1) mobile crisis intervention and crisis stabilization;
2) in-home behavioral therapy and behavior management supports;
3) in-home therapy services;
4) mentoring; and
5) parent/caregiver supports.

While the health needs of Massachusetts’ students have grown increasingly complex, many thousands of students receive no, or inadequate, school health services. At the same time, Governor Romney has proposed elimination of the School Health Program in his FY’05 Budget. By discontinuing this successful program, school nurses will be laid off and thousands of children will no longer have access to needed nursing services which, in turn, will impact their ability to attend school.

To help address this problem, school nurses, parents, students and health care advocates converged on the Massachusetts State House on Wednesday, March 24, 2004 from 8:30 A.M. – 11:30 A.M. for a School Health Advocacy Day.

The event, hosted by the School Nurse Services Collaborative, featured a number of speakers including government officials, parents, school administrators and school nurse representatives. All hoped to educate legislators and demonstrate strong support for legislative efforts to reject the governor’s proposals and to reinstate the $12 million in funding that is needed to maintain the standard of care needed to service the growing population of students with mild to severe health needs. Among those speaking at the event was Anthony Delmonaco, a 10-year-old 4th grader from Pembroke, who helped galvanize support for this issue with letters he wrote that were published in both the Boston Globe and Patriot Ledger detailing his fears of losing access to his school nurse, who helps him cope with his asthma.   (CLICK HERE to read Anthony's full speech in support of his school nurse.)

In 1998, the Massachusetts Department of Public Health presented a plan to the House and Senate Ways and Means Committees for the expansion of school health services. In FY 2001 and 2002, the legislature responded by increasing funding for school health services. In 2003, the legislature rejected the governor’s first attempt to eliminate the successful Enhanced School Health program that funds school nurses in cities and towns with children lacking access to adequate health care.

School nurses provide a valuable social and health care safety net, particularly in tough economic times as school nurses are a primary source for poor or uninsured children to have access to health assessment. Also, in the wake of growing concerns over bioterrorism, school nurses provide a readily available resource for early detection and rapid response in local communities to a public health emergency.

As early as 1992, a special commission relative to the practice of school nursing recognized the unmet needs of Massachusetts students and concluded, “Children attending schools in the Commonwealth today are faced not only with the usual and common infectious disease, they face the threat of other major health problems not always well understood by teachers, parents and the community. Special needs children integrated into classrooms of every town have significant health and nursing needs, including such things as catheterization, suctioning and the administration of complex treatments. The administration of medication and the monitoring of their effects, couple with the needs of children from dysfunctional families, further complicates the picture of school health.”

According to Marcia Buckminster, Director of School Health Services for the Framingham Public Schools, the commission report accurately depicts the conditions in her schools, as well as schools throughout the state. “Within the last school year, our nurses have cared for acute, chronic and emergency health problems such as asthma, attention deficit disorder, migraine headaches, epilepsy, heart conditions, diabetes, life threatening allergies, arthritis and hemophilia. We have had students coming to school requiring colostomy care, intravenous medications, nasogastric feeding and other procedures.”

School nurses are also required by law to conduct annual postural, hearing and vision screening tests on all students and monitor compliance with school immunization regulations. They also provide health education to students, teaching healthy lifestyles, as well as management of illnesses.

Good morning.

I appreciate the opportunity to speak with you today and lend my voice and that of my colleagues in educational administration to the support of essential and quality nursing services in our schools. We should be proud that our commitment to educational opportunity has opened the school door wider than ever before. Today’s schools have very different demographics than those of the past. Our schools are more accessible to medically challenged students and families than ever before. Twenty-five percent of our students come to school today with some form of medical impairment. This number increases in our urban areas. Almost twenty-one percent of children in the United States, between the ages of nine and seventeen, have a diagnosed mental or addictive disorder. (Department of Health and Human Services, 1999) In Massachusetts, twelve percent of our school age children live in poverty and do not have appropriate access to primary care and many lack insurance.

The advances in medical technology have enabled more children with significant health care needs to attend school. Medical procedures that at one time could only be provided in hospital settings are now being performed in school settings by our school nurses such as catheterizations, tracheostomy care, colostomy care, intravenous infusions, feeding tubes, and insulin pump care to name just a few.

The students who attend our schools today have chronic health conditions that range from the minor to the severe. Today’s school nurse must be prepared to treat allergies, asthma, substance abuse, injuries from domestic violence, sexually transmitted diseases, pregnancies, emotional distress, and conditions resulting from congenital defects. The list is endless.

Added to that are the responsibilities of screenings for the early detection of hearing, vision, and postural defects, and special needs. The school nurse responds to the incidence of communicable diseases such as sexually transmitted diseases, chicken pox, hepatitis, and meningitis. Nurses not only work to prevent the spread of disease, but also to allay community fears. Each day hundreds of medications are administered. And it should be understood that requests for treatment are not made by appointment. The flow of service requests defies even the best schedules and organization.

Why do we do all of these procedures in our schools? Is it to increase jobs and expenditures in our schools? Of course not. We do it because it is an essential component of our commitment to serve all children and youth. We do it to provide equal access to education and provide the support necessary to achieve a positive outcome.

We have set some very challenging academic goals for our schools, Massachusetts Comprehensive Assessment System (MCAS); No Child Left Behind (NCLB), with high standards of academic excellence and proficiency for all. Educators want to meet those challenges. We are not afraid of accountability, but we want the tools necessary to attain those very challenging goals. Consider the following. NCLB requires that we maintain a 95% attendance rate in our schools. The school nurse helps us to provide the necessary accommodations to keep students in school, in class, and in the least restrictive environment. Absenteeism would soar without the support of school nurses. Can we expect our teachers to cover more rigorous material and at the same time attend to the medical and emotional needs of our most challenged students?

We need to provide the right supports to our classroom teacher. When a student is distressed and distracted for physical and/or emotional reasons, it won’t be extra tutoring that gets him or her back on track. More often it will be a school nurse.

If we are truly concerned with achievement of high standards for all, we will recognize and support the work of our school nurses. Study after study supports the fact that good school health programs are essential to increased academic performance. Desmund O’Byrne in a 2001 study for the World Health Organization wrote, "Good health supports successful learning. Successful learning supports health. Education and health are inseparable."

An U.S. Department of Health report, 1992 stated "Health is a silent partner to education. The health and wellbeing of children are directly related to their academic performance." (Novello, DeGraw, and Kleinman)

The 1989 Carnegie Council on Adolescent Development reported "Students who are hungry, sick, troubled or depressed cannot function well in the classroom no matter how good the school."

There are those who, despite the research evidence from a wide range of sources, believe that schools should not or cannot take on health issues. This position is absurd when we realize that 95% of our children are in school and that there is such a profound link between health and learning.

We should not underestimate the importance of school nurses. They are critical to our ability to address the health and education needs of our students and their families. Nurses are one of our greatest resources for closing the achievement gap between the advantaged and disadvantaged.

To be effective, education must address the "whole child."

In a joint statement on school health former Secretary of Education Richard Reilly and former Secretary of Health and Human Services Donna Shalala said, " America’s children face many compelling education and health development challenges that affect their lives and futures. To help children meet these challenges, education and health must be linked in partnership… school health programs support the education process… integrate services for disadvantaged and disabled children, and improve children’s health prospects."

In the long run, our ability to keep students in school, healthy, and focused will do more for academic achievement than the drill of academic tutoring. I’ll take a school nurse over a tutor any day of the week.

With effective healthcare we can help students learn more, we can reduce discipline problems in our schools and cities, we can produce more productive citizens for our future. Investment in Essential School Health Services should be a "no brainer."

The school nurse plays an important role as a health educator. Most serious illness and early mortality are the results of high health risk behaviors established in childhood. Six of these behaviors can be altered to prevent disease or death, poor eating habits, physical inactivity, tobacco use, drugs and alcohol abuse, accidental or intentional behaviors causing injury, and unprotected sexual activity. Education can help prevent children from engaging in these behaviors. (L. J. Kolbe, 1990, Health Education Epidemiological Surveillance System to monitor youth risk behaviors that most affect health)

C. Everett Koop, former U.S. Surgeon General stated "Health care is vital to all of us some of the time… but public health is vital to all of us all the time." The school is a very important public health setting. We all recognize that the "biggest budget buster" is the cost of Medicaid. We will never get those costs under control by cutting back on front-end health services in our schools. We must promote healthy lifestyles from an early age if we expect to curtail cost for medical services.

The full funding of the Essential School Health Services program in our schools needs to be increased not eliminated. It is a critical component of a successful school.

The fight for sufficient and quality health services and education in our schools is more than a fight for academic excellence. It is our commitment to the whole child, our commitment to a healthy future, and our commitment to a productive economy and to a healthy society.

I would like to thank the legislators who support essential school health services, the Massachusetts School Nurse Organization, Massachusetts Nurses’ Association, and those organizations that have joined this advocacy.

Besides heavy backpacks, children carry on their young shoulders, the weight of all the issues impacting their families during these difficult socioeconomic times. School health care responds to their ongoing needs for preventative health care, and management of complex, life threatening medical issues or chronic health conditions. School nurses help keep children healthy, safe, fed, clothed, and sheltered...our "bandaids" extend far, but their effects are often invisible to others.

Students come to school to learn and they visit the health room for bandaids and ice packs. Often behind sad, tired eyes or under thin ragged clothes, we uncover stories about the effects of being cold, hungry, scared, or sick. We know that recurrent headaches and stomach aches, and daily trips to the health room, may reflect a cry for help, a need for attention, a need for a safe spot- from such stresses as academic pressures or the trauma of violence. We see hurt spirits and wounded bodies whose minds struggle to stay awake, to pay attention, and to learn in school, and we know when "something" is not right. We look and listen for visible or sometimes hidden signs of emotional, physical, and sexual abuse. We convene school crisis teams and activate appropriate community agencies to help the child and the family. We always maintain the child’s safety and health as our focus and first priority.

School nurses are often the "life line" to families in crisis, in isolation, in stress. We listen to parents pour out their hearts as they describe their struggles with personal or their child’s physical or mental health issues, unemployment, homelessness, violence, and poverty. Parents share in confidence their struggles, fears, guilt, and needs. We are open, caring, and respectful. We provide parents of all socioeconomic, educational, and cultural backgrounds, ongoing health education, assessment of their child’s symptoms, and referrals for medical or mental health evaluation. We assist them to navigate the complexities of medical, legal, and educational systems. We provide clothing and food from donations, and advocate for adequate shelter and housing. We reach out and hold vulnerable young hearts and adult hands offering hope and strength. They turn to school nurses, because we are here in schools, accessible and willing … to help.

School nurses deliver the essence of health care. We care for the total person, the mind, body and heart. Our knowledge base focuses on the child’s physical, developmental, psychological, emotional, and social well-being. We apply a process of problem identifying, assessing and intervening. We don’t turn our backs or close our eyes. We know that no child lives as an island, so we advocate constantly for the child and family- their rights for education, health care, privacy, respect, and safety. We climb up "hills" and we go out on "limbs", and we often are the voice when they cannot speak, so we speak on their behalf, with confidence and compassion.

School health is the front line for children’s health care. All children have a right to an education and school is where most children come. The school nurse sees and knows what medical care is working, if medications are being given at home, if the child’s symptoms are being appropriately responded to, if the family is following up with the recommended evaluation or treatments. We see children who have not had medical intervention, who have not had educational or developmental evaluation, and whose families need support to navigate expert but complex medical systems. We know "it takes a village to raise a child", and we coordinate the collaboration of a child’s village: home, school, and community. School nurses make numerous phone calls and meet with parents, medical providers, with community agencies, with state insurance, and the interdisciplinary educational team. School nurses know that no medical specialists, no prescriptions, and no educational plans alone, will produce a healthy child, able to access education. Our role is to advocate, educate, and intervene constantly, with the child and family. As school nurses, we have the important challenge and satisfying opportunity, to make a difference in the students’ lives.

The reality of these difficult economic times is that school nurses often provide the only health care for most students who lack health insurance. Federal and State budgetary cuts that have decreased parents’ opportunities for employment, affordable childcare services, job- training programs, and affordable housing, have further impaired the families’ access to health care. State legislative decisions for budget cuts affecting health care and the limitations with insurance coverage from MassHealth and the Children’s Medical Security Plan have resulted in an increased number of underserved families without health insurance.

School nurses examine students with numerous complaints ranging from common sore throats, earaches, headaches, and stomachaches to more unusual rashes, behavioral changes, and potentially contagious diseases. With every encounter we assess students, and we advise parents about health management or recommend further evaluation by a medical provider to diagnose and treat illnesses and injuries. As registered nurses we provide education about fluids, and rest, nutrition and warmth, and routine medical intervention to reduce a fever, or cleanse a wound. As nurse practitioners working in the schools, we expand our roles and expertise, and may provide further diagnostic assessment and treatment via a school based or nurse managed health clinic. But for the child with no school nurse, with no health insurance and no health provider, the emergency room becomes the only source of health care. We know that emergency rooms become filled with families, seeking non-urgent health care, and children must wait long hours instead of being home, resting, and recuperating.

Children in Massachusetts, as nationwide, need timely and effective access to health care that promotes normal growth and development, healthy lifestyles, and that prevents and manages childhood and adolescent illnesses, risky behaviors, and injuries. School Health services support numerous health initiatives and programs that promote preventive health care for uninsured and vulnerable student populations. Nurse practitioners provide primary health care through nurse managed health centers. School health programs address issues concerning early screening for cancer, heart disease and diabetes, child/adolescent mental health, healthy lifestyles, dental health, comprehensive vision screening, adolescent risky behaviors, teen pregnancy and parenting, and the impact of child/adolescent exposure to violence, abuse and neglect.

Registered nurses in the schools are first line health professionals 1) to assess for physical and psychological symptoms manifested from bioterrorism or by the ongoing threat of terrorism, 2) to implement mass screening and immunization programs, and 3) to provide first responder treatment and emergency medical care. School nurses identify and respond to the management of communicable diseases. We have readily available data that supports the Massachusetts Department of Public Health with tracking outbreaks of communicable diseases including varicella, tuberculosis, meningitis, influenza and the list is endless. School health services have implemented the development of Emergency Response Planning Programs in school systems. Cutting funding that support school health services, limits the resources of skilled emergency responders for the entire state, during a time of national health and safety concerns. School nurses know how to respond to emergencies with the necessary calm action and skilled intervention.

As school health nurses, we are committed to meet the challenge to keep the child healthy, safe, and able to participate in learning. We promote health, provide health education, assess and manage illness and injuries, provide simple to intensive skilled clinical care, serve as first responders for emergency situations, and overall support the child’s development and opportunity to learn. The school nurse keeps the school setting healthy and safe.

Nurses respond to "red flags"- symptoms, situations, histories that raise our antennae for alerts and attention. We are always talking with parents, students, and staff about health promotion and management concerns. With every encounter the school nurse has the opportunity to assess and educate. As we comply with state regulations for immunizations, lead screening and TB risk, we assess a family’s access to health care, health insurance, and the risk of the child for disease or developmental impairment. As we screen students for vision and hearing we ensure that the student has the fundamental sensory abilities to learn, communicate, and develop appropriately. We work with families to insure follow-up and referral for children whose hearing may be compromised and may need further evaluation or intervention, before hearing impairment compromises learning, communication and behavior. Vision screenings assess for how well the child sees, how the child is visually functioning with behavior and learning, and we may facilitate further eye exams and the purchasing of glasses. School health programs support the promotion of healthy lifestyles from the preschoolers learning to use tissues to substance abuse among adolescent students. Through school health programs, we address concerns about dietary habits- childhood obesity to eating disorders, physical activity- exercise, substance use- alcohol, drugs, tobacco, and the potentially risky behaviors of adolescence including sexual activity and teen pregnancy, peer violence, and motor vehicle safety. School nurses promote healthy lifestyles and prevent injuries that will prevent life long health problems as students and as adults.

The youngest students of public schools and the foundation of our future often need intensive supports from the school nurse as they transition into the educationally focused system. Babies are surviving premature births and congenital medical conditions that were in the past not viable with life. Before the child has entered the school system, they have survived significant medical challenges with the advancements and supports provided by community medical, early intervention services. As they enter the school system at age three years, they may be developmentally delayed and medically fragile. The school nurse becomes a case manager coordinating health care and educational needs. These children and their families have endured mountains of challenges; the school nurse joins now in on the bumpy journey of promoting education, health, and development.

Children come to school with cancer and terminal illnesses and may need support for their energy levels and germ exposure, medication administration, oxygen administration, medical collaboration, and emotional support for the entire family. Children may need, special accommodations with their transportation, environment, activity and academic scheduling to support their ability to learn and develop, while struggling with compromised health. The school nurse facilitates the development of a home-based program to support their medical condition. The nurse provides direct assessment, treatment and communication with all members of the child’s educational, family, and community medical providers. The nurse supports students who receive an education while they endure incredible medical challenges. The school nurse is the link between the medical, family, and educational worlds of the child.

When assessing students with behavioral issues that are impacting their learning and safe functioning in school, the school nurse is responsible for reviewing a comprehensive history including family mental health issues and genetic or neurological conditions, the child’s birth and developmental history, and injuries and medical conditions . The school nurse supports the collaboration with medical and educational specialists to explore and manage mental health conditions including bipolar depression, anxiety disorders, post-traumatic stress disorders, and attention deficit disorders. Students from preschool through high school are being treated with a variety of psychotropic medications. The role of the school nurse to administer, monitor doses and positive and adverse effects for these powerful medications on young bodies and minds, is essential.

The child with epilepsy may safely attend school but needs the expertise of the school nurse to monitor and respond to seizure activity and the effects of medications. Education is provided to the parents and staff about seizure activity and the necessary safety management. Emergency management and medications are planned for in collaboration with the child’s neurologist.

The child with diabetes may safely attend school with the assurance that the nurse will monitor symptoms of high and low blood sugar, the testing of blood sugars, and the administration of the life sustaining medications. The nurse supports the child’s independence and participation in his own care, as he is developmentally capable.

There are increasing numbers of children who attend school with potentially life threatening school allergies. The allergies range from the potentially anaphylaxis causing reactions from peanuts, to all tree nuts, milk, eggs, seafood, as well as such foods as wheat, seeds, mustards. The efforts of the school nurse is ongoing to educate and proactively ensure prevention of exposure to known allergens, and develop an emergency action plan for immediate emergency response in the event of severe allergic reactions. The safety of the student with life threatening food allergies extends beyond the administration of an Epi Pen.

The school nurse is essential for the child with asthma from the early phases of assessment of coughs and wheezing to diagnosis and the development of treatment plan. The nurse collaborates with the medical provider, parent, and student to promote preventative management via control of triggers, monitoring of symptoms, and administration of preventative control medications. The school nurse will assess worsening symptoms, the increased need for medications for asthma reactions, and refer the child for further evaluation of symptoms. The goal is to control the triggers including allergies, exercise, exposure to cold air, or illnesses, prevent exacerbation of symptoms. Uncontrolled symptoms may result in complications that require the services of the emergency room and hospitalization. The support of the school nurse enables the child with asthma to attend school.

For the first time, senate budget amendment texts are available to the public on line at

www.state.ma.us/legis/senate/02budget/amendments.htm

You will find Senators Moore, Lee and Joyce's amendment to the Enhanced School Health Services Grants at Floor 184. In addition to school health legislation, this web site provides information about local issues and topics. To subscribe to the State House News Service, please contact:

State House News Service
Room 458 State House
Boston, Massachusetts 02133
Phone: (617) 722-2439
e-mail: shnews@tiac.net
or visit www.statehousenews.com/public/Using.2.htm.

Massachusetts State Government has a new web site (www.02133.org) which is designed to help citizens make sense of the latest news in Massachusetts politics and public policy. Here you'll find summaries, background information, recent developments and additional learning resources about each issue. There is a special category devoted to Health/Public Health. Please visit:

www.02133.org

You can access who is on what legislative committee by visiting Massachusetts Committees of the General Court. You can also use this site to follow bills and to identify your local Representative and Senator.

For reference:

Joint Committee on Health Care
Telephone: (617) 722-2130
Chairs: Senator Richard Moore (Worcester/Norfolk)
Representative H. L. Stanley (West Newbury)

Ways and Means Committee
Telephone: (617)722-1481 (Senate)
(617)722-2380 (House of Representatives)
Chairs: Senator Mark C. Montigny
Representative John Rogers (Norwood)

These are important people to reach, as well as your local Representatives and Senators. Please continue to call your legislators. Ask them to support funding for school health services and increase the budget by another $10 million.

For reference
• Increased School Health Line Item (4590-0451)
  
• Increased School Health Based Health Center Line Item (4590-0450)
  

  Main number for the State House Senator Lobby: 1-617-722-2000
  House of Representatives: 1-617-722-2800
  
  

You may ask to speak to your Senator or Representative by name or by noting the community where you live. You may also find who your senator and/or representative is by visiting www.state.ma.us.

needs to keep the momentum. Our issues are HOT

The following sample letter is intended to serve as a guide for nurses to keep politically active. Please feel free to keep it on your desk or by your telephone for quick reference when needed.

HOW TO WRITE A SAMPLE LETTER

Address the letter with proper titles:

• The Governor: "His Excellency Mitt Romney."
• The Lieutenant Governor: "The Honorable Lieutenant Governor Kerry Healey".
• Your state senator, state representative, U.S. Senator or U.S. Congressman: "The Honorable."

Salutations: "Dear Governor, Senator or Representative..." Address: State House Boston, Massachusetts 02133

Helpful Hints

1. Always identify yourself as a nurse and a constituent.
2. Make reference to the bill or act you want them to support.
3. Include brief reasons.
4. If possible give examples.
5. Ask for a response.
6. When signing, include your complete name, title, organizational membership, address and telephone number. Remember that it can take just a few contacts from constituents to influence a vote in the legislature.

The HonorableRepresentative/Senator: (Name)
Room (Room #) State House
Boston, Massachusetts 02133



Dear Representative or Senator: (Name)


I am one of over 1800 school nurses in Massachusetts who is concerned with the safety and health care of the children in Massachusetts. Children attending schools today are faced not only with the usual common infectious diseases; they face the threat of other major health problems not always well understood by teachers, parents, and the communities. Special needs children integrating into the classrooms of every town have significant health and nursing needs. The administration of medication and monitoring their effects, coupled with the needs of children from dysfunctional families, further complicate the picture of school health.


Please watch for upcoming legislation for expansion of Chapter 71, Section 3, M.G.L. or bill #. We urge you to support an act/or Bill # of providing a minimum of one school nurse for every public and non- public school building in the Commonwealth.


Thank you for your attention to this important issue.

Sincerely,

Your name, RN (other credentials)
Address and telephone number

TELEPHONE PROTOCOL

Senator Lobby: 1-617-722-2000

House of Representatives: 1-617-722-2800

• Hello, my name is:
• I live in (town):
• May I speak to the legislative staff person?
• I am a school nurse in (school town):
• I am urging Senator/Representative to vote for (Bill # or Act#)

1. Name the title of Bill or Act.
2. Introduce yourself.
3. Use personal experience. Your expertise is valued.
   "I am a registered nurse. I have....years experience in...."
4. State your purpose. Know your argument. Are you for or against?
5. Support arguments with facts. Every fact should be related to the argument. Don't go off on tangents or try to make too many separate arguments. Keep it simple. Have one central idea in mind.
6. Give examples.
7. Avoid quotes from someone else. They are just quotes. It does not really help to support your argument.
8. Use short sentences. Avoid overly technical or "fancy" words.
9. You should acknowledge the other side. Let the reader know you are aware of arguments on the other side. If you can rebut them, do so.