The School Nurse – On the forefront of public health

By John Messmer, M.D., Penn State Milton S. Hershey Medical Center

Your child gets a fever and sore throat while at school. She sees the school nurse who assesses her and determines that a couple Tylenol and rest until dismissal is all that is needed. If that is your image of the school nurse, think again. Minor treatment is only a tiny part of the school nurse's job which today encompasses public health screening, disease management and skilled nursing care of special needs children. Complex medical problems are part of the daily routine for today's school nurse.

The roots of the present day school nurse reach back to 1892 when Lillian Wald and colleagues working in the tenements of New York City developed a program to treat contagious diseases in the school setting to stem the rampant epidemics of lice, ringworm, conjunctivitis and scabies. As part of the public health department, they took their evaluations into the homes of the affected children to prevent reinfection.

The first official school nurse program was run by Lina Rogers in 1902 with a staff of 25 nurses for 129 public and parochial schools with over 200,000 enrolled students in New York. Because of their success, programs soon followed in Boston and Philadelphia.

Since then school nurses have added dental screenings and education, vision and hearing screening and general wellness examinations to their roster of services. In the final decades of the 20th century school nurses continued to meet the needs of our changing population.

Our schools are now called upon to address the needs of students with physical and mental illness, special needs children mainstreamed into the regular curriculum, substance abuse, teen pregnancy and threats of violence. Today's school nurse faces many healthcare challenges-HIV, pediatric cancer, cardiac disorders, family violence and neglect, congenital conditions, and increasing numbers of children diagnosed with Attention Deficit Disorder. Because of the current number of families with little or no health insurance, the school nurse may be the only health care provider a child sees in some cases.

Advances in medical technology mean some in children now return to school after heart and kidney transplants, during cancer treatments and after serious injuries. School nurses are now called upon to not only help manage those situations but to make a wide range of decisions from whether it is too cold to go out at recess to whether the school should purchase a cardiac defibrillator.

As the demands of school nursing grow, school nurses seek continuing education in medical treatments and issues related to school nursing. Advanced practice certification is becoming more common as registered nurses seek to raise the standards for the profession. The Internet has fostered discussion groups where nurses from throughout the United States discuss mutual problems and seek solutions in a forum that did not exist a decade ago.

The national nursing shortage is being felt in the ranks of school nurses-not just in hospitals and private practices. In some school districts, practical nurses and certified nurses aides are being substituted to cut costs. With fewer nurses available, relatively low incomes and about twice the recommended ratio of students to nurses in many schools, the future of this public health resource is threatened.

As parents of school children we should consider the school nurse an important partner in our children's preventive health. The school nurse needs accurate information about our child's current health, medications, allergies, immunizations, treatments to be used in school and family situations that could impact on our child's well being. While we may see these requests as more paperwork for us as parents, this information is vital to those who will be the first contact for our children's health needs at school.

As citizens of communities that finance education we must remember that funding is needed to support the school nurse's work. If we expect skill and quality, we must provide the school nurse the environment to achieve it. After all, on any given week day-your school's nurse will be the first health care professional called upon to care for our children.