Nursing a need

Jordon Morch, a bubbly 9-year-old third-grader at Little Chico Creek Elementary School, is about to have lunch with his classmates. But first he must swing by the nurse’s office.

Jordon is one of several children in the Chico Unified School District who have to check their blood glucose levels daily to make sure they’re neither too high nor too low. If Jason’s is low—say, 70—he may get a couple of Starburst candies to boost the blood sugar up again.

With a quick “snap,” Jordon sticks a special blade into the tip of his pointer finger. A drop of blood swells from it. He smears it on a tester stick, puts the stick in the glucose meter and quickly pops the finger into his mouth, sucking away the rest of the blood.

Jordon was diagnosed with diabetes when he was 7. By now, he says, “I’m used to it—except for the shots.”

When his blood sugar is low, he said, “I feel shaky and stuff.”

“The lowest I’ve ever been was 32,” Jordon remembers. “I was playing at my friend Sam’s house. It was right after Halloween, so I ate a bunch of candy and it was cool.”

School nurse Margaret Rader stands by throughout and then calls Jordon’s mom to report his reading—a little high today.

What school nurses might see in a typical week is about as varied as what appears in the average emergency room: Ritalin-calmed grade-schoolers stopping in for their meds. Pre-teen girls already in the throes of an eating disorder. A nurse could be staving off a life-threatening asthma attack, helping out with family-life education, or administering the state-mandated hearing, vision, scoliosis and special-education evaluations.

Rader was quick on the scene when a Pleasant Valley High School student fractured his femur during football practice. For a while, there was a run on children being hit by cars outside Chico Junior. As for breaks, she says, “wrists are real common.”

It’s a mixture of triage and routine testing that can be as frustrating as it is rewarding.

“Some days you just don’t know what’s going to happen,” says Elli Moon-Tiller, another of the CUSD’s five full-time nurses. “It’s hard to know what the need is going to be.”

That’s become even truer in the last couple of decades. When the federal Education for All Handicapped Children Act became law in 1975, that opened public schools to young people with special health needs but brought with it more challenges for a system that, in California, was also soon to see budget cuts following the passage of Proposition 13 in 1978.

“We have a lot more medically fragile children in the school system,” Rader said. Some have diseases like cancer or cystic fibrosis. Some need breathing machines or use of a catheter. Others have seizure disorders.

“We have more children with childhood diabetes than ever before,” adds Rader, who has been a nurse in the CUSD for 14 years and was a pediatric nurse before that, working in big medical centers. As for the drugs prescribed for such conditions as attention deficit and hyperactivity disorder, she says, “I think it has a lot to do with the medical awareness of these conditions now, and we [as a society] are not just going to give them one pill; we’re going to give them three or four pills.”

Meanwhile, larger societal problems, such as broken homes, continue to find their way inside school walls, and a visit to the nurse may end with the school calling Child Protective Services rather than a doctor. Plenty of students lie down on the nurse’s couch complaining of a stomachache, only to end up revealing a deeper emotional problem, or even abuse.

Schools can’t just ignore these problems, nurses say.

“Healthy children learn better,” Rader says, simply. “Health is really the basis for education.”

In the CUSD, the numbers work out to one nurse for every 3,250 students—about the same as the national average, but well below the 1-to-750 recommended by the National Association of School Nurses. California’s ratio is about 1-to-2,700.

That, say Chico’s nurses, is barely enough time to meet the state mandates, much less check items off the wish list of things they’d like to do for schoolchildren.

“It’s difficult now to get everything done,” Moon-Tiller said. “You feel sometimes like you’re an octopus.”

Besides Rader and Moon-Tiller, who covers Chico High School and Citrus, Parkview and Hooker Oak elementaries, Brigid Miller is responsible for five elementary schools—one a day—while Ann Scott spreads her four-day work week among Pleasant Valley High School, Bidwell Junior and Shasta Elementary. Leslie Mahon heads up the teen parent program at Fair View High School, and the district contracts with Oroville-based Bonnie Erickson to visit Marsh Junior High and Forest Ranch and Cohasset elementaries on Thursdays.

Rader has a nametag and neck cord with the colors of Little Chico Creek Elementary on Mondays. Then, as the week progress, she trades for Chico Junior, Chapman, Neal Dow and Rosedale.

Scott says that at one point she was responsible for six schools. “I felt like I either belonged to everybody or didn’t belong to anybody. It’s unfortunate we aren’t allowed more time to do what we are trained to do, because we could do a lot for our kids given the opportunity and the time.”

When the nurses aren’t there—which is a lot of the time—health aides step in. (They’re the ones, for example, who pass out the prescription medicine.) Recently, the district contracted with a licensed vocational nurse five hours a day just to help students with catheters.

Sometimes, Scott said, “school nurses have a tough time being visible,” and she worries about misconceptions—like, “We put on Band-Aids all day, or we’re a low-level skilled nurse.”

To be called a school nurse in California, one must be a registered nurse—RN—with a bachelor’s of science degree in nursing who has also completed another year of graduate school to secure a school nursing credential.

But while there are 1,500 school nurses in California, districts are under no state mandate to have nurses on campus at all.

“There’s nothing that requires a nurse,” relates Bob Feaster, who, as the CUSD’s director of pupil personnel services, oversees the school nurses. “That’s the stark reality.”

In 1999, the CUSD’s interim superintendent at the time included nurses on a list of possible cuts the district could make to save money. The number would have gone from five nurses to three—two left, if one stayed at Fair View, to cover 22 schools.

Asked about this trying time, CUSD nurses sound like they’d rather forget it ever happened. The district has almost always been supportive in what its nurses want to do in the way of special programs or professional development, but just having nurses appear on the list illustrated a lack of understanding, the nurses felt.

“There was a feeling of being devastated,” Moon-Tiller remembers. “They were looking at dollars and cents, and we were looking at compassion and the needs that are out there.”

“We felt like we had to beg for our jobs,” agrees Miller, “like we had to justify our existence, and we shouldn’t have to do that.”

Scott, who was hired in 1993 but was still “low man on the totem pole,” would have been the first to go.

Says Rader: “We wouldn’t have even had time to do the mandated services. … Even with our current assignments, there are not enough hours in the day. It’s not physically possible.

“We put out fires. We don’t have time to get involved in all the details. There are too many kids and too many problems.”

The nurses and their services were saved, and Feaster said he opposed the cuts when they were proposed. “I certainly didn’t think it was a good move,” he says.

Then, in May 2000, the CUSD Board of Trustees voted to lay off the equivalent of 7.75 clerical staff members at the three junior highs to save money and bring ratios into line with the rest of the district. Trustees seemed surprised when, because of seniority and scheduling issues, the cuts trickled down to the health aide positions, and they directed administrators to try to fix it.

“The cuts for the health aides came at the very last minute,” Rader says.

“That’s a really sore subject for me right now. The problem is getting the school board and the district administration to understand,” she says. “Health is so closely related to education, but it’s still so far out.”

For example, there are still two class periods at Chico Junior where there’s no health aide on duty, as staffers shift from school to school.

Feaster says time has indeed been added back to replace some of the health aides’ lost hours, and especially to get coverage during the lunch rush. Now, he says, “every school has at least four hours.”

Feaster doesn’t disagree that nurses have a tough task. “They really become more program managers than kid managers,” he explains. “They have become more itinerant as the years have gone by. … Sometimes I worry that we’re going to lose good people.”

When enrollment went up in the CUSD, no nurses were added, but, Feaster points out, the numbers are sliding now at the elementary level and there’s been no recent talk of cutting back nurses.

School nurses date back to the late 1800s, when their role was mainly to prevent the spread of contagious diseases. Later, they taught health classes and focused on hygiene, referring children to doctors but not doing much health care themselves, recalls an Education Week article from 1996. But as poverty and divorce in the 1960s and ‘70s led to medical needs showing up in schools, nurses became better funded and more prevalent before that trend slowed.

Now, according to the California School Nurses Organization, responsibilities range from first aid to crisis management to evaluation for chronic illnesses to tube feedings and IV therapy. Some schools have full-blown health centers.

School nurses still can’t diagnose illnesses or prescribe medicine. They do make referrals—an example of what school nurses see as one of their main roles as a liaison to the community.

“We’re not supposed to diagnose,” confirms Rader, “but I’ll tell you one thing: We get pretty good at it.”

“We do a lot of assessing—just general health assessing,” she says, and school nurses may be the first to see a problem.

Miller, who sees the littlest students with her five elementary schools, says, “Several times I’ve identified kids who have pretty severe hearing and vision problems. There was a student who was completely deaf in one ear, and his parents didn’t know.

“They struggle in school until they’re identified,” she says.

It’s not unusual, says Rader, for a child to show up at school only to be send right home because he or she is too sick.

“I think the most frustrating thing for me is when parents don’t seem to care about their children’s health,” muses Rader, quick to point out that these are the exception rather than the rule. “Finances aren’t always the issue—it’s just a matter of being willing to take the time to take the child into their lives.”

The best part, of course, is “the children—just being with the kids. They’re really quite a kick.”

The other day, Rader walked into a kindergarten classroom, and one child said, “Oh, the hospital’s here.”

At Chico High School, Moon-Tiller takes on a typical case: A girl in her junior year walks listlessly into the nurse’s office, past the desks, Merck manual and collection of brochures like “Incredible Body Art Fact” and “Help is on the Way: Panic Attacks.” A poster reads: “Smoking. Next fad: tumors.”

“I have a bad headache and my stomach kind of hurts,” the girl reports. In jean shorts but still boasting a perfect French manicure, the student suspects it has something to do with prom weekend and staying up late.

Moon-Tiller asks how the prom music was ("not that great") and has the girl spit out her gum before taking her temperature: “96.7—no fever,” she pronounces.

The nurse records the details of the girl’s visit in the district’s new computerized student information management system and tells her to lie down for a while. A few minutes later, a boy who doesn’t feel well follows suit.

Moon-Tiller grins, saying that when she was younger, “I wanted to be a professional ice skater. … This job was in the future, but I didn’t know it at the time.” She found her calling through a stint in the Peace Corps and then community nursing. Like most of her colleagues, she chose school nursing for several reasons: She cares about kids, and the hours are more family-friendly than other types of nursing.

Asked if school nurses develop a “sixth sense” about whether kids are sick, faking it or hiding some deeper problem, like abuse at home or a learning disability, Moon-Tiller says it’s difficult to do so not being at a school all the time.

“You have your ‘frequent fliers,” she says, using the school-nurse jargon. “It may be something is not going right in a class, so you make a referral to a counselor. You use the team approach.” And, she says, “you always give them the benefit of the doubt.”

Marlene Merlo, the health aide at Chico High, sends sick or injured children home, makes doctors’ appointments, finds donated glasses, hands out lunchtime medication and does whatever else may be needed on a particular day. When she was hired 20 years ago, it was mostly to keep track of mandated tests and immunization records. Now, the valued health aides have CPR certificates and first-aid training. They call nurses with questions when things are bad; 911 when they’re worse.

During the course of a day at Chico High, Merlo will help 30 to 40 students, “and that’s not even writing down all the Band-Aids.”

“There’s a lot of mainstreamed students with a lot of needs, physical and emotional,” she said. By now, she says calmly, “nothing shocks me.”

Although teen pregnancy rates are down, school nurses are taking on increasingly sophisticated questions. These days, girls as young as the fourth grade are included in teachings about menstruation and other milestones of puberty.

“They mature much faster,” Miller observed. “Now, we’re seeing them develop and get their periods as early as 9.” It was actually parents who asked for the program to include fourth-grade girls, as the girls were getting their periods and “they were scared—they thought they were dying.”

The girls get a lesson in the body and hygiene, plus a little booklet and samples of pads and deodorant—Secret as opposed to the boys’ Old Spice.

Rader said there’s a limit to what schools can—and should—tell young people about sexuality. “They’ve kind of lost interest in the fact that they’re going to have a period and they’re more interested in the personal relationships themselves. They want to know about intercourse.” (Birth control and topics like that wait for the higher grades.)

There are still junior-high-aged girls who show up pregnant. And in high school and junior high especially, Miller said, there are peer problems that manifest themselves at recess or lunchtime, and the students come in “throwing themselves on the bed in tears.”

Miller finished nursing school at Chico State and was hired at the CUSD in 1989. She enjoys it but misses being able to focus more on preventative medicine. “When I first started this job there was time to go into the classrooms and do little health lessons.”

At Bidwell Junior, the couch in the health room is watched over by a row of teddy bears—including a couple in medical garb. A basket holds a comic book titled “Captain Bio: Attack of the Hep B Virus.”

It’s a familiar setting for Nurse Ann Scott. As a child she attended Bidwell Junior, then PV, another campus she covers. She was an obstetrics and emergency nurse before “settling down” with school nursing.

In junior high, “There’s a lot of emotions, a lot of hormones going on,” Scott says. “They’re striving for independence. … Self-esteem is so important at this age, and body image.” Sometimes, a group of girls will come in to reveal that their friend is anorexic. Scott has seen eight or nine such students this year.

“My goal is to help kids get through these issues,” she says. “I see my role as a school nurse as being so diverse. … You have to be like a general practitioner.”

Also, she said, junior high is when young people become more active in sports and may break bones. Or they’ll display a chronic illness or seizure disorder for the first time. “Without a doubt, my junior high is the busiest site we have. We see more significant injuries at junior high. Kids aren’t just coming in with scraped knees.”

Meanwhile, she says, “the mandates have just increased and increased.”

The need shows even more starkly in the CUSD’s schools, where lower-income children make up much of the population. Many have no insurance, and in a way the school nurse or health aide becomes their primary care provider.

During a recent ear check at Chapman Elementary, Rader identified a little boy who likely has infections in both ears. For this case, she’ll enlist the help of Healthy Start in contacting the boy’s parents, who speak only Spanish.

The grant-funded program, explains site coordinator Sheri Zeno, provides “a link to community resources” for parents and offers classes, a once-a-month-clinic, translation, even transportation for families who don’t have a car to get to the doctor’s office.

It all goes back to the same goal: “If they’re healthy, they’re able to attend school. So they’re here and ready to learn,” Zeno says.

But the Healthy Start grant is about to run out, which is part of the worrisome future for school health care.

The California School Nurses Organization’s “legislative agenda” includes getting the definition of “teacher” expanded to include credentialed school nurses. In fact, school nurses in Chico are in the same union as teachers and are paid based on the same salary schedule.

And nurses have already won politicians’ support, with proposed Assembly Bill 163, which would divert some tobacco tax and settlement money toward raising the ratio of school nurses to schoolchildren. The bill calls for $10,000 a year to be given each school site just for that. Another bill, SB 391, would use tobacco money to hire an education school nurse consultant for each county.

Meanwhile, the mandates keep coming. Now, children have to have a hepatitis B shot and a measles/mumps/ rubella booster before entering seventh grade.

Feaster said the district is trying to find grants or other money to help. “We’re looking at ways we can increase the number of nurses that we have,” he says.

“I feel bad because I’m not a nurse, so I don’t always understand their issues,” Feaster says.

At Chapman, in a nurse’s room identified in English, Spanish and Hmong, Rader is rushing to get a class of kindergarteners in for a head-check.

But it’s recess time, and a boy comes in, breathing heavily. Rader gives him his inhaler but also a gentle scolding: “Are you getting ready to run? You already did? How come you didn’t come in before you ran?” She’s only there once a week, but she uses that precious time to fill the kids’ heads full of as much information that will help them manage their own health as she can.

“It can be anything from an accident on the playground … to a child being stung by a bee,” Rader says, beginning to sound a little harried.

“What’s always the shocker is the child that comes in a lot on a regular basis but there’s never really anything wrong … and then you find out they’re a product of abuse and they just needed some attention,” Rader said. “The population’s changing, the town is growing, and we have a lot more higher-risk children.”

“We just do the best we can."