1. Hull, Mona Duplantis RN, CDE


If you think that school nurses' work is boring or sedate, read on to discover the challenges these skilled professionals face.


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A STUDENT NURSE I'll call Katie recently came to spend a day with me, a school nurse. Her instructor had warned her that she might not get much experience because "school nurses don't do too much." To her surprise, Katie found oxygen tanks, suction equipment, urinary catheterization kits, and emergency supplies in the classrooms for our children with special needs. By noon, Katie was out of breath from running to keep up with me and earnestly suggested that I ask my supervisor for a full-time assistant.


In this article, I'll further dispel the outdated image of school nurses by telling you about our many duties and responsibilities and the training we receive to handle them. First of all, let's look at why so many more children with serious medical issues are attending school.


Laws open the doors to school

Years ago, many children were denied admittance to public school if they had diseases such as diabetes. Denying school to such children is no longer allowed. Laws including the No Child Left Behind Act (2001), Individuals with Disabilities Education Act (1990), and the Rehabilitation Act of 1973 require that schools make accommodations for such students. Exceptions are normally limited to students who'd be medically unsafe in the school environment.


As a result of these laws, today's student body includes children with tracheostomy tubes, feeding tubes, and ventricular-peritoneal shunts, as well as those using oxygen and even ventilators. Some students have rare disorders or complicated medical needs. Many others have asthma, diabetes, allergies, or seizure disorders. Wheelchairs and walkers are a common sight on many campuses, as are special lift gate buses that transport students between home and school.


Now let me fill you in on a school nurse's routine duties.


School nurses wear many hats

Contact with the school nurse is sometimes a student's first interaction with health care services when a health problem arises. For instance, one of our school nurses called a parent and suggested she get medical attention for her teenage daughter right away. When the teen was seen in the emergency department (ED), they learned she was in a near-crisis state of hyperthyroidism.


Teachers may send a student to the nurse because, "He just isn't himself." Teachers and staff who spend hours each day with a student are very tuned in to subtle changes. The school nurse needs to know the right questions to ask and assessment tools to use. She may have difficulty assessing a child if he's nonverbal, very young, or unable to explain his symptoms due to language or developmental problems.


We carefully evaluate students who come to the school nurse frequently. Are these students simply trying to get out of class or are they looking for an opportunity to confide something?


At times, I feel as if I'm working in an ED. On any day, I might see students who have a playground injury needing sutures, pink eye, a tracheostomy tube that's been removed by an inquisitive fellow student, a bean up the nose, status epilepticus, or a "stomachache" that could be a sign of appendicitis.


Our tools include but aren't limited to stethoscopes, otoscopes, thermometers, adhesive bandages, warm compresses, and cold packs. Our practice guidelines are limited to medication administration or invasive procedures authorized for a specific student by his physician and parent. We require consents from the parent and the physician for each medication dispensed, whether it's prescription, over-the-counter, or topical.


Besides providing emergency care, school nurses:


* act as case managers for students' continuing health care needs at school


* coordinate height, weight, vision, hearing, and dental screenings


* administer medications


* perform procedures and assessments


* communicate with health care providers, therapists, parents, and school staff


* provide health education to students, school personnel, and families


* provide a career shadowing experience for nursing students


* make presentations at conferences and school meetings.



Tailoring our care

Elementary school, middle school, and high school students each present their own set of rewards and challenges. As school nurses, we face issues such as pregnancy, sexually transmitted infections, eating disorders, drug and alcohol abuse, domestic violence, and sports injuries.


Families with limited English- language skills require an interpreter for student conferences or to communicate pertinent information. I recommend a Web site,, which interprets some languages.


School nurses also have special duties in the wake of disasters such as Hurricane Katrina, which affected many of our students here in Louisiana. In the months following the hurricane, we had to address mental health concerns, cope with some students' missing medical health records and try to replace damaged or lost medical equipment and medications. Some students also needed referrals to appropriate health care providers.


Who can be a school nurse?

In some states, schools can hire only RNs, but in other states, they can hire LPNs; many states require a bachelor of science in nursing degree. National certification, mandatory in some states, requires completion of a 6-month course. Some states have their own certification through the state department of education. To see how states' requirements vary, visit State-by-State Requirements for School Nurses at


In my parish in Louisiana, all school nurses have a 2-week orientation period when they learn routine regulatory requirements, organizational expectations, and legal and practice considerations. They also get updated infor- mation about common disorders, and they must be certified in performing CPR. In the weeks before school begins, all school nurses attend seminars on current issues.


During the school year, we have monthly meetings about existing problems, changes in laws or guidelines, and quality assurance issues.


Spreading school nurses around

In our schools, a few nurses called stationary nurses remain at a single school every day, but most nurses are mobile nurses who are responsible for multiple locations. These mobile nurses are helped by school health assistants who have duties similar to those of nursing assistants. Laws and guidelines regulate student-to-nurse ratios, but many of these programs are underfunded. The American Nurses Association (ANA) calls for a ratio of one RN to every 750 students.1(For more information, visit the ANA's Web site, or the National Association of School Nurses' Web site,


Our school nurses can't always perform all of their many duties, particularly if they're traveling to several schools. Mobile nurses can't always provide care to a particular student at the same time each day. To fill the gap, in some states such as Louisiana, the state Nurse Practice Act lets nurses train unlicensed assistive personnel (UAP) to administer medications and perform selected procedures.


Staff members who'll be administering medications must successfully complete a 6-hour medication training course. An RN observes this staff UAP and uses a specific checklist to verify that he's competent. This observation process is repeated on a regular basis.


Other tasks that may be delegated are catheterization, tube feeding, and suctioning. Although staff UAPs don't attend a specific course for these tasks, an RN must train them to perform tasks for a specific student and check them off initially and at regular intervals.


Each state's Nurse Practice Act determines delegation of responsibility. Clearly, training and delegation of others doesn't absolve nurses of the ultimate responsibility, for patients; to fulfill this duty, we must monitor UAPs.


Do you have what it takes?

If you're intrigued by the many challenges that school nurses face, your next step is to consider whether you're cut out for this demanding job. First of all, you should be an experienced nurse who can work well with children or young people, be a good time manager, and be a great listener. Then think about whether you're flexible, adaptable, and resilient. If you have all of these qualities, you might want to consider becoming a school nurse. If you decide to make this career move, your next step would be to contact a local school system's administrative offices.


School nursing is challenging and rewarding, but it's never dull or sedate. I consider spreading the news about what school nurses do to be a part of my job. When the nursing students leave my campus, I always laughingly tell them to "go and preach the gospel of school nursing." My school does its part-its Web site clearly indicates that our school has a full-time nurse. It's a powerful way to show the community how important our contribution is to the students and parents.




1. Supporting school nurses: ANA takes students under its wing. Nursing2007. 37(7):33, July 2007. [Context Link]


2. National Association of State Boards of Education. State-by-state requirements for school nurses, Accessed August 22, 2007. [Context Link]