Job Security: A Thing of the Past? Julia Lechtenberg RN, MSN, NCSN

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1 Job Security: A Thing of the Past? Julia Lechtenberg RN, MSN, NCSN SPECIAL REPORT ~ SEPTEMBER 2009 Julia is a school nurse in Michigan and the Immediate Past President of the Michigan Association of School Nurses. She served on the Michigan Association of School Nurses (MASN) legislative committee for five years with two of those years as the legislative chairperson. The Issue The economy is faltering. Jobs are being lost in all sectors of the economy at an alarming rate. In this severe economic crisis a staggering number of people have lost their jobs and many others are teetering on the edge of loosing theirs. Economically, the future looks challenging. Government interventions have yet to slow this economic downturn. Job security is faltering along with the economy. School districts across the nation are feeling the impact. It is no surprise that nationally school districts are making cuts including eliminating some school nursing positions. For instance, while an extreme measure, Georgia s governor proposed that the state cut $30 million in state funding that was earmarked for school nursing services. The Georgia legislature was able to avert this crisis but the possibility of losing this funding forced already cash-strapped school districts to seriously consider cutting nursing positions or find other means to pay their salaries (Diamond, 2009). School districts nationwide argue that there is a shortage of adequate funding to ensure school nurse positions. This is a serious trend with monumental consequences to the health and safety of school-aged children because in many cases the school nurse is their primary health care provider. Children are facing a new epidemic: a future without a school nurse. The Consequences This economic insecurity is causing severe anxiety for many school nurses. Many school nurses are tired of dealing with the constant yearly stress and anxiety over whether they have a job (Taliaferro, 2008). This is not just stress related to where s the next paycheck coming from. School nurses care about their student s health and educational outcomes. The job of the school nurse, once considered a highly desirable position, now is a very stressful position. Over the years there have been advances in health care and medical technology which in turn has increased the life expectancy of children with severe medical disabilities. There has also been an increase in the incidence of chronic health conditions. It is estimated that up to 32% of children between the ages of 3 and 18 have a chronic medical condition while up to 18% have a medical disability (Selekman & Gamel-McCormick, 2006). If school nurse positions are cut, who will care for the health needs of these students? Teachers and administrators are not health professionals and have other very important priorities. Who is best qualified legally and professionally to provide safe health services to children? This conflict causes school nurses to experience stress and anxiety related not only to potential job loss but also anxiety related to the negative impact on the health and well-being of the children they serve. Copyright law prohibits reproduction of this article without permission

2 2 School Health Alert September 2009 What Can be Done? What can school nurses do if their jobs are on the chopping block? There are several approaches that the school nurse can utilize. Advocate/Educate It is important during these economically challenging times to go the extra mile. Key stakeholders must be made aware of the critical role that the school nurse makes in the health and well-being of students. A school nurse promotes life-long learning. The school nurse must make it clear to the school district/administrator/community why the district cannot afford to lose them. School nurses must also improve their visibility as well as widen their support base and influence within the school district and the community. School nurses are less likely to be laid off during a budgetary crisis if they are highly visible (NASN, 2004). It is also important for school nurses to build new networks and nurture already existing ones. School nurses never know when they may need the support of school-based and community partners. Increasing visibility and building networks may mean providing presentations (or even providing B/P screenings) to board members, parent teacher organizations and communitybased organizations regarding the roles and responsibilities and importance of school nurses. The National Association of School Nurses (NASN) stresses the importance of assessing the political environment of one s school district to identify key players who would provide needed testimonials regarding the importance of school nursing and the impact that school nurses have on the educational outcomes of students (NASN, 2003). Enlisting the assistance of parents to share student success stories with administrators is also crucial. Don t ever dismiss the power of students parents, especially parents of children with chronic and/or complex health needs. Parents of children with complex health needs are often very passionate about the health needs of their children and can be very persuasive in dissuading a school board/administrator not to cut nursing positions. After all, often their child s life depends on the services that their children receive from a school nurse. Capture the attention of the media. The plight of the Georgia school nurses 30 million dollar budget cut received media attention across the state and generated interest and concern from parents and the community. That attention to the issue may have been part of why the legislature returned the school nurse funding to the budget. Data Collection and Sharing School nurses may feel they are being asked to justify their salaries or their importance. School nurses can justify their position by demonstrating the health benefits for the child and establishing relationships between the interventions that school nurses provide to student health and educational outcomes (Guilday & Selekman, 2006). School nurses operate in an outcome-based environment. Data is a key component that is needed to tie health and educational outcomes. Data validates the complexity of the role of the school nurse, the resources needed, and the effect school nurses have on improving the health and educational outcomes of students (Bergren & Fahrenkrug, 2003, p. 238). Documentation is the first step in collecting data. Most school nurses collect some sort of data. It may be as simple as the number of students seen on a daily basis, types of problems encountered daily, severity of the problem, and treatments and procedures (Denehy, 2003). However, it is important to understand that in this era of limited funds, it is imperative that school nurses establish a link between nursing intervention and educational outcomes. Consider these sources of data: Data that reveals decreased absenteeism after nursing interventions (especially in children with chronic health conditions). Data that indicates that a child received glasses due to nursing interventions and is now reading at a higher reading level. Data that supports fewer injuries resulting in decreased 911 calls.

3 School Health Alert September Data that reveals how many students who, after nursing interventions, are returned to the classroom to complete the educational day instead of being sent home. After all, a child that isn t in school cannot learn. Data that provides the amount of income that was generated through Medicaid billing. All of these are examples of data with measurable outcomes. School nurses need data to prove that what they do makes a difference in the health and well-being and educational needs of the student (Denehy, 2003). School nurses who live in states that have a State School Nurse Consultant (SSNC) are probably already collecting data. SSNCs use that data to successfully advocate for the role of school nurses (Resha & Sheetz, 2007). For those who are new to documentation and data collection, see Appendix A and B for sample school nursing documentation and tracking sheets. Remember, through data collection, the school nurse can ultimately document their roles and responsibilities within the school district as well as the educational impact that school nursing interventions has on student achievement. It is vital to share that data with school administrators, school boards and parents. The Positive Fiscal Impact of the School Nurse Ultimately school districts need to be made aware that it may cost more to actually cut a school nurse position than to keep the school nurse. School nurses keep children in school. Children cannot learn if they are not in school. Poor attendance can directly affect the test results of state-wide educational assessment tools. Often, parents do not want to send their child (children) to a school (district) with low state standardized test scores (Gersema, 2008). School nurses can also save the school district money by providing staff training programs such as cardiopulmonary resuscitation, bloodborne pathogens, first aid, universal precautions and signs and symptoms and emergency treatment of disease specific conditions (such as asthma, allergic reactions, diabetes, seizure disorders, etc.) thereby reducing legal liability for the school district. School nurses in most states can also bill Medicaid for health related services for eligible students. Medicaid provides reimbursement for assessment, direct services and interventions to eligible students (Aldritt, 2006). School nurses often provide services that are eligible for Medicaid billing; however, rarely does the money reimbursed to the school district for services rendered directly support school nursing services and salaries (NASN, 2003). It is important that school nurses track the amount of Medicaid billing that they submit. School districts need to know how much money they would ultimately be losing if they cut the school nurses position. Legal Obligations School districts must be made aware (or reminded) of the laws that require some students to have school nursing services in the school setting. The Individuals with Disabilities Educational Act (IDEA) is a federal law that mandates that school districts provide a free and appropriate education, to eligible children with disabilities, in the least restrictive environment. The 1999 United States Supreme Court decision of Cedar Rapids Community Schools v Garret F. further upheld that IDEA requires school districts to provide necessary nursing services, regardless of cost, when the supportive services are needed to ensure that a child with a disability have full access to benefit from their educational program (Cedar Rapids, 1999). The IDEA provides partial funding for health services (including nursing services) for children with disabilities. School nurse input is crucial since many students who qualify for services through IDEA have chronic and/or specialized health needs. School nurses can help save schools district money by providing data and input regarding the students health needs when determining proper placement in the least restrictive environment (NASN, 2003). Section 504 of the Rehabilitation Act is another federal law that mandates that all public schools provide reasonable and individualized accommodations for students who have physical or mental impairments that

4 4 School Health Alert September 2009 substantially impacts educational activities (Zimmerman, 2006). It is imperative that school nurses educate administrators regarding the importance of the school nurse being an active member of the multidisciplinary team which determines IDEA and Section 504 eligibility because the school nurse is the only person capable of providing input on how the medical condition impacts educational goals and objectives (Oregon, 2009). Improper student placement can be very costly for a school district. Other Sources of Funding School nurses can also demonstrate fiscal responsibility by assisting administrators in securing funding from additional resources thereby potentially protecting their position and possibly even further enhancing health services within the school district. School health services are commonly supported by several different funding sources. Sources may include federal, state and local resources. Potential funding sources include: No Child Left Behind (NCLB) Title 1 funds can be utilized to address the needs of low- income and lowachieving children to cover health and social services that are essential but are not covered by some other source Safe and Drug Free Schools and Communities funds Title V of the Social Security Act (Maternal and Child Services Block Grant) provides funding for the reduction of infant mortality and preventable diseases by enhancing access to needed medical and health services State/local/public/private grants Competitive grants (such as grants through the Center for Disease Control- which often offers grants for programs such as asthma, diabetes, Coordinated School Health, HIV, childhood obesity, etc) Local Intermediate School Districts Center Based Programs Local hospitals (Aldritt, 2006) It is important to clarify to administrators that funding sources may provide funding for specific sets of services. School nursing services often must be documented and outcomes measured for continuation of funding. Districts may need to combine different funding sources in creative ways to fund school nurses. Summary School nurses do amazing things in the schools and in the community. They can and do make a significant difference in a child s life. School nurses must make their voices heard. It is imperative that school nurses educate administrators and other local, state and national stakeholders as to what services they provide to students and how those services ultimately remove barriers to learning. Administrators and state law makers may feel that by cutting school nurses that they are putting the money in the classroom. However, without a school nurse in the building who will ensure that the children are healthy and in the classroom ready to learn? After all children that are having problems seeing or hearing or are sick are most likely going to have problems learning in the classroom. The anxiety related to job insecurity is real. You cannot advocate for nursing positions if you are stifled with emotional and physical symptoms of anxiety and stress. It is important that during these difficult times that you take care of yourself. Remember, you must secure your own oxygen mask before you are capable of helping others!

5 School Health Alert September References Aldritt, L. (2006). Budgeting and accessing funding. In J. Selekman (Ed.), School nursing: A comprehensive text (pp ). Philadelphia: F.A. Davis Company. Bergren, M.D. & Fahrenkrug, M.A. (2003). Development of a nursing data set for school nursing. Journal of School Nursing, 19, Cedar Rapids Community School District v. Garret F. (1999). Retrieved March 23, 2009 from Denehy, J. (2003). Documentation dilemma: What to record and why. Journal of School Nursing, 19, Diamond, L. (2009, February 2). State budget woes imperil school nurses. The Atlanta Journal-Constitution. Gersema, E. (2008). School nurses facing budget ax. The Arizona Republic. Retrieved March 13, 2009 from Guilday, P. & Selekman, J. (2006). Evaluation of school nurse practice. In J. Selekman (Ed.), School nursing: A comprehensive text (pp ). Philadelphia: F.A. Davis Company. National Association of School Nurses (NASN). (2003). Making the case for retaining school nurses: How to impact the decision makers. NASN Newsletter, 18, National Association of School Nurses (NASN). (2004). School health nursing services role in health care: Reduction in force. Retrieved February 28, 2009 from Oregon State Government. (2009). Statues and standards regarding school health and school nursing services. Retrieved March 10, 2009 from Resha, C. & Sheetz, A. (2007). Using data effectively. NASSNC. Retrieved March 21, 2009 from See link for Using Data Effectively PowerPoint. Selekman, J. & Gamel-McCormick. (2006). Children with chronic conditions. In J. Selekman (Ed.), School nursing: A comprehensive text (pp ). Philadelphia: F.A. Davis Company. Taliaferro, V. (2008, October). The impact of the school nurse shortage. School Health Alert. Retrieved March 5, 2009 from Zimmerman, B. (2006) Student health and education plans. In J. Selekman (Ed.), School nursing: A comprehensive text (pp ). Philadelphia: F.A. Davis Company.

6 6 School Health Alert September 2009 School Nurse Tracking Sheet Appendix A School: Nurse: Direct Care (minutes out of class) < 15 Minutes Minutes > 31 Minutes Illness/Injury Home Illness/Injury School Nursing Intervention Assessment First Aid/wound care Rest/reassurance Procedures/checks Blood glucose check Catheterization Tube feeding Other Medication # dispensed Accompany to appointment Home Visit After School Nurse Intervention # Returned to class # Sent home Excluded for communicable disease # referred for immediate evaluation/treatment 911 Calls Contacts/Communication Parent/Guardian School staff Medical contact Community resources Health Screenings Blood Pressure (B/P) Students Staff Total # # referred to MD for TX

7 School Health Alert September School Nurse Tracking Sheet Page 2 BMI Dental # identified with cavities Developmental Hearing Immunization Lead Screening Pediculosis # identified # returned to class after SN Intervention Vision # Screened # Identified # glasses obtained with SN intervention Total # of screenings Medical Conditions Identified Student Staff Total # ADHD Asthma Diabetes Food Allergy Heart Condition Insect Allergy Seizure Disorder Sickle Cell Anemia Other # Individualized healthcare Plans completed # Emergency Protocols Initiated # Emergency Protocols Completed Meetings IEPC/504/Staffings Training/in-services # Participants # Sessions Classroom Instruction # Classes # Students Assemblies Other Non School Nurse Interventions

8 8 School Health Alert September 2009 STUDENT ENCOUNTER FORM Appendix B Student Name: DOB: Allergies: Parent/Guardian: Phone (Wk): Phone (Hm): Phone (Cell): Teacher: Grade: Room: Medical History: Medications: Date: Time In: Time Out: Ht: Wt: Temp: Pulse: Resp: B/P Problem: Illness/Injury Home: Illness/Injury School: Abrasion/Scratches Headache Pediculosis Bruise/Hematoma Head Injury Rash/Lesion Burn Laceration/cut Sore throat Cough Nasal Congestion Sprain/Strain Difficulty breathing Nausea/Vomiting Stomach Ache/Cramps Earache Nosebleed Toothache Eye Injury Pain/Discomfort Other Assessment: Abdomen: Lungs: Ears: Mental Status: Eyes: Skin: Heart: Throat: Other: Nursing Assessment: Nursing Intervention(s): Anger Control Assistance Gargled Observation Consultation Bandage Health Education Reassurance Elevation of injury Ice/Cold Pack Rest Other First Aid Medication Wound Care Returned to class Sent home Referred to MD Sent to ER Health Screenings B/P Hearing (Pass Fail ) BMI Scoliosis Dental Screening Vision (Pass Fail ) Parent/Guardian Contact: Phone Letter Face-to-Face Contact Unable to Contact Parent/Guardian/Emergency Contacts: # of Attempts: Medical Contact: Health Care Provider s Name: Phone # Follow-up needed: No Yes Referred to: Follow-up Notes: