Who is Behind That Needle?

If you have received your COVID-19 vaccine through the Rowan County Health Department, there is a good chance the person giving you “the jab” was a school nurse. Many of us have little memory of a school nurse from our school days. Our memories may include being sent to the health room to lie on a cot until a parent came to pick us up because we “threw up.” If we were lucky, the office secretary gave us an aspirin. Even though times have changed greatly with respect to school nurses, their history actually dates back to the early 1900’s when the first school nurse was hired by the New York City school system to help cut down on absenteeism, which it dramatically did. School nurses were a valuable part of the public school makeup leading up to World War II.

During the first part of the 19^th century, the school nurse’s role was generally defined by providing first aid, screening and referral to physicians for care, and immunizations – remember this was the era of diphtheria and polio epidemics. During World War II, school nurses were largely replaced by health aids because nurses were needed for the war effort, creating an extreme shortage of registered nurses on the home front. After the war, with the development of primary care doctors and health insurance, school nurses were more focused on referring students to physicians, and assisting with children with disabilities. In 1975 the Individuals with Disabilities Act was passed (IDEA), assuring rights for disabled children to access schools, which created a greater need for school nurses to be involved with those children. Even so, by the 1980’s and early 90’s, with economic recessions taking place, school systems and public health budgets were often cut dramatically, and school nurses were difficult to fund. Additionally, nursing shortages during this time made employing and keeping school nurses very challenging.

By 1993, health of children began to have renewed focus, with an attempt to provide funding for some school nurses through Medicaid. We began to see many more children with chronic illnesses such as diabetes and Cystic Fibrosis, we saw a huge increase in allergies, such as peanut, which required immediate emergency care, we saw an increase in children with special needs diagnoses, and an increase in mental health issues in our students. Most school systems employed nurses, but in small quantities. Only the extremely forward thinking and well-funded school systems (only three in North Carolina) partnering with health departments, and sometimes the private sector could afford to have a nurse for every school, although it became clearer that there was a need for more school nurses.

As a mother and a registered nurse, I remember being tremendously relieved to know there was a school nurse at my son’s high school when we discovered he had a tree nut allergy. He was required to have an EpiPen at school and if he accidentally ate a forbidden tree nut (cashew, brazil nut, pistachio) it would be an immediate emergency and someone would need to administer the EpiPen. This was scary! Suddenly I had a new appreciation for school nurses and their value. Then I volunteered as the camp nurse for summer church camp, and my eyes were really opened. I was shocked by the number of children on significant medications, including daily injections, and medications with significant side effects. I realized that school nurses were not just good to have, they were essential!

Fast forward to 2020, and the COVID-19 pandemic, and we have an even more compelling reason to value our school nurses. They are truly on the front line in our schools and have a huge added responsibility for assuring that the schools are safe. While protocols for social distancing, temperature checks and such are dictated by Department of Health and Human Services (DHHS) and the Department for Public Instruction (DPI) on a state level, it often falls to the school nurse to help interpret those guidelines for each school.

In Rowan County, we are blessed to have a vibrant and growing school nurse program. The Rowan Salisbury School System has 19,500 students spread across 20 elementary schools, 9 middle schools and 6 high schools (Enochville and Faith elementary are scheduled to be closed this summer). Many of our schools are small with less than 400 students while the largest school, Carson High School, has over 1100 students. So it doesn’t really work to try to have a nurse for each school, but to have a nurse for every two schools seems to be the sweet spot. That means we need at least 17 nurses. We had 12 nurses in 2012 for the entire RSSS, and efforts began to improve these numbers. By patching together funding from various sources including our school system, the state School Nurse Funding Initiative, and the Covid Cares Act, we now have 17 budgeted school nurse positions. Rowan County is a geographically large county, 524 square miles, so a great deal of travel is involved to cover multiple schools, adding to the burden of the school nurse. It is hard to be in two places at once when needed. To improve the situation, Covid Cares Act funding was also used to create 17 Health Room Assistant positions, pairing a Health Room Assistant with every nurse. Now when the duo covered the two assigned schools, there is either a nurse or a Health Room Assistant manning every school! The role of the school nurse is ever increasing, and also includes a component of employee health due to their role with assuring the health of school staff in addition to the students.

WHAT IS THE REQUIREMENT TO BE A SCHOOL NURSE?

School nurses are registered nurses and are required to hold a bachelor’s degree within three years of taking a school nurse position. They are also required during this three year period to become nationally certified by taking a national exam which is heavy in pediatric knowledge. By the end of summer 2021, all of our Rowan County School Nurses will hold a bachelor’s degree and be nationally certified. Health Room Assistants are typically previous teachers assistants or certified nursing assistants. School nursing is not a lucrative profession, and is budgeted for a 10-month period. But the rewards far exceed the dollars. According to Beck, the best part of being a school nurse is being able to make a difference in the life of kids with chronic health issues, so that they can “attend school, learn and enjoy relationships with other students.” Beck recounted numerous stories that range from helping a child attain glasses and see the leaves on the trees for the first time, to working with children who require urinary catheterization during the school day, or tube feeding for nourishment. By having a nurse to see to these activities, these children can safely attend school and learn.

Beck’s biggest worry going forward is the fragile funding structure for school nurses. Currently the patched together funding sources are working well, but if any of the funding streams dry up, decisions and challenges will need to be addressed to assure our strong school nurse program continues into the future. She also worries about the mental health issues that may surface as a result of the pandemic. She describes the issues as “deep and complex” and is grateful for the social workers and school counselors who partner to address the current and expected mental health impact of the pandemic.

Finally, I asked Sharon about her greatest concern as the pandemic winds down.  “Will COVID always be with us, or will it become an illness that crops up time to time like chickenpox?” The unknown of how the pandemic will play out is with us all.

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