An essential duty of any RN, including a school nurse, is assessing the patient. As I wrote in a previous blog, this duty includes both a physical and emotional assessment of any student who presents in the school nurse's office. In the following case, a school nurse's role should have included assessing a frequently bullied student who ultimately took his own life. The case illustrates the importance of this aspect of school nursing.
Specifics of the Case
A third-grade student at a public school in Cincinnati, Ohio, was the victim of 12 violent, bullying incidents that began when he was a first grader until his death when he was a third grader.
The bullying incidents consisted of students punching, kicking, or hitting him. When he tried to defend himself on one or two of the occasions, he was told "he would be punished if he punched a student in self-defense."
The physical injuries sustained by the third-grader included the loss of two front teeth, a bloody nose and lip, and a thumb injury. After experiencing a bloody nose and lip due to a bullying situation, the boy was treated by the school nurse. The school nurse called his mother and told her that two students had punched her son in the face which resulted in the injury. Although the school stated that they left voice messages with the victim's mother after the other incidents, she denied ever receiving them. In addition, when the school did contact her after one of the incidents, the mother asked to see the video of the altercation. Her request was denied. Another incident occurred two days before the third-grader's death. A student began attacking male students in the school bathroom. When the boy walked into the bathroom, the "aggressor" grabbed the boy's hand and yanked him toward the wall, causing his head to "collide with something." The boy fell to the floor unconscious, with the aggressor "celebrating" his fall. At least a dozen students passed through the bathroom after his fall, "taunting and kicking" him as they entered and left the bathroom. When the assistant principal responded to the situation, the boy was still unconscious and lying on the floor. The principal did not check for vital signs or get help. The boy was unconscious for more than seven minutes.
An hour after the incident, the school nurse examined him after he regained consciousness. She did not call 911. Rather, she called his mother and told her that her son had "fainted," was alert, that his vitals [were] fine, and that he did not require any additional medical attention."
The boy did not tell his mother about the attack. At home, he experienced stomach pain, nausea, and vomiting. His mother took him to the hospital, and she told the ED staff he had "passed out" at school. Since she did not know that her son had experienced a head injury, she could not share this. The boy was diagnosed with the stomach flu, and he was sent home. He did not go to school the next day due to his being ill. When he returned to school, he was attacked once again. He told one of his teachers, but no follow-up took place. The boy came home after school and took his own life.
Family Files Lawsuit
The third-grader's parents and the administrator of his estate on their behalf sued the school district and others, including the school nurse, for a violation of his civil rights under Section 1983 of the federal Civil Rights Act of 1871. Several of the defendants, including the Board of Education, filed a Motion to Dismiss the claims, alleging they were entitled to governmental immunity under state law. The trial court denied the defendants' motion. The defendants appealed that decision and argued that they were entitled to immunity because the plaintiffs failed to establish that their conduct was "reckless." The appellate court's decision reviewed the facts of the case in detail in their opinion. It found that, among other things, the defendants:
- "Withheld information concerning [the boy's] safety and wellbeing" as a student in the school.
- "Failed to punish the students that attacked [him]."
- Failed to contact his parents about the bullying incidents.
- Failed to call 911 for more than three minutes after discovering he was unconscious.
The appellate court affirmed the lower court's denial of the Motion to Dismiss and held the defendants were not entitled to state governmental immunity. Five months after that decision, the Cincinnati Public School System reached an agreement to pay the family $3 million and to institute reforms to strengthen the bullying reporting system that was currently in place, including including "empowering school nurses to report suspected incidents of bullying."
Lessons for School Nurses
If you are a school nurse, you know that school bullying is not a random occurrence. The Centers for Disease Control and Prevention (CDC) notes that in nearly 12% of public schools bullying takes place once a week. Assessing a student who is the victim of bullying is critical to that student's wellbeing.
In this case, it appears the school nurse did not take into account the emotional toll the numerous incidents of bullying had on this student. Had she conducted a careful and complete assessment of both the physical and emotional injuries to this student, the outcome may have been radically different.
The importance of reporting a bullying event as your school protocol requires cannot be overlooked. It is not known what the reporting system was in this case. Apparently, though, it was not substantial enough to provide the school nurse with the personal power to report the bullying outside of the school. Yet, as you know, you must also meet your legal and ethical duties to report suspected child abuse to the proper authorities as required by state law. The duty to report suspected child abuse is not one that you can succumb to pressure from others to not report or rely on a reporting system that does not provide you with the power to do so. The mandatory obligation to report is yours and yours alone. Furthermore, when contacting a parent about his or her child's bullying incident, it is essential that you are truthful about what happened. Why the school nurse in this situation did not do so when she contacted the boy's mother about the bathroom attack is perplexing at best. It is also puzzling why the school nurse did not seek further medical evaluation, either by telling his mother that he sustained a head injury or by calling 911 when he was in her office. Remember, too, that your documentation of the care of any student must provide a clear picture of what you assessed, including what treatment and interventions you provided and your call to the student's parents and what was said. Last, but by no means least, your role in the prevention of bullying in your school is essential. The National Association of School Nurses (NASN) has many resources available to help you fulfill this aspect of your role in your school.
Take these related courses:
Helping Children Who Are Being Teased and Bullied (1 contact hr)
Surveys have shown that about 20% to 28% of American adolescents (middle school and high school age) report being bullied. Research studies have shown that those who are chronically teased or bullied can suffer short- and long-term psychological consequences and physical problems. This educational activity will help you to distinguish between teasing and bullying and will present effective strategies to help children and adolescents, families, and school personnel prevent or respond to harsh teasing or bullying.
Managing Obesity in Young Children (0.5 contact hrs)
The goal of this course is to educate nurses, dietitians, and fitness professionals in the acute setting on pediatric obesity and best practices for management.
Autism Spectrum Disorder (1.5 contact hrs)
The goal of this course is to enhance knowledge of diagnostic criteria, characteristics, clinical interventions, and treatments for those with ASD.
Internet Safety for Children and Adolescents (0.5 contact hrs)
The goal of this course is to provide nurses who work with children, adolescents, and their families in various settings with information about how to support children’s safety on the internet.
