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Rising to the Challenge
By Marcia Solomon, EdD, RN
Additional resources on camp nursing:
Association of Camp Nurses
American Camping Association
Marcia Solomon, EdD, RN, is a professor of nursing at Los Angeles Pierce College in Woodland Hills, where she teaches the didactic and clinical portion of maternity nursing and provides clinical instruction for medical/surgical nursing. She has worked as a staff nurse, project coordinator, and staff development instructor. She has been a camp nurse for 17 years.
If you like children and want to spend time in the summer working with and learning from them, how about being a camp nurse? The kids will test you with their creative afflictions: Campers have said they suffer from maladies such as instant paralysis, amnesia, stripes in their throat, bunkitis, and squirrel's disease. Their imagination makes camp nursing fun and interesting.
Camp directors hire nurses for the summer to provide health care to both campers and staff. Camp directors seek well-prepared, professional nurses who can meet the demands and challenges of the camp nurse role. Over the years, the nursing practice of the camp nurse has become more complex; the demands have increased in the camp setting as they have in all areas of nursing practice. To function competently, the nurse should be knowledgeable about the expectations and responsibilities involved. This article provides an overview of nursing practice in the camp environment.
Each camp is a unique community with a culture of its own. Camps provide services for their campers in a variety of ways, and traditions, rules, and beliefs are the core of each camp's identity.1 Camps are located in all sorts of geographical areas, and staff members offer campers a range of programs and activities. Examples of programs include theater, crafts, swimming, hiking, sports, cooking, and computers.
Staff members include camp directors, coordinators, counselors, and specialists in swimming, crafts, nature, and other areas. Often staff members have spent many years at the camp; they are willing and eager to share camp-related information with novice camp nurses. Nurses benefit from these interactions by learning more about the camp and their own responsibilities.
Camps can be coed, girls or boys only, private, day, or resident. At day camps, both campers and staff are transported to the camp daily and returned home each evening. Resident camps are the traditional "overnight" camps where campers and staff stay for periods ranging from a few days to several weeks.
Specialty camps are designed to serve children with a variety of physical, behavioral, and emotional needs. These include camps for children with developmental disabilities, hemophilia, cancer, HIV and AIDS, spina bifida, diabetes, asthma, and other chronic illnesses. Camps may be accredited by the American Camping Association if they comply with the organization's standards and complete an accrediting process repeated every three years.
Before going to camp, nurses should inquire about medical support staff, responsibilities, salary, work schedule, co-workers, and living accommodations. Nurses who wish to take their own family members to camp should consider their ages and interests and select the camp that most closely meets their needs.
Registered nurses and licensed vocational nurses may be employed to work full time for the entire camp summer or part time for only one or two sessions. The camp may have only one camp nurse, or there may be several nurses as well as allied health professionals. Emergency medical technicians, nurses assistants, nursing students, physicians, and social workers are some of the other people who may work with the nurse. Auxiliary camp staff include secretaries, camper helpers, and drivers to transport campers to hospitals and physician offices. Nurses must be licensed in the state where the camp is located and have a current CPR card; some camps may request a first-aid certificate and proof of malpractice insurance. Nurses always practice under the Nurse Practice Act in the states where they are working.
Most camps do not have a physician living at the site full time. But nurses can contact the camp's physician by phone, so the opportunity to collaborate with a physician on medical decisions about campers is always available. Whenever necessary, campers can be taken to the physician office for further assessment, evaluation, or treatment. Some camps use nearby urgent care centers.
Some camps are near a metropolitan area, meaning transportation to a hospital is easy. Other camps are in remote or rural areas with the nearest medical center hundreds of miles away.
Scope of practice
Good communication skills are imperative for the camp nurse because of the frequent interactions with administrators, camp staff, campers, and parents. As soon as the nurse arrives at camp, he or she should contact the camp director and the administration team to discuss the organization structure of the camp and health center, the center's regulations and protocol, and the chain of communication.
Although ultimate responsibility for maintaining Occupational Safety and Health Administration (OSHA) standards rests with the camp director, nurses are often asked to teach the camp staff about regulations related to universal precautions, bloodborne pathogens, and the handling of hazardous materials. Nurses usually present this information in a teaching session with the staff before campers arrive. This session may also include information about identifying actual and potential health problems and is a good time to stress the need for careful observation and safety precautions. Nurses may go over basic first-aid measures, review CPR and the Heimlich maneuver, give instruction about how to react to an emergency, and communicate the rules and regulations of the health center. It's also a good idea to discuss age-appropriate information about children so that staff can distinguish normal growth and development behavior from serious medical problems.
Since counselors spend the most time with campers, they need to know how to identify problems and to decide when to bring campers to the health center. Health promotion and prevention in a camp depend on an informed staff, so these teaching sessions are important.
Adaptation of skills
One of the most challenging aspects of camp nursing is learning how to adapt skills and care to the camp setting.2 Most nurses are unfamiliar with the outdoor setting of a camp. The nurse must function as a risk manager and gather and analyze information about the environment. After touring the camp, the nurse needs to compile a list of major risk factors and potential health hazards.3 These may include potholes, inadequate lighting, ruts, poison ivy or poison oak bushes, and beehives that need to be removed. All staff members need to be alert to environmental health hazards and to report them to the nurse.
In most healthcare settings, nurses rely on a variety of equipment and supplies, a laboratory, a pharmacy, and physicians and other colleagues with whom they can solve problems. At camps, equipment may be limited, there is no laboratory, and a physician may not be in residence. There may not be another nurse or allied health professional on site with whom the nurse can collaborate.
Nurses must rely on their own skills and clinical knowledge, including critical thinking and problem-solving abilities, to make knowledgeable, independent decisions and interventions. They must also use common sense and good judgment. Nurses should take current drug books, pediatric textbooks, and stethoscopes with them. Nurses may need to determine whether to admit a sick child to the camp health center as an inpatient or refer the camper with a specific problem to a physician, dentist, or other specialist in the community. Nurses may need to decide to send campers home or to the emergency room when no physician is present at the camp.4
Nurses need to review the normal parameters for vital signs, growth and development, and children's special needs. They need to consider methods for moving injured campers from remote areas of the camp to the health center and for finding out who the administration has assigned to help with emergencies. There should be a means of communication available to call for emergency help when needed.
Camp nurses must be acquainted with the healthcare resources near the camp. These include hospitals with emergency care and laboratory facilities to analyze throat cultures, urine specimens, bloodwork, and other types of specimens. Before the start of camp, nurses should provide hospital staff with the dates that the camp will be in session so that the hospital will be prepared to receive campers in the emergency room, laboratory, and radiology department. Phone numbers for ambulances, poison control centers, and the fire department should be posted in the health center.
Most camps have insurance for their own protection. The camp nurse documents any injuries or accidents and notifies parents, the camp director, and the insurance company. The camp nurse should complete insurance forms accurately and send them to the insurance company.
Educational programs to prepare nurses for practice in this unique clinical setting would be extremely valuable. For many years, nurses have learned nursing practice of the camp nurse in a variety of ways: "on the job" with no formal training, from an experienced nurse or allied health worker at the camp, or from the camp procedure book. Every summer the camp nurse must not only learn his or her role, but also adapt to changes in health care, government regulations, and liability issues. Information about these issues and the general functioning of the camp health center should enable the nurse to learn the role of a camp nurse and make knowledgeable nursing interventions.
The multidimensional role of the camp nurse encompasses many diverse responsibilities; the nurse must act as a direct care provider, program manager, educator, health counselor, and consultant.1 As always, the nursing process provides the framework for nursing practice. During health center hours, the nurse triages campers with problems and formulates a plan of care for individual campers. Intervention may include administering medication or sending the camper to a physician. At times, health teaching may be needed to answer the campers' and counselors' questions. Counselors should always be advised of the care their camper is receiving since counselors will be with the camper a majority of the time.
Screening health forms is an important part of managing the health center. Initially, health forms should be checked on opening day for food and drug allergies; health history, including immunizations, chronic illnesses, and special needs; health insurance information; and a parent's signature for consent to treat with a release of liability. Depending on the type of camp, intake exams are performed on the first day; they may include checking temperature and weight and examining the campers' hair for lice or feet for athlete's foot. Records should be kept in a locked file in the health center so that the information is accessible, but confidential.
Throughout the day, nurses care for children who may have been admitted to the health center for fevers, infections, or other health problems. Nurses also administer medications and handle walk-in problems such as abrasions and beestings. Some of the common medical problems seen at camp are URI, strep throat, rashes, stomachaches, headaches, conjunctivitis, twisted ankles, jammed fingers, and ear infections. Different types of injuries may be more prevalent during specific activities, such as burns and cuts resulting from crafts or cookery, sports injuries from athletics, arrow sheath burns from archery, and tics and blisters following hikes. It is not uncommon to have children with diabetes, asthma, anorexia, and attention deficit disorder in a regular camp population. Periodically, campers need emotional support for homesickness, problems with other campers, performance of an activity they don't like, or general malaise. This group of campers comes to the nurse for emotional support, a hug, and some TLC.
Whenever possible, nurses should walk around the campgrounds and observe campers during their activities. At this time, some kids and staff may talk informally to the nurse about health problems that they may not want to talk about at the health center. Such walks also provide a chance to identify possible health hazards.
Every camp should have a procedure that defines emergency measures and how to obtain help (walkie-talkies, phone, pagers, etc.) at the camp setting. The nurse should review these procedures when he or she arrives at the camp. All camps should have intubation supplies and standard emergency equipment and medications available. At the beginning of camp, oxygen tanks should be checked by the respiratory therapy department at the local hospital. Sometimes equipment is kept in a carrying case so that it can be easily transported to different locations around the camp.
The nurse needs to maintain a daily logbook of care administered at the health center. The entry in the book should include the date, time, camper's name, complaint or illness, and treatment; separate medication forms noting the dates, times, medication, and nurse's initials should be completed too. Other documentation to be completed may include incident reports, insurance forms, and lab request or reports. The nurse may be required to complete an evaluation of the camp's health program at the end of the session.
Administration of medications
Studies of medication use patterns in more than 250 camps across the country indicate that the most common categories of drugs administered at camps are antihistamines and decongestants, analgesics, antibiotics, bronchodilators, and cerebral stimulants such as methylphenidate (Ritalin).5 It is the nurse's responsibility to check all stock and emergency medications for expiration dates and to discard outdated medications. As with patients in any setting, the nurse needs to be sure that campers do not have a drug allergy before administering any new medication.
At the beginning of camp, the camp physician writes, dates, and signs a list of standing medication orders, which may vary from camp to camp. (See "Standing Orders.") These include common over-the-counter medications, doses, and the times that the medications can be administered as needed by the nurse. This list should be displayed in a prominent place in the health center.
Campers bring a variety of medications to camp, and these medications need to be screened on opening day. (See "Campers' Medications.") Medications should be in prescription containers, clearly dated, and labeled with the physician's orders and the expiration date. Many camps require the child's physician to write all current medications and the reasons for their use on the child's health information sheet. Nurses may also be asked to administer allergy injections and growth hormones. When another nurse is present, it is good nursing practice to double-check the order and doses sent by the physician. Unlabeled or improperly labeled medications and those sent in plastic bags should not be accepted. If necessary, the nurse should call parents for clarification of any discrepancies about the physician's order, dose, or time of any medication that was brought to camp.
There should be first-aid kits in areas such as the swimming pool, ropes course, athletic fields, and arts and crafts. Groups going out of camp on hikes and field trips should take first-aid kits with them.
Properly labeled medications that need to be administered while campers are off the campgrounds on hikes or outings should be given to the counselors beforehand. Counselors need to be informed of the medications their campers are taking. The phone number of the health center, physician, and local hospital should be included with the first-aid supplies. Some camps send duplicates of the consent-for-treatment forms to be used if a problem should occur. Depending on the type of camp and medical staff available, sometimes the nurse may be required to accompany the camper group on its outing.
Providing care for children and the camp staff is challenging and rewarding. It requires the nurse to creatively adapt his or her clinical practice to the camp environment, to exercise critical-thinking skills, to use sound judgment, and to assume a leadership role--all of which will help enhance your nursing practice in any setting.
Lishner, K.M., & Bruya, M.A. (1994). Creating a Healthy Camp Community. Martinsville, Ind. American Camping Association.
Lishner, K.M., & Busch, K. (1993). Beyond Calamine and Pepto Bismol: Safe Delivery of Medications to Children in Summer Camps. Spokane, Wash.: Intercollegiate Center for Nursing Education.
Czupryna, L. (1989). "Partners on the health and safety team." Camping Magazine Annual Report, 61(6), 29-31.
Czupryna, L. (1984). "Primary prevention in a camp setting." Maternal Child Nursing, 9(4), 197-199.
Tone, B.W. (1994). "Off to camp." RN Times, 2(12), 5.