Nurse's Orders

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Baby boomers may remember their school nurse as a kindly maternal figure who patched up their playground injuries. A woman, most often, who would tend to her young charges' bloody noses, put ice on their fat lips, and dab antiseptic on their scraped knees and elbows.

Glass jars filled with tongue depressors, cotton balls, and gauze bandages probably lined the work tables in the small but sunny room down the hall from the principal's office. A portable cot covered in clean pressed white sheets--comfortable enough for a short rest but too hard to coax a student into a deep sleep--usually stood at the ready in the corner.

Although most school nurses still work out of one-room offices, little else about their job remains the same. School nurses aren't just treating bumps and bruises anymore. They are administering a wide range of sophisticated health services--from gastric-tube feedings to birth-control counseling and suicide-prevention strategies--to a growing number of youngsters who all too often have little access to medical care.

And in many school districts, even the traditional nurse's office has given way to a more fully equipped, state-of-the-art health center. In fact, more than 600 of these school-based health centers are up and running nationwide, a staggering 141 percent increase over the 40 such centers in operation in 1985.

Experts point to two recent trends when explaining what has catapulted school nurses into their new role as front-line health-care providers for the young. The passage of the Education for All Handicapped Children Act (the precursor to the Individuals with Disabilities Education Act) is the first. The landmark legislation, which President Gerald Ford signed into law in 1975, required that special-education students receive medical attention on school grounds so the learning process would not be disrupted. As a result, nurses began caring for children with tracheotomies and performing catheterizations, tasks they rarely performed in the past.

The second explanation can be found in the growing number children who come from families with little or no medical insurance. In 1994, more than 10 million children under age 18 in this country had no health insurance. That's 2 million more than in 1987, according to U.S. Census Bureau reports. This increase can be attributed in part to the ballooning number of parents working temporary jobs with no medical benefits. But even those with benefits report shorter hospital stays because more and more health-insurance policies limit inpatient care. Patients, in response, are seeking out community-based health-care options.

School-based clinics have stepped in to offer families and their school-aged children an affordable health-care alternative. And as they have, nursing-school professionals across the country have stepped up their efforts to train a generation of school nurses ready to do just that.

Nurses first set up shop in the nation's public schools toward the end of the 19th century. As school attendance became mandatory and large numbers of poor immigrants enrolled in schools, doctors and nurses were called in to identify students with contagious diseases and exclude them from the classroom.

As early as 1870, the New York City public health department authorized nurses to conduct screenings for communicable diseases among the city's elementary school students, according to a paper written by Julia G. Lear, the director of the Robert Wood Johnson Foundation's Washington-based program on school-based health centers.

Nurses also visited students' homes to urge parents to send their children back to the classroom once they had recovered from their illnesses.

By 1911, 102 cities across the country had hired 415 school nurses. By the end of World War I, nearly every state had enacted legislation mandating that school systems take measures to protect student health.

But attempts to expand services beyond contagion control ran into fervent criticism in the ensuing years. School-health advocates who argued for extensive medical, dental, and social services in schools prompted angry responses from prominent private physicians who argued that school health was an intrusion into their domain, Lear writes. And many parents of school-aged children also feared that health supervision in schools would infringe on the family's influence over their children.

In large part as a result of this opposition, the nation's schools retreated from offering expanded health services to students. School nurses from the 1920s through the 1950s, Lear says, confined themselves primarily to teaching health and physical-education classes, as well as attending to students' personal hygiene. They focused on improving student health by gathering medical data and referring cases to community physicians. Their role during this time was to facilitate the delivery of health-care services, not to directly offer them.

The Cherry Ames Nurse Stories, a best-selling book series that became popular reading for many young girls in the '50s, promoted this image. The stories chronicled the adventures of a daring yet proper young nurse who comforted passengers on cruise ships, assisted handsome country doctors, and tended to homesick boarding school girls.

But pressures to change school-health programs resurfaced in the 1960s and 1970s when reports revealed that the medical needs of many poor children were not being met and a new influx of immigrant families began to demand more health services. The rise in divorce rates and unwed teenage pregnancies, not to mention deteriorating economic conditions, contributed to an overall decline in children's mental, physical, and emotional well-being, Lear writes.

During this period, President Lyndon B. Johnson's War on Poverty helped promote awareness of the needs of poor children, and school-reform advocates succeeded in winning more government funds for school-health services. More young nurses also sought out the school setting, which had a reputation for better hours and better benefits than nursing posts in community hospitals.

"In the old days, people thought of the hospital nurse as the one who drove the Volkswagen and the school nurse as the one who drove the Mercedes," says Judith B. Igoe, a professor at the University of Colorado's school of nursing in Denver.

Today, salaries for school nurses average about $29,000, depending on one's expertise--thousands of dollars less than nurses generally earn at hospitals. Few nurses working in public schools today would claim they took their job so they could drive a luxury car.

Ilene Hirsch wasn't thinking about buying a Mercedes when she quit her job as a registered nurse at an outpatient pediatric clinic to pursue an advanced degree. She was focused more on finding the answer to a nagging question: "I wanted to know what the mystery was when a patient goes into a room with a doctor or nurse practitioner and comes out feeling satisfied," Hirsch says, sifting through a stack of medical charts. "I thought, 'I want to learn how to do that.'"

So she enrolled in the nurse-practitioner's program at the University of Massachusetts at Amherst to pick up a little medical magic. And now, two years later, she's putting that wizardry to work, this time at a school in nearby Springfield.

As Commerce High's unflappable nurse practitioner, Hirsch whips around the school's two-room health center. It's time for morning triage. Well before the lunch bell reverberates through the halls, more than two dozen students have marched into the clinic seeking aid. With the help of her four-person staff, Hirsch checks to see that the girl in the blue basketball jacket keeps an ice pack on her twisted knee. Then, with a stethoscope coiled around her neck, she interviews a heavyset girl suffering from persistent chest pain.

Behind a partition, a nervous 15-year-old twists a her hair around her finger as she waits to talk to Hirsch about birth control.

A staffer standing at the opposite end of the clinic checks her watch and announces: "Tropical storm Frank is about to hit!" Within seconds, the punctual senior bounds into the room, downs a shot of Ritalin from a paper cup, and zips back out into the hall.

Suddenly, the school's antiquated intercom buzzes with an urgent call from the principal's office. A student just fainted in the cafeteria. Hirsch grabs a gray plastic emergency-aid kit and races down the stairs to find a girl in the lunchroom curled over on a chair, her face soaked with tears. Hundreds of students abandon their hamburgers and Tater Tots to see what's causing the commotion. Hirsch wraps a blood pressure cuff around the student's arm, puts a cold compress on her forehead, and escorts her back to the clinic to lie down. She picks up the telephone and arranges for the student to see a physician at a nearby health center for tests the next day.

Since the 36-year-old mother of two started at this urban high school in western Massachusetts just a year and a half ago, the center's staff has administered dozens of pregnancy tests, screened many students for sexually transmitted diseases, and hospitalized three students who threatened to commit suicide.

"Sometimes, it feels like a little ER," says Hirsch, who worked for eight years in hospitals before coming to Commerce High. "Little crises come up, and some things we can handle, and some we can't."

Teaching school nurses to manage crises large and small means making sure they have an upgraded medical kit at their disposal.

"The problems in the schools are ones that really require skilled nurses now," says the University of Colorado's Igoe, who is a leader in the drive to further professionalize the field. Today's school nurse, she says, needs even more specialized training and hands-on experience.

Registered nurses, who make up the majority of practicing school nurses today, are trained to administer prescriptions from a doctor, treat certain conditions, and educate students about unhealthy behaviors. But they aren't qualified, for example, to diagnose many illnesses and prescribe medications, as nurse practitioners can.

Igoe contends that the modern school-health center should ideally have both: a nurse practitioner to be the manager and diagnose and treat the more serious cases and a registered nurse to take case histories and tend to less serious conditions.

To become a registered nurse in most states, students must complete either a four-year bachelor's or a two-year associate's degree. Only a few states still offer diplomas through a hospital-training program, once a popular route into a career in nursing. All graduates must also pass a national licensing exam, which each state board of nursing administers.

To become a nurse practitioner, nearly all states require students to complete a master's degree and pass a licensing exam before they can practice.

In recent years, a handful of pioneering nursing schools across the country have launched campaigns to better prepare nurses to work in schools by offering graduate programs that emphasize public health. Some colleges and universities have also added courses on school-based health practices to the standard menu of microbiology, chemistry, and hospital-based care. Many of these institutions are promoting a learn-by-doing philosophy that gets students on-the-job training in school-based clinics. And school-health electives are popping up more frequently in undergraduate nursing curricula as well.

School-nursing leaders hope these innovations will help stimulate growth in the field. Today, about 40,000 nurses are working in schools--a number that experts say has remained steady for decades. Though the demand for more advanced nursing services is considerable, the funding often is not. School nurses must compete with counselors and other specialists for limited school dollars. Despite the financial strain on the profession as a whole, however, experts say the need for advanced school-based health services will continue to swell the ranks of school nurse practitioners and boost enrollment in nursing schools.

One such nursing program can be found just 25 miles north of Springfield at the University of Massachusetts at Amherst where Hirsch studied to become a nurse practitioner.

Christine King, a professor at the university's school of nursing, holds a small graduate seminar in her sun-filled kitchen. Three students sit on bar stools and gulp strong black coffee from clay mugs. Steel wind chimes clang on the porch outside. It's a cozy venue to discuss the weighty topics of teenage violence and psychological trauma.

King's students, all experienced nurses, are enrolled in the college's two-year program for nurse practitioners. The trio flips through their notes for today's assignment: to prepare a presentation on dating violence for 9th-grade students at a nearby school.

Julie Kulas, 33, thinks they should offer the teenagers suggestions for coping with physically threatening situations. "We need to give them ways to get help," she says, "because it's so hard to get untangled from these relationships."

Someone else suggests including an exercise where young students define what behaviors they would label as violent.

Once the graduate students have come up with a few ideas of their own, King hands out red folders filled with more talking points the students can use in their presentation as well as materials on local shelters and crisis hot lines.

When talking about school nursing to her students, King is a zealous saleswoman, marketing the career as a once-in-a-lifetime opportunity. She bills the school nurse as a mental-health worker, substance-abuse specialist, health educator, and surrogate parent all in one. "School nurse practitioners are the ultimate holistic providers," she says.

Roy Rogers, who has worked as a registered nurse in a nearby veteran's hospital for 22 years, cites yet another reason to work in schools. He's drawn to school nursing because he hopes to be able to identify and treat problems before they get out of hand. "It's like working upstream instead of downstream," Rogers says. "Instead of waiting for kids to get in trouble and float downstream so we can pick them up, we're treating them before they fall in."

State leaders are discovering that school-based health centers staffed with highly educated nurses can become cost-effective health-care providers. And they are banking on the adage that an ounce of prevention is worth a pound of cure.

In the past few years, a handful of state licensing boards--including those in Tennessee and Connecticut--have set out to raise the school-nursing certification standards to prepare a cadre of professionals who could staff their vision of modern school-health centers into the 21st century.

In Massachusetts, the state education department issued new guidelines in 1993 that require registered nurses to have a bachelor's of science in nursing to practice. Previously, they were only required to earn an associate's degree or pass a diploma course.

This year, the Massachusetts health department also set standards for school-nursing practice and published a 16-chapter comprehensive school-health manual that covers everything from anemia to whooping cough.

"People were begging for information," says Ann Sheetz, a former pediatric nurse who serves as the state's director of school health. Her office receives about 20 calls a week from nurses in the field. And many of those calls aren't just about immunization or other routine medical procedures but about how to handle the sticky public scrutiny that often accompanies the installation of a school-based clinic.

Like their predecessors, nurses working in schools today must often respond to parents who object to their influence over children's lives. Parent groups across the country have successfully organized against proposals to establish health centers at schools. Many charge that the reproductive-health services clinics offer, such as pregnancy tests and birth-control counseling, run counter to their religious belief in abstinence before marriage.

Partly as a result of such parent opposition, few clinics make condoms available to students. Instead, most school-health centers have a show-and-tell policy: School nurses can discuss contraceptives and explain how they're used, but they can't provide them to students. States, local school boards, and health departments have tried to further assuage community concerns by requiring a parent's signature before a student can use any service the health center provides.

If a clinic prompts controversy from the outset, school nurses say that being able to count on support from the top is particularly important. Nurses often rely on school personnel--from the principal on down--to help educate parents about their role.

"The principal can make or break you," says Kathleen Cassidy, sitting in a meeting of school-nurse practitioners at Bay State Medical Center in Springfield. The large hospital pays her salary at a Springfield high school and also supports several other school-nursing posts, including Hirsch's at the Commerce High clinic. "You are in their school as a guest," she adds.

When conflicts erupt over the care they can legally provide and school administrators do not come to their defense, Cassidy says nurses can feel like orphans. Straddled between the health and education fields, school nurses often operate in virtual isolation, with few professional advocates to lobby on their behalf.

At a recent meeting at the Radisson Hotel in Chelmsford, Mass., a group of key state players in the field have come together to remedy that problem. Five college nursing departments have set up a school-health institute to sponsor professional-development seminars for school nurses and offer them a support network that many do not find at school.

The seminars are partly financed through a state tobacco tax, the proceeds of which are earmarked for health initiatives. Monies from the tobacco tax have also gone to open 21 school-based health centers in Massachusetts over the past five years.

The meeting room is packed with 100 experienced school nurses who mill around talking about chronic diseases, immunization delivery, and child abuse. Munching on pastries and sipping coffee, they complain about the paperwork hassles and share their fears about proposed funding cuts in Medicaid. The government health-insurance plan for the poor and disabled is under attack in Washington by lawmakers who argue that the program costs too much. And school nurses are concerned that they won't be able to provide the necessary health care if the government cuts back on benefits. Currently, Medicaid reimburses recipients for certain services provided through school-based health programs.

But when it comes to national debates like this, some in the field say school nurses haven't raised a loud enough voice. They point, for example, to the 9,500-member National Association of School Nurses--the country's largest school-nursing organization--and argue that the group failed to have a strong presence during the 1994 debates on federal health-care reform legislation.

Some explain the lack of influence on the political scene as a matter of personality.

"Nurses don't like to make waves," says 46-year-old Paula Dobrow, who has been a school nurse in a Marblehead, Mass., elementary school for three years. "We are passive and polite. We don't like to step on toes."

But school-health experts are quick to point out that more than a few nurses in history were not afraid to kick up a little political dust.

Clara Barton, who cared for injured soldiers during the Civil War, went on to become the founder of the American Red Cross in 1881.

Back in the early 1900s, Margaret H. Sanger, the leader of the American birth-control movement, was troubled by the connection between poverty, overpopulation, and high infant-mortality rates while working as a nurse in New York City. After she opened the nation's first birth-control clinic in 1914, she served 30 days in a workhouse for "maintaining a public nuisance." Sanger later became the first president of the International Planned Parenthood Federation.

Lillian D. Wald, a public-health nurse in the late 19th century, emerged as a champion of the urban poor. She helped initiate a revision of U.S. child-labor laws, worked to improve housing conditions in tenement districts, and advocated for a national health-insurance plan.

Brenda Millette, a nursing professor at the University of Massachusetts at Amherst, teaches her undergraduate students to think like these crusaders of the past.

"You are the vanguard," she says to the 55 students gathered in a classroom next to the school's gymnasium for their course on adolescent health. The air from the corridor smells of chlorine and sweat.

"You all need to know what enormous power you hold to help people lead healthy lives," she says.

Millette slips a transparency into a slide projector and begins her lecture on nutrition. "If a 15-year-old Hispanic female who is 30 weeks pregnant and is eating one meal a day comes into the clinic, what do you do for her?" she asks the class.

Tanya Carlino, a nursing major sitting in the front row, says she would first find someone who could speak Spanish to the student and then she would tell her about the need to eat three healthy meals a day. Other students suggest referrals for parenting classes and child-care providers.

Millette moves on to next unit, the legal principles that apply when treating a minor. "Who must consent to treatment? Who can be treated without permission?" she asks. "When you're nurses, you'll need to know this."

She tells the class about a few standard rules: If a minor is a parent, he or she is considered emancipated and does not need parental consent for medical care. If the parents of a minor cannot be reached in an emergency, the school nurse can administer care without approval.

The problem with laws governing adolescents, Millette explains, is that legislation varies from state to state. To complicate matters further, individual school board policies add to the complex mix of rules to follow.

After class, a group of students in their early 20s chat about sex, drugs, and the younger generation.

"We need to educate kids because there are pregnant girls who don't know about the egg meeting the sperm," says Amy Courtemanche, a 21-year-old junior from Massachusetts.

And look at what they're inhaling these days, adds Carlino, a 22-year-old junior from New Jersey. "It's not just marijuana. Kids are taking cigarettes and dipping them in formaldehyde."

As they make their way into the crowded hall, the conversation turns to talk of an upcoming health fair the class will run at a local high school. Who's going to run the booths? Who wants talk about nutrition and smoking and exercise? What about having a NordicTrack at the fitness booth? No, they don't mind this homework assignment at all.

And listening to them, it becomes clear that these students think their age may one day give them an edge as school nurses.

"These kids need younger people to understand their issues," says 19-year-old Kristin Clark, a sophomore from Keene, N.H., as she hikes a 30-pound backpack on her shoulder and rushes out the door. "Besides, we know what's going on."

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