1. The Role & Value of School Nurses in the Worcester School System
I want to thank you for giving us the time today to make this presentation. As you know, my name is Nicole Kazarian and I am co-chair of the Worcester School Nurses local bargaining unit of the Massachusetts Nurses Association. I am also the school nurse at the Elm Park Community School, where I provide comprehensive school health services to 500 students. I am joined here today by a number of my colleagues, each of whom has years of experience in providing first-rate, professional school nursing care to the students in our community. In all, here in Worcester we have 42 full time school nurses providing care to nearly 24,000 students in 47 schools.
We are here to provide you with a better understanding of the importance of school health to our educational environment, the role of school nurses in promoting school health and the added value we bring to the school system.
Keeping Our Children Healthy & Ready to Learn 1

2. Health & Learning Go Hand in Hand
“…there is increasing knowledge that integrating quality health care through competent, professional school nurses into the academic framework for schools, supports an environment that produces academic results.”

3. Health & Learning Go Hand in Hand
“Today’s specialized school nurses are… part of an interdisciplinary school team working to ensure that all students benefit from quality education, and health prevention and intervention services that reduce barriers to learning.”

4. Health & Learning Go Hand in Hand
An unhealthy child has difficulty learning
An undernourished child cannot concentrate well
Medical/mental health problems caused by a troubled home environment interfere with a child’s ability to learn
A recent survey of school nurses in the Commonwealth found that more than 8 percent of students experience chronic health conditions that require nursing assessment and/or interventions to maximize their educational experience. Here in Worcester we deal with three times that number, more than 25 percent of our student body.
In Worcester we have more than 6,000 students with a variety of special health care needs. Special Health Care needs are defined as those that require health and related services of a type or amount beyond those required by children generally. The average number of special needs students assigned to Massachusetts school nurses is For example, Ellen Capstick, who works at the Sullivan Middle School, is personally responsible for 60 such students.
Asthma and allergies account for the most common chronic health conditions among this group and are the leading cause of absence from school. Another significant number of students is being treated for attention deficit disorders that require daily medication monitoring.
Complicating this picture is a related growth in socially driven problems, such as substance abuse, crime and related emotional disorders.
In fact, a new national study on mental health issues for students in schools found that one-fifth of students receive some type of school-based mental health care, with school nurses spending as much as a third of their time on mental health issues, including post traumatic stress from domestic abuse, a wide variety of mood and anxiety disorders, as well as other issues related to complex family problems.
I will now turn the presentation over to Ellen. 4

5. School Nurses Help Keep Students in School by:
Managing chronic health conditions
Shortening illness-related absences
Lessening the number of students sent home needlessly
>93% of students seen by our nurses return to class
Health and learning go hand in hand: a child must be healthy to learn – and learn to be healthy. A wealth of scientific research has clearly demonstrated the link between a child’s health and his or her educational performance.
At a recent forum in New York on methods of promoting student achievement, school administrators and school nurses were brought together to explore the relationship between academic success and healthy behaviors.
As noted on this slide, a key conclusion of this conference was “there is increasing knowledge that integrating quality health care through competent, professional school nurses into the academic framework for schools, supports an environment that produces academic results.” 5

6. School Nurses Help Keep Students in Class by:
Identifying health-related barriers to learning
Providing early detection and correction of health problems
Helping teachers accommodate students with special needs

7. School Nurses Help Keep Students Safe by:
Inspecting the school’s physical environment
Teaching the use of universal precautions
Supporting a non-violent, drug-free environment
Administering and monitoring medications
In surveys of teachers, the three main problems they identified that prevent children from learning are: impaired health, poor nutrition, and abuse and neglect at home.
Sound school health programs can play a vital role in addressing these problems and improving a child’s ability to learn.
And when you talk about school health, you are talking primarily about school nursing services. 7

8. The New Landscape of School Nursing
School nurses make a real difference in the lives of school children. It has been shown that school nurses keep students in school by better managing chronic health conditions, shortening illness-related absences and lessening the number of students sent home needlessly.
For example, through February of this year, there have been more than 83,0000 visits to our school nurses offices for a variety of illnesses and conditions. Of those, only 5,600 students were dismissed. Our return to class rate is nearly 95%, which is above the state average. 8

9. Changes in Family Structure and Patterns of Parental Employment:
Increase in divorce
Later marriages, increase in unmarried parents
Rise in single-parent families
More mothers in the workforce
Some of you may question the importance we are placing on school health. Your skepticism is probably based on your own experience as children in school. You may be thinking back twenty or thirty years ago when the school nurse’s role was largely confined to such areas as infection control, vision and hearing screening.
I am here to tell you that times have indeed changed. To get a clear picture of this issue, we must first have an accurate understanding of the needs of our school age children, and recent changes in our society that impact their health and well being.
Schools of today are much different than even when you were a principal Councilor ____________. What has changed? Let’s take a look at just two major changes that have taken place in recent years. 9

10. Increase in Number and Severity of Illness of Students with Special Health Needs:
1 in 12 school children has limited, fair or poor health
15% have chronic health conditions
Growing population of families without medical insurance or access to primary care
Mass Department of Public Health
School nurses keep students prepared to learn by identifying health-related barriers to learning, providing early detection and correction of health problems, and helping teachers accommodate students with special needs. 10

11. Children with Special Health Care Needs
6,069 Students in Worcester Schools
Life threatening allergies
Arthritis
Asthma
Blood dyscrasias
Cancer
Cardiac conditions
Diabetes
ADHD
Depression
Migraine headaches
Neurological conditions
Eating disorders
Mental health/emotional issues
School nurses also are there to prevent injuries and other types of harm. We monitor the school environment to identify and then remove potential safety hazards. We work with the staff to teach universal precautions, first aid and other measures to protect the school community.
We work closely with staff, faculty and the student body to maintain a non-violent, drug-free environment and use our time with students to educate them about these issues.
And, of course, we are responsible for administering and monitoring a full range of complex medications for students who need these medications to maintain their health and manage their conditions. 11

12. Beyond Band Aids and Ice Packs
School Nurses of Today
According to a recent U.S. Census report, several trends have altered traditional family systems over the past few decades. These include: an increase in divorce, later marriages and parents who are unmarried, a rise in single-parent families and a growing number of mothers in the labor force.
The fact is, fewer and fewer families have one parent in the home during the school day and working parents are not always able to be home with a sick child.
Here in Worcester, we have to confront additional problems common to many urban centers, including dealing with the children of immigrants, and children living in homeless shelters, or in substandard housing arrangements. And in these tough economic times, we can expect to see these issues increase for our school population.
There is a parallel trend of increasing dysfunction in families and a rise in the poverty level of children in single-parent families. These factors have combined to have a number of effects on our children’s physical and mental health. Coping with these effects inevitably becomes the responsibility of the school system.
Beyond Band Aids and Ice Packs 12

13. School Nurse Qualifications
Must be a licensed Registered Nurse
Hold a bachelor’s or master’s degree in Nursing (same as teacher)
Minimum of two full years of experience as an RN (more than a teacher)
Passing score on the communication and literacy test (same as teacher)
Pass courses in continuing education throughout career to maintain license to practice (same as teacher)
Mass Department of Education
The second major change in the world of school health is in the nature and scope of health problems experienced by the student population.
Currently, there are more than one million school age children and youths in the Commonwealth. In the last twenty years, the movement to mainstream children with disabilities and special needs into the general school population, combined with the passage of the Americans With Disabilities Act, has resulted in more and more children entering school with specialized health care needs and conditions that need to be addressed by the school health system.
According to the Department of Public Health, it is estimated that one out of every twelve school-age children in Massachusetts is either actively limited or in fair or poor health.
Approximately 15 percent (about 125,000 students) have a chronic health condition, and 7 percent (more than 60,000 students) have limited or poor health. In addition, there are approximately 5,000 students with mental retardation, 3,000 with cerebral palsy and almost 500 each with muscular dystrophy and spina bifida, and over 200 with cystic fibrosis.
Without school nurses, many of those 125,000 students couldn’t attend school, and any school that failed to accommodate them would be in violation of state and federal law.
There also is a growing population of children whose families lack health insurance. For these kids, the school nurse is the first and only link to primary medical care. 13

14. School Nurse Role and Responsibilities
Health encounters with students and faculty
Worcester nurses averaged per day, including the provision of:
Assessment of ailments and complaints
Basic first aid and injury assessment
Monitoring of medications and conditions
Emergency care when necessary
We are first and foremost Registered Nurses, who possess between three to five years of nursing education, including pathophysiology (what happens to the body when it’s sick), advanced pharmacology, adult education, and psychology. Nurses must pass a state licensing exam and continually upgrade their education every two years to maintain their license.
In recognition of the varied and complex demands placed on the school nurse, regulations have been passed to require school nurses to have educational preparation and experience above and beyond that required of nurses in other settings. Every school nurse must have at least a bachelor’s degree (the same as a teacher), and like teachers, we must pass the communication and literacy test. We must also pass the National School Nurse Certification exam.
School nursing is a specialty branch of professional nursing. It seeks to identify or prevent student health problems, and intervenes to remedy or modify these problems. As the primary health professional on staff, we also are charged with taking care, not only of the students, but the teachers and other personnel at the school.
Today’s school nurse needs the acute care skills of a hospital nurse, the case management training of a community health nurse, the first aid and intervention skills of an ER nurse, and the understanding and compassion of a parish nurse all rolled into one. Unlike other nursing professionals, the school nurse works alone, providing 90 percent of the care delivered on the school grounds. 14

15. School Nurse Role and Responsibilities
Managing and administering medications
1,900+ students/day on meds per day
800+ students/day have inhalers & nebulizers
250+ students/day with severe food allergies with epi-pen injections
Thanks Nicole and thanks again for allowing us to make this presentation today.
In light of these changes Nicole has described, society has looked to the schools to fill the gaps in the health and social safety nets.
As we alluded to earlier in our presentation, the person in the school system most responsible for keeping that safety net stitched together is the school nurse.
Just who is the school nurse of today? I can tell you we are a far cry from the stereotypical band aid nurse you knew when you were in school. In fact, we are way beyond band-aids and ice packs.
Today’s school nurse is a highly skilled, well-educated registered nurse who must possess a variety of talents and a breadth of knowledge. 15

16. School Nurse Role and Responsibilities
Specialized medical procedures
Colostomy care
Catheterization
Tube feeding
Suctioning
Chemotherapy
So what do school nurses actually do?
Allow me to provide a snapshot of what is expected of a full time school nurse working in the Commonwealth.
A health encounter refers to any contact during which the school nurse provides ad hoc counseling, treatment or aid of any kind. Statistics from last year’s school year showed that Worcester school nurses had an average of 660 health encounters per day, or more than 119,000 for the year.
This could include assessment and treatment for a number of ailments and complaints, including headaches, nausea, colds and flu; providing basic first aid and the assessment and treatment of injuries. And remember, these encounters also could include a nurse’s emergency response to a serious injury or incident on the school grounds.
I want to emphasize here that the unique value we bring to every encounter with a student or a staff member is our ability, based on our education, training and experience, to make a PROFFESIONAL nursing assessment. It is not just the task we perform, such as giving a medication or changing a dressing on a wound, it is our understanding of what is going on with that child or staff member while we are performing that task. 16

17. School Nurse Role and Responsibilities
Health Screenings
24,000+ vision and hearing screenings
5,400+ postural screenings
2,700+ medical screenings for children in early childhood and kindergarten

18. School Nurse Role and Responsibilities
Nursing case management
Thousands of phone calls to parents/physicians to manage students’ conditions
1,300 + Individual Health Care Plans written
Nurses are responsible for managing and administering a range of medications for a variety of conditions for an increasing number of students.
Our nurses see more than 1,900 students on medications each day.
We see more than 800 students each day who have inhalers or nebulizers to deal with asthma and other serious breathing problems, as well as a significant number who are on insulin to control their diabetes.
And we monitor another 252 students per day that have epinephrine, a very serious medication specifically prescribed for treatment of life-threatening allergies.
Again, the value we bring to this process goes well beyond administering the specific medication. The value of a professional nurse lies in our ability to assess the student to see how they are reacting to their medication; the ability to spot changes in a student’s behavior or condition that could spell major problems. 18

19. School Nurse Role and Responsibilities
Health education
One-on-one health teaching
Small group health instruction
Classroom teaching
Health curriculum development
The number of students requiring specialized medical procedures has increased dramatically.
In a typical school year, we could administer more than 6,000 medical procedures, including: colostomy care, catheterization, oral feeding, suctioning, central venous lines, taking vital signs, and other procedures including oxygen therapy, and gastric tube feedings.
I had have a number of students with special health care needs including students with cancer undergoing chemotherapy that I had to closely monitor; children who are insulin dependent, brittle diabetics, asthmatic children who are on inhalers, students with attention deficit disorder and children with autism -- just to name a few.
To give you a true picture of the complexity of this care, we have brought some of the equipment we use in treating these children. Go into the demonstration, starting with the trach stuff.
Remember, not too long ago, none of these students would have been in the schools. 19

20. Support for School Nursing Is an Investment in Our Future
Public schools in Massachusetts are required by law to conduct regular postural, hearing and vision screening on all students. School nurses are responsible for ensuring that these screenings are completed and for referring students for follow-up care when needed.
Last year, we conducted more than 24,000 vision and hearing screenings.
5,400 postural screenings.
And more than 2,700 medical screenings for children entering early childhood education and kindergarten.
In all, our nurses conducted more than 38,000 screenings. All of these screenings are essential to identifying potential problems that may hinder learning and a child’s development. 20