S.D. School Nurses Often a Child’s Only ‘Doctor’

Between 7 and 10 on a recent morning, Billie Hendrix had 32 patients file through her waitingroom--among them several with severe stomachaches, one unsteady from a fall, another pale from suspected bronchitis, one with a broken arm, another with a bruised rib, one with a badly infected eye and four in the latter stages of pregnancy.

Despite all the hubbub, Hendrix examined each one, had several lie down, wrote excuse notes for some, and strongly encouraged others--in a few cases admonishing them--to visit their family physicians for immediate treatment.

It was just another schoolday for Hendrix, the nurse who cares for the diverse ethnic and socioeconomic mix of students at Hoover High School in Mid-City. Although not a doctor--although as a nurse-practitioner she can make certain diagnoses and perform physical examinations--many students treat her as their primary

source for care, and in some cases their only source, due to family economics.

The daily flow of children with significant medical needs takes place at schools throughout the San Diego Unified District--the nation’s eighth-largest--in large part because a growing percentage of its students and their parents are increasingly poor and immigrant, with no regular access to treatment.

At Euclid and Hamilton elementaries in East San Diego, at Washington and Sherman elementaries near downtown, at Serra High in Tierrasanta and Lincoln High in Southeast, to name just a few, nurses regularly see students with illnesses that, if not treated promptly, could result in lifelong handicaps or learning disabilities. At schools such as Hoover, the nurse sees more than 1,000 students a month.

In their spare time, the nurses give state-mandated immunizations and try to carry out health education, ranging from toothbrush instruction for primary kids to alcohol and driving issues for teen-agers to visual and health screenings to pick up on chronic conditions.

Hoover administrators last fall realized the extent of the care, especially after the longtime nurse asked for a transfer because she was “burned out” from ministering to 80 students or more day in and day out. As a result, they have been developing a proposal for a campus health and social service center to serve the high school and its surrounding middle and elementary schools. The plan is expected to go before the Board of Education sometime this summer.

But even if such a comprehensive health clinic is approved and funded with private foundation money, as planned, most of the district’s 180 schools will still be left to rely on the district’s 120 nurses.

Spread Too Thin

And that looms as a larger and larger problem. Many schools have nursing service as little as one or two days a week, the result of several years of budget cutbacks. The rest of the week, the schools must rely on health clerks, who are trained only in first aid, or on office secretaries. Prevention and screenings go unmet.

The needs are not limited solely to schools in poorer areas. District integration programs, through which thousands of students can bus to non-neighborhood schools of their choice, mean that health needs can crop up in affluent La Jolla or Point Loma, where resident parents are more likely to have regular pediatric preventive care for their children.

In addition, the district must now handle more widespread medical needs of special education children--many of whom have chronic health problems--as these students are placed throughout regular schools as a way to cut down on their social isolation.

In an effort to address school health-care needs, a committee of district administrators has proposed adding as many as 20 nursing positions, plus a health clerk at each school to handle paper work. The plan would cost up to $2.24 million to implement and would have to survive the ax of budget planners, who are faced with an expected shortfall of $10 million or more in the district next year.

Supervisors of the weeklong outdoor integration program on Palomar Mountain for all district sixth-graders also want added money for nursing care. The one full-time nurse now works an average of 60 hours a week and is on call 24 hours a day for the special medical problems that can occur with children who are away from home for the first time and at the 6,000-foot elevation.

“In many, many cases, our nurses are serving as the primary-care providers for students,” said Frank Till, assistant superintendent for educational services who chaired the special committee that is recommending added funding. “But the (recommendations) may be only a goal to be met eventually, because of our budget problems.”

Needs are Many

“Even a full-time nurse is not enough sometimes given the problems of 1,600 kids who mix and mingle each day, let alone injuries from contact sports, from industrial-arts shops, etceteras,” said Nancy Shelburne, principal at Crawford High School.

Her school has large numbers of Indochinese, Latino and black students too poor to have regular family doctors. But assigned nursing time is based on school enrollment, not on the socioeconomic needs of a student body. As a result, principals such as Shelburne must use their school’s discretionary money to fund added nursing time, money that otherwise could be used for supplementary class instruction.

“Add to the basic health needs of my students the issues of alcohol and drug abuse, the stresses of being a teen-ager, and the nurse becomes a focal point for a lot of informal counseling as well,” Shelburne said.

Ideally, district nurses would like to see school-sponsored clinics to treat students who now delay or fail to seek medical help, even when referred by nurses, because they cannot afford the care. But they also argue for additional nurses so more schools can have nurses five days a week. And they would like to change regulations so more nurses--a third of whom have nurse-practitioner licenses--can perform more medical procedures, and perhaps dispense certain medicines as well.

“Even if we could just get better and faster care of sore throats or fevers, that would be a big plus for us and the students,” said Judy Beck, district supervisor of nurses.

Hamilton nurse Claudia Hildreth, a strong supporter both of school clinics and more nursing time, realizes that many people say schools should be in the business of education, not health.

“The reality in many cases is different, however, and all too frequently families will be unable to get health care, or counseling, unless we provide them through the school,” she said.

Frustrating Problem

The frustration of many nurses, Hildreth said, is that despite all the screenings and referrals they make, too many parents frequently cannot afford the medical care.

“I spent a whole day trying to get a child with a horrible ear infection treated before it developed into deafness and the need for a hearing aid,” she said. “But the mother had it treated initially but then didn’t go back to the doctor when (the infection) continued because of financial constraints . . . . Even low-cost clinics are not free and many parents fear that when they are unable to pay an entire bill, that they will be turned down for help the next time they go back.”

Frequently, the busiest time of the day for nurses is before school, when their offices are crowded with children sent by parents who want the nurse to determine whether the children are really sick enough to have to go to a doctor.

“There is so much difficulty in the follow-through,” said Jeff Black, a UC San Diego pediatrician who serves as a special consultant to the school district. “A nurse will identify a skin rash that is contagious and tell the parents, but the parent may not be able to leave work, may not have transportation, and then not have the money, and so the nurse checks a week later and finds that they haven’t seen a doctor, and it becomes more of a problem.

“The key in having a clinic is not only to mitigate the financial need but to get minor complaints and treatment much more quickly, so that a child with red eye or head lice does not have to miss school for days” while a parent seeks affordable help or keeps the child at home until he or she recovers.

Extra Efforts

School nurse Steve Martin, who has served Washington and Burbank elementaries two days a week each for the past decade, went back to nursing school for a nurse-practitioner credential several years ago so he can make better diagnoses for parents.

“Now I can do minor diagnoses, like urine and throat infections, and actually do better referrals, so I can tell parents exactly where they need to go for treatment rather than having to wait two or three days to see how a case develops.

“Otherwise, 75% or more of my parents will not seek medical care unless a child has a real bad pain or there’s an obvious bone hanging out.”

Martin said many parents around some schools live in residential hotels with no refrigeration and that even if they take their children to a doctor, they either do not follow up on a prescription or have no refrigeration for the medicine.

“I bought a refrigerator at school and keep medicines in there for some kids,” he said.

Because Martin must divide his time between two schools, he finds little time to do classroom inspections, education programs and other preventive efforts that are part of a school nurse’s job description.

“What keeps me going is when I do follow-ups and the parents thank me for finding a vision or hearing defect in their child and the resulting treatment cured the problem,” Martin said. “We (nurses) are a community resource.”

At Serra High, the Navy provides a doctor one morning a week to assist nurse Jacqueline Allen with the large number of military dependents from the nearby Murphy Canyon Naval housing complex.

“It’s a great help,” said Allen, who schedules Navy children for the doctor on an appointment basis because many have no transportation to the regular clinic at the Navy Hospital in Balboa Park.

“We see basic stuff, such as a sprain, back pain, some sore throats and the like,” said Dr. Donald Coullahan of the Balboa facility’s adolescent care clinic. “And, in addition to these minor illnesses, we can encourage the student to come to the clinic for care on more serious matters.”

Coullahan said that in his opinion, schools “are an appropriate place for health-care facilities, an excellent way to go, given careful guidance . . . because in the U. S. we haven’t extended health care to people who don’t have access, particularly in inner-city areas.”

But even in schools outside the urban core, many say, nursing time is inadequate. Martha Thum splits her time between La Jolla High, four days a week, and Bird Rock Elementary, one day a week.

“The difference between La Jolla and Hoover, for example, is that at La Jolla I don’t have the tremendous numbers and the parents have more resources,” Thum said. “But I do have students who have no doctors, whose parents may work but have no insurance, and when they get sick, it’s a problem to find them care.”

A Five-Day Need

Thum believes that all high schools should have nurses five days a week.

“So many students at the high school level have acute emotional and social problems, such as thoughts of suicide or depression,” that can be masked as physical ailments, Thum said. As for elementaries in more socioeconomically stable areas, Thum believes that such schools should have a nurse at least two days a week.

“Just the paper work alone requires that,” she said. “And it would allow me to get into the classroom to teach about social health, to do the dental program, to make sure my screenings are done as early as possible,” so that kindergarten children with vision problems don’t have to wait until late spring for a vision test.

While San Diego city schools offer a minimum of nursing service to all facilities, many county districts, especially in North County, provide only health clerks at schools, in large part because these schools believe they have avoided the changing demographics of more urbanized areas.

In the Grossmont high school district, health clerks perform first-aid treatment and call parents on all other matters. If a student is unable to afford medical care, the parents will be given a list of clinics or charity arrangements will be made on a case-by-case basis, El Capitan High School Principal Art Pegas said.

“Our communities here are not comparable to those around Hoover, for example,” Pegas said.

Poway High Principal David Hughes said that district’s philosophy “is that the medical well-being of a young person is primarily the responsibility of the parents, and our method of dealing with problems is to communicate with parents and advise them to seek medical advice.”

Hughes said he is not aware of any student ever having a problem obtaining health care, although a Poway High parent active in education said the district “has a tradition of ignoring health issues until a crisis takes place,” citing the suburban district’s belief for years that it had no drug problems.

Oceanside does provide school nurses on a regular basis and administrators credit a nurse at Lincoln Junior High for catching a student with tuberculosis last fall more quickly than if there had been only a health clerk.

“A school nurse can pick up on a problem more out of the ordinary because of training,” Oceanside nursing coordinator Art Gamble said. “I just wish we had the money for nurses full time at all our schools.”

Added Philip Nader, a UCSD pediatrician who follows school health issues nationally: “You get what you pay for. Without a nurse watching kids, a student will fall through the cracks, a child can go through a couple of grades before someone figures out a need, and learning problems can develop that could have been picked up on earlier.”