Giving a Voice to School Nursing in Georgia

For my first article as president of GNA, I would like to update you on the history and status of school nursing in Georgia. GNA has a tremendous amount of involvement in this history and efforts to put school nurses in the schools.

It is that time of year again to focus on children returning to school. For the past two years, the number of school nurses in Georgia schools has increased. This is partially due to the passing of HB 1187 (which is the Education Reform Bill ) in 2000. The bill states “each board of education shall establish policies and procedures regarding a school health nurse program. Such school nurse programs shall be staffed by licensed health care professionals.” GNA advocated for this bill and suggested language changes to include an RN in each school but the suggested change was not accepted, primarily due to funding implications..

Over the past decade, the advocacy for school nursing has been on the forefront of GNA’s legislative efforts. Giving a voice to School Nursing is occurring gradually in Georgia thanks to efforts of many agencies including GNA with members who have served on the Georgia Partnership for School Health over the past 10 years. Prior to the formation of the Georgia Partnership for School Health (GPSH), GNA established a School Nurse Task Force that formed a collaboration with groups to advocate for school health programs. This group was instrumental in introducing legislation for school nurses in the past.  This group met each year at convention to discuss school health status.

History and Need for School Nurses in Georgia

It is apparent that “Education and health are interdependent systems. Healthy children are in a better position to acquire knowledge and no curriculum is brilliant enough to compensate for a hungry stomach or a distracted mind.” Georgia’s children are less healthy than children in other states.  According to 2001 statistics from Kids Count Annual Survey, Georgia ranks 44^th in the health and well being of children. Forty-five percent of all fourth graders in Georgia are below grade level, and 12% of all children drop out of high school-ranking Georgia 41^st in the nation.  In addition, 22%(1999) of all Georgia’s children live in poverty. Approximately 77% of the state’s 1.4 million school children are eligible for the free and reduced lunch program, putting their family incomes below the 185% poverty level ($31,542 per year for a family of four). Other problems include dental disease and lack of health insurance. There are approximately 286,740 children with no source of regular insurance-based care, many of whom are eligible for PeachCare for Kids. Approximately 70% of these children are between the ages of 6 and 18.

Research has shown that poverty and the lack of insurance coverage play a major role in affecting the health status of children since uninsured children are less likely to see a doctor. There are many more disturbing statistics about the children and adolescents in Georgia. But the fact remain that we are just beginning to provide services for children in the place that they spend most of their time and transportation to and from that location is not an issue. School nurses can provide services and referrals to these children in the schools that will facilitate healthy behaviors and increase their educational potential.

GNA’s Participation in the Georgia Partnership for School Health

Since the beginning of the Georgia Partnership for School Health (GPSH), GNA members have served in  leadership positions in the organization including positions on the Board of Directors.  The GPSH is composed of approximately 40 organizations whose vision is for Georgia’s children to be healthy and to learn to be healthy. The GPSH proposes a School Health Program that includes the eight components advocated for by CDC.  They include: 1) a Healthy School Environment; 2) School Health Education; 3) School Health Services; 4) School-based physical education; 5) School Nutrition; 6) School-Based Counseling, psychological and social services; 7) Employee Health Promotion & School, Parent, Family, and Community Health Promotion Partnerships. The member of the GPSH advocate and support  all components  to have a comprehensive school health program. School Nurse Programs and legislation have been supported by this group.

In 1998 GNA members addressed the need for school nurses and funding with Governor-elect (at that time) Roy Barnes. Then GNA members met with Senator Nadine Thomas, Commissioner Russ Toal and other representatives of Governor Barnes Office to discuss the possibility of funding school nurse programs through the Tobacco Settlement Funds. Members of the GPSP and GNA Commission on Legislation (previously named Cabinet on Governmental Affairs) wrote the proposal for the Tobacco Settlement Funds. When HB 1187 was passed, the $30 million dollars to fund the school nurse program was approved.

Implementation of the School Nurse Program in Georgia

Even though the legislation had been passed and money was allocated for a program, there was confusion and chaos in the implementation process. The money allocated was specified for salaries and there was no funds available for supplies and equipment. It was projected that local school boards and businesses would contribute to the School Health program with the supplies and equipment. Also, many districts had no idea how to implement a program. A group from the Georgia Partnership compiled materials and took to the State Department of education who was to allocate the funds but the materials were not distributed.

School systems were hiring unlicensed individuals to work in school clinics even though the legislation stated "licensed health care providers." RN’s were concerned about the legal responsibilities involved with supervising Unlicensed personnel to perform nursing functions. GNA through representation with the GPSH visited the Governor and Commissioner Russ Toal to state concerns, and a letter was written to the State Department of Education to voice concerns about the lack of compliance to the law. There are still many different compositions of work forces in the school districts in Georgia’s school districts today.

Some hospitals are hiring school nurses and providing education for these nurses. One of the first to do this a few years ago was Coffee County which used indigent care funds to put a RN in all schools in their county.  The parents, students, principals, and superintendents were interviewed after one year and everyone was very much in favor of having school nurses in all schools. The companies in the area also, found that having school nurses kept their employees on the job since they did not have to constantly go to pick up children who did not need to go home.  The school nurse evaluation kept most of the children in the classroom.

It became aware very early that school nurses need orientation to the role and education. The nursing education programs do not provide knowledge of school environments and special tasks to be performed by the school nurse.  Children’s Healthcare of Atlanta put together a manual with the assistance of members of the GPSH to send to each school district.  In addition, education programs for school nurses were made available at the Georgia School Nurse Convention and more intense programs at the universities. DHR has been very involved in all aspects of education for the school nurse.

Research

The Georgia Health Policy Center surveyed electronically the Georgia School Superintendents Association. Of the 180 surveyed, 178 completed the survey to state that they supported a school nurse program.  Toni Barnett, PhD, RN interviewed parent groups to assess perceptions of parents related to the health needs of children, strategies to resolve these health needs, and school-based health services.  She obtained this information through focus groups in South Georgia. Dr. Barnett found that parents identified the following as problems: lack of nutritious and culturally sensitive meals, unappealing school meals, prevalence of obesity in children, lack of physical education, lack of soap and paper towels in the bath room and lack of sex education.  Parents endorsed school based health services provided by school nurses.

Present Status of School Nurses in Georgia

Data collected by the Children’s Health Care of Atlanta shows that 100 districts in Georgia have some School Nurse Program with over 1000 school nurses in place in the state. There are several model programs in Forsyth County (Gainsville) ,Camden County (St. Marys), and others where they have an all RN staff, while in many other school districts there is a mixture of RN’s ,LPN’s,andUnlicensed Personnel.  The School Nurses continue to make a difference in the health of Georgia’s children. In Fulton County, within a six month period there were a total of 236,998 visits (mostly ill and injury) to the school, nurse: of those visits 183, 234 students returned to class and only 36,704 were sent home. There are thousands of dosages of medication given each day in all of the schools. Some of the most prevalent medications include Ritalin, asthma inhalers, and insulin for the diabetic children. School Nurses giving and supervising the administration of medication ensures decreases in medication errors that have been reported in the past.

There are many children with chronic conditions that are in the classroom and requires special care from the school nurse during the school day. There are many procedures to be performed by the school nurse for these and all children in the school.  Some of these procedures include catherizations, tube feedings, colostomy care, suctioning, care of child on the respirator, dressing changes, and care of children due to accidents and injuries.

School-Based Nursing and the Nursing Shortage

Nurses applying for the school nurse positions are not nurses presently employed in agencies, they are mothers who have been stay-at-home mothers who want to work the hours that their child is in school. They are willing to work for low salaries to keep the same schedule as their children. At this time, low salaries are a point of contention and discussion among school nurse groups. The budget crunches over the last year has prevented any possibilities of adding funding for the school nurse positions.

Some Legal Aspects of School Nursing

It is within the scope of practice of the RN to be a school nurse and function independently in school clinics but the scope of practice for the LPN requires supervision by a RN or physician.  There are other screening restrictions for the LPN, also.  Dental screening can only be performed by the RN, dental hygienist, or dentist.  At present, the legislation is not being enforced as to personnel.  Continued efforts are being made as to recommendations to the State Board of Education.

Continuing Efforts Toward School-Based Health Programs

There is an Advisory Panel on Student Health Achievement appointed for this purpose and I serve on the committee. The Advisory group has representation from health, education, hospitals and other agencies. The group will make a recommendation to the DOE Board of Directors.

School Health Program with School Nurses do make a difference in decreasing absenteeism, decreasing emergency room visits, and better compliance with chronic illnesses such as asthma and diabetes. School nurses need to increase their voices, gain power through, visibility, viability, and value. This can be achieved though marketing and political involvement in communities and at the state level.

It is time now for school nurses to publish more program outcomes.  Over the past year, there has been a review by the Budget Review Oversight Committee (BROC) to determine the effectiveness of the school nurse program and review of funding efforts. GNA members and organizations provided data that assisted this committee with this review.  Outcomes are necessary at this time to retain the funding that has been appropriated for a licensed health care provider in each school.

GNA appreciates school nurses and their challenges in the schools. Keep up the good work. Be visible, show viability and make your value known. The collaborative efforts of the member groups of the Georgia Partnership , Georgia School Nurse Association, DHR School Nurse Coordinator, and Children’s Healthcare of Atlanta are essential to provide health care and referrals for Georgia’s children so they can be healthy to learn and learn to be healthy.

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