School Nurse Trends: Tales from the Frontlines Episode 2

This is episode 2 of the series:  School Nurse Trends: Tales from the Frontlines

Episode 1: In this episode, we explore the vital role and evolving responsibilities of school nurses. The discussion delves into how school nurses coordinate care with parents, teachers, and healthcare providers while addressing major health challenges, such as mental health issues, chronic illnesses, and the impact of social media on students. Tune in to gain insights into the crucial work school nurses do in supporting student health and well-being. 

Episode 2: This podcast episode explores emerging trends and challenges in school nursing, including the impact of COVID-19, mental and behavioral health issues, and the needs of LGBTQ+ and gender nonconforming students. The discussion also covers school safety, emergency preparedness, and promoting health equity. Emphasis is placed on the importance of advocacy and the role of school nurses in fostering safe, supportive environments, with practical advice for nurses considering a transition into this specialty.

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Series:  School Nurse Trends: Tales from the Frontlines

Transcript

School Nurse Trends: Tales from the Frontlines

Guest: Robin Cogan, MEd, RN, NCSN, FNASN, FAAN 

Dr. Cogan is a Nationally Certified School Nurse, entering her 24th year as a New Jersey school nurse in the Camden City School District. Robin is the New Jersey Director of the National Association of School Nurses. She is proud to be a Johnson & Johnson School Health Leadership Fellow and past program mentor. Robin has been honored by multiple awards for her work in school nursing and population health. She serves as faculty in the School Nurse Certificate Program at Rutgers University-Camden School of Nursing. Robin writes The Relentless School Nurse, a popular blog. Her extensive work in school nursing was included as a case study in the National Academies of Medicine Future of Nursing 2030 report. You can follow Robin on Twitter at@RobinCogan. 

Host: Candace Pierce DNP, MSN, RN, CNE  

Dr. Pierce is a nurse leader committed to ensuring nurses are well prepared and offered abundant opportunities and resources to enhance their skills acquisition and confidence at the bedside. With 15 years in nursing, she has worked at the bedside, in management, and in nursing education. She has demonstrated expertise and scholarship in innovation and design thinking in healthcare and education, and collaborative efforts within and outside of healthcare. Scholarship endeavors include funded grants, publications, and presentations. As a leader, Dr. Pierce strives to empower others to create and deploy ideas and embrace their professional roles as leaders, change agents, and problem solvers. In her position as the Sr. Course Development Manager for Elite, she works as a project engineer with subject matter experts to develop evidence-based best practices in continuing education for nurses and other healthcare professionals. 

Episode 1: School Nurse Trends: Tales from the Frontlines

Transcript

Candace Pierce: This is Dr. Candice Pierce with Elite Learning by Colibri Health Care, and you are listening to our Elite Learning podcast, where we share the most up to date education for healthcare professionals. Welcome to our podcast on school nurse trends, where we're going to spend some time exploring the critical role and responsibilities of school nurses. Now the National Association of School Nurses reports that there are around 95,000 school nurses across the U.S. and that's providing care to over 50 million students. So, to help you gauge this amount, that is about twice the population of Texas. So, school nurses really play a vital role in ensuring the health and well-being of students, which is going to directly impact students' abilities to learn and succeed academically. So, over these two episodes, we're going to discuss how the role of the school nurse has evolved over the past decade, the primary responsibilities they hold today, and the ways they coordinate care with parents, teachers, administrators, and outside providers. We'll also touch on the biggest health challenges they face, how they manage chronic illnesses, and their role in health education, screening services, and preventative care. Joining me for this discussion is Robin Cogan, a nationally certified school nurse in her 24th year as a New Jersey school nurse. That's amazing, Robin.

Robin Cogan: That is a long career, but I have to tell you, I'm celebrating my 40th year as a nurse. Yes, so more than half of my career has been a school nurse, but not all of it.

PIERCE: It's amazing that you have been in this hat for so long, plus being a nurse for 40 years. What an achievement and still going and you look amazing.

COGAN: Well, thank you. Still going strong. Yes, still going strong. I'm not ashamed to say I just had my 64th birthday, so.

PIERCE: No, I don't believe you at all. Not at all. Well, you look amazing and I'm so thankful that you're taking time to share your expertise and your experience. Not just, as 24 years as a school nurse, but I mean, you have a breadth of experience and so what a privilege it is to talk to you today. 

COGAN: Well, thanks for inviting me and also really thank you for giving voice to school nursing and school nursing practice, a very misunderstood and underestimated nursing specialty. So, I'm excited to have this conversation today.

PIERCE: Absolutely. And I agree with everything you're saying. You don't hear a lot about school nursing and a lot of nursing students don't look at the area of school nursing. It's not really talked about in nursing curriculum. And when they're going through nursing school, it's usually how can I get in the hospital? So, I'm really excited to learn about school nursing because I don't have a lot of experience with school nursing either. So, I'm curious how you got started in this area.

COGAN: So, my journey to nursing and actually to school nursing is not a typical route. Prior to becoming a nurse, I actually studied art therapy. And when I was in my program, there was a practicum part of my program. And in my practicum, I happened to be in a general hospital on a psychiatric unit. And at that time, which was 1981, there was a group of nursing students that were coming through my inpatient psych unit where I was the art therapy intern. And it just so happened that one of their colleagues was an inpatient on our unit when their entire group of nursing students came through to do their psych rotation on that unit, and it was a fascinating experience. It probably wouldn't happen today, because of HIPAA and privacy but at that time things were quite different. And it made me realize that I was missing a lot of information to be able to help patients. And so, I had to make a decision at that time for furthering my graduate education as an art therapist or kind of revamping and retooling and going in a completely different direction. And so, I decided to go to nursing school.

PIERCE: That is completely different. I mean, that's like on this end of the spectrum from where you were. What made you decide that was it?

COGAN:  Well, first of all, I did become a psychiatric nurse. I did work in substance use disorder, but I have to say my background in psych has been the best series of skill sets that I can bring with me to school nursing. So, I don't think my time was not well spent. It's just not a typical route to nursing. I didn't have that calling to be a nurse, but I have certainly enjoyed the decision. But I can say I've made like really clear decisions even to get my route to school nursing. I'm one of these people, I do like to plan, but I'm also very much in the moment. So, when I finally became a nurse, it was three years later after graduating from my art therapy program, I quickly went into psych nursing, and I loved it. I also was involved in occupational health and case management. So, I really was exploring different aspects of nursing. And I ended up for the longest period of time in occupational health, and I worked for a railroad. Actually, I worked for Conrail and I loved my job. It was so fascinating and high energy and great responsibility but the company was bought out by another railroad. And I very soon found myself unemployed. And I had two small children who wanted to go to overnight camp. And so, I contacted the overnight camp, and I had a heartbeat, and I had a nursing license. They didn't even really talk to me. They just knew I had a heartbeat and a nursing license. And I ended up going to camp with my kids and all the other nurses at camp were school nurses, and they talked me into becoming a school nurse. So  that fall, and this was the fall of 2001. So, think about what happened that fall. I went back to school to become a school nurse, because in New Jersey, you have to have a certification much like a teacher to be certified through the Department of Education. Now that's very different. State to state, it differs widely what the qualifications, recommendations, certifications are. But I went back to school, and the first night of my first class, the instructor said, there are openings for emergency certification in the Camden City School District. And so, I applied there immediately for an opening for a job. And I was actually called to come to my job interview on September 12th, 2001. So, the day after September 11th. you know, I remember thinking, what am I doing, like, isn't the world coming to an end? I just remember just having this kind of out of body experience, but feeling really grateful that there was a place where I could practice school nursing and make it work with my family schedule. And anyway, I have been there ever since. This is my 24th school year.

PIERCE: So, I just turned 40 this year. So, I am close for being like half of what you have already done in your nursing career, just to put some perspective out there, but it's amazing what you have done in your 40 years and the vast experience that you just described from psych to art, to bring those to the students. Wow, I'm sure that it is a privilege for them to have you, and what a great role model that they have in you.

COGAN: Thank you. It's been a great ride. It's a fascinating career. And I loved your introduction because you talked about how many nurses aren't even given an introduction to school nursing during their training, during their education. Thankfully, that is changing, I can say. And one of the reasons that's changing outside of we need more school nurses, but there's a lot of psych, I'm sorry, peds experiences. that nursing students do not get because of how practice is now and how pediatric units are in general hospitals and that doesn't happen as often anymore. There's much more children's hospitals. And so, many times in nursing school, I know I've had this happen in my own health office. We will be asked to precept pre-licensure students so that they can have that pediatric experience. And so that's one way that nursing students find out about school nursing. And the other way of course is if they were involved in their own school nurse. If they were lucky enough to have a school nurse in the school where they came from. In fact, I wanted to ask you during your introduction, either you didn't have a school nurse in your school building, or you were just not the kid that went to the nurse.

PIERCE: So, I didn't really go to the nurse. I remember we did have a school nurse, but I think she went around to all because the only interaction I really had with a school nurse was when she came in to give a vaccination. And I remember that very clearly, because I don't like shots personally and my mama had to come get me. So, it was a little traumatizing.

COGAN: And so that raises such an important point. First of all, that's one of the reasons, I mean, we'll do it, but we don't like to be the vaccinator in our schools, because we don't want to scare the kids. We don't want our school health office to be a place of anxiety. It's really a safe space for students. And so that's really interesting that you brought that up. And the other point you brought up that happens all across this country is that you did not have a school nurse all day, every day in your building. And so that nurse, like many other school nurses across this country, travel from school to school. And then people who are caring for students are most likely unlicensed assistive personnel who don't have, they may have the same level of care and compassion, but they don't have the same level of training and education and experience, and that's a critical issue.

PIERCE:  Right. And I will say here where I am now with my girls, one of their schools has a nurse. The other school has a tech, and I just was reading. We have, so I had one going into high school this year, one going into middle school, and I still have one in elementary. So, the middle school, I just read their little note that says that they're blessed to have an LPN, however, they're not paid very much, so, they're asking families to donate you know, like $20, $10, whatever you can donate to help to offset the salary that that LPN is receiving to be there. But they have it in-house.

COGAN: But how did you feel when you read that? 

PIERCE: I didn't like it actually. I felt.

COGAN: And how long do you think that person's really going to stay?

PIERCE: Yeah, I don't know. And this is our first experience with middle school.

COGAN: See, the point of school nursing is that, a nurse is not a nurse is not a nurse, especially in school nursing, and I have great respect for my LPN colleagues. We have different levels of training and levels of responsibility though. And in New Jersey, for example, an LPN can definitely work in a school, but under the supervision of an RN. There's certain assessment, there's certain, depending on the Nurse Practice Act, state by state, that RNs can do, but maybe LPNs are not licensed to do. And so, there are a lot of assumptions made about who is a school nurse. And it is not always a protected title. 

PIERCE: It's not, and I will say because there was another school that my other daughter was at and they had a, they called them a nurse tech and they refer to them as a nurse.

COGAN: And they're not.

PIERCE:  Right, so you wouldn't actually know that if you were a parent, you would just hear, oh well, they're in the nurse's office, or they're with the nurse. And so, you assume, I assume that it's a nurse because of the education and training that we have. However, then to find out, that's actually a tech. They don't even have a certification or anything.

COGAN: Specialized training. No. And so that's one of the misconceptions that happens in school. And there are many reasons for it. Number one, and I believe the worst reason, is budgetary constraints. But if we don't prioritize the health and well-being of our children, what should we be paying for then? There's lots of things that schools pay for for extraneous things that are unnecessary or lots of maybe unnecessary levels of oversight that maybe schools can look at those budgets and put them more towards health services. Because if you don't have a healthy school community, your children will not be healthy, safe, and ready to learn. They will not, and honestly, neither will your staff. So, it's all about priorities. And as we see priorities shift. And sometimes I don't, I have to say, I don't think parents understand the power of their voice, the power of their presence, the important questions that they should be asking their schools. Who is caring for our children? What is their background? Is there specialized training? What do they receive to be able to work in this independent practice as a school nurse?

PIERCE: And how often do parents think of this except for when they need it? You know, for those that are chronically ill that come in, for those that have type 1 diabetes, for when you actually need that professional to take care of your child is really when we start to think about it. Other than that, it's out of sight, out of mind. I feel like for a lot of us.

COGAN: Or if an emergency happens at school, and it's your child in the emergency. That's why doing your due diligence, really asking the hard questions is super, super important. I mean, just asking, is there a school nurse every day in this school? And if there is, and what are their credentials? And if there isn't, number one, why not? And what can we do to change?

PIERCE: Right, absolutely. So, can you kind of walk us through what are some of the primary responsibilities and duties of a school nurse today?

COGAN: How long do you have?

PIERCE: Well, we have more things to cover, but we want to touch on all the things for those who really don't know. Because I really don't know. 

COGAN: It's such a loaded question. It's a really super important question, but it's such a loaded question because I just have to say, you know, I like to put it this way. And this is not hyperbole, but everything that the light touches is part of our job description. Everything. From brand new students who are new to this country, who are coming into our schools to help them acclimate, to get them what they need, to make sure they have what is needed even to be able to enter school, to working with new families or children who maybe from the area but have never been in school before, to connecting and working with our families, with children with chronic health conditions, to working with students who are medically fragile, to working with students who have complex health and social needs, to working with students who have deeply concerning behaviors that are showing up in school, to working with students and families who are dealing with family dysfunctions that will impact school. Things have changed in the family. Is there an incarcerated parent? Is there a recent separation in the family? Has the family just moved or has the family split up. I mean, all of these things impact what a school nurse will do every day. We provide direct care. We provide emergency care. We take care of episodic events, of chronic mental and physical needs. I mean, just I could list the things that we do, but we are so much more than our tasks. We connect students and families to resources. We are great collaborators. The care coordination is a huge part of our practice. We focus under the school nursing practice framework. And within that framework, thinking of it as a school nurse is kind of embracing all of these aspects of care for her, not just her students, but the families and the school community. And that can be anything from community and public health concern. We can just say COVID, and I could talk to you for five hours about COVID. Community issues from social determinants of health, from community violence, from the impacts, anything community that the community is experiencing that will impact children's ability to learn and flourish at school. From quality improvement, things that we want to focus on every day, part of our data collection. You know, our practice is evidence-based, and that takes a lot of time and determination and research and implementation to make sure that we're providing not just the best care, but that our care is based in evidence. You know, so it's an ongoing evaluation. We are constantly goal setting. We are always learning to professionalize our practice. You know, and then in the community and public health arena, we have to provide culturally sensitive, inclusive, and holistic care to all of our students. From a perspective of, you know, kind of the day to day, sure, we conduct health screenings on every single student in that building, some more than less depending on the year. We do surveillance outreach. We are the immunization compliance gatekeepers. So those are very important roles that we play. We are always looking to collaborate with community partners to develop and implement partnerships that will bring health services right to our school communities. We educate about health population, health issues, health promotion, disease prevention. You know, we are, and as I say this over and over again, we are the chief wellness officers in our buildings. Even if we don't have that actual title, that's who we are. 

PIERCE: Right. Yes, I think you should have that title personally, but you right, you are not paid, you know, what you deserve, so to say. But so, I know you talk a lot about that coordination of care and collaboration. So, what does that look like with, parents, teachers, administrators, and even maybe some outside providers for students?

COGAN: Well, the big thing is we are constantly looking for resources that we can bring to our community, not just handing off a phone number, but a warm handoff that we spend time developing relationships with these resources. So, for example, we would collaborate with families, school community on mental health issues. And that would include if your school's lucky, once again, lucky enough to have these positions and they should, school counselors, school social workers, school psychologists, and the students' medical home outside of school, their primary care provider, their pediatricians. We work together to develop and implement plans of care for those students that are developmentally appropriate. We want to foster independence in our students and then teach them and teach the families about self-advocacy, right? And then we also provide evidence-based counseling, health counseling. This is so important. When we talk about school health, it's a team, but often it's a team of one or a team of a half, a half of full-time equivalent. So, what would the ideal team be? The ideal team would be all the things that I just said, working together in collaboration so that we can meet the vast needs of our students, which has only escalated monumentally, not just in the last 10 years, but in the last five especially since COVID.

PIERCE: Right, and that kind of leads into my next question that I had, and that's what are some of the biggest health challenges that you're facing in the student population?

COGAN: There are enormous health challenges. I have to tell you that prior to COVID, school nurses spent up to 35 % of our time on mental health issues. That's only increased since COVID. We don't have the data point for that, but I will tell you, I believe it's closer to 50%. We are, yes, you know, students are coming to school with the social and emotional challenges that we see in communities. None of us, we all carry that invisible backpack of our issues with us, don't we? Teachers, students, parents, administrators, it's a fallacy to think that those things don't come to school with us. School is not this magic bubble that doesn't get touched by the outside world. Actually, it's the opposite. School is the Petri dish for all of those things that then come home to, you know, leave school, and come home and it's almost like this symbiotic relationship. So, we need to stop separating it out as if it were separate issues. It's just like, you know, physical health versus emotional health. They are one in the same, right? Being healthy at school should also mirror being healthy at home, and when those two areas of importance don't follow the same guidelines, that's when we get a real disconnection. So, for example, in school, we're seeing students who are very, very stressed, who have tremendous anxiety. We're seeing students who are dealing with depression. They have addictions to things like social media. I mean, even most recently, the Surgeon General called out what is absolutely true that the impact of social media is deeply affecting students' mental health. He's even suggesting that a black box warning label be put on social media, that there is an intentional effort, right, to turn the student into the product for some of these social media companies. And so, we're dealing with that. We're certainly dealing with not feeling safe at school. And it won't mean that every school will ever have a school shooting, God forbid. But you know what? Every school has an active shooter drill multiple times a year. And sometimes those drills are incredibly traumatizing. So, there are these outside influences that absolutely come into school and impact the culture, the environment, how school feels. I think the greatest thing we're dealing with at school and it's since COVID, is that sense of feeling connected. How can we repair the ruptured relationships that happened during COVID? And there were many. So that's what's happening for us now, right?

PIERCE: Absolutely. And I will say that, you know, as my daughters are getting older, I'm seeing how many children are struggling with even communicating with people. I mean, you walk in there, and they're on their phone, and then they can't carry on a conversation. They don't know how.

COGAN: They physically, emotionally, psychologically, developmentally do not know how to communicate with each other. And it is that it is the advent of that smartphone. It did great damage to this country. And yet we live and die by it, literally. And so, we have, thankfully there's tremendous efforts out there pass laws that will protect our kids. But I have to tell you, it's not just the kids that are addicted, it's the parents, it's the adults. I mean, when I send a child home, and a parent comes in and isn't even looking at their sick kid, but engrossed in a phone, just I don't know what they're looking at, but it's not their kid, that tells me that we really have a problem. It's bad enough to go to the grocery store and not say hi to the person checking in because you're on your phone. But that's what kids are seeing. They're not learning how to communicate, and they're not learning how to problem solve, and neither are the parents. So, we have a huge challenge, that's why I said, to repair ruptured relationships. Whether the relationship is within your own family, yourself, your colleagues, your students, each other.

PIERCE: Right. So, I know we talked a little about mental health, but can you kind of talk about how school nurses are dealing with the chronic illnesses like diabetes and severe allergies and asthma because you know, now we even have a lot of students becoming type two diabetics. They're not even out of elementary school yet.

COGAN: Right, yes, we have a tremendous health crisis in our country, a crisis of lack of activity. 

PIERCE: Goes back to phones and video games and computers.

COGAN: Right, things that keep kids sedentary. We also have, we don't know our neighbors the way we used to. There's been a real pullback in terms of community activities. I mean, there's sports, there's always sports, so sports are good. But for those non-sporty kids, you know, there's we just don't have the same sense of community that we used to have that were built around our community schools. We really don't. Things have changed dramatically. And I believe personally that some of that is people not necessarily feeling safe in large group gatherings when you think about it, safe for many reasons. I mean, the other piece of that is when we look at just the case work, the caseload of what school nurses are doing at school, I think it's important to understand that there's a real disparity between what school nursing coverage in rural schools versus urban schools. Rural schools employ 56% of full -time school nurses. So, there's a huge chunk of rural schools that have probably either very part-time or no school nurse at all. And I would bet in those rural schools that was 56% that they had a very large caseload. Now in urban schools, it's a little better, it's 70%, but I know that they have a large caseload. I happen to work in an urban school district. And then regionally, it's vastly different. In the West, there's only 33 % of schools that have a full -time school nurse. And I don't know what those ratios are for student nurse to school nurse to student ratio. 51% have a part -time nurse and almost 16% don't have any nurse at all. The Midwest is a little better: 59.9 % have full -time, but 7.5% of none and almost 33% only have part -time. Northeast, it's a little better: 88 % have full -time, 11% have part -time, similar to the South. But this latest workforce study was done in the middle of COVID. And we know, so we're not really sure what those numbers, the actual numbers are, because this is a snapshot of a time during the pandemic when there was funding to increase school nursing workforce. We know that once those COVID funds dried out, which was June of 2024, that many of those positions were going to be eliminated. And that's what we've been dealing with towards the end of this last school year and into the summer. And I know we're going back to school with a lower number of school nurses.

PIERCE: Yes. Well, that wraps up our first episode on the role and responsibilities of school nurses. We hope you have found this episode insightful and gained a better understanding of the vital work school nurses do every day. Robin, thank you for joining me for this discussion.

COGAN: Thank you for having me and for taking on these important topics.

PIERCE: Absolutely. To our listeners, if you enjoyed this episode, join it. Robin and I for episode two, where we're going to take a deeper look at the emerging trends and continue to discuss issues impacting school nursing.

Episode 2: School Nurse Trends: Tales from the Frontlines

 Transcript

PIERCE: Welcome back to the podcast series on school nurse trends. I'm your host, Dr. Candice Pierce. And joining me to continue this discussion is Robin Cogan. Robin, thank you for continuing this discussion with us.

COGAN: Well, thank you so much for having me, and asking some really important questions. I'm thrilled because I really want people to understand the full scope of school nursing practice. And I think your questions really help illustrate those.

PIERCE: Good, because over the next 30 minutes for this episode, I'm hoping to cover some significant trends that have been shaping the school nurse field and the impact of COVID -19, maybe some current mental and behavioral health issues that we're seeing today, and really just try to understand how school nurses can better address the LGBTQ plus and gender nonconforming students. And I know that school nurses also play a role in school safety and emergency preparedness and how you promote health equity. So, we have so much to cover and not a lot of time to cover it all. So, you want to jump right.

COGAN: Sure, let me just give you an overview in terms of like a bigger picture of school health and some of the chronic health conditions that we often see in school. So, in our country, more than 40% of school-age children and teens have at least one chronic health condition, and that would include things like asthma, obesity, other physical conditions, and that also includes behavior and learning problems. So, 40% of our student population of more than 90 million is a lot of kids. The health care needs of these children with chronic illnesses is complex, and it's continuous, and it includes daily management and also addressing potential emergencies. This is why it's so important for parents to communicate with their school nurses. I think we talked about this in the last episode. Make sure your school has a school nurse there every day, all day, and find out what their qualifications are, what their education and their background is.

PIERCE: Right. Is it a nurse? Is it a tech? What's their level of education? So, what are some of those emerging trends that you see impacting school nursing here in the last 10 years?

COGAN: From a chronic health condition perspective, we have seen a rise in asthma, certainly. We have seen a rise in diabetes, type 2 especially. We have also seen a rise in food allergies and anaphylaxis happening, emergency reaction to a food allergy that can be life threatening, happening in students who had no known food allergies. So that's really concerning. And all of these things have impacted how we practice. So, for example, when I first started in school nursing 24 years ago, there was no EpiPen. We would have to draw epinephrine up and keep it in a dark place and a handy place to use. Just talking about things like diabetes management, what's happening now is tremendous technology used to help students and staff and parents manage sugar highs and lows so that kids are much more even. And so, the technology is ever changing, and we need lots and lots of training to keep up with these many, many different and often competing pharmaceutical groups that are coming up with new technologies to measure things like blood glucose without a finger stick, that's a huge change for us at school, to diabetic pumps where kids are, you know, being able to manage their own care during the day. And of course, the school nurses hopefully always involved in promoting independence and really promoting students being able to understand what their chronic health condition means and how they can stay on top of it even things like asthma really educating the entire family, looking at what's triggering your specific asthma. Because asthma is often triggered by things that people don't necessarily realize. For example, I had a student whose parents smoked, and they just did not realize that even though they didn't smoke in the house, that smoke stayed on their clothes. And so, their child would be triggered just by smelling the smoke on their clothes. So, we have so many opportunities to provide very important health education promotion and prevention to not just our students, but our students and their caregivers at home. 

PIERCE: So, every year since I got married, I have gone to be a camp nurse for a week at a camp in Northern Georgia. And so now I have girls and so I actually go that week and I'm the camp nurse. I try to leave them alone, but it's really cool because you get to be there with them and kind of watch from the behind the scenes. But I have noticed an increase in growth hormones, allergy shots, the amount of medications for mental health to include, you know, like depression and anxiety and even ADHD. The amount of medications that we are giving our children has grown tremendously to where it's kind of stressful now to from when I started in 2007 to 2024. It's kind of stressful that week that I'm there at camp trying to keep track of all of these kids and all of these medications. Some taking multiple medications. I definitely see that increase that you're talking.

COGAN:  Well, you would make a great school nurse because let me tell you, compared to overnight camp nursing, school nursing is a part -time job because we can at least, when we need to, send our students home. You can't do that at camp. They live with you.

PIERCE: 24 -7, you were open. I have been woken up in the middle of the night with hands that were cut because they went through a glass window. How did that even happen? To somebody falling off a 50 foot,  yes, after hours.

COGAN: call that camp after hours. That's camp after hours, that camp is actually run by children, and they have camp after hours and that's the kind of things. 

PIERCE:  Yes, so you know, but doing that for a week is when I come home, I am mentally exhausted. It takes me the whole weekend to recover. Just it's a lot to keep track of. So, I can't imagine being in a school where you have that many kids that you have to ensure that they have all the medications that they need. And I just how do you manage that? 

COGAN: Let's imagine the documentation alone, making sure you have every single, you know, t’s crossed, and I’s dotted because we need specific documentation to be able to provide medication during the school day. We also have to stay on top of you talked about ADHD medication. They are considered controlled substances. So, we have to keep them under separate lock and key, double lock and key and count them and do all the things that we would do, you know, in acute care setting. And the other thing is that, you know, we're also tasked with collecting all the non, well, I would say emergency medication in case of, so all the albuterol, all the EpiPens, anything that a kid might need should something happen, and so, it's a huge undertaking. And then you put on top of that, making sure that every child in your school has every single immunization that they are required to have to be at school is, all of these things are very time consuming. We have to do a whole lot better job utilizing the technology that is afforded to many other practices. We finally in New Jersey, in my school district, are able interface with our state immunization registry and to be able to get immunizations uploaded into our electronic health record. Now, that doesn't happen everywhere. There are still many, many districts that are handwriting everything. There are still many, many districts that are still sending information to physicians or providers, counting on the parent to be the deliverer of the information. We should be using technology to the utmost within the parameters of HIPAA and FERPA. I understand that. But we could be saving time, money, lost workdays, lost school days, if we really take the time to take advantage of the technology we have.

PIERCE:  Absolutely, the efficiency and the effectiveness and really being able to open up time for you to do your job just like at the bedside. Nurses don't have a lot of time to do the job that they went to school to do because they're doing all the paperwork and all the, you all the extra stuff.

COGAN: And the job has expanded, and the needs have expanded exponentially. And that was, you know, we're still working in a model from more than 100 years if you think about. 

PIERCE: So,  we had COVID come through and really, really kind of wrecked us in our schools as far as, you know, sending kids home, not being able to go in the schools. So now that we're back and getting back to that more normal pace of life for our school children, how have you seen the effects of what COVID has done as far as your roles and responsibilities as a school nurse?

COGAN: So initially when COVID first reared its very ugly and dangerous head, there was a huge push for the appreciation of not only school nurses, but of teachers because of our rapid pivot to having to go virtual. Unfortunately, that really high level of appreciation soon turned to blaming school nurses for having to implement the ever-changing CDC guidelines that we were trying to follow. And I think what the general public didn't understand about public health is that we were living through a pandemic in real time, that the science that was being used to change those guidelines was in real time. They usually have much more time to craft mitigation responses. But we were learning as the science was being understood and, you know, analyzed. And then they were coming up with quick turnarounds. You know, one day we're quarantining for 14 days. The other day we moved it back to five where, you know, there was so much confusion because of masking. My God, they're still litigating wearing a mask or not wearing a mask, you know, four years later. The problem happened because COVID was not addressed primarily as a public health emergency. It became a political hot button. And then there were competing interests because it was also during the time of a very, very consequential presidential election that our most trusted, previously trusted, and independent public institutions were being questioned and degraded. And it was really, it created a cascade of misunderstanding and then purposeful spreading, not by them, but of other people with their own interests of misinformation across the country. And so, the school nurses role, while we follow CDC guidelines, it didn't mean that school districts were willing to follow CDC guidelines. And so, it was a real, I'm trying to think of the phrase, moral injury, truthfully, to school nurses to be put in the place, to be put in the space of being the messenger to families of things they did not necessarily want to hear. And we were in between, telling families that they needed to pick their child up for this, this, and this exposure or this, this, and this symptom, and then telling teachers, no, they can stay because they weren't within six feet of so-and-so and they weren't on the bus and they weren't in the lunchroom. And the contact tracing that we had to do, mean, the hours and hours of effort that were put into trying to keep our school community safe was truthfully, not only was it not appreciated, but it was attacked. It was questioned. Our integrity was questioned. Our knowledge base was questioned. I mean, I'm kind of making broad statements, but I've spoken to enough school nurses. I have run a support group for school nurses for the last five years through COVID about the things that we've all experienced. And so, there were some school nurses who were incredibly supported. There were other school nurses who were very disrespected. All in all, it impacted all of our mental health and wellbeing.

PIERCE: I think when we look at COVID as far as nurses in general, I think we all have a moral injury that we carry from our time spent at the bedside, in the schools, in the clinics. I think that unfortunately our population as a whole, we do carry that and have a lot of mental and emotional scars from what was experienced for exactly what you're saying, being stuck in that role in the middle, and being told what to do this way and being told what to do that way and trying, and all we want to do our best to provide high quality care to all of our patients, regardless of their age, regardless of who they are.

COGAN: Based in evidence, right? Based in evidence. And so, when we were being asked to do things that are not evidence-based, that's where the moral injury comes. And so, what we've done in the last few years, now COVID's on a bit of an upsurge now. Granted, we have medication, we have vaccine, we have ways to handle it, but we're you know, now COVID is being classified in schools anyway as any communicable disease in terms of staying home for 24 hours, do not come back until you're fever free with no medication, that kind of thing. But we know COVID has spread like wildfire this summer, hasn't it? Lots and lots of people who never got COVID before happened to get it this summer. But the other piece of that is, so to repair the ruptured relationships. And there were many ruptured relationships. We have to acknowledge what is, what happened, and come up with ways to create opportunities to improve our connections, to not gaslight people, to say, yes, that was wrong. We need to learn next time, because we know there's going to be a next time plan with you ahead of time so that we're not caught so off guard. You now, we were, most of us were told you're going to be home for two weeks and then we're all coming back. We didn't come back for a year. So, there's a lot to that. A lot happened during that year. And then even when we came back, was very stop and start. There was, we came back part-time, only some grades came back. I mean, it was complete chaos. It definitely calmed down, you know that thanks to science, things quickly turned around, but the damage has been done and we're still seeing the aftereffects in our kids and in our adults. I'm more hopeful now than I was even two years ago, but it's there. I'm never going to forget it, and it definitely drives my advocacy and the need to speak out when you see things that are not appropriate, or you know are going to go away that is not safe.

PIERCE: Absolutely. So, I want to move in because, you know, we also know that COVID has, as we've said, a lot of mental and emotional aspects to that for nurses, for students, for parents. But I want to move into, and I have two questions. I want to kind of combine them together because I think they flow really well together. And the first one is what are some of those current mental and behavioral health issues that school nurses are assisting with? And then also how can school nurses better address the needs of the LGBTQ and gender non-conforming students? Because I know a lot of those also fall into some of those mental health issues.

COGAN: Well, if you want to talk about moral injury, I feel for the students, the families, and the school nurses who are working in states that do not respect gender fluidity, who do not respect a student's right to choose, who do not respect some of the social changes that have been a part of our country, especially in the last five to 10 years. There are many competing interests that are trying to turn back the clock. I can tell you the story of a phenomenal school nurse I know, this was before COVID, but she was one of the first school nurses that shared a story with me that I thought was so brilliant. She was a high school nurse, and her high school insisted on graduation that students must choose the color of their graduation gown. They must be white if they're a boy and red if they are a girl. And her point was, why are we dividing our kids? Why don't we make everybody wear white or everybody wear red? Why do we have to put up with these barriers and other people out? And she went on a campaign. Now, she did it as she was getting closer to her retirement. So, I give her so much credit, but she was at the point where what are they going to do to me? I'm going to retire soon. This is the hill that I will die on. I refuse to be part of making kids choose a gender that at this moment maybe they're not comfortable with, maybe they' are questioning. They have the right to do that. Why aren't we supporting them exploring? Why are we judging this important kind of phase that they're going through? Let them figure it out with support, but why are we adding to the stress duress? And we know the mental health impact when kids are not supported in this very fragile time. So, she won, they all won, and those kids now only graduate in the same color gown. 

PIERCE: I'm just trying to figure out why. Why do we need two separate colors? I've never been in a school where we had two color gowns to choose from.

COGAN: History, tradition, yes. Why? We can ask that question about a lot of these decisions that are made. Why do we do?

PIERCE: Yes, absolutely. Like, why? What's the point?

COGAN: So, it was a huge learning. It was such a simple answer to an issue that is taking up way too much time and oxygen out of the room. And it's none of our business, actually. It's none of our business. But what we can do is create healing-centered environments where kids don't feel judged and maybe feel more connected. But I also have to say that nursing is political. We have a license to touch people. That in itself, it's even almost radical at this point, right, to be able to touch somebody else. And so, I give that nurse so much credit for taking that issue on. And my hats off to her and any other school nurse who will stand up for the mental health of their students, who will speak and say things that people, you know, want to put their hands up to their ears about. I speak out often on gun violence prevention. I have found a way to talk about it that is respectful to people who own guns and people who don't own guns, just like my friend found a way to come to a mutually, like a safe space, a space where everyone can agree that we don't have to stress out kids by making them choose a color, let's just all have the same color. I work in a space of, can we agree that keeping our kids safe is a shared value? So, working on safe storage, promoting, having gun locks at school, promoting education around safe storage. And we know that guns are here, they are not going away. There's almost a hundred million more guns than people in our country now. Since COVID, almost 80 million guns were purchased just in those few years. So, the question is, they're here, how do we live safely among them? How do we do that? We can do that. But first, we have to recognize our own rights and be respectful from where people come. But if you're choosing to have a gun, that's your choice. You have the right. What will you do to be a responsible gun owner and keep kids safe having access to it, because we know our kids know where everything is?

PIERCE: They do. And they are, they're pretty savvy with electronics. So now sneak right under your nose and you won't know. So, what types of school safety and emergency preparedness really fall underneath the role of a school nurse?

COGAN: Well, don't I wish they all did? And I have to tell you, I don't think you'll be too shocked to know that when it comes to safety, school nurses are not the first person that's on the school safety team. And that is really unfortunate. 52 % of safety committees even have a school nurse on their team. And we are a critical role in school connectiveness, which is the key factor when you think about safe and supportive schools. And since we're the first responder for any school emergency, including a school shooting, how can we not be an active member of that safety committee?

PIERCE: You are right.

COGAN: And these statistics come from a survey done by the National Association of School. Now, sometimes the committees that school nurses should be on but aren't on are because there is no school nurse in the building or they're covering three or four buildings. But that shows you, you know, we are more than just tasks. We are added value to designing safe and supportive schools. So can you create a framework for what a school health services suite of professionals should look like so that we can participate and attend in these important meetings.

PIERCE: Absolutely. And I do think that we are a missing team member in a lot of areas, even in hospitals, boards, school board meetings, you know, we have a lot of expertise and critical thinking abilities that can be brought in. And I will say to our listeners, we have a few podcasts that are all about how nurses can use their voice in community policy advocacy. So, we do have two podcasts that we released for 2024 specific to that. So, I think it's really important that we get out there and use our voice for the expertise that we have to offer in a lot of areas that we don't even realize.

COGAN: Right, especially in school nursing, you know, when we're not at the table, who's listening, right? Because school nurses bring the voice of health to an education setting. That's our role. And often we're the only health professionals in the school if we're even in the school full-time. You know, not to mention that can be not just lonely, but challenging to navigate a school community when we are the only health professional in the building. And  the connection that we have between health and learning is not always well understood by non-nurses at school. So, you know, there was a recent study that showed less than 50% of the nurses that responded felt that they were understood and respected by their colleagues a majority of the time. And only one out of four school nurses reported satisfaction with parental Even when it comes to the wellness team at a school, even on the wellness team, school nurses are underrepresented and underutilized.

PIERCE: Absolutely. I think that is a general theme for most areas where nurses work, understaffed, underutilized, not respected to the extent of their education and the abilities and opportunities that they could bring to the areas where they work. So, this is definitely a theme for our profession in general. But I want to go to how school nurses can help with promoting health equity and address the social determinants of health that's really becoming some hot topics these days.

COGAN: Right. So, it is a huge issue. I mean, first of all, I am a white nurse in a predominantly Brown and Black urban school district. And so, I know every day I have to walk in cultural humility to be able to effectively work with my families. And so that takes a long time to really develop relationships, to create trust, to be the person that people want to come to them solve these very important issues. But school nurses can also really advocate for, let's say, you know, this is a great example. During COVID, all of our students, no matter what their background was, their socioeconomic status, they all received, once we came back to school, they all received free breakfast and lunch. That is something that all students would benefit from, right? And that's actually happening in some states across the country. In fact, I believe Minnesota is one of those states where all students have access to free breakfast and lunch. And it's these things that school nurses can call out, can look for resources, can be part of the solution by bringing programs and services to school. There are so many school nurses that have food pantries, clothes pantries. In my district, we have spent so much time and effort creating really important, solid relationships with community health organizations who bring immunizations on site, so families don't have to miss time from work or school to get those important immunizations. We have groups that come on site to do those all-important school physicals and sports physicals. Anything we see that we understand is becoming a barrier for students, number one, to be able to stay in school, to attend school, to be healthy and well, we can try to bring in those services. So, whether it's a food bank, dental clinics, there's just a myriad of resources out there, but it takes time and effort and grant writing sometimes to be able to bring these resources to your school district. But there are school nurses all across this country that are doing that every single day for their students.

PIERCE: That's amazing. It's amazing to hear about. So, we're coming down to the end of our time and I want to ask you this question. What advice would you give nurses considering transitioning into a school nursing?

COGAN: Well, I think what's really important, honestly, is that they spend time as a sub in a district to see if they really want to make that transition. I think once you sub, you really see what it's like. I would also say be an overnight camp nurse, because if you can handle overnight camp nursing, you can handle school nursing hands now, no problem. But put yourself in circumstances where you can either follow the school nurse and see what it's like, take a class to see If your state requires certification, just take one class, dip your toe in and see what it's like. But get that hands-on experience. All schools need subs. And so, if you can find yourself able to sub, even if it's once a week, twice a month, it will make a big difference in making your decision about whether or not you want to make that transition. And I believe you really need to know, obviously, the expectations, is there certification? What is the support like? What is the training like? What is the on-site job training? Are they just dumping you at the beginning of a school year, and telling you to figure it out by yourself, which is pretty much what happened to me 24 years ago, or will you have a mentor? And also, what's the strength of your state school nurse association? Every state has a state school nurse affiliate, and most of those affiliates are all connected to our National Association of School Nurses. So, there's a lot of support out there for us educationally, in advocacy, tremendous support through our state and national associations. And find out if your state has a state school nurse consultant as well. Ask those hard questions. You know, talk to your own kids school nurse. Do they love it? Are they leaving? Are they saying you'll be perfect here? And they're like running out the door and trying to get you to take over their school. Like, what's the deal?

PIERCE: So that's going to wrap up our time for this episode and our series on school nurse trends. just listening to you talk, Robin, one of the words that really stuck out to me the entire conversation was advocacy, using your voice. This is a big role where you have to advocate and you have, your patient is basically the community, those students that are in the community and the parents and the family units of each of the students that are in that particular school or even the district that you're in. So, advocacy just really stood out as a huge role. So, for nurses that are really interested in using their voice to advocate and to work towards meeting problems within that particular community, I think this would be a really great role for them. What do you think?

COGAN: It would be a wonderful role for them. And I want nurses to understand, just like parents, the power of their voice. You know, we bring such a unique perspective. And I want parents to understand that we're on the same team as them. We want what they want for their kids. We want their kids to be safe, healthy, and ready to learn. Our role is to keep kids in school, not to send them home. And we want to work hand in hand with our families to make sure that that happens and to lower those barriers as much as we can to create that safe, healing-centered school environment where kids can flourish.

PIERCE: So that wraps up our time for this episode and our School Nurse Trends podcast series. Robin, thank you. Thank you so much for being here to just be a part of this discussion to advocate for this small niche of nursing and share your invaluable experiences that you're able to bring. So, thank you for being here with me today.

COGAN:  Well, thank you. Thanks for inviting me and for this opportunity. I'm looking forward to listening to it!

PIERCE: Yes, absolutely. To our listeners, thank you for taking time to listen to our discussion. We hope that you have gained some really valuable insights into the emerging trends and issues and what it means to really be a school nurse and the impact that school nurses get to have. There are some organizations that you can look at that have some valuable resources, such as the National Association of School Nurses and even the American Academy of Pediatrics can offer a wealth of information, training, and support to help school nurses stay up to date on best practices and emerging trends that they should know about. So, if you have not already, I also encourage you to explore many of the courses that we have available on elitelearning.com to help you grow in your careers and earn CEs.