“Did you eat breakfast?” This is often the first question school nurse Carolina Sandoval, MSN, PNP, RN, asks a student who comes to her office complaining of a stomachache. Usually, the child says no, and Ms. Sandoval takes the opportunity to discuss the value of a nutritious breakfast. “I give them a little speech,” she said, “and then I give them a little snack.”
What might sound like a simple interaction is anything but simplistic. Ms. Sandoval’s work at a junior high school and an elementary school in Chino Hills, CA, draws on her graduate education and incorporates many aspects of nursing: patient and community education, child advocacy, public health, infectious disease monitoring, trauma care, chronic illness management, nutritional counseling, reproductive health, and medication management, among others.
School nurses may be among the unsung heroes of health care, but occasionally they take the spotlight. “Hero,” in fact, was how many described Mary Pappas, BSN, RN, the school nurse who first alerted infectious disease authorities to the outbreak of influenza A (H1N1)—swine flu—at her New York City high school in April 2009 (Jacobson, 2009). Not only did Ms. Pappas’s decisive action protect the thousands of children in her charge, but within days she had prompted a worldwide alert for what would soon be declared a pandemic.
Yet even the smallest gesture, such as giving “a little snack,” corresponds to the National Association of School Nurses (NASN) definition of school nursing: “nursing that advances the well-being, academic success and life-long achievement and health of students.” At the same time, Ms. Sandoval does not sugarcoat the fact that most school districts, including her own, fail to meet the NASN and Healthy People 2010 recommendation of one nurse for every 750 healthy children. She is responsible for 2,000 children and works part-time at each of the two schools.
Indeed, California is 42nd on NASN’s list of states ranked by student-to-registered nurse (RN) ratios, with 2,187 students for every school nurse (Vermont is first and Michigan is last, with 311 and 4,836 students per RN, respectively) (NASN, 2010). To fill the gap, some school districts hire non-nurse technicians, a move Ms. Sandoval said does not benefit students. She pointed out that nurses’ skills in assessment and critical thinking come into play constantly in handling the conditions that affect students’ ability to learn: obesity and chronic illness, vision deficits, behavioral problems, allergies, and asthma, to name the most common.
Having moved to Southern California at age 15 from Mexico, where, she said, a school nurse would have been an unthinkable luxury, Ms. Sandoval has a particular appreciation of the school nurse’s role as child advocate. She now acts as a spokesperson for NASN’s Voices of Meningitis Campaign (www.voicesofmeningitis.org), sponsored by Sanofi Pasteur, a vaccine manufacturer. Preteens and teens are at the greatest risk for meningococcal meningitis, a preventable infection that can rapidly be fatal and is spread through utensil sharing or kissing. Through radio, television, and other venues, Ms. Sandoval teaches parents and children, in Spanish, about prevention, symptoms, and treatment.
School district regulations do not permit Ms. Sandoval to use all of her skills as a nurse practitioner. She cannot diagnose or prescribe in the school, for example, even when children have symptoms of conjunctivitis or otitis media; she must refer them to other providers outside of the school. And because many of the children she sees come from uninsured families that may not have access to affordable care, she often refers families to a low-cost clinic where she works one evening a week as a nurse practitioner and can practice to the full extent of her training and licensure.
Ms. Sandoval tells the story of another routine intervention, involving a seventh-grader who was falling behind in his classes. She met with the boy and checked his vision; it was quite poor, and she gave his parents a certificate for a discounted eye exam and glasses. “We cannot change the whole world,” she said. “But maybe we can change one student. And someday that student is going to go to college, and he’ll remember the school nurse who took the time to look at his eyes.”