A leading advocate for school nurses reflects on the central role school nurses play in advancing health equity within schools and communities.
The 2022-2023 school year will be the fourth marked by COVID. With schools facing unprecedented challenges, school nurses are preparing for a demanding year.
No one is more familiar with these challenges than Robin Cogan, MEd, RN, NCSN, FNASN, FAAN, who has spent more than two decades of her 35-year nursing career as a school nurse in Camden, New Jersey. She is New Jersey Director for the National Association of School Nurses and faculty at Rutgers University-Camden School of Nursing. Here, she discusses the essential role nurses play in advancing health equity in schools and communities as well as what they need in order to continue caring for children.
Students Have Urgent and Growing Needs
One of my most vivid memories is discovering that a 4-year-old pre-school student wasn’t eating her school lunch. Instead, we noticed her stuffing food into her pockets, day after day. Her family was new to our country and had endured a grueling journey on foot from El Salvador to get here. When we asked why she wouldn’t eat, the child shared that she felt responsible for feeding her family. Our school came together and provided a food pantry to support the family and other families in similar circumstances.
That is just one example of how school nurses advance health equity within schools and communities. We are the chief wellness officers, the care coordinators, the people who know what resources are available in our communities. We recognize emerging problems and mitigate the struggles children and families face. We eliminate barriers by connecting families to resources. We get eyeglasses for children who can’t see well, and do tube feedings for medically-fragile children, which allows them to be in school.
We also deal with life-and-death situations. Twenty-five percent of students with an undiagnosed food allergy have their first anaphylactic event at school. Students have asthma attacks at school that can be deadly. Some are medically fragile. Some are newly diagnosed with diabetes. Up to 30 percent have chronic health conditions. COVID remains with us, and now monkeypox.
Ultimately school nurses are an investment in student wellness and achievement because health happens in the community and at school. So having a school nurse democratizes healthcare. But just 40 percent of schools have a full-time student nurse and 25 percent have no school nurse at all.
Stressed Communities Create Stressed Children
A few years ago, I heard from a former student who I had known when he was 8 or 9 years old. Now a grown man, he reminded me that I had once invited him to sit with me in my office when I noticed that he wasn’t having a good day. He disclosed that he had been contemplating suicide that day, and my words and presence saved his life. He is now a thriving adult and father to three boys.
You never know the impact you have. One caring adult in a child’s life is a protective factor. Often that caring adult is a school nurse.
We know that no dysregulated child ever calms down because you tell them to, that a stomachache is often a sign of anxiety, depression, or a problem at home. We can encourage a child to identify emotions and connect her or him to a school counselor or psychologist. We can open communication with parents.
Prior to COVID, we were spending up to 34 percent of our time on mental health issues. These mental health needs escalated with COVID and the resulting isolation. We even faced a divisive election season and may be heading for another. All of this turmoil seeps into what happens at school. Children observe adults and absorb stress and conflict within communities which ultimately affects their ability to learn.
I sometimes say that school nurses are population health gold. We are the epicenter of every concern a child brings to school, be it racism, hunger, homelessness, threats to undocumented families, opioids, or something else.
COVID Exacerbated Challenges
For school nurses, COVID added a second full-time job on top of the full-time job we already had. Many of us became the de facto community health department, engaging in intense COVID-related duties. We conduct contact tracing and testing; we track students who are quarantining. We put mitigation strategies in place in schools. We monitor outbreaks, run school-based vaccine clinics, and are responsible for reporting new cases, which is complex and time-consuming when it involves a city, county, and state. We inform parents when their child is symptomatic or exposed to contagion.
Many school nurses have been so preoccupied with protecting children from COVID that we are terrified we’ll miss a more typical health problem.
As challenging as facing COVID has been, it’s also transformed public perceptions of school nursing. Suddenly, headlines acknowledged our role on the frontlines of the pandemic. That has been gratifying.
Diverse School Nurses Deliver Culturally Sensitive Care
I am inspired by the remarkable trailblazer, Charity Collins—the first Black school nurse. She served a segregated, underserved Black Atlanta school community in the early 1900s. Still, today, school nurses are currently 90 percent white and trend older. We need school nurses who reflect the communities they serve.
I work in a community that is largely Black and Brown, and I am White. My urban school district is 13 miles from my house, but there’s a 10-year life expectancy gap between where I live and where I work. That’s the difference between privilege and poverty. I don’t reflect the community I serve, so I walk in cultural humility.
We don’t just have a shortage of school nurses; we have a diversity problem among school nurses and a failure to pay a livable wage. Some school nurses are paid on a teacher scale, starting at an entry level that may ignore decades of nursing experience in another, non-school setting. It varies from locality to locality, but nearly all school nurses take a huge pay cut when they leave the acute care setting. One school nurse told me she donated plasma twice a week to make up for it.
And we don’t have an infrastructure for upward mobility for school nurses. I’ve been in the same job for 22 years. We need a place to grow.
We need more diversity, better pay, better mobility—and making that happen starts with doing a better job sharing the true story of who we are and what we do. School nurses care for other people’s children. It doesn’t get more consequential than that.