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School Nurses Seek Broader Role In Wake of New Health Concerns

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ANAHEIM, CALIF--Voicing frustration over the misperceptions they say have limited both pay and respect for their profession, school nurses have put self-promotion high on their agenda for the coming year.

Participants at the annual meeting of the National Association of School Nurses here said that despite the rising significance of health concerns in schools, most administrators still view the delivery of health services as "a fringe.''

"They want to narrow the nurse's role to a specific duty,'' said Beverly Farquhar, the group's executive director, "but our role has expanded.''

Dealing effectively with such problems as AIDS, teen-age pregnancy and suicide, child abuse, drug use, and changes in the ability of families to monitor children's health needs will require, she said, that school nurses be involved in duties that go well beyond "putting on a Band-Aid or doing sports physicals.''

Their role should include, in addition to the traditional screenings and first-aid, more emphasis on preventive medicine, counseling, community outreach, and teaching, she and others said.

The Health Manager'

"We should be the health manager and the leader of the health-care team,'' argued Lynne Gustafson, the group's outgoing president. She said that the school nurse can play a valuable collaborative role with educators because she has, ideally, gained "educational skills and professional expertise in many areas, especially child development.''

Said the incoming president, Vivian Haynes: "The school nurse is the nonevasive, nonthreateningliaison between the school and the community.''

To advance this multifaceted view of the profession,, the organization is working with a public-relations firm on a possible advertising campaign and plans to increase its visibility this year at meetings of the American Association of School Administrators.

Leaders of the association, whose 5,000 members include only registered nurses, said they hoped increased collaboration with the school administrators' group would help dispel stereotypes and raise professional standards in their field.

The approximately 30,000 school nurses nationwide, they said, now represent a range of experience and expertise, with some states allowing licensed practical nurses or paramedics to fill such jobs and others requiring baccalaureate-level training.

But according to Ms. Gustafson, the field's increasing demands are pushing school nurses into a period of professionalization similar to that occurring in teaching.

"Do you remember when teachers went to normal schools and had trouble upgrading people's skills to a level that would be recognized as that of a profession?'' she asked. "I think we are paralleling that right now.''

But the movement to professionalize, nurses said here, is both driven and thwarted by pressures stemming from inadequate staffing, dramatically altered functions, and poor job security.

Uneven Commitment

In addition to changes in the attitudes of school administrators, the NASN, which met here June 28-July 2, is seeking to increase the modest support most states have given school nursing. This is especially important, leaders noted, because of efforts to teach greater numbers of severely handicapped children in regular classrooms.

Currently, Ms. Gustafson said, the commitment to school programs is uneven at both the state and local levels. "There is no common denominator,'' she said, adding that some districts have excellent programs while others offer little support.

"When you have school nurses available only with local monies, the poor school districts are the least able to support nursing positions,'' noted MaryElle Hatfield, a consultant to schools in South Carolina, where the provision of nursing services is optional. In those districts, she added, the school nurse may often be "the only health-care professional many children see.''

Only 11 states now mandate that districts provide access to school nurses. The association's goal is to have all 50 states require at least one nurse in every district.

But reaching this goal will still leave many school systems far short of meeting the association's recommended ratio of one nurse for every 750 students. In some locations, especially isolated rural areas, the ratio can jump to one nurse for every 20,000 children or more, officials here said.

Judy Ressallat, chairman of the association's legislative committee, suggested that the public is not only ill-informed about what school nurses can offer but also "unaware of the cost-effectiveness of their services.''

Ms. Gustafson illustrated the primary consequence of such misinformation--understaffing--by relating her encounter with one enthusiastic teacher who said she was thrilled that, finally, a school nurse was making regular visits to her building.

"I asked her how often,'' Ms. Gustafson recalled, "and she said twice a month. What kind of impact can you have twice a month? To us, that's not school nursing.''

Care-Giver and 'Confidante'

What school nursing is has been evolving since the field's recorded beginnings at the turn of the century.

New York City hired the first school nurses in 1902 as a way to combat communicable diseases among immigrant children, according to the NASN The 26 nurses hired that year were able, through a combination of primary health care and efforts to educate both staff members and parents, to lower the incidence of such diseases dramatically--from 10,567 cases to 1,101.

But with the development of immunizing vaccines and improvements in health-care delivery, school administrators slowly began to relegate the nurse's role to what Susan Lordi, a California consultant, called "a much more mechanical function.''

Today, school nurses are seeking to go beyond such traditional duties as screening for vision and hearing loss, checking immunization records, administering first-aid and other needed medical procedures, and managing health crises.

They view themselves, nurses here said, as integral parts of the educational process. They pointed to colleagues' work in many quarters to help develop AIDS-education and other health courses. But they also argued that the learning process depends on the maintenance of good health among both teachers and students.

"The bottom line,'' said Ms. Gustafson, "is that if a child can't attend school because of a physical illness he can't learn.''

Others stressed the importance of school nurses' role as independent advocates for and confidantes of children. As Laura Rima, a practitioner in Fairbanks, Alaska, explained, students who visit the school nurse "often have a hidden agenda.''

"We go into the room, shut the door, and have a chat,'' she said. "Kids know there are safe places to talk, things are confidential.''

More Jobs, Less Pay

The passage in 1975 of the federal Education for All Handicapped Children Act, P.L. 94-142, added further complications to the health-care functions of schools, participants noted, by requiring that districts provide services to make it possible for even severely impaired pupils to take part in public education.

In many districts, teachers--not school nurses--have been asked to perform complicated medical procedures, such as cleaning tracheal tubes and applying catheters, in order to make this participation possible.

School nurses have joined with teachers' groups in opposing this practice. But some here acknowledged that even in districts where school nurses are available, they often do not have time to tend to the needs of the medically fragile child.

Nor has the addition of such responsibilities as care for the medically fragile, they said, meant salary increases for school nurses, whose pay has not kept pace with that of educators. The NASN has made achieving pay equity one of its chief goals.

According to Ms. Gustafson, the nurse is often the lowest-paid professional in the school building and also earns less than her hospital counterparts.

Pat Donovan, a former pediatric nurse, said she took a $15,000 pay cut to work for the Westbrook school district in Portland, Me. But the chance that job has given her to "impact change,'' she says, has left her with few regrets.

Others cite the greater independence and better hours as reasons they prefer the school nurse's job to positions in hospitals, despite the pay differential. Although a few states, such as California, are witnessing the beginnings of a school-nurse shortage, most districts have found it relatively easy to fill positions.

But officials here stressed the importance of filling such positions with registered nurses, rather than paraprofessionals with little training. Liability has not yet been an issue in the field, they said, with no known malpractice suit against any school nurse. But providing the degree of care the times demand, they said, necessitates higher levels of training

The NASN estimates that two-thirds of the school nurses now employed are registered nurses.

Job Security Key Issue

The results of a survey conducted by the association last year and released at the conference show that job security, not salary, is members' number-one concern.

They must cope, participants here said, with the uncertainty of not knowing from year to year whether their jobs will be eliminated in favor of other state or school budget priorities.

Ms. Farquhar argued that school nurses "should be a part of the line item'' in state budgets "and not the bottom line where they cut.''

But school nursing remains a budget item that many legislators deem expendable.

In July, the legislature in financially troubled Louisiana eliminated state funding for the 199 school nurses employed by local parishes. They voted to refunnel 75 percent of the $2.9 million budgeted for that program back to local school districts as a block grant.

According to Edia Harris, who headed the school-nurse program and lost her job in the legislative reshuffling, the education department tried "to impress upon the parishes'' the need to continue funding at the local level. The state's high unemployment rate, she said, has made it difficult for many parents to provide health care for their children and losing the school-based services will be "a hard blow.''

In California, the budget-tightening that followed passage in the 1970's of Proposition 13, a tax-limitation measure, thinned the school-nursing ranks.

Dorothy Strand, a nurse in Orange County, Calif., recalled at the meeting that the number of nurses serving the 25,000-student district was reduced from 18 to 4. Three of the casualties were later rehired, she said, but "people don't realize we are no longer able to do any classroom teaching because there aren't enough of us.''

Cost-cutting at the district and building level has led some administrators to contract for limited nursing services, or to employ what are known as emergency medical technicians to fill nursing positions.

The NASN objects to contracting arrangements, in which outside nurses are hired by districts only to provide screening or other services, because they cannot offer what NASN leaders say is the essence of school nursing: continuity of care.

The association's members are more adamant, however, in their insistence that poorly trained candidates should not be hired to fill school-nurse positions. Only registered nurses, they say, can properly conduct the screening, assessment, and follow-up procedures that are the field's basics--or serve as case managers in the expanded, collaborative role they say school nurses should play.

"There really needs to be somebody who is a skilled health professional in the schools,'' said Carol Iverson, who was named the association's School Nurse of the Year. "Health aides cannot be educated to look for those sophisticated changes in the health and development of children.''

Ms. Iverson offered a dramatic illustration of her argument: She accurately diagnosed a brain tumor in a student whom school officials had suspected of suffering from an intense school phobia.

She made the diagnosis, she said, from one comment by a teacher--a description of a peculiar type of vomiting the boy had displayed. From her reading, Ms. Iverson knew that that symptom was traceable only to a brain tumor.

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