna be the first to go'."

In many states, funds for school nurses are being cut; nurses who leave are not being re placed and ratios of students to nurses are climbing at the same time that the school nurse is having to handle dozens of new prob lems arising from social and economic upheaval.

Nurses who once spent much of their time doing health screening, occasionally treating a sports injury, or sending a student home be cause of exposure to measles or mumps, are handling everything from the psychological effects of parents' divorce to a rising incidence of youthful hypertension, which Ms. Macdon ough, for one, blames partly on the high salt content of junk food.

Beverly Grotsky, a school nurse from Ful lerton, Calif., works in a school system that once had eight high schools with a nurse for each. Since cuts forced by the passage of Pro position 13, "One high school has been closedand we now have two nurses for the remaining seven.''

"We're being shafted in terms of increased workloads and decreased help," Marilyn Fitz gerald, school nurse at Roberto Clemente High School in Chicago, says. "We lost 10 nurses this summer because of the loss of fed eral funds and have not gotten a new nurse in two years."

Hectic Schedules

In many school systems, nurses' time is di vided among a number of schools; Ms. Fitzger ald has only one school but it has 4,000 stu dents stacked on eight floors of one building with a gym across the street. "My office is like crazy," she says.

A graphic description of how crazy it can get comes from school nurse Mary Ann Heil of T.C. Williams High School in Alexandria, Va., where the school health responsibility for 16,000 students and employees is divided among 15 nurses:

"One day I may be counseling a janitor about high blood pressure while dealing with a child who has been beaten by a parent with a broom handle. There was one day--I'll admit this doesn't happen every day, but it did hap pen that day--when I had one little girl in the clinic who was miscarrying, while another girl was there after a suicide attempt and a third was brought in after having a schizo phrenic episode and running through the cor ridors freaking out."

Ms. Heil is one of numerous nurses inter viewed who speak of a rapid increase in child abuse. "We always knew about it," one former school nurse said, "but in the old days, what could you do? There was no authority for tak ing action, but we knew. We knew why those kids instinctively ducked when an adult passed."

"It has really skyrocketed in the past three or four years," Ms. Heil points out. "It is a white middle class problem now."

Carol Mollohan, a former school nurse who is a consultant to the West Virginia Depart ment of Health, says that increasing economic pressure on middle-class white families seems to be a major factor in the rise of child abuse. In the oil-boom areas of coastal Louisiana, ac cording to Paula Johnson, incidence of child abuse has been related to two periodic events on the calendar: issuance of report cards and the return of fathers from offshore oil platforms.

Pregnancy, abortions, and ailments con nected with birth control pills are another seg ment of the school nurses' concerns. "Because of the drop in the age of first menstruation and the new level of sexual activity, we're seeing pregnancies at a very early age," Ms. Heil says. "So many more 12- and 13-year-olds, so many abortions that mothers never know about. It's a heartbreaking situation, and as far as I'm concerned, Madison Avenue is to blame. When I saw nine- and 10-year-olds modeling [tight] jeans on TV, I thought I would croak."

"We're seeing pregnant children as early as the fifth grade," says Marion Bush of Abilene, Tex. "And, of course, incest and sexual abuse have come out of the closet into the nurse's office.

"We had two sixth-grade sisters who had been abused by a stepfather," she continues.6"Their story finally came out after they saw a wonderful film done by our rape crisis center, suggesting different people that children can talk to. One of the girls came in to see me with a headache and stomach ache, and I asked if there were anything at home that could be causing her to feel sick. It came out immedi ately. Afterwards, one of the teachers said she felt so bad because she had seen that child hanging around after school, and she never realized that the child wanted to tell some body something."

In Abilene, Ms. Bush notes, the school nurse accompanies the child through the legal pro cess that follows such discovery of sexual abuse.

Abuse and Accidents

The school nurse's new concerns range from these problems of abuse to automobile acci dents involving young drivers, and the sad af termaths of keg parties. "The parents are re sponsible," Ms. Mollohan says. "They give the kids the beer because they want their kid to be popular."

Then there are sports and physical-educa tion accidents--Ms. Heil says, "I must hand out 22 icebags a day"--and regional problems such as the high incidence of bee stings in some schools in California where lists of aller gic students are posted and some students car ry bee sting kits to classes.

Between January and May of the senior year in high school, there are also the over achiever breakdowns. "An unbelievable num ber of kids are seeing psychologists or analysts during those months," Ms. Heil said.

In Vermont, school nurses were the first people contacted when the state's environ mental protection agency wanted to know about asbestos used in school construction. Elsewhere, school nurses are asked to checkfor children who may be wheezing as the re sult of pesticides that have been sprayed on nearby agricultural operations or in the school itself to kill insects.

But if there is one problem that shows up in schools all over America, it is that described forthrightly by Ms. Cleary: "Our schools are lousy," she said. "I mean literally." Head lice, she said, seem the nurse's most invincible foe.

In some areas, health problems are spread through the schools from new immigrants. But in Florida, according to Charlotte Boorde, of the Florida Department of Health, visitors from other states also bring unwanted conta gion. "We just hope our kids will stay away from Disney World," she says.

Schools seeking nurses good enough to han dle all these assignments are having to com pete with higher-paying hospitals. In St. Paul, according to Wanda Miller, supervisor the school health program, the starting sal ary for a school nurse is $11,900 and for a hos pital nurse, $17,000.

For all the talk of school nursing being on its way out, however, some states are holding their own in numbers of nurses. In Vermont, Audrey Poole, consultant for school health services to the state department of health, did her own survey and found that Vermont school nurses are actually increasing in number.

One of the tasks that nurses at the asha convention set for themselves is a study of standards to help provide comparability. School nurses are hired by different jurisdic tions and according to different requirements. "We really need some studies on what school nurses do and the effect of eliminating them where that has been done," Ms. Poole says. "We really need to get together."

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