SARAH: This is At the Core of Care. A podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities.
I’m Sarah Hexem Hubbard, executive director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.
On this episode, we’re going to continue with our coverage of school nursing as part of our Access to Care series.
As we heard previously on the podcast, school nurses have constantly had to adapt during the COVID-19 pandemic, provide telehealth, do digital outreach, stay on top of evidence-based practices and keep their communities healthy through testing, contact tracing, and vaccination efforts… All on top of the general health and wellness screenings and care they provide day-to-day.
But as we’ll find out on this episode, school nursing continues to be an under-recognized and under-resourced field. And to put it simply, more data is needed to help augment this crucial line of community health nursing as we’re going to hear from Erin Maughan. She’s the director of research at the National Association of School Nurses or NASN and brings a combination of practical, policy, and research experience to the job. Before her current position, Erin taught public health nursing full-time at Brigham Young University. Erin spoke with us on Zoom and as she’s about to tell us, she started out as a school nurse working in Utah before she made her transition to policy-based work, and then ultimately into research.
ERIN: I've always loved working with children. Thought I would be a pediatric nurse in the hospital. And then at the time, they just weren't hiring nurses in the hospital on pediatric full-time. I was on a float pool. And so, an opportunity arose where they were looking for a Spanish-speaking school nurse, and I do speak Spanish. So, I was a school nurse, absolutely loved it. I was a school nurse in schools that were mostly children of migrant farmworkers. That's where my Spanish came in, as well as immigrants from all over the world, which was just so fascinating to learn. I loved it. And just mostly schools that served areas that were lower income. I really loved doing that. But it was overwhelming because I went from having four schools because we were had a grant to then covering 25 schools to covering 11 schools. Because we're able to hire some additional nurses. And I just, I could see all the needs and just felt like the role of the school nurse is so needed, but covering that many schools, it was really hard to do what I could see needed to be done.
At the same time, I wanted to go back to school, get my master's in public health. And the program had classes during the day, which made it really hard to be a practicing school nurse. So, I actually got a job working for the Utah Department of Health in school and adolescent health. So, it was a good fit, it just wasn't the same hands-on. And then in that position, it kind of morphed into being the state consultant for the Department of Health. There are about 32 states that have a state consultant, either in the Department of Health or in the Department of Education. A few states have one in each, which is fantastic. And that role is to help guide school nurses in state policy, state laws as it exists as well as other you know, just things that as a help, and a guide for the practice frontline practicing school nurses. And I love that. And again, it came down to I was not the only one as a school nurse that was covering so many schools.
And of course, they always want the data to show how does the school nurse impact children's health? So, I went to the library to go find it and realized they couldn't find it. And first thought, well, maybe I'm you know, I mean, I’m not searching correctly, and come to find out there just wasn't a lot of research in school nursing for multiple reasons. And so, I actually went back and got my PhD specifically so that I could focus on school nursing issues. And particularly, just to clarify for me, it's not about a topic that happens to be in a school, like what is asthma? What is diabetes, those are all really important, but my focus is looking on how does the infrastructure, so how does school nurse staffing, impact school children's outcomes, if they have asthma, if they have diabetes, the focus is more of a systematic approach. So that was my dissertation.
SARAH: As Erin mentioned, research on school nursing is limited and there are some reasons why as she’s about to explain.
ERIN: There's not a university that's known for doing school nursing research. And so I think that also makes it hard, so when people go back to school to do research in school nursing, the faculty that are there to help them learn how to do research methodologies and things don't have the experience and oftentimes really don't understand the role of the school nurse. And so that causes concerns. In my role, as the director of research, get quite a few phone calls from students that are really trying and want to do research related to school nursing. But their faculty don't understand what they're trying to do and keep switching and say why don't you just do it on this, and not really understanding that role. So, another area that we're hoping that we can address to bring people together. And if universities want to start focusing on it, great. And/or having a network that brings school nursing researchers together to help mentor and help the new researchers really better understand, get more techniques, you know, better energy and have the support that they need, that they can really pursue the type of research they'd like to do.
And so, with more opportunities, and also doctorates of nursing practice, which are practicing doctorates, they're different than research doctorates, but they do more of the application of the research. There's more school nurses going into getting either a PhD or a DNP is what we call them.
And so, one thing that I'm actually working with some colleagues to start a Center of School Health, Innovation and Quality. And one of the things we really want to do is be that hub to really help network and bring new school nurse researchers and those that have been around for a while together as a mentor-mentee relationship as well as just fostering. Because one of the barriers of why we don't have the research we have is that school nursing, public health nursing the way you do the research doesn't always follow the typical random control trial research methods that are oftentimes taught in nursing programs. I mean, we need that information because we use that too. But there are other techniques and methods. And so, looking to see how we can help bring those methods forward in a way to help other researchers so that we can really study and get the information we need to really advance school nursing is our goal.
SARAH: Essentially, Erin and a small group of colleagues are really trying to build up the infrastructure around school nursing in order to advance the field and address some of the barriers she just described. And Erin says how research funds are allocated is also an area of focus.
ERIN: Many research funds, particularly from the National Institutes of Health, or other big researchers, they also follow that more traditional way of doing research. And so, some of the methodologies that we use, traditionally have not been seen as rigorous so they don't score as well. That is being changed with Dr. Shannon Zenk, Director of the National Institute of Nursing Research, who really is focusing on population health, inequities, and social determinants, all three things very much aligned with the school nursing well, that we're hoping to hoping that will really help change. And that other research funders will also follow suit in that because it's the same for public health nursing, it's just a slightly different way of doing some research that doesn't fit traditional lines. And so there hasn't been the funding for it. And because of that, researchers, if they want to get tenure at their universities need to bring in a certain, not that it's a specific number, but need to show and bring in large grants. And if they are not available, really hard, they then sometimes switch topics if their goal is to stay at the university doing research. So, I think that's another barrier as well. So, if we can help have funds that would really fund school nursing, I think, then we'll also have an increase in those that would want to stay in this as a research trajectory.
SARAH: Aside from the underlying infrastructure needs that Erin just laid out, we’re going to hear more now about the school nurse landscape, potential cost-savings, and some of the ongoing obstacles on the job.
ERIN: About a quarter of schools don't have a school nurse across the United States. And then about another third, these are approximates, only have a part-time school nurse. Or there's ones like me that I was a full-time school nurse, but covering multiple schools. And educators meaning teachers, principals, all of them, there is no, usually, it would be the exception, in their training programs like to become a teacher and become a principal, they don't really have classes on what the role of the school nurse is or the role of the school psychologists or some of these other support systems. And we have found, then that principals and teachers, their understanding of the role of the school nurses is whatever they had as a school nurse, and so if they didn't have one, they don't understand their role or even if the nurses are doing great things, but it was 20 years ago, the complexity of kids have changed so much. So there's still a lot of misunderstanding that a school nurses like ice, lice, and band-aids, that is not the role of the school nurse, you know, they can give out a band-aid, and they certainly assessed during that program. But there's so many more complexities that kids have. And not just from the physical. But now we're learning more and more about mental and emotional, social, as well as complexities of, you know, the social determinants of health, those things are social needs to impact them and their families. All of that are key parts of the role of the school nurse, but if educators don't understand that, then they don't know how to really use the nurse. And they might not understand why they need a school nurse and how there's actually studies that show when there's a school nurse, it saves principals time every day, which saves districts money, but it that kind of information isn't always well known.
SARAH: Given what Erin just explained, the role of a school nurse is not always fully understood. And therefore, the resources they need to do their jobs, such as having access to research, is another obstacle school nurses face.
ERIN: One of the barriers I say that school nurses have in making sure they work to their full evidence-based practice is that many of them don't have access to the research because it's through usually academic libraries. So we try to facilitate as that as much as we can, if they precept a student from a university, a seeing if they can get access as an adjunct, to have access to the library to get some of that. And particularly with COVID, it was moving so fast. It wasn't always in those traditional academic journals or things are published and so it went to going to the best evidence was CDC and others that were established experts but staying on top of it because it was constantly changing.
SARAH: Another development of the pandemic impacting many school nurses is contact tracing, which we heard about previously on the podcast from some of the school nurses we profiled. As Erin is about to describe, some school nurses have used contact tracing as an opportunity to do even more broader health care outreach.
ERIN: School nurses did a lot of contact tracing things that they normally don't do. So, they had to balance some of the other things too. And while they were on the phone doing the contact tracing, I think it's one of the beauties of the role of school nurses. Yes, others can make phone calls. But we hear stories of while on the phone, talking about one thing or doing helping with a vaccination clinic or something like that, you know, school nurses using their critical thinking skills to identify other issues from families needing food or issues with medical access, or, you know, whatever it is, that's, I think, a critical part of having the school nurses there, that that might not be their primary purpose of doing some of the activities. But it's part of that holistic approach that school nurses take to children. It's not just about COVID it's still always about that child and how are they dealing with the anxiety and the stress? There's been a lot of outreach that school nurses have done with that in that area as well is trying to really meet the needs of the students so that they can be focused enough to learn and be in school.
There has been a study that was done in 2014 in Massachusetts that actually did show that for every dollar spent in school nursing, $2.23 or 24 cents was saved. But that study didn't show anything about, like education or prevention, or some of the other big roles of school nursing. And we all are looking at, we would love to be able to do that study again, that looked at some of these other factors because I think the cost savings would be tremendously more. I also want to say that schools can use depending on their state Medicaid law and plan, But many schools are able to be reimbursed for certain things that school nurses and other health professionals do in the school that helps doesn't support the higher salary of a school nurse. But it certainly can help. And I think that's another way that we need to relook at the funding for school nursing. They save money, but different funding sources that can help pay for school nurses.
SARAH: While Erin was thrilled to see school nursing highlighted in the recently released Future of Nursing 2020 to 2030 Report from the National Academy of Medicine, she’s also cognizant of the deep infrastructure needs that will continue to persist. And for Erin, demonstrating impact is paramount, and to do so, school nurses need to be well-positioned to collect data in the first place.
ERIN: What is the best practice of school nursing? NASN has Every Student Counts, which is a national uniform data set of definitions for certain things for all school nurses to collect the same way. Because we found that if there's not something like that, everyone's collecting it slightly different, then you can't bring it together. And if you can't bring the data together, you can't do the analysis, it's needed. And so, if states really worked together on some of these things, and then we did it nationally, we would have the type of data to better understand the complexities of our kids. But also what is the best staffing formula that's needed, because it's not just number of kids, there's too many complexities of kids to just say, one nurse per X number of students even, you know, what's the number of kids that have a certain chronic condition or, you know, speak multiple languages, or are living in poverty or move every few months, all these things impact their health, as well as what school nurses do. And it's got to be all looked at together, as well as what are the unique contributions that a school nurse makes to make sure that they're able to do those functions well? Because we, unfortunately, hear if school nurses sometimes still having like bus duty or recess duty or something, which are very important roles but might not be the best use of your school nurse when there's so many other complexities and issues that are going on.
When a school nurse is covering so many schools, it's really hard to show the impact of a school nurse.
The more they cover, the more difficult it is to show their impact, which from a policy perspective then makes it more difficult to have the data points we need to show why we need a school nurse. And then it just becomes the cycle of not having the manpower needed to show what they could be doing. But then it's like what come first chicken or the egg? Do you need the policy first? Or do we need the data first? or somewhere in the middle?
So, I think the role of school nurses in using data to help others understand what they do and the impact that they have has always been important and it's even going to be more important moving forward.
SARAH: Special thanks to Erin Maughan for taking time to talk with us. And make sure to check out our recent episode with three different school nurses who share about what their jobs have been like in response to the COVID-19 pandemic.
Funding for our special Access to Care series comes from the Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP, and AARP Foundation…along with the National Nurse-Led Care Consortium.
At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.
I’m Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.