Post-Its and other priorities
July 9, 2009 -- In the June 4, 2009 premiere of USA Network's new hit summer drama Royal Pains, the brilliant and heroic physician character Hank Lawson was fired and blackballed by a New York City hospital for treating all patients equally. Afterwards, Hank lamented that he could not even find a job as a school nurse! (See the Quicktime clips at broadband or dialup speed.) The message for the episode's 5.6 million viewers was that there could not be a more trivial and unskilled job for a health worker than that of school nurses, who presumably spend their days placing band-aids on scraped knees. But in fact Hank could not get a job as a school nurse because he has not spent years in nursing school, has no nursing license, and knows little about nursing. While the contempt in this episode continues to infect the mass media, it's no surprise that real school nurses struggle for the resources they need to save lives and improve student health. Ryan Blackburn's May 8, 2009 story in the Athens Banner-Herald (GA) explained that school nurses manage chronic health issues like allergies, diabetes, and seizures so students can continue learning. Anemona Hartocollis's April 28 New York Times article described the work of New York City school nurse Mary Pappas. She became "a sort of folk hero to nurses" for setting in motion the governmental response to the recent swine flu outbreak, identifying and managing hundreds of students' symptoms in a way that might even impress Hank Lawson out in the Hamptons! And today the Associated Press ran an excellent item by Lauran Neergaard about Pappas's "riveting" performance at the Obama Administration's swine flu summit. There the nurse explained how she handled the huge triage challenge in April, and her plans for the coming flu season, offering this pointed advice to the government: "Every school needs a nurse." Kris Sherman's March 8 article in the News Tribune (Tacoma, WA) offered a tragic example of what happened in October 2008 at a local school with no nurse: A fifth-grader died from a massive asthma attack, even though she was taken to a school health room where materials were reserved specifically to save her life. No one with significant health training was there to use them. These recent press pieces paint a picture of a vital professional specialty worthy of more than the undervaluation that has strained its members beyond the breaking point--and that continues to take our children's lives. We urge everyone to help change that situation. Join the National Association of School Nurses in the effort to pass the student to school ratio improvement act and ask your organization to join their list of supporters.
Ryan Blackburn's Athens Banner-Herald article is "School nurses: A lot more to it than Band-Aids." On the occasion of National Nurses Week, the story describes the work of school nurses at local elementary schools. It explains that the school nurses do the expected "triaging" of students with bumps and bruises, but they also help those with mental or physical disabilities function, ensure those with life-threatening allergies get medication, check diabetic students' blood sugar levels, and monitor those with seizure disorders.
As modern medicine allows more students with health problems to attend school and live relatively normal lives, school nurses' role grew, making their job a vital part of the school system, teachers and administrators say.
The piece includes supportive quotes from those teachers and administrators, but it also quotes nurse Emily Hawhee, who has a "clinic" at Oglethorpe Avenue Elementary. Hawhee explains that school nurses do "a whole lot more" than deal with cuts and stomach aches, stressing how they work with parents and teachers to evaluate the nature and effects of students' health issues.
We're an advocate for the child when they're at school, because their medical issues may have contributed to them not being able to learn.
(In fact, the June 29 episode of Showtime's Nurse Jackie included that kind of advocacy, as a New York City public school nurse played a key role in alerting Jackie to her young daughter's anxiety issues, though it was not a role that Jackie appreciated.) In any case, the Banner-Herald piece also says that Georgia's 1,200 schools now "have cause to celebrate" because the state legislature resisted a $30 million budget cut proposed by Governor Sonny Purdue that "would have eliminated school nurse jobs across the state." The generally strong piece might have followed up, at least briefly, to address the critical understaffing of school nurses, which often means that nurses like Hawhee are stretched too thin to protect students in a crisis or on a day-to-day basis.
The April 28 New York Times article by Anemona Hartocollis, headlined "School Nurse's Response to Flu Wins Applause," offers good examples of what school nurses can do. The story gets to the larger dynamics in its first paragraph:
Too often school nurses are all but forgotten in the education wars over test scores, standardization and vouchers. Across the country, from Atlanta to New York City, amid budget cuts and economic turmoil, advocates say, the jobs of school nurses are increasingly at risk.
The piece then says that New York school nurse Mary Pappas's "quick thinking...might have lifted the status and perhaps even saved the jobs of thousands of nurses."
It was her call to the New York City Health Department last Thursday morning that prompted the city to send samples from sick students to Atlanta for testing, and resulted in the first eight confirmed cases of swine flu in New York State on Sunday, triggering a nationwide response.
Within a few days, Pappas had become "a sort of folk hero" to other nurses. Most of the piece describes what happened at St. Francis Preparatory School in Queens during the first couple days of the outbreak. Early in the day, five or six students came to Pappas's office with sore throats and fever; by 10:00 a.m., there were dozens of "nauseous and confused" students outside her office. By 10:30 a.m., she had alerted a "supervising" physician in the "bureau of school health" that many students had temperatures as high as 101.5 or 102; he connected her to a nurse who works with the Centers for Disease Control in Atlanta. When Pappas returned to her office, it was "pretty chaotic," with her two assistants and many other school staff taking temperatures, "triaging cases," and calling parents to take their kids home. The piece has some quotes from Pappas:
I don't feel like I'm a hero...But I feel like I have very good instincts, based on my experience, and that's why I'm here. I think school nurses should be at all schools. You're like the hub, if something doesn't go right.
Pappas is indeed the hub, since she appears to be the only nurse responsible for the school's 2,700 students. Yet Pappas also notes that no staff who worked with her that day have become sick, though apparently the only precaution they had time to take was hand washing. That's pretty impressive, and the piece paints a pretty good picture of Pappas's leadership and initiative in a very difficult situation, including her ability to identify symptoms. We're always uneasy when nurses refer to their "instincts," which may lead some to undervalue their training and skills. But here Pappas was clearly the sentinel, a critical nursing role in many settings. And like the Georgia school nurse piece, this one provides context about the threats to school nurse funding, though like that piece, this one does not tell readers about the endemic understaffing of school nurses--despite including the fact that Pappas is responsible for 2,700 students, a number that is several times what any school nurse should be assigned. The closest the piece comes to comment on staffing levels is Pappas's own statement that "school nurses should be at all schools," which does at least suggest that some schools do not have a full-time nurse.
Today, the Associated Press ran a short but effective item by Lauran Neergaard about Mary Pappas's appearance at an Obama Administration swine flu summit held earlier in the day. "NYC school nurse recounts swine flu triage" reports that as the long line of students formed outside Pappas's office door, she "thrust thermometers and a pad of Post-It notes at a security guard: Take their temperatures and slap the numbers on their chests." That move--worthy of MacGyver, or at least Hank Lawson--was "the key to triage" at the "site of the nation's most explosive school outbreak." Pappas also explained that she had realized that phoning parents one by one to come get their kids would take too long, so she delegated the calls to the kids with cell phones, then "went down the row updating each parent with their child's temperature and condition." Pappas told the summit that she was the only nurse at the school, sending home 120 children that first day. Holding her audience "riveted," she offered advice for the coming fall flu season. Her plans include text messages to parents' cell phones, faster forehead thermometers to replace messy oral ones, and using an auditorium to keep sick kids at greater distances from each other. The piece explains that Pappas will also educate kids about how to prevent infection:
Cover coughs and sneezes, stay home if you're sick, and, the crowd favorite, "If it's wet and it's not yours, don't touch it."
The item closes with Pappas's bottom line:
Many schools lack nurses, and how much authority they wield varies widely. She offered advice to the federal government: "Every school needs a nurse."
This brief piece is an impressive look at a skilled nurse's creative problem-solving and strong performance under pressure, as well as her ability to advocate for patients and her fellow school nurses. We commend Neergaard, and of course Pappas.
Kris Sherman's long, sad News Tribune article from March 8 shows what can happen when not every school has a nurse. "Parents seeking millions against school district for asthma attack death" sets the scene at a Tacoma area school in October 2008:
Fifth-grader Mercedes Mears lay gasping for breath on the health room floor at Clover Creek Elementary School. "I'm gonna die," she said.
The 10-year-old was right. Four school employees reportedly tried to comfort and calm the crying, gasping child, "urging puffs on an Albuterol inhaler," but her lungs could not pump oxygen. A school nurse had signed a care plan for Mercedes just weeks earlier, but no school nurse was there during this severe asthma attack. The piece says schools "don't routinely have nurses on site, as they rotate between buildings." Apparently no one at the school performed CPR. And even though paramedics arrived only six minutes after the 911 call, they reportedly found Mercedes unresponsive and in "full arrest." The paramedics gave epinephrine, oxygen, and other drugs, to no avail. They rushed Mercedes to a hospital, but she was dead less than an hour after first having a problem.
Mercedes's parents have made a $15 million negligence claim against the school. Mercedes's mother says the child would be alive if someone at the school had simply "snatched up the EpiPen with Mercedes' name on it and injected its contents into her thigh." The family's attorney notes that Mercedes had often visited the health room for "puffs from the inhaler," including the day before her death, and that she had often been absent because of the illness. The family also says that it was the school's "health clerk," who had "no formal medical training," who escorted the wheezing Mercedes to the health room. School district spokeswoman Krista Carlson notes that the 17,500-student district has the equivalent of 11 full-time registered nurses (less than one per 1,500 students) and five licensed practical nurses; "[e]ach elementary school gets 1 to 2 1/2 days a week of nursing time." Cheryl Sampson, president of the School Nurse Organization of Washington, says having a nurse at each campus has "fallen victim to other priorities."
This story powerfully illustrates the potential costs of regarding school nurses as expendable. The long article might have done more to explain why a school nurse like Mary Pappas could have saved Mercedes. Nurses are skilled professionals trained to act in life and death situations, and better nurse staffing might even have enabled the nurse to educate others at the school about these issues. The piece might also have let readers know how widespread this kind of understaffing is in the current educational climate, in which funds are tight and this year's test scores are often the main focus.
Taken together, these recent media items make clear that school nurses must be a part of the educational mission at every school. The National Association of School Nurses (NASN) recommends that every school have a nurse present all day every day. Both the NASN and the U.S. Department of Health & Human Services recommend that no nurse be responsible for more than 750 students. We urge everyone to do whatever she can to make those recommendations a reality.