School Nurses Learn How to Take Care of a Crowd : Practitioners Cope With Less Staff, More Difficult Health Problems

Joan Banks recalls that when she left her school nursing job in Virginiaand moved to California three years ago, “I figured I was coming to Mecca. I thought California was probably on the cutting edge of everything.”

Instead, she found working conditions to be “the pits” at her new job with the Anaheim Union High School District. In Virginia, she was responsible for 345 students at a single school. After the elimination of a nurse’s position last spring, Anaheim relies on two nurses to serve 25,000 students in 17 schools.

And another nurse scheduled to retire in January may not be replaced, which would leave Banks shouldering all of the district’s nursing duties.

“I have to keep going 90 miles an hour . . . and I feel we are Band-Aiding things because there isn’t time to spend with each student,” she said.

A major task of school nurses has been testing for vision and hearing, and making sure that students get the glasses or hearing aids that they need to succeed in class.

But because of the nurse shortage, Banks said, “sometimes it’s as late as May or June before I learn about someone who can’t see the blackboard or can’t hear the teachers.”

Banks is not alone in her lament. In an era of funding cutbacks that began with passage of Prop. 13 in 1978 and intensified in the current recession, school districts throughout Orange County and statewide have been cutting back on nursing positions to help balance their budgets.

At the same time, the responsibilities of Orange County’s 300 remaining school nurses have grown with an influx of children with greater medical needs. Because of improvements in medical technology and new anti-discrimination legislation, children with more severe handicaps are being taught in neighborhood schools instead of being kept in special county institutions.

And since the recession began two years ago, nurses countywide report that parents without jobs or medical insurance have been instructing their children to “see the school nurse” with complaints ranging from sore throats to broken bones. While the school nurses cannot treat serious illnesses or injuries, they can refer the students to low-cost community clinics.

But Sandy Landry, the administrator of health and wellness programs for the Orange County Department of Education, noted that the person seated in the nurse’s office nowadays is often a health clerk or volunteer, rather than a school nurse.

Increasingly, school districts are relying on outside consultants to do the state-mandated hearing and vision testing of students.

“There are 11 school districts in Orange County now with only one nurse each,” Landry said. “They are doing more program management than hands-on nursing.”

Under California law, a school nurse must have a bachelor’s degree and be a registered nurse. But there are no state requirements for the health aides and health clerks that many districts are using to fill the nursing gap.

And while some of these paraprofessionals are licensed vocational nurses, others are simply high school graduates who receive training--frequently from a district nurse--in first aid and cardiopulmonary resuscitation.

“A lot of parents don’t realize that a school no longer has a nurse, because teachers and students tend to call the health aides nurses,” said Trina Williams, president of the Orange County School Nurses Organization.

Many nurses welcome help from health clerks in certain areas, especially for keeping track of immunizations and other medical records. But they contend that thorny issues such as teen pregnancy, suicide attempts and child abuse, not to mention the problems of caring for handicapped students, require special training and capabilities.

Elizabeth Winokur, a nurse and director for the Safe Place, a child abuse prevention program at Martin Luther Hospital in Anaheim, said all school personnel who suspect child abuse are legally required to report it, but they often defer to the school nurse.

When the nurse is absent, she said, cases can fall through the cracks.

“The consistent message I hear from nurses is, ‘I am on overload. I don’t see how I can do it all,’ and they should not be expected to do so much,” Landry said.

“But if some kid comes to your office and says he wants to kill himself or starts to cry or is upset by a drive-by shooting, what do you do?”

The nurses say they learn to cope. When a nursing position was cut at Westminster School District this year, the three nurses who were left started wearing beepers “to make sure we could find them in an emergency,” said Aileen Manley, the district’s administrator of special services.

Beeper at her side, Jane Lum, a 10-year school nursing veteran, spent a recent morning trying to assess the hearing and vision of several developmentally handicapped preschoolers at John F. Land Jr. School in Westminster.

Since the children were unable to speak, Lum closely watched the movement of their eyes and heads to discover if they could hear the sounds coming through their earphones.

That same day, another Westminster district nurse, Joey Van Camp, was dealing with the onslaught of students to the health office shared by Ada E. Clegg Elementary School and Helen Stacey Intermediate School in Huntington Beach.

Van Camp, in between giving sight and hearing exams, helped one teen-ager link up with the Lions Club for financial assistance to buy glasses, and reassured another that her itchy scalp was not caused by lice but by drying shampoo and hair spray.

Van Camp, who had brought along a bag of her son’s clothing for a seventh-grade boy and keeps a stash of toothbrushes and other supplies for children whose parents cannot afford them, said she regards her function partly as a social worker in a district that has deep pockets of poverty.

Dennis Kreil, director of pupil services for Placentia-Yorba Linda Unified School District, which two years ago slashed its nursing staff from 8 1/2 to 2 1/2 nursing positions, said, “It’s unfortunate that the needs of the community probably go up as resources to provide them with services goes down.

“We use contracting for sensory screenings and we have brought in health clerks to do clerical kinds of work. They are also trained in CPR and first aid. If something happens on campus, the administrator usually makes a decision to contact a parent right away, and the parent finds medical care for the child. If it was an extreme emergency, they would dial 911.”

Rich Johnson, coordinator for pupil services at Capistrano Unified School District, said he is confident that since the district in 1982 eliminated six of seven nurses, it has managed to provide the same services at less cost with one coordinating nurse and a cadre of health technicians and health clerks.

But in most districts, these nursing assistants also are in short supply or work part time. When they are not stationed at a school, it is now up to secretaries and administrators to handle medical emergencies.

Most school nurses concede that changing economic conditions mean that nurses must now be used more judiciously.

“We are coming to realize that we will need a restructuring that will have people like health clerks work under the supervision of a nurse,” said Williams of the Orange County School Nurses Organization.

However, Barbara Bradstock, president of the California School Nurses Organization, cautioned: “What is dangerous is having health clerks without nurses to supervise them.”

Bradstock said her organization recommends a minimum of one nurse per 100 to 150 students with special medical needs and one nurse per 1,200 to 1,500 of the other students.

Nurses have learned that they must be more vocal politically, Bradstock said. “We are beginning to shout on behalf of kids.”