According to Oregon Health & Science University’s Office of Rural Health, Oregon has 53 service areas in 24 counties where the population’s health needs are not being met. That means that Oregonians in those areas are not getting adequate access to primary physical, mental and oral health care services.
Among those most affected are the youngest and most rural residents in the state.
Nina Fekaris has been a school nurse with the Beaverton School District for almost 30 years. Last summer, she was named president of the National Association of School Nurses. She believes that providing more school nurses to rural Oregon would have a deep impact on not only the health of rural Oregon communities, but also the educational outcomes.
School nurses are much more than the person you go to when you’re not feeling well and you need a note, Fekaris said. Rather, school nurses are community educators who provide preventive health care that keeps kids in school and boosts graduation rates.
Fekaris talks about a school nurse in Chicago who discovered that students who were being expelled for bringing weapons to school were actually so afraid for their safety they brought them in to protect themselves from being attacked. Another school nurse in rural Tennessee organized Telehealth, health care telecommunication technology, to get students and families access to vital health care.
And for students in low-income families, students who are homeless and especially students in rural areas with little access, sometimes the school nurse is the only health care option.
Sarah Hansell: You said in 2016 that the ideal school nurse to student ratio should be 1 to 750, but in Oregon, the ratio is something like 1 to 3,000. It’s estimated that 40 percent of school districts throughout the state don’t have school nurses at all. So where are we now?
Nina Fekaris: I do not think those statistics have really changed any. I haven’t heard that districts are eliminating positions, so I don’t think we’re worse off, but I also don’t think we’re much better.
S.H.: Could you tell me what some of the big impacts are of that vast ratio?
N.F.: The (job) of the school nurse is to make sure that her students are healthy and that they’re safe and that they can be in the building and ready to learn. We’re looking at trying to build capacity, not only within our students, but we also support our families. When we have such high ratios, or even when districts don’t have any school nurse services, we believe that there are unmet health needs that are going unnoticed or undernoticed. The number of children with chronic or acute health conditions has kind of skyrocketed over the past 10 years. The number of children with anaphylaxis, which is a life-threatening allergic reaction, that has increased dramatically. Our number of children with Type 1 diabetes has increased dramatically.
And those are life-threatening health conditions that, unless school staff understand the signs and symptoms and know how to treat quickly, can result in a child’s death. And so if there is no health care provider, and school nurses are oftentimes the first front line kind of health care providers that children have in school, if that service isn’t available, then I believe we’re putting children in Oregon at risk.
S.H.: What are school nurses seeing these days that they weren’t seeing in the past? Essentially, what’s the experience of the 21st-century school nurse in Oregon?
N.F.: The dramatic increase of children with life-threatening allergies and Type 1 diabetes: These medical conditions significantly impact the amount of time and planning and preparation that a school needs to have in place to keep those students safe. The other huge issue that we’re seeing is mental health. Mental and behavioral health concerns have also skyrocketed, and that has been within the last five years that we’ve really seen that huge increase.
It’s children coming to school with severe anxiety; early, early diagnoses of kids with potential eating disorders; children that are experiencing such kind of traumas or adverse childhood events in their life outside of school that coming to school is kind of their safe haven.
S.H.: How much would you say housing insecurity and homelessness affects students’ health and school performance?
N.F.: It’s a dramatic effect. There have been studies that have shown that homeless children develop acute and chronic health conditions at increased rates over children that have stable housing. The stress of their living situation definitely negatively impacts their ability to learn. It keeps triggering that trauma brain. So we have a part in our brain that is really our fight/flight thing, which is from way back when we were hunter gatherers, and you had to be aware of your surroundings or a saber tooth tiger would eat you, that kind of thing.
And so children living in homelessness experience chronic stress at such higher levels that that part of their brains is constantly triggered, and that prevents you from higher-level thinking. And learning is one of those higher-level-thinking experiences. So it takes a long time once a child enters a school to be able to develop enough trust in their environment for that part of their brain to be able to calm down enough that they’re able to learn.
I think homelessness is huge as far as impacting our children’s graduation rates. If you track attendance, if a child’s not at school, then obviously they’re not going to be able to learn. And the more a child misses school, the more anxiety they’ll have about coming back to school, because all of a sudden they’re sitting in a classroom and they don’t know what’s going on. And they feel ridiculed by others. They can feel like they’re less smart because they don’t know what’s going on. And it’s not necessarily a matter of their intelligence; it’s just that they weren’t there. All those impacts can dramatically decrease a child’s chance at graduation, a chance at higher education, a chance at a higher-paying job, a chance to get housing security.
It’s kind of this vicious cycle that we’re in. If we’re able to educate those children, provide the emotional support that they need, provide for their basic needs of trust and security, food, clothing, those kinds of needs: Give them the ability to start feeling more self confident, have some self motivation – because that’s the other thing that really gets damaged quickly, is a child’s ability to be motivated to learn, to continue to fight, to continue to strive. That gets damaged early.
S.H.: The housing crisis is especially felt in rural communities. Do we see more of these cases and their impacts in rural communities?
N.F.: I think the impact is definitely there. I think it’s difficult to see the impact because there are fewer eyes out there, there are less service providers. Rural districts in Oregon, those are the districts that don’t have any school nurses. They also probably don’t have school counselors. There are fewer health care providers out there. In a few counties in Oregon, it’s over 100 miles to get to a dentist. So with fewer eyes out there seeing and uncovering the problem, I think it can go unnoticed.
I have a nurse down in southern Oregon, and the school district goes across the mountains, so part of the district is in the east side, part is on the west side. The main office is on the west side, close to the valley, and she had a student with diabetes that lived across the mountain. She said especially in the winter, there is no way for a school nurse to get there — because there was one school nurse for the district — or for the child to get to a health care provider. So her charge, and what she felt she had to do, was to teach everybody in that community – the school community especially, but she also had meetings with the volunteer emergency firefighters who were there – all about diabetes: how to care for the child, what signs and symptoms to watch out for, if the child was unable to check their own blood sugar. So really kind of developing that support, realizing that if there were an emergency, they were going to have to rely on themselves. She made sure that everyone understood how to take care of that condition.
We’re uncovering more and more stories like that. (Many rural youth) don’t have access to dentists routinely, so many of them have never had dental screenings. They don’t have access to eye care, eye visits, eyeglasses. It’s kind of shocking the number of children who were referred for special education services for learning disabled because they’re unable to read and it’s because they can’t see; their vision is bad. Those are the kind of things; it’s primary preventive health care that we’ve kind of gone away from, because we expect every child to have a pediatrician. The concept is, every baby that’s born has a pediatrician, so they have pediatrician visits. And then they get their wellness visits once a year. Well, that’s not a reality for a huge percentage of our families and our children. I think we're seeing the effects of that with high dropout and poor graduation rates. It’s time for us to start picking that back up. That’s what I love about school nursing, to make sure that every child has that equal access for their education. We’re really trying to provide that health equity for them.
S.H.: What other effects is poverty having on students, their education, their health in rural communities?
N.F.: I think, in a way, our rural communities are more disadvantaged than our urban communities because of homelessness and poverty, because they lack many of the social service agencies that the metro area has. Rarely will there be homeless shelters in rural communities. There’s a dramatic lack of health care, health care providers, school nurses, school counselors, school social workers, those that can help connect families to services. That’s what I think is sad, and I do believe that schools have some responsibility in providing for our rural communities. Because oftentimes, in rural communities, the school really can be the hub of community support.
Definitely we are seeing the impact of poverty, homelessness, food insecurity, hunger, lack of health care. And that’s the thing that has us all worried. We were thrilled the last couple years to be able to say every single one of our students had health care. We could get any child in to see a doctor that needed it. And now the option that families have to opt out of insurance, our fear is we’re going to go back to what we were five years ago where, sorry, we don’t have any insurance, so we’re scrambling trying to find a free clinic somewhere but they’ve all closed up. I’m worried about the near future and what that means for health care coverage for our kids.
FURTHER READING: 'Housing is health care'
S.H.: Do you think improving health care services in schools, having a healthy proportion of school nurses to students, would impact graduation rates?
N.F.: Absolutely. There are primarily two reasons why kids miss school: It’s either health related or it’s mental health behavioral related. If school nurses intervene early in those absences, and we get kids back to school, then we break that chronic absentee cycle, which is a huge impact as far as kids being able to graduate. Some of the recent studies coming up now about absenteeism say if a child misses, I think it’s more than three days of school in the first month of school, then they’re more likely to drop out.
S.H.: What do you think it would take for school nurses all over Oregon to have the capacity to provide those sorts of services that would be needed to have an impact on students’ success?
N.F.: Of course my ideal would be you have a school nurse in every building. Especially with bigger school districts. Now, I understand we have some schools that have 50 children, you’re not going to have a nurse for those. You need a nurse in every building, to be able to address those health needs. I would really like to see big concentrations at the elementary level because that’s where we pick up a lot of stuff. Nurses with more behavioral and mental health training in the middle and high schools, because that’s where we see a lot of that going on.
Washington state has done this model for a while — they identify regions in more rural areas, and they have regional health teams. So it includes a nurse, it includes a counselor, sometimes it includes a social worker, and those regional health teams then go visit those schools and do assessments. The school nurse would go into a rural district, do a needs assessment, find out how many children have whatever kind of chronic diseases, they would look at attendance, they would look at all that stuff, put those plans in place. And then identify how frequently they felt they needed to go back to follow up on some of those things, provide routine vision and hearing screening, those kind of services for those rural areas, and operate that regionally.
What must happen, however, is health care must start to contribute to school nurse and school health team pay. This can’t just fall on education dollars, which is what it is now in Oregon. It is primarily education dollars that provide school nurses. So there are, I think, 13 nurses in Beaverton (school district) right now for our 60-some buildings. But you go to our administration and they say, “Well, we can add another one or two nurses, or we can add another one or two teachers.” A school should never have to make that choice. It should never come down to a nurse versus a teacher. Health care and public health have got to start identifying that a school nurse, while part of the education team, is an integral part of the health care for our community and our school community. Because really, we have children five days a week, six to seven hours a day. Children are with us oftentimes more than they’re at home. We see them for longer periods of time. Health care has got to start stepping up. They’ve got to recognize the importance of providing these services to children at school because that’s their point of access.
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