Reading, Writing and Rx
Vermont school nurses are on the front lines of child health care
Some days, Christine Armstrong wishes she could turn back the clock to the 1950s, when she was a student. A school nurse at Burlington’s C.P. Smith Elementary for the last 20 years, she says her students would be much healthier if they were growing up in a world without super-sized sodas, prepackaged lunch meats, TVs in every bedroom and weekends spent playing video games.
Armstrong remembers the job of a school nurse being far less complicated in those days than hers is now. Back then, the school nurse bandaged skinned knees, handed out ice packs, and sent students home when they had fevers or head lice. Such Norman Rockwellian days are long gone.
“Today, I have kids with life-threatening allergies. I have kids with seizure disorders. I have kids with diabetes. And I have a ton of EBD,” she says, referring to emotional and behavioral disabilities. “Where were all the sick kids when we were growing up?”
Armstrong loves her job and adores her students. But, like other school nurses in Vermont and across the country, she finds her job increasingly complex and time-consuming. School nurses now manage a dizzying array of chronic and acute medical conditions that would have been unimaginable a few decades ago: They treat students with spina bifida, severe autism, sexually transmitted diseases, mental illnesses and posttraumatic stress disorder, to name a few.
Currently, Vermont boasts one of the highest rates of insured students in the country; 96 percent of residents under the age of 21 are covered. Still, many families lack a “medical home,” which is the latest buzzword for a primary-care provider. As a result, school nurses are often the first, and sometimes the only, medical practitioner a child sees all year. Yet, as school boards and administrators wrestle with ever-tighter budgets, school nurses say they’re often the first to see their hours cut.
Today, school nurses report that only a quarter of their workload involves traditional first aid. The rest consists of long-term planning, special-ed meetings, and case management for students with complicated medical, psychiatric and emotional needs.
Nancy Coleman, a 17-year school nurse at Mount Anthony Union Middle School in Bennington, says it’s not uncommon for her to provide a vagus nerve stimulator to a student with epilepsy, or to administer Diastat, an antiseizure medication that’s given rectally.
Coleman now sees many more students taking daily prescription drugs. Thanks to long-lasting, timed-release varieties, some of these can be administered at home, but that situation leaves Coleman not always knowing which meds her students are on, or when their regimens have changed. As she puts it, “I think our [health care] challenges really reflect the challenges of society at large.”
Lola Noyes is president of the Vermont State School Nurses Association and a nurse at Spaulding High School; she provides nursing services to about 1000 students there and at the adjacent Barre Technical Center. Several years ago, Noyes had five permanently disabled students in wheelchairs — in a building that wasn’t equipped to evacuate them in an emergency. Though crisis management isn’t officially in her job description, she says, “I feel that’s my role, to plan for the safety and health needs of any student who comes through my door.”
Like other school nurses, Armstrong says she sees problems that are closely tied to poverty. Twenty years ago, she had 375 total students and a school-wide poverty rate of 4 percent. Today, she has 275 students and a poverty rate above 50 percent. Some of her kids are new Americans whose families fled such countries as Somalia, Congo, Nepal, Bosnia and Vietnam.
On a recent October morning, Armstrong met with one such immigrant father to follow up on a conversation she’d had with him two years before. His daughter, a C.P. Smith student, grew up in a refugee camp, where poor nutrition left her with rotten teeth that needed to be extracted, Armstrong says. The father has yet to address the problem, and the situation increases the likelihood of the girl developing serious complications.
When public-health threats emerge, school nurses can be canaries in the coal mine. In April 2009, Mary Pappas, a school nurse at Saint Francis Preparatory School in Queens, N.Y., was the first to alert the Centers for Disease Control and Prevention that the H1N1 virus had arrived on American soil. That same year, the Vermont Department of Health ran an H1NI pilot project in Chittenden County. It found that flu symptoms showed up in school nurses’ offices two weeks before H1N1 was seen in doctors’ offices and emergency rooms.
“Even people in the [nursing] profession don’t realize what school nurses do. They think we just sit around and hand out Band-Aids,” says Louise Mongeon, a nurse at the Integrated Arts Academy at H.O. Wheeler Elementary in Burlington’s Old North End. “Until they work the job, they have no clue. I had no clue.”
Mongeon, who’s been a school nurse for 15 years, says she never envisioned the kinds of cases that now routinely come through her door. Sometimes students arrive at school exhausted because a parent was arrested the night before, or because the family is homeless and spent the night in a car. She recalls one family who wandered the streets of Burlington all night because their roof had caved in. The parents, recent immigrants, didn’t know their landlord was responsible for fixing the problem.
Mongeon also sees many ailments that reflect families’ growing economic distress. For example, she says she now expects more stomachaches on Mondays. Why? Schools don’t offer free breakfasts and lunches on weekends, she explains, when many families go hungry.
Another poverty-linked medical problem is asthma. Mongeon says about 10 percent of her students have it, the highest rate in the district. She suspects some is attributable to substandard housing, parents who smoke at home, and the practice of sleeping outdoors or in cars. A few years ago, several kids came in at the beginning of the school year reeking of campfire smoke because their families were camped long term at North Beach.
Some problems, Mongeon suggests, should have easy solutions — such as basic eyesight issues.
“Medicaid only pays for one pair of eyeglasses per year. But kids break them, they lose them, they scratch them up. That’s really frustrating,” she says. “How are we going to get their education done when they can’t even see?”
Other issues require more time and case management. Mongeon recalls one first grader who came in with a bad burn on his hand. Mongeon, who trained at the burn unit at Brooke Army Medical Center in Fort Sam Houston, Texas, couldn’t figure out how he’d done it, so she asked the boy to draw her a picture. It looked like the sun.
Only later did Mongeon realize the boy had drawn the rays of a gas stove. When she asked how it happened, the boy told her, “It was my fault because I was being bad. Dad taught me not to play with fire.”
On the surface, Vermont schools seem to be doing a good job with their nursing coverage. Vermont law requires that schools have at least one registered nurse for every 500 students. In actuality, the National Association of School Nurses ranks Vermont first in the nation for its students-to-school-nurse ratio — one RN for every 396 students.
Yet even the Vermont State School Nurses Association and the Department of Health admit those numbers simplify the picture and belie a sobering truth. Many Vermont schools don’t have an RN on the premises every day, while others use only licensed practical nurses, who have less training and clinical experience.
Emily Pastore is Vermont’s state school nurse consultant. Since school nurses straddle the line between educators and public health providers, Pastore’s half-time position was moved from the Department of Education to the Department of Health in 2008. She lacks the authority to tell schools what to do and is limited to making recommendations.
What’s the most common complaint Pastore hears from Vermont’s school nurses? They have trouble convincing administrators, she says, of the importance of having a nurse on duty all the time.
The absence of a nurse can pose problems, for example, in dealing with the rising numbers of students with insulin-dependent diabetes. More students — some as young as kindergartners — are arriving at school with insulin pumps, and Pastore says many are just learning to manage their diets and blood sugar.
“To not have a nurse in the building is scary for nurses, and I would think it would be scary for parents,” she says. “I believe that many families aren’t even aware that there’s not a school nurse in the building all the time.”
How are districts dealing with such problems? In Burlington, several schools, including Burlington High School and the Integrated Arts Academy, have on-site health centers. Twice a week for four hours at a time, a physician or nurse practitioner sees patients and makes referrals, when necessary. The goal is to keep kids in school and not missing lessons.
Adjacent to Mongeon’s office is a dental clinic where any child in the district without insurance or Medicaid can receive free care, including cleanings and fillings. The district will even arrange transport from other schools. Currently, 600 Burlington students participate.
Although Mongeon knows that the school’s response to certain medical and psychiatric issues is constrained by tight budgets, handling others doesn’t cost a thing. She notes, for example, that in the year of the H1N1 virus, her school’s absentee rate was lower than those of other schools. Why? Because teachers made a point of showing students how to wash their hands. Once the pandemic subsided, however, that lesson fell by the wayside.
“That’s a bit frustrating for me, and not just because I’m a nurse,” Mongeon says. “It’s because I’m trying to keep kids in the classroom. Because you can’t learn if you’re not here.”