A Broad Understanding of HealthSan Francisco's School Health Programs Department (SHPD) serves more than 57,000 children at more than 100 schools throughout San Francisco. It administers a range of health-related programs that take an expansive, modern view of just what health means. Based on something called the Coordinated School Health Program Model, programs fall into one of eight categories:
- Health education
- Physical education
- Health services
- Nutrition services
- Counseling, psychological and social services
- Healthy school environment
- Health promotion for staff
- Family/community involvement
- Assessing physical and mental health and developing a schoolwide system for administering first aid
- Assisting school sites with the implementation of school health programs and services
- Facilitating or conducting mandatory health screenings
- Connecting students and families to community health services
- Conducting asthma education and educational support groups
- Coordinating and participating on coordinated service teams, student success teams and student assistance programs
- Working on and teaching in tobacco and alcohol use prevention programs
- Providing guidance and support to school staff for medication protocols and emergency care plans
- Creating and presenting health-related classroom curricula, including research-validated programs
- Working with families to facilitate school involvement
- Playing an instrumental role in crisis response teams
The School Health CenterAt a Haight-Ashbury District elementary school, an otherwise well-behaved boy was grabbing other students. Concerned about his classroom behavior and suspecting vision problems, nurse Paula Baum referred Luis to the School Health Center, where an assessment revealed that his vision was seriously impaired. Nurses Diane Goldman and Cathi Fuller quickly connected Luis with a renowned pediatric neuro-ophthalmologist. After agreeing to see Luis for free, the doctor found that the boy was suffering from an untreatable degenerative problem: He was going blind. Fuller and Goldman referred him to SFUSD vision services to help Luis cope with the coming changes in his life. "Without the assessments and referral that school nurses made, it's likely that Luis' problems would not have been addressed in time to get him the help he needed for school and future success," says Fuller. In a school administration building that has the gray look of far too many institutions, the School Health Center is a cheery outpost with its colorful posters and children's drawings on the walls. Goldman, the center's coordinator, is on the phone, trying to ensure accommodations at a local college for a disabled student who will be graduating this spring. Goldman began working as a San Francisco school nurse in 1989. "After that first year, I realized there was a missing component for the district," she says in a voice with unmistakable New York roots. "We [school nurses] were seeing a lot of kids who were not doing well in school, but if they didn't qualify for special education, they were getting no services, even though there may have been physical and mental factors affecting their learning." Goldman believed that she had the skills and training to help these children. She wound up as the central figure in the creation of the School Health Center, and has served as its coordinator for the last 15 years. At the center, children in kindergarten through fifth grade whose health care is covered by the low-income programs Medi-Cal, Healthy Families or Healthy Kids - or who don't have any insurance at all - are evaluated for problems that may be interfering with their academic success. Originally joined by a developmental pediatrician, Goldman now staffs the center with Fuller, who is a graduate of the School of Nursing's Family Nurse Practitioner program. Every Tuesday and Thursday, Goldman and Fuller do physical, behavioral and learning evaluations of students whom school nurses or other school staff members have referred. In addition to writing a full report for each child, Goldman and Fuller often create and coordinate a behavior plan with the family, principal and classroom teacher. "In our reports, we work to find something to build on, so we can reframe behaviors into something positive," says Fuller. "We can do that because even though it's a onetime meeting, we have the time to focus on students as individuals - not a case or a diagnosis." (Despite the supposedly onetime meeting, it's not unusual for Goldman and Fuller to form lasting relationships with students and their families.) "We also bridge the gap between community and school," says Goldman. "We connect students to a network of community providers." There's more. Both Goldman and Fuller spend time serving as nurse of the day, where they field phone calls from the many schools throughout the district that don't have an on-site nurse. In that capacity, they dispense health advice about everything from whooping cough and chicken pox to allergic reactions and the availability of dental services. And Goldman serves on the District 504 committee, which safeguards the right of disabled students to the appropriate accommodations; Fuller coordinates the district's dental services. "It's so fulfilling working with high-need students and making a difference," says Goldman. "It's a small difference, one student at a time, but I'm still enthusiastic."
Elementary School Road WarriorsTwelve years ago, Paula Baum formed a friendship with a hyperactive 5-year-old kindergarten boy, who in his first year of public school broke two arms. The county sent him to live with his grandmother because of his parents' drug use and neglect. Baum worked closely with the grandmother to get the boy into counseling. In 2006, the young man - who has a black belt in karate and still stays in touch with Baum - graduated from high school. "It was another reminder that one person that cares can make a difference," says Baum.
Ardis Hanson at George Washington Carver Elementary School.
Teaching and NursingHanson believes teaching skills are critical to the role of school nurse. "For example, because we're only here a couple of days a week, we try not to do everyday first aid, and instead train staff to address things like playground injuries and minor illness," she says. UCSF graduate Martha Parker also believes teaching skills are critical, and relishes the opportunity to apply the teaching skills she learned in other settings (25 years of hospital work, in her case) to a very different environment. In addition to frequently teaching health lessons in the classroom, Parker talks excitedly about an assembly she helped arrange with the Dairy Council, which brought a cow into her very urban school. "It created a wonderful discussion where we talked about the importance of agriculture in the students' lives and about why they need to drink milk to get calcium in their diets," says Parker.
Assessment and AdvocacyIn addition to teaching, nurses in elementary schools do a lot of formal and informal assessment of student health. "When I walk down the hallway, I'm doing assessments all the time," says Paula Baum, a Navy nurse during the Vietnam War who subsequently received her master's degree in UCSF's Pediatric Nurse Practitioner program. "I watch how the kids walk, communicate, interact with their peers and their teachers." In addition, says Baum, "My background at UCSF in behavioral pediatrics helped me to be more assertive and advocate effectively." Given the grinding poverty and social problems with which many of her students wrestle, she and others have come to feel advocacy is a particularly crucial role. "We see so many kids with ADHD [Attention Deficit Hyperactivity Disorder], some diagnosed, some not. Others are dealing with grief and loss - neighborhood shootings or deaths in the family that leave them immobilized. We have to help students address those things," says Kathy Babcock, another elementary school nurse and UCSF graduate. In the SFUSD, nurses do that by getting students connected to health providers in their home neighborhoods, and by playing a key role in student success teams - groups of school staff, social workers, families and nurses whose job it is to help struggling students.
Chasing the MoneyUnfortunately, helping students to be successful by addressing all aspects of their health is often compromised by scant resources. School funding in general seems to be in constant state of crisis, and in many districts across the country, funds for school nurses have been cut dramatically. While SFUSD fares better than those in many cities - city funds from Proposition H, the Department of Children, Youth and Their Families, the San Francisco Department of Public Health and SFUSD itself support many health-related programs - funding remains a concern. "Our department is traditionally funded by soft money from 25 different sources," says Katy Ekegren, another elementary school nurse and UCSF graduate, who spent eight years at UCSF's Pediatric Clinical Research Center and knows well the vicissitudes of relying on grants. She also knows the rewards. Before going on a 15-month maternity leave and returning this spring, Ekegren spent two years working on special asthma-related grants for the district, including a telemedicine project that identified children with asthma symptoms, and then enrolled them in educational programs and connected them to primary care providers. The project was enormously successful. "We really started a process in the community," says Ekegren. The value of contributions like this has not gone unnoticed. At Sanchez Elementary School, where Parker works, when the School Site Council agreed to continue funding support for the school nurse position, it made a formal public statement that the nurse is a critical part of the school environment. "I think what they recognize is our ability to help change systems for the better," says Parker.
Caught in the MiddleWhen Katy Ekegren was working in a middle school, she taught classes for both teachers and students on recognizing asthma symptoms. One day, a teacher called about a student who looked as though she was having trouble breathing. An examination and subsequent discussion revealed that the labored breathing was related not to the girl's asthma, but a panic attack caused by the girl's knowledge of a cousin having been raped that morning. Ekegren convinced the cousin to come in and speak with her, and report the rape. "The training we have and the trust many of these kids have in nurses made a difference in this case," says Ekegren. Middle school children are a breed unto themselves: preteens that are virtually bouncing off the walls with energy, hormones and anxiety about change. To work at a middle school means finding ways to deal with that level of energy. Lynda Boyer-Chu's approach seems to be to match it. In the course of a half-hour interview, the health coordinator at Gloria R. Davis (GRD) College Preparatory Academy checks in on the guest speaker she arranged for a school science class, calls security to deal with an unruly eighth-grader, talks to a staff member about where staff massages would be that day, hugs a volunteer on a school care team who's come by to thank Boyer-Chu and tell her he's moving on to a graduate program, and gives a teary girl her Tylenol and a pep talk. Through it all, Boyer-Chu keeps up a steady and coherent stream of talk that describes her multifaceted role at the school. A registered nurse with a master's degree in public health from Johns Hopkins University, Boyer-Chu serves on UCSF's Community Partnerships Council and works with MEPN students from the School of Nursing, as well as medical students and faculty at the School of Medicine. "We define health here very broadly," she says, "and my job really has four main pieces. One-quarter is direct work with students, dealing with physical complaints that almost always have an emotional component." The direct work with students includes linking families to health services in the community, as well as home visits, sometimes with UCSF medical students in tow. The second piece is using team meetings to facilitate communication between teachers and nonteachers, such as counselors and parent liaisons. At GRD, there are five such teams that discuss how specific students are doing, collect information and come up with strategies for student success. The third piece is working with community-based organizations (CBOs) to bring in resources. For example, Boyer-Chu organizes biannual roundtable breakfasts for CBOs. She also has created an interactive journalizing program, where students with severe defiance issues gain insights into their own behaviors. A private foundation, a community group called Bayview MAGIC and the Public Defender's Office support the program. The fourth piece is providing medical and health instruction inside and outside the classroom. (Later, Boyer-Chu notes a fifth piece: being available to staff to support their physical and emotional needs.) After 17 years in the district, Boyer-Chu still clearly relishes her job, but she also recognizes that it demands a special type of nurse, one who understands well how organizations behave. "In any organization, there are politics," she says. "How well we do our job rests to some degree on our leadership ability, because we're going up against the old-fashioned stereotyping of what a nurse does."
Crashing into AdulthoodIt was just a brief talk at an assembly, where Maryann Rainey introduced herself to the sophomore class at Lowell High School and let them know she was an available resource. Later, one of the students came by to ask about hepatitis. When the girl seemed reluctant to leave, the truth came out: Her mother was dying from hepatitis C, just the tip of the iceberg of a tragic home situation. Rainey and the girl formed a close relationship, with Rainey giving the whole family strategies for dealing with stress and for getting the mother appropriate care. "A nurse is a person you can talk with about personal things, behind a closed door," says Rainey.
Maryann Rainey at Lowell High School.
Crisis ResponseToo often, those reasons are connected to tragedies that seem particularly characteristic of urban youths. This spring, the tragedies seemed to pile up for UCSF graduate Deborah Bryant at Galileo High School. One week, a student at the school was shot and killed. The next week, another died in a car crash. As a result, Bryant was consumed with helping to create two crisis response programs in less than a week. Along with the principal, assistant principal, two other members of the wellness team, a representative from the dean's office and teachers, Bryant had to help come up with a plan appropriate to each crisis. She is well prepared to do so. In 1990, she was one of the original authors of the district's crisis response manual. In addition, she's a nurse practitioner with a master's degree in social work. "A lot of what I do with kids here has to do with mental health," she says.
Pregnant Girls, Young MothersBryant also is an effective recruiter for school nursing, having been instrumental in bringing Kim Walker into the fold. Working as a school nurse wasn't what Walker envisioned when, after getting her master's degree in child and adolescent community mental health, she began the UCSF Pediatric Nurse Practitioner program in 1993. But during that time she met Bryant, who encouraged her to look at school nursing. "When I saw how much they actually did and how much I could do working with families and young people..." At the Hilltop High School Pregnant Minors Program, Walker teaches classes on pregnancy, childbirth and parenting while overseeing the health needs of 50 to 60 young women and their babies. Even by SFUSD standards, the Hilltop program is an unusually heavy teaching assignment for a nurse. Every Monday, Tuesday and Wednesday, Walker teaches prenatal classes to the pregnant girls. On Thursdays, she teaches well-baby classes, since girls in the program can continue to attend classes at Hilltop until their children are 16 months old.
Kim Walker at the Hilltop High School Pregnant Minors Program.