Nurse Case Scenario : Providing Health Care in Schools Has Become a Daunting Task

Head lice, tummyaches, prenatal care and knife wounds. They can all be part of a day’s work for Ventura County’s corps of school nurses.

Part moms, part social workers, part friends and part healers, nurses and their surrogates assume many roles, sometimes bouncing among several campuses and occasionally visiting a student’s home.

“I’m basically mom to 600 kids,” said Jan Spaulding, a health clerk who works part-time at Westlake Hills Elementary School in Westlake Village. “Sometimes I just give them a hug, because that’s what they need. Sometimes the kids from broken homes come to see me and they just need a little TLC. They just need me to listen.”

But members of this dedicated crew have seen their jobs change dramatically on several fronts over the years. For one, their ranks have dwindled in most districts as administrators made painful staff cuts to absorb diminished statewide funding.

“It’s a shame that we’re only here 3 1/2 hours a day,” Spaulding said. “Because kids need us all the time.”

The reduction in their numbers has come even as students’ needs are getting more complex, their problems more profound. Nurses say they see more cases of clinical depression and students on psychiatric drugs at the high school level, something that did not exist when many of the veteran nurses were starting out two or three decades ago.

And they were not seeing pregnancies in junior high then, either. There are more students from single-parent homes now and more students whose parents have no health insurance, nurses say. And in many households, either headed by one or two parents, no one is home during the day to pick up a sick child.

“We have parents who tell us, ‘If you call me again at work, I’ll lose my job,’ ” said Caroline Ferber, a registered school nurse in Simi Valley. As she spoke, a Hillside Junior High student with her hand on her cheek walked in. “What’s the matter, hon?” Ferber asked.

Her tooth was hurting. After taking care of the girl, Ferber returned to her conversation. Many parents, she said, are working, but at low-paying jobs without benefits.

“They have to choose between paying a utility or making the rent and taking their child to the doctor,” she said. “We see a lot more of that today.”

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And in lower grades, the nurses say they are now dispensing more medication, primarily for students with attention-deficit disorder or hyperactivity, asthma or even diabetes.

The nurses say that kids of all ages have always gotten into fights, but they weren’t using weapons a generation ago.

Harriett Winkelbauer, a school nurse for 20 years in Simi Valley, was on duty the day 14-year-old Chad Hubbard was stabbed to death at Valley View Junior High School in 1994.

“I was giving him mouth to mouth until the Fire Department got there,” Winkelbauer said. “Someone else was putting pressure on his wound.” The emotional experience, she said, was “total devastation.

“That’s why I went into school nursing, because there were no deaths at schools,” she said. Now, when she teaches classes in cardiopulmonary resuscitation, she includes a section on techniques needed for chest wounds.

“We talk about possible disasters such as earthquakes, but also a drive-by shooting or a stabbing,” she said. “Twenty years ago, we wouldn’t even have thought of that.”

Bonnie Rossborough, a health clerk who works part-time at Thousand Oaks High School, said Thousand Oaks was a much smaller community with small-town needs when she started 15 years ago.

“You did not expect to be dealing with knife wounds because this was a smaller community and you didn’t have that kind of activity then,” she said. “It’s a reality now. Economic times are such that depression and violence are part of our daily lives.”

She said her students’ problems cover a broad range in any given school day, from typical teenage angst to domestic violence.

“It can be ‘I don’t have a date for the prom’ or ‘Nobody likes me,’ ” she said. “But I also hear ‘I’m pregnant and my boyfriend beat me up.’ Or it’s ‘Dad beat Mom up last night.’ Then I get the counselor involved because that’s a police matter.”

However, she adds, her tasks can run to the mundane as well.

“Sometimes my role is more like school mom for 2,228 kids,” she said. “I sewed a kid’s sweater back together this morning.”

In most schools across the county, the days of one nurse for each school are long gone. Registered nurses in Simi Valley, Thousand Oaks and Ventura districts each serve several schools.

In Simi Valley, there are five full-time and two part-time registered nurses for 18,000 kids, with health clerks filling in part-time at the junior high and high schools. There is one nurse who covers elementary schools.

The nurses hold office hours in Simi Valley, but they also teach classes in sexually transmitted diseases, tobacco use and family life.

“Elementary schools need nurses,” Ferber said. “There are health problems there that could range from seizures to muscular dystrophy or diabetes.”

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Some schools have ratios as high as 4,000 students to one registered nurse, said Sandra Holmgren, a nurse with Ventura Unified, where one part-time and four full-time nurses serve 16,560 students.

“The California School Nurse Assn. recommends a nurse-to-student ratio of one to 1,500,” she said. “The nurses are definitely stretched more thinly today.”

Two of the nurses are assigned to the high schools and three share the district’s elementary schools. Part-time health clerks work at the middle schools, and they work half-days, every other day, at elementary schools.

But she said school nurses--who carry a bachelor of science degree, a registered nurse degree and a school nursing certificate that requires an additional 37 units--are not needed for taking temperatures and putting on Band-Aids, tasks they performed years ago.

“That’s basic first aid,” she said, and is easily performed by the health clerks who are unlicensed but trained in first aid. “Nurses are specially trained to do physical assessments, medical treatments, health counseling and education.”

Holmgren, who was an elementary school nurse in Simi Valley until 1990, when her position and those of five other elementary school nurses were cut, said school nursing, for the most part, is still satisfying work.

She enjoys teaching students to be more self-sufficient when it comes to their health. Still, she said, more nurses are needed on campuses.

At the Oxnard Union High School District, administrators agree. Each of the district’s five high schools and one continuation school has a full-time nurse on campus.

Wayne Edmonds, personnel director for the district, said the nurses work with students who are at risk of dropping out as well as those with medical problems. The also serve on crisis management teams.

For instance, after one student injured his back in a car accident, he had to work standing up. The school nurse helped coordinate things to make that possible, Edmonds said.

Even during budget cuts, the district never considered cutting its nurses, Edmonds said.

“They are an integral part of our delivery system,” he said.

School nursing is not all high drama and serious medical situations, the providers agree.

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One recent day, nurse Mary Johnson was called to Lincoln School in Ventura on her way to her regularly scheduled day at Sheridan Way. At Lincoln, one of the seven schools for which she is responsible, she found an outbreak of head lice among a dozen youngsters.

Once she arrived at Sheridan Way, she found more head lice, a tummyache, a headache and a Barbie doll crisis.

Nine-year-old Dulce Sanchez had a headache. It was her first visit to the nurse, because she was relatively new at school. Johnson took her temperature and had her lie down.

“Does your head hurt every day?” she asked. Dulce said no. “Did you have breakfast this morning?” Yes, the girl answered. After an eye exam, Johnson determined that the girl should be referred to an optometrist to find out if she needed glasses.

Sheridan Way Principal Trudy Tuttle Arriaga came to the door, holding the hand of a dark-eyed first-grader with tear streaks down her cheeks.

“She said she has a tummyache but that came directly after a dispute over who owns this Barbie doll,” Arriaga said, pointing to the doll the girl clutched. “I leave it to you to determine the connection, if there is one.”

The two women smiled at each other as the girl waited her turn to talk to the nurse.

“Mary’s wonderful,” the principal said later. “She is someone that any school would love to have full time.”

But on most days, when Johnson isn’t there, the nursing duties fall to the principal and the front office.

“Three days a week, I’m the receptionist and the school nurse,” said Mary Cathcart. “It gets very hectic.”