Managing Student Health: Q & A with a School Nurse

By Joan McMahon Verardo, RN, BSN and Louis Verardo, MD, FAAFP

The history of formal school health programs goes back to the early 20th century. Multiple professional and governmental organizations have weighed in on the responsibilities and roles of clinicians caring for students, with the majority of these involving the duties of the school nurse. While often joined in this role by other educational staff, as well as a school medical director and community practitioners, the nurse is clearly central to the overall supervision of student health in both classroom and athletic settings.

What follows is an interview between a family physician (LV) and a school nurse (JMV) about the day-to-day experiences seen in a school setting. Full disclosure: we are a married couple, both now semi- retired, who worked briefly together in a school setting several years ago, but who otherwise have maintained separate professional careers.

LV: Could we start off by having you describe what was a typical day for you?

JMV: Sure. Once in my office, I would review messages which came in from parents and others, returning calls as needed; I’d assess symptoms on any students coming to school sick; I’d restock any needed supplies for the office; then I’d pre-pour medications scheduled to be given out to students that day.

LV: That sounds very busy. Do you have any help with all this work?

JMV: I typically had a part-time office assistant, plus additional clerical and clinical resources were made available for volume events such as sports physicals and mandated screenings.

LV: Continuing with the daily work, you mentioned medications. Could you be more specific?

JMV: Students need written authorization from their prescribing clinician (as well as a parent or guardian) to take any medication during school hours, and usually this is done by completing forms. Once on file with the school nurse, this allows the student to either come to the office for administration or, in the case of an epinephrine auto-injector device, to self-administer the medication. Examples of medications I’d administer included psychotropic drugs (primarily for ADHD) and asthma inhalation treatments.

LV: What about emergency situations, where a student is ill or becomes injured; how are those handled?JMV: For a true medical emergency, I would assess the student to identify the symptoms and clinical status, providing any needed first aid; a call would go out to the local fire and rescue department for assistance (their nearby location provided a faster response time than going through 911); and contact would be initiated with the student’s parent and school administration to communicate what was happening to the child. There are less urgent situations which happen, certainly, and those are handled on a case-by-case basis. One of the lesser- known roles I would perform on occasion was “pill identification.”

LV: What’s that about?

JMV: A student or a pill, or both, would be brought to my office for two purposes. For the student, a clinical assessment of symptomsbeing experienced (e.g., dizziness, loss of consciousness, impaired reflexes, impaired coordination) would be performed. If an unknown pharmaceutical was discovered either on the individual or somewhere on school grounds, a drug identification resource would be utilized to identify the specifics of the substance, including dose and manufacturer. And this would involve both prescribed and OTC medications.

LV: Would any of these situations involve a possible drug overdose, and if so, how would that be handled?

JMV: I never had to deal with a drug overdose on the school grounds, but there was Narcan available in the office, and I had received training in its administration.

LV: Let’s move on to a different aspect of your work. Could you describe the screenings you do on students at the school, and who orders those?

JMV: Those are actually mandated by New York State, and they include hearing, vision, and scoliosis screenings done periodically throughout the pre-K to 12th grade. While many of these same tests are actually being done by the personal clinicians of students, the school screenings provide an additional opportunity to ensure no child falls between the cracks. I’m aware that scoliosis screening has been re-evaluated recently by the United States Preventive Services Task Force, or USPSTF, but this remains an item mandated to be performed in our state. Any deviations from anticipated norms on these screenings require notification to the student’s parent for referral to the student’s clinician and subsequent close clinical follow-up.

LV: OK, let’s move on to student exams, both general and sports physicals. What involvement would you have with community physicians in this process?

JMV: The ideal would be for each student to have a personal physician who would fill out a (now standardized) examination form, which would then be reviewed by the school nurse for any significant finding (e.g., if a student was “cleared” following a prior illness, injury, or surgical procedure). Completed forms would then be forwarded to the designated school physician for his or her signature. During the review process, any need for further medical evaluation would be identified, or referral to a specialist recommended, before the student could be permitted to return to usual school activities.

The percentage of students with a dedicated family doctor in our district I’d estimate at greater than 90%. If there were any health issues which needed further clarification, it was always helpful to be able to pick up the phone and reach out to a familiar voice regarding any concerns. However, I will add that for certain school exams, a significant percentage of kids with their own doctor would opt to get their exam done by the school physician; this was largely for purposes of expediting the process of getting clearance for sports participation.

If the student did not have a personal physician, the school nurse would place that student on the school physician’s list for examination, then actively assist the student in locating an available resource where they could obtain ongoing primary care. In our community, this usually involved new students coming into the district as recent immigrants with limited English-language skills. The process of getting these students established with a clinician was greatly enhanced several years ago by affiliation of our local community clinic with an integrated health system operating in the region, offering the additional benefit of access to specialty clinicians in a variety of disciplines. An added plus was that this major health system also provided continuing education geared to school nurses on diverse topics pertinent to school health.

Sports physicals occurred typically as a baseline each year, and then periodically throughout the three school year seasons, i.e., fall, winter, and spring. Processing all the forms and coordinating with the various sports teams involved a close working relationship with the athletic trainer (AT), and that individual often provided early recognition of a previously unreported injury or condition. If not already counseled by the AT, I would be responsible for contacting the student and parent to arrange appropriate follow-up for this issue, including review by the student’s personal doctor, the school physician, and any required specialist. By the way, all of this information needed to go from paper to computer, and that data entry required a significant time commitment.

LV: Sticking with athletics, did you utilize a concussion protocol?

JMV: Yes, there is a New York State concussion protocol which follows a standardized process for returning a student to both academic and athletic activities. Students are evaluated by their personal clinicians and any specialists as indicated, and reports on their progress are reviewed by the school nurse against the protocol. In some cases, this might involve arranging for individualized instruction for those students unable to return to classroom learning; in other instances, it could be the provision of classroom accommodation for an injured student athlete while on campus.

LV: Are there other school staff with whom you’d interact during the course of the school day?

JMV: Teachers may often send students to the nurse’s office for any number of reasons, ranging from unusual behavior to personal hygiene concerns. In addition, by reviewing health exam forms (and through contact with kids on a daily basis), you discover additional mental health issues, such as anxiety, which require discussion with the parent, school social worker, and school psychologist. As the school nurse, I sat on a committee which met regularly to discuss students experiencing problems within school for varied reasons. HIPAA protocols would be observed during any discussion related to a student’s medical information.

LV: Any particular cases come to mind as an example?

JMV: There was one student case I recall discussing. The student was new to the district and came from out of state. It soon became clear that he had significant mental health issues as he accused others of harassing him, resulting in several unprovoked assaults on students. As a consequence, the student was suspended from school (which he already wasn’t attending regularly), and he then became uncooperative with any attempts of outside school instruction. CPS initially refused to intervene, as there was no substantiated physical abuse at home. It was only when I contacted them and changed the complaint to educational neglect, with the student being a potential danger to himself and others, that the state stepped in with additional services, including mental health.

LV: Pretty dramatic. Let’s go to something more mundane. How do you get vaccine information on students?

JMV: That used to be one of the more labor-intensive parts of the job, especially prior to the initiation of the school year: a lot of paper forms to review, a lot of repeated requests for immunization information, a significant influx of last-minute faxed records needing verification prior to the student’s entry into the classroom. Much of that process has become simplified with access to NYSIIS, or the New York State Immunization Information System. This centralized registry now provides access to the vaccine records of children registered in the state, and a copy can be easily included in a student’s school health record. Separate from the data management, however, is the continuing educational need to keep current with updates within the vaccine schedule; this requires regular study and ongoing review of both the New York State regulations and recommendations from the CDC.

LV: What kind of teaching did you do with students?

JMV: Most of the teaching I did was done in one-on-one communication with students I saw throughout the school day for various reasons. I also arranged school-wide events for specific health topics: these included The Great American Smoke-out for tobacco cessation and a presentation by the Donor Network on organ donation. For high school juniors and seniors, I provided resources for instruction on breast exams to female students and testicular self-examination to male students. Our school’s formal health curriculum, however, was under the direction of the physical education department.

LV: You’ve provided a very comprehensive and detailed description of a school nurse’s work. Could you talk about the impact of the COVID-19 pandemic on that work?

JMV: Well, although I retired a few months before the virus hit, I still remain on the substitute list within the school district. Between conversations with the current high school nurse, as well as my return to several of the district campuses during the past year, I have observed both physical and procedural changes. The initial procedural change was the use of remote learning, which resulted in no physical presence of students at any location; later, when the district re-opened, the use of PPE and the need to immediately isolate any student coming to school with suspicious symptoms created a markedly different work flow in the office. Gone were opportunities for what I’d call the “therapeutic cot” in the nurse’s office, where students would find respite during the school day for any number of reasons, and where they might often be comfortable enough to share information about their lives with the school nurse. Some of this sharing provided insight into either a medical or behavioral issue a student could be experiencing; sometimes it offered a glimpse into the student body culture which was not readily visible in the course of the typical school day.

LV: Do you have any closing thoughts you’d like to share?

JMV: When we are talking best practices, I think having a dedicated school physician available to the school nurse, especially someone willing to provide immediate access, is the ideal situation. Having the ability to contact community practitioners in a timely fashion about their students is another big plus, especially as it relates to continuity of care. Having access to community resources, including those for mental health, would be another essential factor needed to adequately manage student health.

Receiving regular continued education pertinent to the issues faced by school nurses is a key component to maintaining both competence

and excellence in caring for students. An annual “meet and greet” involving district school nurses, community clinicians, school staff, and other parties active in school health: that would greatly foster both enhanced communication and interdisciplinary care.

All of these measures would enhance the school nurse’s ability to advocate for their students, which is both a personal goal and a stated objective of professional groups like the New York State Association of School Nurses (NYSASN). Membership of a school nurse in that organization and its affiliates (zone and national) provides a framework for shared experiences and further professional development.

LV: That seems like good place to end this interview. Thank you for sharing your experiences with our readers.

JMV: You’re very welcome. School nurses would welcome forming clinical partnerships with clinicians in the community; that can only advance the cause of school health for all stakeholders.

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NOTE: Included in the list of selected references are articles which describe the role of the school physician specifically, as well as articles which detail opportunities for collaboration between community clinicians and the school nurse. Some of the citations are of historical interest, others are more current and focused on specific health issues involving secondary and college-age students, and one is a policy statement from the American Academy of Pediatrics. On the AAFP website, if you search the American Family Physician (AFP) database using terms “school health”, “school physician”, or “school nurse”, you will find an extensive listing of condition-specific references for a variety of clinical and psychosocial issues involving school-aged children and young adults.

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REFERENCES:

Sellery, C. Morley. “Role of the School Physician in Today’s Schools”. American Journal of Public Health, 1952 July; 42: 813-817

Maclachlan, Kenneth. “School Health and the Family Physician”. NEJM, 1955 November; 253 (18): 767-769

Council on School Health. “Role of the School Physician”. Pediatrics, 2013; 131 (1): 178-182

Allen, Claudia; Diamond-Myrsten, Sharon; and Rollins, Lisa. “School Absenteeism in Children and Adolescents”. Am Fam Physician, 2018 Dec 15; 98 (12): 738-744

Riley, Margaret; Morrison, Leigh; and McEvoy, Anna. “Health Maintenance in School-Aged Children: Part I. History, Physical Examination, Screening, and Immunizations”. Am Fam Physician, 2019 Aug 15; 100 (4): 213-218

Locke, Am; Stoesser, Kirsten; and Pippitt, Karly. “Health Maintenance in School-Aged Children: Part II. Counseling Recommendations”. Am Fam Physician, 2019 Aug 15; 100 (4): 219-226

Unwin, Brian; Goodie, Jeffrey; Reamy, Brian; and Quinlan, Jeffrey. “Care of the College Student”. Am Fa Physician, 2021 Aug; 104 (2): 141-151

Joan McMahon Verardo, RN, BSN completed the RN program at SUNY Farmingdale and received her BSN degree from Stony Brook University’s School of Nursing. She is a former president of the Suffolk County chapter (Zone #2) of NYSASN and currently serves as the communications liaison for that organization.

Louis Verardo, MD, FAAFP completed his medical degree at the University of Bologna, Italy, and is currently on the voluntary faculty of the Renaissance School of Medicine at Stony Brook University. He is a member of NYSAFP and serves on the Editorial Board of Family Doctor.