Frequent Flyers

[alligatoRN]

Hi All!

This is my first semester of school nursing after being bedside for 2 years. I am starting in the middle of the school year so I'm playing catch-up and trying to figure out all of the stuff the previous nurse left. With that being said, I feel as if she welcomed the frequent flyers, which is a problem to me.

I have found that a few students come in every day, with stomachaches or headaches, but no temps and seem absolutely fine. The same few students come in during lunch as a big group, where one student will ask for lotion or a salt water gargle. As I ask the group of girls to wait outside for the one student who requests the gargle, the rest of the group will all the sudden say they have stomachaches or headaches, when they did not need anything when I asked previously. I cannot have a crowd of students malingering in my small office every day. How do you cut the habits and reduce the frequent flyers?

Thank you!

[halohg, RN]

Which grades are we speaking of here? Who is permitting these students to come to you? If you do not have a pass system from teachers...implement one. If a student presents without a pass send them back to where they came from...no excuses unless from gym, active bleeding, or breathing issues. If lunch staff is permitting large groups of students to roam the halls and they find there way to you, then I would speak with that staff directly and lay down the rules. If they are not receptive then bump that issue up to administrators. You are there for skilled nursing care, if a student presents with a pass and the friend who is keeping them company comes up with an issue of their own, I send them back to get their own pass. If the student is not going home I always send the friend immediately back to where they came from. I thank them for making sure their friend arrived to me safely and instruct them to go back to class. I also keep my office very simple so not to make it ‘fun’ to see my office. The first year is the most challenging...it gets easier... I promise.

[Flare, ASN, BSN]

Ditto to the passes, especially if you're dealing with middle school or higher. Reason for visit written on pass is a nice bonus as the reason given to the teacher is often one thing then becomes something completely different by the time they reach you. You'll be amazed the lightning speed that illness progresses in school children trying to avoid work. A kid can have a headache and then return to you in 20 minutes claiming to be on their deathbeds. Granted, some of these kids CAN have fevers shoot up quickly, but those usually aren't the ones that keep returning to your office - it's usually the ones that are frustrated that you forgot your magic wand that ends colds (you received your school nurse package, right? It contains a magic wand, x-ray specs and a crystal ball! make sure you bring all of them every day! ?)

[SaltineQueen]

They're testing you. I agree with halohg that you should insist everyone come with a pass. When they do come, no chit-chat, check their temp & if it's fine send them on their way. MAYBE 5-10 minutes of rest if they're looking particularly pitiful. Will you send back a kid who ends up puking? Yup. It happens to all of us.

But...just something to keep in the back of your mind is that sometimes frequent vague complaints are a symptom of things happening at home. If your spidey sense starts to tingle, listen to it.

[NutmeggeRN, BSN]

17 minutes ago, SaltineQueen said:

But...just something to keep in the back of your mind is that sometimes frequent vague complaints are a symptom of things happening at home. If your spidey sense starts to tingle, listen to it.

This, all day long...

[LikeTheDeadSea, MSN, RN]

Welcome!

ONE OF US! ONE OF US!

I have to do a lot of staff education in order to decrease frequent flyers. I wish I could help but elementary is a bit different. I imagine middle school is even harder with the amount of teacher changes. No one knows who has been to you already that day so to that teacher it's the student's first request.

[BunnyBunnyBSNRN, ASN, BSN]

I dealt with that during my 3rd year of school nursing. I switched schools with another nurse in the same district, so I went from elementary to middle school. The very first day of school, a student came in during her lunch just to sit in the nurse's office instead of being in the cafeteria, since "the last nurse let me do it". My response was, "I'm not Nurse So-and-so, and this is not the cafeteria, so you will not be spending your lunch here." Of course I got the reputation of being "mean", but I didn't care.

Basically, I'm trying to tell you, you need to stand your ground. They can't come on their way to or from lunch, they can't come during lunch, and they can't come between classes, unless they are experiencing one of the "3 Bs" - blue, bleeding, or bone sticking out.

You will do great! Your first year is always the hardest. You will be amazed at how different you feel at the start of next year!

[pedi_nurse]

Welcome! I'm a middle school nurse as well!

I second (or third or fourth?) the pass system. I started out excepting any type of pass, but now I require either a nurse pass I created or a phone call from the teacher.

Additionally, I opt not to allow students to rest in the clinic unless they have a documented condition requiring it (migraines, for example) or they are going home sick. Nor do I hand out ice packs unless there is visible swelling or skin irritation from a minor allergic reaction. I check every stomach and headache for fever and do a brief assessment, offer for them to call a parent to bring medicine, encourage water, educate them a little on what might be going on, and try to treat them all kindly and compassionately.

And then I send them promptly back to class.

Most kids are in here for only about five minutes. After doing that for a few weeks, you'll see a drop in a lot of those frequent flyers when they learn you really aren't going to let them hang out. The persistent ones will get more phone calls home regarding the concerns, discussions with teachers/counselors, and in extreme cases, banishment from coming to the nurse except for a quick temp check during lunch.

It's important to not have a crowded clinic - if there is an emergency, you need to be able to get the clinic covered or kids out quickly. It's important for kids to be in class learning if they are not sick enough to be excluded from school. Fortunately for us, middle schoolers are old enough to start learning to handle discomfort in light of the responsibilities they need to attend to.

Hang in there! It gets better/less hectic!

[ruby_jane, BSN, RN]

Ask for a pass all day, every day (unless they're profusely bleeding, not breathing, or legit limping....that one bit me last year).

Realize everything everyone else said is true.

Fully assess everything anyway. I had a kid with a stomach ache Tuesday and Wednesday, no fever, tolerated crackers. Today she has a 100.2 temp and a sore throat so it may have been strep. Who can say??

Good luck!

[Flare, ASN, BSN]

1 hour ago, pedi_nurse said:

It's important to not have a crowded clinic

This! I have impressed this upon my staff who, when there have been times that I have had an office full Murphy's law always seems to kick in and there is suddenly an emergency on the other side of the school. It can take forever to clear the office, especially if I have littles that are just dumped off then don't know how to get back. I delegate that to older students in these circumstances.

[Jedrnurse, BSN, RN]

Middle School is both my kryptonite and the bane of my existence. They're losing (not loosing) the cuteness of elementary school and gaining more attitude. Also, their higher reasoning isn't at the high school level yet...

Give me the elementary munchkins any day.

[EnoughWithTheIce]

13 years of school nurse experience here, 10 in middle school. I agree, you have to stand tough with students AND staff, even if you get the reputation of being mean. Otherwise, you will get everything dumped into your clinic. Behavior problem kids, stinky kids, sick staff kids, kids that don't want to go to pep rallies, kids that have been banned from going to student bathrooms, SPED kids whose teacher does not want to deal with them on a particular day, etc, etc.

I try to be as proactive as possible. Because students see 7-8 different classes a day, teachers won't always know Johnny has been to see you every day this week or 3 times already this morning. I will e-mail teachers updates - "teachers, Johnny was cleared to remain in school by me at 8:32 this morning. I spoke with mom and the plan is________________."

Also, it is important to get your frequent sender staff members under control. I have had one on one conversations with teachers and many are under the perception we are mini ER's with well stocked pharmacies, crutches, boots, a backroom dental office and a food hall worth of snacks and drinks . When they learn what our role (and limits) are, they will (mostly) back off. Others will tell you the story of "the last district i worked at got sued by a parent for not letting a child with an untied shoelace go to the nurse" and there is NO stopping them so don't waste your breath. Although I do like to counter act that with "they may have sued, but did they win?"