If you're of a certain age, you might remember your school nurse as the nice person you saw when you didn't feel well and wanted to go home early.
Time to file that notion away.
Today, school nurses juggle busy panels of students with diabetes, asthma, allergies, physical disabilities, or other special needs. They serve as public health educators, helping parents and teachers understand the individual needs of each of their young charges.
In short, they are on the frontlines of a disjointed healthcare system — and, if deployed correctly, they can be a key to managing population health.
“We catch things before they end up in the emergency room," says Beth Mattey, MSN, RN, NCSN, the president of the National Association of School Nurses (NASN), describing her role as lead school nurse in the Brandywine School District in Wilmington, Delaware.
But in an era of tightening expenses and disconnected providers, Mattey says, many school nurses lack the resources they need to deliver care most efficiently. In many cases, they're responsible for multiple buildings spread out over a school district. And they often use electronic systems that don't speak to the partners they need to reach.
A changing role
For a sense of the changed role of the school nurse, consider the job of Nina Fekaris, MS, BSN, RN, NCSN, a 27-year veteran in the Beaverton, Oregon, School District.
“My job is to make sure kids are safe and healthy," she says. That's a complicated task. By mid-September Fekaris had completed 300 individual care plans for some of the 4,200 students at a comprehensive high school, a middle school, an elementary school and an alternative Earth science high school program. She also supervises two classroom nurses who provided direct nursing care for medically fragile students.
“I'm almost a consultant," she says.
Fekaris, the NASN president-elect, still provides direct care to her student-patients. She manages outbreaks of influenza or norovirus — which she says spread from one student to half an elementary school within three days two years ago.
But much of her time is spent in care coordination, taking histories and planning, then sharing those plans with teachers and physicians.
“Population health is the future," Mattey says. “So many children come from working families, single-parent families, where it is very difficult for families. We can recognize where there are issues and offer support."
Some of her changing caseloads are a direct result of improvements in neonatal care. Premature infants are surviving with anomalies and syndromes that once proved fatal, and now require consistent and coordinated care.
There's also an increase in care needed for children with chronic diseases.
Fekaris notes that Type 1 diabetes cases were rare when she started. Now, cases are up — though researchers are unclear why — and she attends to more than 100 students with the condition.
That means checking blood sugars five to eight times a day, because something as simple as the addition or cancellation of recess can affect those levels. She also checks carbohydrates before lunch and administers insulin when needed.
And these growing caseloads come at a time when resources have not kept pace. The Centers for Disease Control and Prevention's 2014 School Health Policies and Practices Study found that while 85.2 percent of elementary schools have nurses, only 48.7 percent have an RN on staff for 30 hours or more.
Uneven electronic records exacerbate the challenges school nurses face. Mattey's office, for instance, is connected digitally to her education system, but not to the local healthcare infrastructure.
“School nurses are now starting to get access to pediatrician records, usually read-only," she says. “Nurses in remote areas still use paper and pen."
The rise of the school-based health center
Because registered nurses cannot diagnose or prescribe, some communities supplement their services with school-based health centers, often operated as a partnership with community health organizations.
Here, students can be treated for acute illnesses, such as flu, and chronic conditions, such as asthma and diabetes. They can also be screened for dental, vision, and hearing problems. Other services offered can vary based on community needs and resources.
The centers bill insurance companies, and receive funding from the Health Resources and Services Administration through Affordable Care Act funding.
Nearly 2,000 schools across the country have school-based health centers, according to the most recent National Assembly on School-Based Health Care census. Most are open every day school is in session.
But that amounts to only 4.6 percent of schools nationwide. Another 34.5 percent of schools have arrangements with organizations or healthcare professionals to provide health services to students at other sites outside school property.
And while more than 90 percent of schools administer medications, CPR, and first aid, fewer than 66 percent provide prevention services, such as tobacco-use prevention, in one-on-one or small-group settings.
The uneven landscape means nurses must act as public health educators — and as links within a fractured healthcare system, Mattey says.
“While I don't think we need to provide primary care in every school, we do need the infrastructure to allow every school to optimize health and learning for a child," Mattey writes in the July 2016 issue of NASN School Nurse. “The school nurse connects students to the community healthcare provider and the healthcare home when needed, and the school nurse can lead the team supporting all of the factors that influence health."
Jerry Berger is a writer based in Boston.