Not Just Aspirin and Band-Aids Anymore

Photo by Daniel Dubois

Tyler Ralph slumps into the yellow chair looking as limp as the untied shoelaces on his back-to-school sneakers. But the fourth grader knows to get down to business – swabbing his fingertip, pricking it with the lancet, putting the drop of blood on the test strip, waiting for the blood sugar reading that explains why he feels so bad: 48. His goal is 120, so 48 is way too low.

Under the supervision of school nurse Kathy Warren he reaches into the special drawer that has held his
diabetic supplies since he was diagnosed in first grade and pops two glucose tablets into his mouth.

As the sugar rush kicks in, he perks up quickly and shows off his magic tricks, meticulously folding a dollar bill to give George Washington a crooked smile and making quarters disappear into his pockets.
He and Warren have an easy relationship from three years of multiple daily visits to the clinic to manage his diabetes.

After about 15 minutes, Tyler checks his blood sugar again, gets a reading of 124, and Warren sends him off to lunch. When he comes back, his magic trick dollar has been converted into a bag of popcorn, and he rattles off the rest of his lunch so they can calculate his carbs and determine how much insulin he needs – a hot pocket, a peanut butter and jelly  sandwich, chocolate milk, a baked potato.

Warren’s eyes get wide. “That adds up to 160! That’s 60 over our goal.”

They talk about choices he could have made to have a lower total. He usually gets water instead of chocolate milk. And maybe he could have saved the peanut butter and jelly sandwich in her fridge for a later snack. “I’m not fussing at you,” Warren reassures him. “This is a nutrition lesson.”

This is what school nursing looks like today.

It’s no longer just tummy aches and Band-Aids. It is managing chronic conditions like asthma and sickle cell anemia and mental conditions like ADHD and depression and navigating social conditions like poverty, hunger and homelessness.

“I’m seeing so much more asthma and diabetes, plus the behavioral and learning disabilities,” Warren said. “The dynamic of the classrooms has changed and they’re integrating everyone. I have had students with severe seizures and one with cerebral palsy in a wheelchair. That would have been unheard of in regular public schools years ago. The demand for nurses is obviously there.”

Front Lines
Vanderbilt University School of Nursing supports three nurses in local Nashville schools in low-income neighborhoods as a facet of its community health outreach. The program has evolved through various grants and contracts since the first nurse was established at Fall Hamilton Elementary School in 1994 as a complement to the Vine Hill Clinic.

The bottom line is simple: healthy children are better learners, and better learners are more successful in life.
“We look for ways that nurses can make a positive difference in the health status of populations in our community,” said Bonnie Pilon, DSN, RN, senior associate dean for Clinical and Community Partnerships. “Our three school nurses are an amazing resource, are a stabilizing force for the children, and create a safe place to be. I have terrific respect for them.”

This summer, Metro Nashville Public Schools renewed the contract for VUSN to manage the school-based health centers at Fall-Hamilton Enhanced Option Elementary School, Taylor Stratton Elementary School and Park Avenue Enhanced Option Elementary School.  The contract will run for five years.

“Our nurses have been in these schools for many years and have established relationships with the students, parents and staff. It’s great to continue the contract and provide some consistency at these schools,” said Terri Crutcher, MSN, RN, assistant dean for Clinical and Community Partnerships.

In 1975, the implementation of the Individuals with Disability Education Act (IDEA) brought more children with disabilities and chronic conditions into the public schools. Today an estimated 25 percent of children have health conditions that should be managed by a school nurse, but 25 percent of U.S. schools have no nurse.
Many school districts, including MNPS, have nurses that visit multiple schools in one day to manage the serious medical needs. That leaves teachers and office staff to give daily medications and provide first aid.

“Money is a growing concern,” Crutcher said. “Based on the available resources, most schools have been driven to have nurses cover more than one school. MNPS can’t afford for our nurses to be there for the full day. Everybody wishes we could do more, but it’s a matter of balancing the resources and the needs of the children to be cared for.”

Recognizing the evolving role of school nurses, Vanderbilt recently changed their title to “case manager.”
“We’re not just putting Band-Aids on, and I think that is a profound statement,” Pilon said. “There’s the Band-Aid and temperature-taking view of the school nurse, and then there’s the health promotion, improve the lives of children view of the school nurse, and we very much go with that broader view. They’re a part of the team that gathers around today’s children who come in all shapes and sizes and have all kinds of needs.”

Chronic Conditions
Warren cares for 700 students at Taylor Stratton Elementary in Madison, Tenn., just north of Nashville. Her school is the most diverse of the three, with one-third white, one-third black and one-third other ethnicities, including Hispanic, Somali and Indonesian. This immigrant population comes with some unique

“A lot of the children have allergies with runny nose and stuffed up ears and the parents don’t know what to do because they’re from a totally different climate,” she said. “They also use a lot of home remedies and aren’t as willing to follow doctor’s orders.”

Each year, Warren teams with school staff to create about 80 individual health plans, the formal document that explains how the school will manage a student’s chronic condition. She also informally cares for teachers and staff.

“I have an open door policy and make the clinic a safe place where they can stop in and chat. Some need their blood pressure monitored or just to talk.”

Warren is very protective of the children she cares for and struggles with what some of them face outside the classroom – going home to an empty house or bouncing around from relative to relative, only getting full meals at school, having to wash their own clothes.

“The kids need somebody, an advocate, and I’m there every day. I’m a constant. There’s nothing I can do about their home life, but I can make their day a little better, help them get clothes, clean up their hair. They know I’m not going to do anything to hurt or embarrass them. I feel like it is my mission in life to care for these children and do whatever I can for them.”

Nutrition Education
The story is legendary:  At Fall-Hamilton Elementary, school nurse Theresa Hook had taken her “Lean Green Veggie Machine” cart into a classroom to share samples of vegetables. There was a new student who said she didn’t like vegetables, and the rest of the classroom let out a collective gasp. They couldn’t believe she wouldn’t try the veggies. And when Hook traveled to other classrooms and recounted the story, those students couldn’t believe it either.

Theresa Hook holds one of the tools of her trade – a digital thermometer – in front of a mural of the neighborhood painted by students at Fall-Hamilton Elementary School. Photo by Joe Howell

For years under the guidance of Hook, Fall-Hamilton’s 325 students have been snacking on squash sticks and cherry tomatoes, learning how vegetables differ when they’re raw or cooked, and how to make healthy choices in the cafeteria or at the drive-thru window.

“All I ever ask is for them to give it a try. If they don’t like it, I explain that taste buds grow up and they may like it in a few years. The kids will try anything now, especially if ranch dressing is involved,” Hook said.

It started with a $10,000 grant from Hidden Valley, the only one awarded in Tennessee, which funded the Lean Green Veggie Machine. She is also involved in the Healthier U.S. School Challenge Program, a U.S. Department of Agriculture initiative that sets benchmarks encouraging schools to create healthier environments through increased physical activity and better nutrition. The school, located near the Tennessee State Fairgrounds, also has a garden and walking path.

When the school reached the silver benchmark, Hook traveled to Washington, D.C., last fall to celebrate with First Lady Michelle Obama on the south lawn of the White House.

Hook’s focus on nutrition is part of a much larger goal to teach her students that they are in control of their own health.

“In many health concerns, a child has no control,” Hook said. “Making a good food choice when options are presented is something they can do for themselves.  Many eat breakfast and lunch at school, and they have the choice of eating the fruit and veggies or throwing them out. When a parent takes a child to a fast food restaurant, the child can ask to have fruit or yogurt rather than fries or onion rings.”

Every day, Hook creates a daily health tip that is read after the pledge of allegiance. It is always something the children can do for themselves, like getting enough sleep, washing their hands or making sure their shoes are tied.

If children take daily medication, Hook makes sure they know why they are taking it and asks them to reflect on if they think it is working. Children with asthma are taught their early warning signs and how to properly use their inhaler.

Even an upset stomach is a learning opportunity.

“Is it a tummy ache because they forgot their homework or got in a fight with a friend or ate something bad or are coming down with a virus? I always ask ‘What do you think is going on?’ to get them thinking about their health and their habits,” Hook said.

“One kid told me he thought the eight chili dogs he had for dinner were making his stomach upset. I said ‘Yes, I think that’s it too.’”

Saving Lives
At Park Avenue Elementary, west of Vanderbilt in the Sylvan Heights neighborhood, every student is a “sweet angel.” Nurse Marie Phillips gives that nickname to each of the 700 students she cares for. None of them can escape her clinic without multiple hugs.

“A lot of my visits are a cry for help. They’re just needing a little attention. The hug I give may be the bright spot in their day. I want the children to know they have a place to come and be loved.”
Phillips was one of the six original nurses on Vanderbilt’s LifeFlight helicopters and had years of experience in the emergency room.

School nurse Marie Phillips sees fourth grader Antonique Gill twice each day, giving her water and medications through a gastrostomy tube. Photo by Anne Rayner

“After working in the ER, I thought nothing could shock me. I’ve seen every possible body part pierced. But the stories these children tell. They’ll come in and share about fighting in the home or hearing gunshots in the night. A lot of my job is hugging.”

In addition to the hugs, Phillips has a lot of skilled nursing work to do. A fourth grader with cerebral palsy gets two daily tube feedings. She has more than 100 children with documented asthma, and she gives about 15 medications per day.

She works to develop strong relationships with family members, teaching them to call the doctor for a clinic visit instead of heading straight to the ER.

Each year Phillips holds a health fair, which is one of the ways VUSN students are involved in these schools. Students in the Community Health track will rotate through each school, and at Park Avenue they help with screenings for height, weight, blood pressure, hearing and vision and follow-up with children who fail.
“The nurse practitioner students learn important lessons, like not everybody has cars or a job that allows them time off for regular doctors appointments. They have to learn how to work around that. It’s the real world for them.”

She also shows them what a difference a hug can make.

“Someone asked me how I could do this after flying in the helicopter, and I say it’s just as rewarding,” Phillips said. “I may not be doing CPR daily, but I feel like I’m saving these children’s lives too. I’m teaching children how to take care of themselves and keeping them healthy to learn. If I make just one child have a better day, then it’s been a success.”

– Leslie Hill