In schools for children with physical and mental developmental disabilities, the curriculum is as likely to include lessons on health management as reading, writing and arithmetic. Whether it’s a lesson on self-catheterization or a primer on nutrition for students who use wheelchairs, the instructions are provided by school nurses who work with this patient population.
“We hardly ever use Band-Aids, that’s what people think of when they think of school nurses, but we rarely do that,” said Gail Nolan, RN, BSN, MS, LAC, head nurse at Henry Viscardi School in Albertson, N.Y. Nolan got her start in school nursing 23 years ago when she was hired to work with the first ventilator-assisted student enrolled at Henry Viscardi.
Since then Henry Viscardi’s nursing staff has grown to four full-time nurses who care for about 200 students with disabilities ranging from cerebral palsy to osteogenesis imperfecta. Nolan and her colleagues catheterize, administer respiratory treatments to students who have ventilators, monitor intravenous feedings and dispense hundreds of medications each day.
But that’s just the technical work. School nurses also are the messengers, explaining to their students the reasons for and the importance of what they do.
“The majority of what we do is teaching,” said Kathie Riedman, RN, BSN, school nurse at Skills Life Program, Center for Community Adjustment in Wantagh, N.Y., which is one of about 300 educational programs operated by the Nassau Board of Cooperative Education Services. “All of the nurses in BOCES have to be able to take a holistic approach. Weight management, hygiene, a whole range of things because the ultimate goal is when these students leave they have to be at their best.”Gail Nolan, RN
The sky’s the limit for many children whose disabilities center on the physical, Nolan said, which is why interventions and lessons on self-catheterization start at a young age at Henry Viscardi. “We start getting them involved during the toilet-training stage, when they’re interested,” she said. “It becomes imperative for them to learn that because there’s nothing stopping them from going out into the world.”
School nursing 101
Because such comprehensive care must be provided to students with special needs, nurses in such settings must possess a varied skill set.
Ann Caruso, RN, BSN, coordinator of health services for BOCES, said the majority of board nurses have either pediatric acute care or psychiatric nursing backgrounds. Before becoming full time, many BOCES nurses substitute in district schools. All new hires, who must obtain certification in dealing with child abuse, undergo an orientation in protocols, policies, state guidelines, medications, CPR and infection control.
New hires also are “buddied up” with a more seasoned staff member to learn the ins and outs of the school, Caruso said.
“You have to have a wide range of hospital experience and bring all of your past experiences to the school setting,” said Aimee Coffey, RN, BSN, school nurse at Rosemary Kennedy School in Wantagh, N.Y., which enrolls students with physical, communication, emotional and learning disabilities.
Nurses at BOCES schools for students with physical impairments help children with tube feeding and suction, and manage ventilators, Coffey said.
Tracy Gherardi, RN, BSN, school nurse at Jerusalem Avenue School and Children’s Readiness Center in North Bellmore, N.Y. adds nurses in schools for children with mental and behavioral disabilities often administer choking responses, cardiopulmonary resuscitation, relaxation techniques and coping mechanisms.
Nurses agree strong assessment abilities are critical when caring for disabled children, especially because many of them have impaired or nonexistent verbal communication skills.
“Let’s say there’s a student who’s upset but can’t speak to let us know that his orthotic is pinching him. The student might not even cry, just get sweaty and his heart rate goes up,” Coffey said. “We have to assess the whole student from head to toe to find out what could possibly be causing him to be upset or in pain. It’s up to you to see the subtle nuances of change.”
Labor of love
When a change in the health of a child with special needs goes unnoticed, crisis can come quickly. “Because the children are so medically fragile, even though they’re stable and going to school, anything can happen at any time,” Nolan said. “So we definitely have to be prepared for an emergency — and we do have a lot of those. I would say that one of the biggest challenges is to act as if you’re in the regular place where you’re going to school and that there are no real problems and to be prepared at any time.”
But emergencies aren’t the only traumatic situation school nurses must be prepared for: death is a routine occurrence in schools that cater to children with degenerative disease.
“I guess that’s part of the difficult part of this job,” Nolan said. “We do have a lot of loss, and you don’t know when it’s going to be, if it’s going to happen in school. We really try for it not to happen in school. When we see a student is deteriorating and not stable, we have a lot of regulations about attendance.”
While witnessing death is heart breaking, the nurses said becoming part of the students’ support networks and watching them flourish is rewarding. Gherardi said simply building a level of trust with students so they are empowered to overcome the anxieties about medical care and counsel gives meaning to the job.
“It’s rewarding when you’re in a setting, not like a hospital where they’re only staying for a week or two, where you can watch the child grow and blossom into a young adult and be able to go into the community and work in any work setting they’ve been trained for,” Caruso said.