In many ways, the school nurse’s office is a clearing house for health issues affecting students in school and at home.

School nurses handle everyday health needs such as the occasional nosebleed, stomach-aches and administering medication on a daily basis. But they also have to address health issues that arise from situations outside of school — such as modeling and teaching healthy behaviors for taking care of themselves.

“We always model and educate them,” said Dawn Dill, a full-time nurse at Dike Newell School in Bath.

She has been working with children since 2004, and has worked as a school nurse since 2009; Dill joined Regional School Unit 1 four years ago.

Sometimes, however, addressing ongoing health issues can be more complicated and require reaching out to a student’s household to figure out what’s going on.

“Nurses are trained to treat the whole person. So when a child walks into my office, I may end up calling home, establishing a rapport with the family, and that way you can keep the communication open with home,” said Dill. “You can at least have a picture of what the needs might be there and how we might support them.

“Knowing who’s working with students outside the school, the primary doctor, the eye doctor, what kind of health insurance they have,” she added. “It takes a lot of work and it takes a little bit of time to get to know how to help people with that.” Linda Morris had already been a nurse for 20 years in a number of settings before she started as the school nurse at Coffin Elementary School, moving Harriet Beecher Stowe Elementary School when it opened in 2011.

Having been surrounded by nurses and doctors, she started her first day as a school nurse realizing: “I am the only medical person here.”

Most intimidating were the regulations she had to become familiar with. She still has the state’s school health manual, a thick binder.

“I thought how am I ever going to know all this information,” Morris said.

A new school nurse orientation she attended that fall helped, one of three workshops that took place over the course of the school year that broke down the information. “There was a lot to learn — and I had been a nurse for probably 20 years with a lot of experience in a lot of fields,” said Morris. “But school nursing is different, it’s its own little specialty.

“I am so glad I had 20 years of nursing experience,” she added, “because it takes everything I’ve done almost every day of my nursing career up to that point to be a school nurse.”

Jenny Strout had been working in an emergency room when she became a nurse at Brunswick High School two years ago. With a career now going on 20 years, she was looking for a new challenge.

“I was very interested in the health promotion and prevention arenas,” she said.

That isn’t something she can do in the emergency room. Nor was developing deeper connections with those she was serving.

“One cool thing that I get to do here, that I haven’t been able to do previously, is develop relationships,” she said.

And that’s not just with kids that have a medical issue.

“My goal for these kids is to keep them healthy so that they can be in class,” Strout said, adding she wants them ready to learn, whether that means meeting their medical needs or helping them reduce their anxiety.

In her third year at Mt. Ararat High School, Ann Chang said individual time with students can sometimes be hard to find.

“One (challenge) I encounter almost daily is lack of time for in-depth conversations with students who would often benefit from them,” she said. “With so many students in and out of my office, it can be difficult to find the time and space for confidential conversations about difficult topics.”

Chang’s day is usually full with her many responsibilities within the school. In addition to providing direct care for illnesses and injuries in emergency situations, Chang provides important health information to more than just students — educating parents and staff is also part of the job.

Identifying issues and providing a support system for students is important to Chang. “I strive to treat my students the way I would want my own two children to be treated,” said Chang. “I want my office to feel like a safe space and I want them to feel cared about, as well as for, when they come to see me.”

Maintaining health

Morse High School school nurse Katrina Barter began her school nurse career at a private boarding school in 1994. She’s been working in public school nursing for nine years, joining Regional School Unit 1 in 2009.

“Since I’ve been a school nurse, I feel like there’s been a growing number of my students that have chronic or more serious health issues,” said Barter.

Diabetes, asthma, and other issues are a growing trend she sees among the student population. Diagnosing the source of that is difficult, but Barter said the lack of proper health care could be one factor.

“Unfortunately, we have students who don’t have proper health care for their physical exams and able to be treated to prevent serious health issues,” said Barter. “Is it that there really are more serious issues or is it that they aren’t receiving the care to prevent them?

“I think that some folks may not realize the care we give to our diabetic students,” said Barter, noting she could be seeing a newly diagnosed diabetic student six times a day.

“Some people don’t see school nurses as teachers, (but) we educate our students and families,” she added.

School nurses are constantly teaching students how to use medical equipment such as inhalers properly.

“I think sometimes folks are handed items and there’s a belief that they know how to use them properly, and we as school nurses can teach the students how to do that,” said Barter.

Management of chronic diseases requires Morris to pull from her years of experience.

“I didn’t realize how many students attend school that have chronic health conditions,” she said. “It can be asthma, diabetes, seizure disorders, anaphylactic potential. We have students allergic to different foods. They may be allergic to bee stings.”

Organization is key, Morris said. She keeps spreadsheets to keep track of all the students’ health needs, in addition to her electronic medical records.

Part of managing chronic diseases is making sure the school staff that work with students know on the first day of school which students have a potentially life threatening health conditions, are prepared with emergency plans, know who has an EpiPen and know when students need to see her. Morris is busy by mid-August checking student records and organizing lists for her and for teachers.

One of the growing trends Morris has seen is food allergies. When she started 13 years ago she could count on one hand how many students had food allergies — now she has a spreadsheet two pages long.

“Why, I don’t know,” she said.

Morris does hand out a lot of Band-Aids and ice bags, because she helps students in grades 2 to 5, who go out to recess once or twice a day. That means she sees a lot of scrapes, bruises and twisted ankles, sore throats; one of the most common complaints is of stomach-aches.

“There’s a lot of reassurance,” she said.

Often she tells them to check back later in the day, when they usually tell her: “I’m all better.”

She tries to have fun with the students who come to see her to lighten the mood so they’re not scared.

“They come in, they’re little, they’re hurt, they want their mommy to hug them.”

Strout has conversations with students about sleep, hygiene, eating habits, exercise habits and anything she can do to encourage overall mental and physical health.

As a nurse, she’s seeing students come in with both chronic and acute health problems. A student with diabetes may need help managing their disease with carb counts and insulin dosages. It also could be asthma or seizures she’s helping manage.

Out of approximately 720 students that Strout sees, about a dozen come for scheduled medication.

She also sees a wide range of acute problems from flu symptoms to a bloody nose or rolled ankle, “you name it.”

There are times when there’s a line at her door, and her office operates like a triage center. She can usually look out her door and know why everyone is there, and quickly prioritize new faces.

As part of promoting good health, Strout also has to be aware of communicable diseases.

“We’re in constant contact with the CDC: What’s hot in the community right now, what should we be looking for,” she said.

This month, for example, is Lyme Disease awareness month, so Strout will send out educational letters to the staff and students about ticks.

School nurses also do immunization tracking, so they know who needs what, when, and do vision and hearing screenings.

Chang pointed out that Mt. Ararat is fortunate to have the school-based health center. The health center is staffed with a part-time nurse practitioner that can diagnose and treat students, including those without health insurance.

According to the Maine Primary Care Association, school-based health centers can provide routine physical exams, diagnosis and treatment of acute and chronic illness, treatment of minor injuries, and screenings and immunizations. They can also connect students with mental health services and are available to all students in school, regardless of ability to pay. Services offered are decided by the local community, based on the health needs of students.

Beneath the surface

While Chang can’t protect her students from bullying or the temptation of substance abuse that lies beyond her office walls, she works to provide support where she can.

“I try to educate as I am able, encourage them to advocate for themselves, and then be there as a caring adult if they access my office,” she said. “A final challenge is that a significant portion of students lack access to health care services, for financial or other reasons, and often do not receive adequate care.”

Strout also encounters students who she would like to refer for health services that don’t have insurance or their family can’t afford it. It’s then she works to find them resources within the community, but those are the most frustrating cases she handles.

“On at least a weekly basis, I have a child who I would like for them to be referred to their physician, and the parents can’t afford it, can’t qualify for MaineCare — whatever it is,” she said.

The school also works to address food insecurity, which like children without health coverage, are often from families who have fallen in the cracks. Their parents may have had to fill the oil tank up and skimp on the groceries.

“That’s a big piece of me having them ready to learn in the classroom,” Strout said. “They have to be fed because they are not going to be ready to learn if they’re hungry.”

Strout always keeps a food pantry stocked with snacks. There is also a homeless population of students, so she keeps warm clothes on hand as well as personal care items, which the Emergency Action Network often helps provide.

“One thing that I have seen an increase of is the number of homeless families and students that are couch surfing,” said Barter, adding that she has a liaison to help school nurses with those cases.

Communication

Some schools are recognizing the increasingly complex web of health needs students face and the burden that places on school nurses, who are sometimes stretched between multiple schools and hundreds of students.

“When I started (in Regional School Unit 1), I was one nurse for four schools. I talked to my principals and I said I really think we need more nurses for what’s going on,” said Dill. “We’ve got the bare minimum covered, but I know that we can do better.”

Those conversations led to the addition of more staff at the schools she was working with. Another full-time nurse was brought into one of the other schools, and a part-time nurse was brought into one of the smaller schools, she explained.

Communicating those needs can be a process for school nurses though, who have a different background than teachers and administrators, who are often former teachers themselves.

“Sometimes when we are trying to communicate what our needs are to teachers and administration, it’s a little hard because we speak a little bit of a different language,” said Dill.

Learning to communicate clearly can take time, but it can bear fruitful results.

“Once I learned how to communicate with teachers and educators, my job became a lot easier,” said Dill.

“Get to know your school nurse, because you’ll find out when you do that it’s more than some of those ideas you had about the school nurse,” said Dill. “Maybe you’ll find there’s more to it than that.”

According to Barter, a lot of what she does is helping families coordinate health care services for their children.

“For example, helping them navigate through getting their child a doctor appointment. Helping them figure out transportation if they don’t have a vehicle,” she said. “If they have MaineCare, helping them understand who accepts what they do have for insurance.”

Impact

There is no question that school nurses make a difference in their students’ lives.

Morris’s office was decorated with cards students made for her last week on national nurses day, her favorite one that read, “Best nurse ever. She has saved 1,800 people.”

The victories of her work come when Strout sees students graduating.

“I spend a lot of time having conversations with these kids about life choices, decision-making and I try to incorporate that into my daily interactions with them,” she said.

Talking in her office, Strout took down a postcard from a former student, who addressed it, “How’s my favorite nurse?”

“This kid I saw daily because of a chronic health problem and we just had amazing conversations about life in general and now he’s hiking and traveling across the world,” she said. “To me, if you can make that kind of impact as far as the important things in life, that is success.”

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