RWJF学者警告说,学校护士短缺可能危及一些儿童
Erin Maughan, PhD, MS, RN, director of research at the National Association of School Nurses (NASN) and an RWJF ENF (2013-2016), agrees. Nationally, the number of school nurses is “woefully inadequate,” she said.
Students in a quarter of the nation’s public schools do not have access to a school nurse, according to the NASN. Fewer than half (45 percent) of all public schools have a school nurse all day, every day, and another 30 percent have a school nurse who works part-time in one or more schools. Wide disparities exist between and within states and school districts.
The situation is especially dire in rural America, said Tami Thomas, PhD, RN, FAANP, an RWJF Nurse Faculty Scholar who works in Georgia. Many rural counties lack even a single physician or nurse practitioner, so the school nurse—if there is one—becomes the “frontline expert” during the school year and sometimes during the summer too, she said. “In these rural communities, school nurses are viewed as the conduit of health care information.”
Demand for school nurses is growing.
Medical advances are allowing more premature babies and others with severe health conditions to survive into adulthood, but these children often require complex, continuous care at home and at school. There is a rising incidence of diseases with life-threatening implications such as diabetes, seizures, asthma, bleeding disorders, and severe allergies, according to a 2010 report on the future of nursing by the Institute of Medicine (IOM). And there is an increase in mental health disorders, such as substance abuse problems, eating disorders, anxiety, depression, and aggression. “What we saw 20 years ago in acute care hospitals is what we’re seeing now in the schools,” Newell said.
Growing poverty rates are also taking a toll, Newell added. She sees students with rotting teeth who can’t afford dental care; students who share asthma inhalers and insulin strips with relatives because their families cannot afford enough supplies for each individual member; and students who go to school sick because their parents can’t afford to take unpaid time away from work to care for them.
Under these circumstances, an inadequate supply of school nurses can be deadly. In September, Laporshia Massey, 12, died after suffering a severe asthma attack at a Philadelphia school on a day when no nurse was present. Massey’s father has said that an on-site school nurse could have saved his daughter’s life. “We’re worried that more tragedies like this will occur” if students don’t have access to a school nurse, Maughan said.
A Vital Role
School nurses serve nearly 50 million students nationwide in nearly 100,000 public schools, according to the IOM report. They are a subset of the nation’s public health nursing workforce; learn more about this workforce in a 2013 RWJF report.
School nurses play a vital role in improving the health of children and the public, experts say. In 2009, to cite one example, a school nurse alerted health authorities to the arrival of the H1N1 flu virus in New York City, helping to curb the spread of the disease.
Ensuring that all students have adequate access to a school nurse is a daunting challenge, however, especially in the wake of a severe recession that has led to cuts to education and public health budgets across the country.
School support services, including nurses, are often targeted when budgets are tight, Maughan said, and nurse positions are sometimes “under-filled” with licensed practical nurses or health aides. “Educators are worried about test scores. If they don’t have the experience to understand how school nurses help students stay healthy so they can learn, they see under-filling nursing positions as an easy way to cut the budget.”
Recruiting school nurses is a challenge for other reasons as well, Maughan and Newell said. School nurses tend to earn lower salaries than peers in other settings, and suffer from an image problem that deters some nurses from entering the field. “People think it’s just handing out Tylenol and ice packs,” Maughan said. “But it’s much more than that.”
The National Association of School Nurses is adopting a number of strategies to address the problem. They include a public relations campaign to educate the public about the critical role school nurses play in education and in public health; efforts to encourage more school nurses to continue their education so they better understand their role in collecting and using data to advocate for their positions and to provide high-quality and effective care; and work to help develop a common data set so all school nurses collect the same kind of data in the same way.
The association is also supporting data collection to demonstrate the effectiveness of school nurses to policy-makers, as well as efforts to lower the ratio of students to school nurses in certain states. It also backs a prevention and public health fund created by the Affordable Care Act.
The IOM report, meanwhile, highlights the important role played by public-private partnerships, in which school nurses coordinate care among providers outside the school setting, and by primary care clinics located on school campuses. There are about 2,000 school-based health centers nationwide, it says, including one launched by Newell in Washington state as part of her RWJF ENF project.
But prospects for ensuring that all students have access to a school nurse, let alone comprehensive health care, may be bleak, Thomas said. “Children may be only 25 percent of the population, but they are 100 percent of the future.” But because school children don’t vote and have very little political power, she fears it is unlikely that they will have more access to school nurses any time soon.
" data-isabstract="false" class="cmp-text">2000年秋天,玛丽·纽维尔(Mary Newell)辞去了护士教育工作者的工作,以便照顾当时正在上幼儿园的儿子卡梅伦(Cameron)。卡梅伦是早产的,出生时体重只有一磅多一点,在童年早期就患有慢性肾病。5岁时,卡梅伦准备上幼儿园,但当地的小学没有学校护士可以定期给他换导尿管。
因此,博士、注册护士、NCSN的纽厄尔决定自己承担这项工作。她休了一年的假,帮助卡梅伦上完幼儿园,希望卡梅伦上一年级后她能回到原来的工作岗位上。但这从未发生过。不到一个月,纽厄尔就被聘为学校的专职护士,这个职位已经空缺了将近一年。几个月后,她被要求监督整个学区的护理工作——从那以后她一直担任这个职位。
纽维尔的故事有另一个圆满的结局。卡梅伦能够正常上学,几个月后就不再需要导尿了。他去年春天从高中毕业。
但许多其他孩子没有得到他们在学校生存和发展所需的照顾罗伯特伍德约翰逊基金会(RWJF)执行护士研究员(ENF)项目(2006-2009)成员,并担任国家咨询委员会委员。
Erin Maughan博士,医学硕士,注册护士,全国学校护士协会(NASN)和RWJF ENF(2013-2016)的研究主任,同意这一观点。她说,在全国范围内,学校护士的数量“严重不足”。
根据NASN的数据,全国四分之一的公立学校的学生没有学校护士。不到一半(45%)的公立学校每天都有一名学校护士,另有30%的学校护士在一所或多所学校兼职。各州和学区之间以及学区内部存在着巨大的差异。
美国农村地区的情况尤其严重,注册营养师、FAANP博士塔米·托马斯(Tami Thomas)说RWJF护士学院学者他在乔治亚州工作。她说,许多农村县甚至连一个医生或执业护士都没有,所以学校的护士——如果有的话——在学年期间,有时在夏季也会成为“一线专家”。“在这些农村社区,学校护士被视为卫生保健信息的渠道。”
对学校护士的需求正在增长。
医学的进步使更多的早产儿和其他有严重健康问题的婴儿能够存活到成年,但这些儿童往往需要在家里和学校里进行复杂而持续的护理。根据2010年的一项研究,糖尿病、癫痫、哮喘、出血性疾病和严重过敏等威胁生命的疾病的发病率正在上升报告医学研究所(IOM)关于护理的未来。精神健康障碍也在增加,比如药物滥用问题、饮食失调、焦虑、抑郁和攻击性。纽维尔说:“我们20年前在急症护理医院看到的,现在在学校也看到了。”
不断增长的贫困率也造成了损失,Newell补充道。她看到一些学生牙齿腐烂,买不起牙科护理;因为家庭负担不起每个成员所需的医疗用品而与亲戚共用哮喘吸入器和胰岛素条的学生;还有那些生病上学的学生,因为他们的父母负担不起从工作中抽出无薪时间来照顾他们。
在这种情况下,学校护士供应不足可能是致命的。今年9月,12岁的拉波尔什·梅西(Laporshia Massey)在费城一所学校因严重哮喘发作而死亡,当时没有护士在场。Massey的父亲说,现场的学校护士本可以救他女儿的命。莫恩说:“我们担心,如果学生无法获得学校护士的帮助,还会发生更多这样的悲剧。”
至关重要的角色
根据IOM的报告,学校护士为全国近10万所公立学校的近5000万学生提供服务。他们是国家公共卫生护理人员的一个子集;了解更多关于这个劳动力的信息2013年RWJF报告.
专家表示,学校护士在改善儿童和公众健康方面发挥着至关重要的作用。举个例子,2009年,一名学校护士向卫生当局报告了H1N1流感病毒在纽约市的到来,帮助遏制了这种疾病的传播。
然而,确保所有学生都有足够的机会获得学校护士是一项艰巨的挑战,特别是在严重的经济衰退导致全国各地削减教育和公共卫生预算之后。
莫恩说,当预算紧张时,包括护士在内的学校支持服务经常成为目标,而护士职位有时会因有执照的实用护士或健康助手而“供不应求”。“教育工作者担心考试成绩。如果他们没有经验来理解学校护士如何帮助学生保持健康,这样他们就可以学习,他们认为护士职位空缺是削减预算的一个简单方法。”
莫恩和纽厄尔说,由于其他原因,招聘学校护士也是一项挑战。学校护士的工资往往比其他环境中的同行要低,而且由于形象问题,一些护士不敢进入这个领域。莫恩说:“人们认为这只是发放泰诺和冰袋。”“但它远不止于此。”
全国学校护士协会正在收养有很多策略来解决问题。其中包括一项公共关系运动,向公众宣传学校护士在教育和公共卫生方面发挥的关键作用;努力鼓励更多的学校护士继续接受教育,使她们更好地了解自己在收集和使用数据方面的作用,以宣传自己的立场,并提供高质量和有效的护理;并致力于开发一个通用的数据集,以便所有学校护士以相同的方式收集相同类型的数据。
该协会还支持数据收集,向政策制定者展示学校护士的有效性,并努力降低某些州学生与学校护士的比例。它还支持《平价医疗法案》设立的预防和公共卫生基金。
与此同时,国际移民组织的报告强调了公私合作伙伴关系以及校园内的初级保健诊所所发挥的重要作用。在这种伙伴关系中,学校护士协调学校以外的提供者之间的护理工作。报告说,全国大约有2000个以学校为基础的健康中心,其中包括纽厄尔在华盛顿州发起的一个,这是她的RWJF ENF项目的一部分。
但托马斯说,确保所有学生都能得到学校护士的照顾,更不用说全面的医疗保健了,前景可能很黯淡。“儿童可能只占人口的25%,但他们是未来的100%。”但由于学生没有投票权,也没有多少政治权力,她担心短期内他们不太可能有更多的机会接触到学校的护士。