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February 5, 2004 -- Today Salon posted a powerful piece by San Francisco school nurse Elisabeth Ochs, who details her efforts to manage an extraordinary range of serious health and social problems among elementary school students, despite being responsible for about 800 of them in two different schools. Ochs' matter-of-fact description underlines both the serious skills required of school nurses and the dangerous nurse understaffing many schools now face, even as more and more students attend with increasingly serious problems.

Ochs notes that when she was in secondary school, the school nurse was there "all day, every day" in a "peaceful little office." Today, Ochs is "considered fortunate" to be responsible for only two schools; some colleagues travel to as many as seven, each with hundreds of students. Even as they are stretched by lack of help, school nurses like Ochs confront increasingly difficult practice issues, including students who are homeless, hungry, or in the country illegally. Many lack health insurance, and depend on clinics and emergency departments. An increasing number come to school with chronic conditions, including asthma, obesity and the fallout from violence. Working 60-hour weeks, Ochs finds emergency mental health care for an apparently suicidal 8-year-old, teaches about critical public health issues like handwashing (first graders) and puberty (fifth graders), educates teachers about head lice, attends "interdisciplinary team meetings," publishes a health newsletter, follows up on immunizations, and ensures there is a proper system for the administration of medications.

Ochs' ability to provide good care appears to be compromised by having to shuttle back and forth between two schools, which makes proper evaluation and monitoring difficult. She describes a child reproaching her: "I threw up yesterday and you weren't there." Ochs also discusses her struggle, when first starting as a school nurse, to function effectively in a more autonomous yet less equipped environment than she had been used to in her previous clinical experience. "Most troubling, what should be done with 5-year-old Justin, who--feverish, coughing, miserable--burst into hysterical tears when I prepared to call his mother and cried, 'I don't want to go home!'"

Ochs terms much of what she does "social work, case management and teaching," distinguishing that from "nursing." But while what she describes may not be the kind of bedside care she was used to during her years in the hospital setting, it strikes us as being at the heart of nursing, which is holistic and focuses on community health, patient education and facilitating access to health services. We think it's important to make clear that these types of tasks are indeed nursing, and that they should be done by a nurse. We fear that if this is not stressed, cost-conscious administrators might be tempted to stretch school nurses even further, and to assign even more critical nursing tasks to unlicensed personnel--or no one. Indeed, Ochs notes that she is discouraged from providing first aid, and while this may stem from an understandable desire to free nurses for activities that seem more technically demanding, it could also amount to assigning the triaging and provision of initial care to non-nurses who are not trained to perform those potentially critical tasks, at a serious risk to student health.

Ochs punctuates her article with quotes from anonymous notes students have placed in the envelope tacked to her office door. These include "How do you get AIDS?", "Why do people catch asthma?", "Do people get cranky when they eat drugs?", "If you eat nothing but junk food, will you die?", "Where do babies come from?", and "Help us."

See Elisabeth Ochs' "Help us" in the February 5, 2004 issue of Salon.


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