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School Nurses Become Medical Safety Net

Posted: Feb 03, 2012

NEWMAN, Calif.--When Bernice Arnett accepted a school nurse position with the Newman-Crows Landing Unified School District seven years ago, people suggested the job would entail little more than applying Band-Aids to boo-boos.

But as the sole medical provider for seven schools in the west Stanislaus County district--where about 70 percent of the 2,841 students are Latino and about 75 percent of students receive free or reduced-price meals--Arnett's job has been far from simple.

"It is a kaleidoscope," Arnett said one Tuesday afternoon in January, between providing ice packs to two boys injured on the basketball court and helping a girl with type 1 diabetes maintain her blood sugar.

"We can plan, but we just never know what the day is going to throw our way," Arnett added.

Today’s Nurses Spread Thin

Years ago, school nurses were stationed at a single school and were mainly responsible for monitoring student immunizations, screening students for scoliosis and vision and hearing problems, and providing students with first aid and medications.

Today's school nurses do that--and more.

Due to previous budget cuts, nurses in San Joaquín Valley school districts are spread thin. They oversee more schools and treat more students with severe health problems, at a time when struggling families have less ability to access medical care.

Now, school nurses--who earn significantly less than registered nurses at hospitals--visit multiple schools in one week--or even in one day. Beyond the typical headaches and bellyaches, they are also responding to an increase in students with chronic diseases that require regular care, such as diabetes, asthma, allergies and seizures.

In California’s Central Valley--a rural region marked by crippling poverty, unemployment levels above the state average and high levels of the medically uninsured--school nurses are also facing greater challenges in linking families with medical care.

Sometimes, nurses provide bus tokens--out of their own pockets--to ensure families reach doctors' offices. Other times, nurses will simply transport families themselves.

Too often, school nurses have become families' medical safety net.

"Things that should be easy to take care of have gotten much more complicated, and that is because families are losing their access to health insurance," said Aurora Licudine, who chairs the school nurses association for Modesto City Schools.

Often Students’ Only Health Provider

"Sometimes, we are the only health care providers that these students and their families see," Licudine observed.

Although she had received an insulin injection after lunch, a young girl with type 1 diabetes--who sported a pink backpack and pink sneaker--returned in the afternoon to Arnett's office at Newman's Hurd Barrington Elementary School with complaints of shakiness.

The girl pricked her finger and then tested her blood sugar: Her monitor read 78, indicating her blood sugar was too low.

Arnett handed the girl an string cheese, a sugar-free cookie and apple juice, all of which would help raise her blood sugar.

About 15 minutes later, the girl tested her blood sugar again. It had returned to healthy levels, and the girl skipped back to class.

California schools do not keep a database of student health conditions, but Katy Waugh, president of the California School Nurses Organization, said diabetes--as well as asthma, allergies, seizures and obesity--are some of the biggest health challenges students currently face.

Nurses agree there are more students with these conditions than in years past.

"It just seems there are more in general--there are more kids that have more severe health problems," said nurse Linda Trujillo Cayabyab, who oversees licensed vocational nurses at 13 sites within Modesto City Schools.

But school nurses are unsure whether this is because students are less healthy now, or because more students with chronic conditions now attend school with their peers.

More with Chronic Illness

"We feel there are more students [with chronic illness,] but I don't know if it is because they didn't come to school in the past," said Patti Cassinerio, director of health services for Stanislaus County Office of Education. Her office employs 11 full-time equivalent school nurses to serve about 16,000 students in 15 schools.

"We just know that we need to make the accommodations" for students, she said.

Caring for students with health conditions also means working closely with families -- sometimes overcoming language barriers and cultural differences -- to ensure students are healthy, safe, and succeeding in school.

"When you see a child, you are not just seeing a child, you are seeing a whole family," said nurse Sandy Dutch, who works in seven schools in the Tulare County Office of Education, where 64 percent of district students are Latino, and 67 percent of kids receive free or reduced-price meals.

"You don't just take care of that child, you help the parent take care of that child, and you help the parent find resources," Dutch said.

That was evident early on a Tuesday morning in January, as Cayabyab analyzed the care plan for a student with seizures.

One to three times a day, the student closes his eyes, falls asleep and slumps in his chair, a licensed vocational nurse, stationed at a Modesto area elementary school, told Cayabyab. The seizures typically don't last more than three minutes, she said.

"We need to find out when mom wants us to call 911," Cayabyab said.

After speaking with the child's mother by phone, Cayabyab updated the child's care plan: The licensed vocational nurse would call 911 only if the student's seizure lasted longer than four or five minutes.

When young students complain of being tired or fall asleep in class, Arnett, the nurse at the Newman-Crows Landing Unified, occasionally provides them with a glass of milk, graham crackers and a pillow to cuddle with in her office.

The snack and rest, she said, often serve as a short-term solution to a deeper problem at home. Sometimes, children are not sleeping well due to living in an overcrowded home, domestic violence or the stress of living amidst a dysfunctional family.

But as she is providing students with some immediate comfort and care, Arnett is also collaborating with school officials, counselors and area nonprofit organizations to ensure the students and their families don't fall through the cracks.

Poverty Aggravates Existing Problems

Across the Valley, school nurses are attempting to keep students healthy, while battling the barriers posed by poverty, stress and limited access to medical care.

In some homes, poverty can aggravate existing health conditions. For example, in some families, a lack of transportation makes it difficult for children with poor vision to get the glasses they need.

"Because of limited economic resources, some of our families are burning wood in their homes to provide heat, and that makes many of these kids who have asthma have a flare up," said Licudine, of Modesto City Schools, which employs more than 16 full-time-equivalent school nurses to serve about 30,000 students across 34 schools.

Sometimes, poverty and stress create other health challenges. When parents lose their jobs and health insurance, and there is not enough food on the table, students manifest that stress-- maybe as stomach aches, headaches or general complaints, such as, "I'm not feeling well," Licudine said.

These conditions also makes it more difficult for families to access medical care.

"There are less resources in the home, because of a variety of reasons, and it is harder to get them into care, and harder to get the things they need," said Dutch, of the Tulare County Office of Education. Tulare employs five full-time and two part-time school nurses, who serve about 14,600 students across 35 rural school districts.

The increase in serious health issues, coupled with the tough economy, requires school nurses--more than ever--to act as community liaisons, connecting families with Medi-Cal or low-cost insurance, doctors and dentists and free backpacks and clothing.

As school nurses, "our common goal is to remove the barrier that is keeping these kids from being successful," Arnett said.

Call to End Budget Cuts for Nurses

These compounding challenges underscore the important role school nurses play in the lives of San Joaquín Valley students. For Licudine, of Modesto City Schools, they also emphasize why nurses should be protected from further budget cuts.

"I think that in general, school nurse shortages will only make the problem bigger," she said. "School absences will cause students to be less academically successful, and that limits the economic future of students, and limits their access to health insurance."

"By removing the health barriers that will make children academically successful, [nurses] can directly impact their academic future and their earning potential," she said.

Cassinerio, of the Stanislaus County Office of Education, summed up school nurses' responsibilities to students and their families.

School nurses, she said, "are really advocates for students, so they can succeed in school, and work in the community," she said. Nurses "have to work closely with their families and the community and all the health care providers in the community."

"Liaison,” said Cassinerio , “it is a small word, but it is a big job."

Send e-mail to: rplevin@vidaenelvalle.com

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