San Francisco School Nursing Rediscovers Its Roots and Expands Its Mission

In 1902, smallpox and influenza were among the contagious diseases threatening New York City schoolchildren. To help treat and prevent these diseases, the district hired a nurse named Lina Rogers. In just her first month of service, Rogers worked with hundreds of students and their families, both at school and in students' homes. When the Board of Health hired a dozen additional nurses to help with the workload, school nursing was born. In the ensuing half century, modern medicine contained many of the most immediate health threats to schoolchildren, and so diminished the role of the school nurse. Most of today's adults probably only have vague memories of a kindly woman off the main office dispensing Band-Aids and ice packs. But today's schoolchildren face a new wave of health threats - from asthma to teen pregnancy, STDs, substance abuse and depression. While the nature of these threats is different from those of a hundred years ago, they are no less virulent. Perhaps it's not surprising, then, that a few school districts across the country are again looking to nurses to help turn the tide. San Francisco Unified School District (SFUSD) is at the forefront of this movement. As the district forges a new and expanded role for the school nurse, graduates and faculty from the UCSF School of Nursing are at the center of the effort.

A Broad Understanding of Health

San 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
Under this umbrella and in conjunction with other SHPD staff, the department lists what school nurses do, including:
  • 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
Former UCSF faculty member Diane Goldman credits the district with recognizing that school nurses can and should do more than administer Band-Aids. "The SHPD's original director, Beverly Bradley, believed that the formula was to hire very skilled nurses who could play a larger role," says Goldman. "Nurses provide an enormous bang for the buck because they bring physical, mental health and teaching expertise to the table," says Meyla Ruwin, the current executive director of the SHPD. The combination is proving to be a boon for the health of San Francisco's students.

The School Health Center

At 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 Warriors

Twelve 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.

The rolling luggage carrier that Ardis Hanson transports between Cesar Chavez and George Washington Carver elementary schools is stacked high with crates full of file folders. "It's my office," laughs Hanson. Elementary school nurses typically travel between at least two schools. In addition to two days a week at each of her schools, Hanson coordinates the district's Open Airways Curriculum, working with other school nurses to help 8- to 11-year-olds better understand how to care for their asthma. She also serves as part of a community group (the San Francisco Asthma Task Force School and Child Care Committee) and the district asthma team; both work toward improving asthma management in schools. In the midst of all this, she finds time to act as preceptor for nursing students from UCSF's Master's Entry Program in Nursing (MEPN) and San Francisco State University. After getting her master's degree and becoming a pediatric nurse practitioner through UCSF, Hanson worked for six years in school-based clinics in New York City and completed an adolescent health fellowship at Cincinnati's Children's Hospital. She returned to UCSF in 1993, where she worked with Goldman and Pat Jackson (a clinical professor now retired from UCSF School of Nursing) to create a state-approved school nurse credential program in conjunction with the UCSF Pediatric Nurse Practitioner program. (Many of the nurses working in SFUSD are graduates of that program.) Hanson ran the program for six years and had a faculty practice at San Francisco's Mission High School Health Center it until closed its doors. In the fall of 1999, Hanson was part of a community task force charged with developing a model for the SFUSD High School Wellness Centers, which led to her leaving UCSF in 2000 to help the district start its initial centers. In 2003, she moved on to elementary schools to coordinate a Centers for Disease Control and Prevention-funded asthma program.

Teaching and Nursing

Hanson 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 Advocacy

In 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 Money

Unfortunately, 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 Middle

When 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 Adulthood

It 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.

Once part of the multidisciplinary adolescent fellowship program at UCSF, Rainey believes strongly in prevention, which is why she loves the concept of the High School Wellness Centers. The centers are decidedly not clinics, but places where high school students can get important health education and information - and also get connected to community health resources that they can use after they leave the relative safety of high school. At Lowell, the wellness center runs programs that cover everything from tobacco use prevention - every year, there are fewer smokers at the school - to nutrition and physical activity. The center has been instrumental in getting sodas out of the school's vending machines, running a food and fitness fair, and installing a climbing wall. Staff at the center engage students by training them as outreach workers and having them help create lessons. Rainey is also a "condom nurse," a licensed person that the district authorizes to make condoms available to students. Less formally, the wellness centers are where students can form important relationships with adults. "All of us [the center includes a wellness coordinator and a health outreach worker] have an open door policy, with students dropping in to see us for a variety of reasons," says Rainey.

Crisis Response

Too 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 Mothers

Bryant 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.

"The first year was difficult," she admits. "I'd never taught before - just done bedside nursing - and my first class, with 31 girls, was a disaster. But every year, I learn how to do it better." In addition to her teaching load, Walker says, "I'm a walking consultant on health issues in this building." And like nurses at other schools, she is also the link to external health resources, doing such things as speaking with labor and delivery nurses or working with the Teenage Pregnancy and Parenting Project, which occupies space in the same building as Hilltop. "Every year, I fall in love with these students," she says, after describing how impressed she is with the way one 17-year-old girl mothers her twins. "I just wish we knew what happened to them after they leave. We do so much here, but what happens five or 10 years down the road - we don't know that."

The Appeal of the Job

What many of the nurses do know is that the job demands are quite different from the ones they trained for in their nurse practitioner programs - not harder, necessarily, but different. Nevertheless, says Bryant, the training that nurses and nurse practitioners bring plays itself out in very important ways in the school setting. "Even though we're not doing physicals and not prescribing, I'm grateful for the enhanced assessment skills I learned that give me a much better grip on the full person I'm looking at in my office," she says. There are times when gaining that better understanding of a struggling child can be disheartening and the rewards hard to find, but most of the nurses find a way to adjust. "In the hospital," says Cathi Fuller, "you focus on things like changes in vital status, improving wounds and decreasing pain to regulate how you have made a difference for your patient, and usually those signs occur over hours and days. Changes in school and community happen more slowly. I quickly discovered that to find a sense of accomplishment at the end of the day, I had to look at results over time and in context of their lives, rather than for immediate, visible signs." But sometimes the changes - positive changes - are quite visible. Susan Kitchell, another UCSF graduate who works at a middle school and a high school in the district, believes that developing relationships and seeing the big picture have rewards that are hard to find in other nursing settings. "You go to graduation and you see a girl who in ninth grade wouldn't make eye contact with anyone, felt totally isolated and cried continuously," says Kitchell. "And then you see her walking across the stage at graduation, beaming, with her head held high, her family in the audience, and she's ready to be a productive citizen. That's very exciting stuff." Photos/Elisabeth Fall

Related Links:

UCSF School of Nursing School Health Programs Department of the San Francisco Unified School District