On strike for student health

HOW MANY years have you been a school nurse and a member of the Seattle Education Association?

Claire: I'll be starting my third year as a school nurse and my third year in the union.

Mariah: I'm just starting my third year as a school nurse and SEA member.

WHY ARE you out on strike?

Claire: Lots of reasons! Here are a few of them.

Professional pay: Seattle is becoming one of the most expensive cities in the country. It is essential that our teachers and educational staff can afford to live in the city they teach. We want our educators to be invested in their school community. We want to be sure that working in education is a career, not simply a job you take until you can get paid more.

ESA workload relief: Educational staff associates (ESA), which includes psychologists, physical therapists, occupational therapists, and speech and language pathologists, have no cap on their caseloads. Nurses are the only ESA who have a cap, which according to our last contract was capped at 1,500.

Reasonable testing: The past few years, I have been shocked to see how much time our students are spending on standardized tests. This testing takes students out of the classroom for weeks on end, not to mention the countless hours preparing for the tests.

Mariah: It seems the district is relying solely on quantitative outcomes, rather than a combination of quantitative and qualitative outcomes with its students. Just as hospitals are requiring health care providers to spend more time entering data and less time with direct patient care, so Seattle Public Schools is expecting improved experiences for students while it simultaneously doesn't provide the support to do so.

For example, with school nursing, we're each expected to keep track of more than 1,000 students' reported health concerns; vaccination records; vision and hearing screenings and follow-ups; medications, including up-to-date prescriptions, authorizations to give at school and training staff how to administer; daily care and management for students with chronic conditions, like diabetes; preparation and staff training for life-threatening health concerns; annual thorough health assessments of any student receiving or wanting to receive special education services; and more.

Meanwhile, we're supposed to be able to complete all of this while unwell students are in our office. Most of us daily address upper respiratory complaints, GI complaints, head and other injuries, depression (sometimes with associated self-harm), and sometimes abuse or neglect. Many students and their families don't speak English as a first language, and we often don't have interpretation services.

My understanding in talking to more senior school nurses is that SPS used to have a much lower ratio of nurses to students, and that more buildings also used to have LPNs working alongside the RNs.

WHAT HAS your experience been so far on strike and what are the most important issues that you are fighting for?

Claire: Most of the responses to the strike have been very positive. There has been lots of support from the PTA and students. Since I'm an itinerant employee at my schools, the strike has given me the opportunity to bond with staff over common goals.

WHY IS it important to have a school nurse on campus every day?

Mariah: Safety is my first concern. On the days nurses aren't present in their buildings, which is often less than half of the time, the front desk secretaries are expected to perform layman's triage on students. Although they can always call Student Health Services, it isn't realistic they would call for every student they see.

Sometimes, problems that a nurse would see as quite threatening aren't adequately addressed because non-nurses may not recognize them. Nurses can only delegate components of care, but pervasive nursing practice such as assessment, planning, evaluation and nursing judgment cannot be delegated.

For example, say a six-year-old comes to the office with a fever. The office staff see that it's 102 degrees, so they call home and have the child lie down. They don't observe that he has a rapid, shallow breath, that his mucosal membranes are pale, and that his temperature increases during the 45 minutes until parents arrive. If a nurse was present, she would assess these problems as well as observe diminished lung sounds and rapid heart beat.

She may also know that a dangerous virus is circulating in the community and be on high alert for these types of signs and symptoms--and thus ensure the child goes straight to the emergency room, rather than home to rest. Her evaluation and judgment could be critical here for the child to have the best outcome by early intervention.

Claire: Many students still don't have access to regular health care. Having a nurse in the building gives those students the opportunity to access our health care system. The rates of EMS calls when a nurse is not on site are much greater. I always encourage my schools to call EMS when in doubt as there is no one present with the clinical background to support students in potential medical emergencies.

DO ALL schools have a nurse every day?

Mariah: Most high schools have a full-time nurse, most middle schools have a nurse at least four out of five days, and most elementary schools have a nurse between one and three days a week. Most K-8 schools have a nurse between two and three days a week. Nontraditional schools vary widely. Medically fragile schools have a full-time nurse.

HOW MANY students are in your caseload?

Claire: I can't be sure without access to my school computer, but my best guess would be that I have about 1,200 students in my caseload.

Mariah: I believe I'll have about 1,200 this year, spread over three schools.

WHAT IS your pay like compared to other nursing jobs?

Mariah: As an advanced practice nurse--the majority of us do have our master's degrees--we are paid on the same salary schedule as the teachers. The median salary for a third-year nurse practitioner in Seattle is about $120,000, while I make about $58,000 at SPS. Despite the fact that we do get more time off, this still doesn't add up.

The salary schedule is especially noncompetitive for nurses coming to SPS with years of valuable, hospital work experience, as the salary schedule does not adjust to be competitive.

CAN YOU share a few of your experiences working as a school nurse?

Claire: School nursing is a great way to get into community health. I get to work with individual students with chronic health conditions to make sure that these students can be safe while at school, as well as work with the population as a whole to better their health. Last year, I was able to work with community partners to provide dental screenings, health screenings and opportunities for registering for insurance to all of my schools.

One of my favorite things to do as a school nurse is to provide handwashing classes. Many students have atrocious handwashing skills, putting both them and their families at increased risk of infection. I have Glow Germ kits that show students all the germs that they are missing on their hands. The younger students are so sweet and always want to see how well their teachers wash their hands.

One of the most crucial parts of being a school nurse is to increase immunization compliance in our city. Last year health services made a huge impact on measles immunization rates.

Mariah: Every time I walk into the front office of my buildings, there are always exclamations like, "Yay! The nurse is here! Thank God..." Then often followed by comments like, "We've been so busy with sick and injured kids that we haven't been able to get our normal work done."

Then they'll say: "We've had many parents concerned about a disease going around or planning for overnight school trips or lice vaccination letters, etc., that need to get followed up on. And you have three faxes from Children's Hospital, and Mrs. X is waiting in your office to talk about her daughter's asthma, then after that, the school counselor wanted to meet with you regarding safety plans for a student."

This is my daily experience in each of the three offices where I work, and this is just the first five minutes. We're very busy, and although I love my job, I dream of how much more we could accomplish if we were more like Vermont, where in 2009, there was one nurse to every 311 students.

The National Association of School Nurses declares that to have adequate school nursing, there should be one full-time RN for every 750 "well" students, a goal that has been adopted by the Centers for Disease Control. Washington is among 37 other states that failed to meet that goal in 2009.

School nurses are committed to keeping kids healthy, in school and ready to learn. For example, last year, we began to focus on how we could help to improve Black male student graduation rates. In reviewing the data, we observed our Black male students had higher rates of asthma than their peers.

Because we know that asthma can lead to missed school days--for reasons such as the child was experiencing asthma symptoms because maintenance medications were not well understood or parent fears that their child may have an attack at school--we collectively worked to learn about our Black male students and how their asthma was being treated, so we could help educate students and their families about the disease, as well as assure parents that staff was well educated to recognize and address an asthma attack at school.

The goal is for us is to see that Black male students don't miss days of school related to asthma problems, because we know that missed days of school are correlated to lower graduation rates. We know this is only a piece of the puzzle, but we are eager to make any contribution we can.