Dressed for action and wearing comfortable shoes, Aloni George gets to work each day at 7:45 a.m., hauling her rolling office.
To some, this “office” might look like a piece of carry-on luggage for an airplane flight.
In reality, that’s not far from the truth. As one of three registered nurses who serve the Missoula County Public Schools district’s 8,500 students, George has four “connections” on any given day.
Putting in miles and hours in her SUV, George travels daily to keep students and staff healthy at Meadow Hill Middle School and at Chief Charlo and Cold Springs elementary schools. Twice a week, she is at Sentinel High School.
“All of the three high schools – Big Sky, Hellgate and Sentinel – have a nurse there throughout the day,” George explained. “In the elementary and middle schools, it’s us visiting nurses that meet the needs.”
On the fly, literally all day, George relies heavily on that rolling office.
What’s in that bag?
A laptop computer, a headlamp, a notebook, sterile gloves, blood-pressure screening cards, an otoscope for checking ears, a carb-count chart for students with diabetes, staples, pens and telephone lists.
“It’s my brain on wheels,” she said. “I’d be lost without it.”
A day in the life of a school nurse in 2012 is far different from what people might imagine.
Tending to fevers, handing out Band-Aids, doing the occasional head lice check and taking care of tummy aches are still an important part of the workday.
But with increased access to education for all students, school nurses are now responsible for monitoring serious health issues among their students, said Linda Simon, MCPS health supervisor.
“Diabetes Type 1 is the thing that has truly changed,” she said. “Just 15 years ago, we would see a couple of kids a day at lunchtime, because most were on a long-lasting insulin.
“Now we have between 40 and 45 students with diabetes Type 1, and the management of the disease has changed. While it’s improved their lives, it also means these students get insulin more frequently throughout the day.”
On George’s daily rounds, for instance, she is back and forth between Meadow Hill and Cold Springs at least four times to monitor the sugar levels and insulin shots for a handful of students, and to help some of those students choose their daily carbohydrate and caloric requirements.
School nurses are also dealing with increased populations of kids with life-threatening allergies, everything from peanut allergies to bee stings.
In just the schools she serves, George has more than 45 children who have prescribed EpiPens, which are used for the emergency treatment of life-threatening allergic reactions.
Another chunk of time is dedicated to assisting students with daily medications, everything from psychotropic drugs that help with attention deficit disorder to medication for chronic viral infections and seizure disorders to providing assistance with asthma inhalers and oversight for 600-some students districtwide who have asthma.
Added to the daily needs of those children are also the demands of students who are tube-fed two to three times a day.
With the increased nursing demands come increases in record keeping, writing and updating health plans for each child, maintaining medical supplies for each child, ongoing communication with parents, and educating teachers and staff about the many specialized needs of their students.
George gets help juggling this tremendous workload from Angie Gulick, a licensed practical nurse, and from all of the school secretaries.
“At times, it feels like we are just putting out fires,” George said.
The national standard recommends a ratio of one registered, professional school nurse to every 750 students, according to the American Academy of Pediatrics, the National Association of School Nurses, the Centers for Disease Control and Prevention and the American Nurses Association.
Current 2012 data indicate that Montana has a ratio of 1 registered school nurse to 1,985 students, according to Montana Association of School Nurses’ April 2012 comprehensive study of school nursing services.
The survey shows that Montana is now ranked No. 42 of 50 states, and that 26 of Montana’s 56 counties have no school nursing services. In fact, 98 percent of Montana students have no registered school nurse or too few school nurses in their county.
In the AA schools in Missoula County, the ratio is 1 registered nurse to 3,408 students. By comparison, Billings’ ratio is 1 to 1,875 students; Bozeman’s 1 to 5,679 students; Butte’s 1 to 1,222 students; Great Falls’ is 1 to 4,465; Helena’s 1 to 1,187; and Kalispell’s 1 to 1,863.
“In 2008 we first did the survey and took the show on the road to get a mandate with the (Montana Board of Education) to get a ratio of 1 registered nurse to every 750 students in Montana,” said Sue Buswell, recent past president of the Montana Association of School Nurses.
“It was a four-year process, and it was a good process because we were able to educate all sorts of departments and government agencies and people in general about why we need more school nurses, but it was not put into action and we are at a standstill right now.
“We are actually between a rock and a hard place,” she said. “What we are doing now is doing our best to educate our administrators in the various school districts where we work to provide for the needs of our children – and we are trying to get more nurses.
“In some places it works and some places it doesn’t. It’s a financial issue.”
The struggle to meet increasing medical needs of students with too few registered nurses – professionals who have bachelor degree-level education and clinical training – is frustrating on many levels, Simon explained.
Unlike the number of counselors or teachers each school must have, “there are no mandates or requirements for school nurses,” she said. “That’s not unique to Montana, although some states do have strict recommendations that they follow.”
In the Missoula district, four licensed practical nurses with a starting pay of approximately $12 an hour help manage the workload by focusing on a specific body of tasks, but the registered nurses, who earn a starting wage of about $23 an hour, are in charge of students’ individualized health care plans and providing comprehensive clinical care.
The situation can make for tense situations, say for example, when a child at another school in the RN’s loop is in need.
A nurse’s calling is to help, and when you have to drive from school to school under stressful conditions, “you do feel more likely to turn left on a yellow light than stay and wait for the lights to change,” Simon said.
With the lack of guidelines for the number of nurses comes another issue: Where to put them when they’re at the schools.
At Cold Springs, George operates out of little room attached to the school’s staff break room. Her mailbox is a green file folder that sits atop a filing cabinet and the medication she dispenses for students with regular needs, such as asthma, are stored in a Tupperware box under an examining bed.
At Meadow Hill, her mailbox is a drawer in the school’s front office, but often, people leave her sticky notes on a desk she has in the school’s behavioral intervention room. Here, the “nurse’s office” is a corner of that classroom carved out by portable cloth partitions, and the examining area is also home to two shopping carts stuffed with basketballs, soccer balls and lacrosse sticks, and crates filled with softballs and other sporting equipment.
“This is not ideal,” George said of the space, “but there is no place to put us.
“If I have to make a private call or have a confidential conversation, I have to find another room if this room has other students in it.”
The less than ideal situation hasn’t gone unnoticed by Alex Apostle, MCPS superintendent.
It is the goal of the district to provide a safe and healthy environment for all of its students so that they can learn to their best potential, Apostle said. School nurses, he said, provide a critical role in helping children stay in school in order to learn and graduate.
Now that Graduation Matters Missoula and other academic agendas are well under way, Apostle said he will turn his focus to bolstering the district’s infrastructure.
“We know we need to increase the number of registered nurses, and we are contemplating putting another registered nurse with one of the elementary schools that has a lot of special needs students,” he said. “We would like to have something in place by the first of the year.”
What would it mean to have more nurses in the school system?
For George, it would mean she could spend time doing more health outreach and education within the schools.
Stigmas and misinformation abound when it comes to health issues, and nurses could play a huge role in setting the record straight, such as issues surrounding lice.
“I know it’s a stereotype, but we do have the issue from time to time, and I really see my role as an opportunity to educate people,” George said.
“For instance you don’t get lice because you are dirty – lice don’t like dirty hair, and they don’t jump or fly.
“They crawl, and a lot of kids get lice from sharing hats and brushes.”
And with more children dealing with chronic health issues in the schools, she said, nurses have a large role to play in helping all students understand that living with challenges is a part of life, and we all thrive with the caring support of each other.
For certain, nurses do manage to squeeze in the big-life lessons in and around their necessary medical rounds, said Shalayne Price, whose daughter, Olivia has Type 1 diabetes.
“I really appreciate everything the nurses do for Olivia and for us,” Price said. “They put my mind at ease when I can’t be at the school to help Olivia and that makes my life a lot easier.”
Quin Winger was diagnosed with Type 1 diabetes five years ago, and through the years, the 10-year-old has learned how to manage his health and give himself insulin shots.
At Cold Springs where he goes to school, it’s no big deal for him – or his classmates – when George checks in on him throughout the day to help monitor his blood sugar levels.
It takes but a quick moment to check and to get a shot, and then he is back to class almost immediately.
“There is a wonderful support system here,” said Quin’s mother, Robin Babcock. “Quin is very at ease with it all and accepted and treated with respect by everyone.
“It’s a wonderful community of support here and the nurses are wonderful too – they are a big part of what goes on here.”
It is because of the caring expertise of school nurses that Gina Matosich and her daughter, Jillian, have thrived with the challenges of monitoring Jillian’s diabetes.
School nurses have helped guide them through the tough early days when the disease was first diagnosed when Jillian was in third grade, and now that she’s in middle school, taught them how they could live a fairly normal independent life even with the disease, Matosich said.
“School nurses play a huge role in the health of all our kids,” she said. “There isn’t enough of them and I believe there should be a full-time nurse in every school.
“In Missoula, our nurses are spread pretty thin, and when I first found out that there wasn’t a full-time nurse at every school and that the few nurses there are had to drive to different schools all day long, I thought ‘Are you kidding me?’ ”
“Their role right now is so crucial, especially with the increase in so many special needs kids.
“They should have their own office, their own place to put stuff, their own place to keep stuff – just like the counselors do.
“They need a home base, and it’s good for the kids to have that kind of stability – it’s a health and safety factor for everyone.”
George admits it would be nice to have more nurses to share the workload, and it would be nice to not have to scramble between schools each day.
No matter what changes unfold in coming years, she wouldn’t want to work anywhere else.
“I love this job, I love being busy, and it is really a great fit for me,” she said recently during a rare quiet time after a 20-minute rush that included monitoring a child’s blood-sugar level, handing out an icepack to a girl who twisted a knee in gym class, helping to staunch another little girl’s bloody nose, calling a parent and comforting a kindergartner with a tummy ache.
“I love working with the kids, and nursing is such a multifaceted profession,” she said.
“There are always opportunities to learn and to teach, and to help.
“A healthy child is the best learner, and if we can serve our kids in school and help keep them healthy and happy, it makes for child who is a better student and one who is better prepared for life.”