Too Many Visits - advice for teachers?

[moreoreo]

(Disclaimer: I freely admit this is a whiny post and have bolded my actual questions for any who prefer not to read it!)

I know this is a repeat question but I also know it's not the first time for a repeat question to be asked here, and I would like some guidance from those who have been at this for longer than me.

I like to be busy and I am in no way wanting an empty health office. However, an issue I ran into at the end of last year has continued into the beginning of my first full year and I (and seemingly every one else) am at a loss as to why or how to fix the issue.

By the end of last school year, we were seeing 70-90 children most days (not including ~10 meds and procedures). My prek-5th elementary school has about 800 children. This means that on the days we saw 100 we were seeing a whole 1/8 of the school. Even on those days, I think the most I ever sent home was 5. Already, I am seeing 40-50 every day this year. It only took 3 days to go from 20s to 30s to 40s. Sometimes I see nearly 20 in one hour of recess and most of them have no visible/palpable sign of injury and end up chit chatting and smiling, walking around to get water, etc. by the time I work through the masses and see them. I would say most of these students leave the health office without any intervention at all other than assessment. (I have all but stopped using ice packs because I have found that that has cut down on students coming in just because they want one.)

Any given time that I have 10 in my office, I usually only feel that 1 needs attention, and rarely is it urgent. I think the most telling fact is that the other elementary school nurse in my district sees around 10 students in a day even though it is about the same size. I asked if she has run into this issue before and she said no. Our front office is also shocked by my numbers and questioning out loud what is going on. In these first 8 days of school I have seen 180+ different students (many of them several times). This is 1/5 of my school. I have only had 1 legitimate fever, 2 serious injuries, 2 less serious injuries, 1 with asthma trouble, and a handful who have vomited.

My main question is what pointers have you given to teachers about problem-solving in the classroom? (And did it help?) Because some of my visits from classrooms are things like "blister" (intact) or "leg started hurting while sitting" or "foot fell asleep." A lot of walky talky smiling stomachaches all throughout the day. I am starting to suspect that some of our teachers are not really asking the children any questions before sending to me and I am hoping that I will be permitted to give them some guidance.

I have already started discussing with students the appropriateness of their visits ("I understand you fell, but your knee looks exactly the same as your other knee, and you are walking so well. Do you think next time we could rest and see if it feels better?"). I have become more stern and honest with them than last year because it has been suggested to me that the children come because they like me and I want them to know that the health office is not a place to go just because you feel like it. The students I have already seen 4 or 5 times in this first 1.5 week of school, I am also communicating with their parents about speaking with them to see if they need to see the doctor or if they need help identifying when they need to come see me. Children and parents have been somewhat receptive but I would also like to help the staff.

I know I have seen something like the "5 B's" here (breathing, bleeding, barfing??). Any other ideas for staff tips and/or other ideas would be greatly appreciated. I have so many things I want to do for the student body as its nurse (speak with parents to get actual information about food allergies, investigate the hundreds who have "asthma" noted in their history to see who is actually still at risk, etc.). Teachers ask me questions and I don't have time to get the answers. I love these kids and don't mind seeing them all day; the worst part of this for me is the constant traffic makes it impossible to actually assess school health, promote health, and plan for the year. I know having frequent flyers and assessing nonsense complaints is par for the course but I am concerned that this is more than that and don't want to contribute to the problem.

Posting this before Labor Day Weekend might seem like folly but maybe other people like me still have their minds at school. Thank you to anyone who takes the time to read this, I am open to any suggestions any time

[SchoolNursey]

I am currently dealing with this same problem, except I am in a middle school, 6th-8th with almost 900 students. I am only here 3 days a week, but see about 60+ daily. I have 14 daily meds also. My visits start as soon as I walk in the building. I have a school based health center in my campus and since they opened, my visits have tripled. I have no words of wisdom but hopefully someone else does!

[moreoreo]

I am currently dealing with this same problem, except I am in a middle school, 6th-8th with almost 900 students. I am only here 3 days a week, but see about 60+ daily. I have 14 daily meds also. My visits start as soon as I walk in the building. I have a school based health center in my campus and since they opened, my visits have tripled. I have no words of wisdom but hopefully someone else does!

Of the 60+ would you say the visits are warranted? Of my 40-50 a day, I usually send 2 home, and I'd say at least a dozen are for things like "I bumped my elbow on my chair."

I don't want to point fingers but in all my fussy analysis I wonder if it's in part due to teachers jumping to attention at every tiny thing (I recall commiseration on this board between nurses about how we are disinclined to run to a child who has fallen down... it's something I feel strongly about, that when we don't give a child five seconds to even decide that they're ok, of course they will opt for the attention-getting "it hurts" route). I imagine in their classrooms they sometimes are too quick to coddle and end with "go to the nurse!" I have teachers who bring in a student with a scrape who are more antsy than the student and are trying to get my immediate attention while I'm already working on someone else. When I smile and say to sit down and I'll be there later they say "ok the nurse is going to be RIGHT here!"

This might sound mean but I'm starting to train myself not to jump out of my own seat every time a child walks in. You can do a lot of across the room assessment in the few minutes it takes to complete the task you're working on. I feel like part of why the school doesn't realize I have other duties is because I always get up the second they walk in.

I have tried to implement so many things, from having children apply their own bandaids, to not sending ice packs out of the office, to keeping visits shorter, to making them longer, to having conversations with children and parents alike for coming too frequently... we had a meeting with our principals and are sending out numbers and suggestions (I've seen 33% of the entire student body in just a few weeks!) and if this all fails then I will just try not to lose it when we end up with 100 daily like we did last year

[SchoolNursey]

Of the 60+ would you say the visits are warranted? Of my 40-50 a day, I usually send 2 home, and I'd say at least a dozen are for things like "I bumped my elbow on my chair."

I don't want to point fingers but in all my fussy analysis I wonder if it's in part due to teachers jumping to attention at every tiny thing (I recall commiseration on this board between nurses about how we are disinclined to run to a child who has fallen down... it's something I feel strongly about, that when we don't give a child five seconds to even decide that they're ok, of course they will opt for the attention-getting "it hurts" route). I imagine in their classrooms they sometimes are too quick to coddle and end with "go to the nurse!" I have teachers who bring in a student with a scrape who are more antsy than the student and are trying to get my immediate attention while I'm already working on someone else. When I smile and say to sit down and I'll be there later they say "ok the nurse is going to be RIGHT here!"

This might sound mean but I'm starting to train myself not to jump out of my own seat every time a child walks in. You can do a lot of across the room assessment in the few minutes it takes to complete the task you're working on. I feel like part of why the school doesn't realize I have other duties is because I always get up the second they walk in.

I have tried to implement so many things, from having children apply their own bandaids, to not sending ice packs out of the office, to keeping visits shorter, to making them longer, to having conversations with children and parents alike for coming too frequently... we had a meeting with our principals and are sending out numbers and suggestions (I've seen 33% of the entire student body in just a few weeks!) and if this all fails then I will just try not to lose it when we end up with 100 daily like we did last year

Well, because I have a School Based Health Center, I am required to refer every student that has a consent form to be seen. BUT I am supposed to assess them first, which is frustrating because if a kid wants to go there, I can't deny them. So why do i assess them? My SBHC serves 2 schools and is owned by a separate company, not the school district. I have not sent home any kids from either school this week.

With that said, I used to triage before sending to SBHC. I would only send kids that i would otherwise send home or advise to be seen by MD. But the owner of the SBHC went to my boss and threatened to close down the center if I didn't start sending more kids......

I always make the kids sit for at least a minute while I finish what I am doing, usually charting on the last student. This gives me time to assess them without them knowing I am assessing them. Tells me A LOT when I just watch body language.

[ruby_jane, BSN, RN]

Y'all are making me happy about my 45 high schoolers who visit each day. I love the different ways nurses express themselves to teachers and I will be stealing some of these tactics. I think after 2 PM the teachers have just given up...

[nursetlm, ADN]

I haven't read everyone's replies to this thread yet- but here's a letter I use: I am elementary school though.

Guidelines for Nurse's Office

Reasonable Expectations for Self-Care in Classroom:

As the new school year begins, it is a good time to educate the students as to when it is appropriate to come to the nurse's office. This will help prevent students from misusing their education time by spending it in the nurse's office for minor complaints.

Our mission is to provide a safe, healthy learning environment in our school and to keep the student in CLASS for optimal learning. All students sent to the nurse's office MUST have a Nurse Referral Slip filled out with both first and last name, primary complaint and room number. We understand that emergency situations occur where this is not possible, but is the expected daily procedure.

Each classroom teacher will be given a Ziploc bag of gloves, band-aids, gauze pads and other items to allow for minor cuts/scrapes to be handled in the classroom. If you are in need of band-aids, gloves, etc please notify the nurse and she will provide them. Each teacher will be informed of students in his/her classroom with chronic health conditions or potential for emergent conditions.

Questions to ask students before sending them to the nurse's office during class: Have they used the restroom? Hungry? Tired? These are not emergent reasons to see the nurse.

Students should stay in class:

-Approximately the first 45 minutes of instructional time UNLESS they are vomiting, have hit their head, are having breathing issues (including known asthmatics), broken bones, pink eye, injury to eye, loss of consciousness or seizure, lice or bleeding profusely.

-When an old, healed abrasion (scab) is merely sore or itches. This is part of the natural healing process.

-When there is soreness from an old injury. If no bump, bruise, swelling or redness or it is more than 24 hours old- no ice should be given- it will not help at that point.

-If a student has a bandage that was applied by a physician-I am not able to reapply or change it (without doctor's written orders) I can only reinforce it.

-When a student regularly finds excuses to leave class and rarely has to go or stay home because of illness.

-When a student frequently asks to go to the nurse at the same time of day.

Reasons to call Nurse to site/location for assessment:

-Loss of consciousness

-Bone/Joint injury (possible dislocation/fracture)

-Seizure activity.

-Serious falls/accidents that involve head/neck/spine.

-Signs of allergic reaction: Swelling of mouth/lips, hives, vomiting, nausea, hoorificeness, and wheezing or abdominal pain.

Valid reasons for leaving class and coming to nurse's office:

-Vomiting (not just spitting up phlegm)

-Bleeding (minor scrapes can be handled in the classroom)

-Breathing difficulties (wheezing, shortness of breath)

-Bone/joint injury (I can also come to location if needed)

-Undiagnosed rash.

-Splinters- imbedded splinters cannot be removed, but will be cleaned/covered.

-Nosebleed- student should pinch own nose closed with Kleenex, breathe through mouth and walk to clinic.

-Suspected head lice/excessive head scratching.

-Human or animal bite.

-Injury to eye

*For students who complain of headache or stomachache, and it is close to their lunchtime (these symptoms may indicate thirst or hunger): 1. Give them a drink of water, 2. Have them put their head on desk for a minute or two (if possible) and when time, 3. Have them go to lunch. 4. If they continue to complain after lunch/recess, then they should be sent to the nurse's office.

[naveiak]

Some teachers will always feel like it is "not their job" to handle anything even remotely medical, and with 30 kids in a class, they might not have time to ask the student follow up questions. And depending on the student, they might just be happy to get them out of the classroom.

But that being said, they do need to take a moment to fill out a pass and hopefully in that moment will realize that it is ridiculous to be sending a student who's "foot fell asleep" to your office.

When I first started, I redid my passes with only 6 options for the teachers to pick from, and if they write one in like "stomach ache", those kids are in and out as fast as possible and I write on the bottom of the note that "unless their symptoms change, they should remain in class."

With a lot of staff communication I've been able to bring my numbers down from to 70+ when I started, to an average of 30 daily (not including meds or treatments). There are still some teachers who will ALWAYS over send, but a lot did respond in a positive manner.

I'd love to see a copy of the passes you created... would you mind sharing? Thank you!

[MrNurse(x2), ADN]

I know this is an old post, adding this for someone who may be looking for advice in the future: before you ever accept the pass ask "would this stop you from playing if you were home?". You would be surprised how many turn around and go back to class.

[Amethya]

It's an old post, I know but I remember when I first started I had more than 50 students in my office the first day. But as I been here longer and I gained a reputation and experience, my numbers have dwindled to only 10 or less. I made it a priority to let teachers know and that if they can please check on students first in the classroom, if nothing works, then please send to me. It works, plus I do not accept students between passing periods and must have a pass, unless it's an emergency.

[beachynurse, ASN, BSN]

Then send it to a couple of teachers at a time.. theres more than one way to get the point across..

[EnoughWithTheIce]

I have had one on one conversations with teachers before to try to get at the root of why they specifically send so many kids. Often, they just think they should!!

At my prior school, there were approximately 85 teachers. I often explained to my "frequent flier teachers." I am so glad not all teachers send 8 students a day like you. If they did, then I would see 680 kids a day (half the school).

But truthfully, anything above 40-50 daily means you are not giving proper assessments.

[CoastalSchoolNurse]

Hi there!

I use a Power Point in the beginning of the year that delineates "when to visit the nurse" and "when not to visit the nurse." I was once encouraged by a fellow nurse to "shut the door!" to the office and put a note (back at 11:20am, etc... call for emergencies only). I thought she was crazy but it does decrease visits. I used this trick to go into each individual classroom, put my face out there, and give a 10 minute presentation at the beginning of each year.

I typically have from 50-70 visits a day in my 200 student school with a handful of chronic students. I am the sole school nurse. After completing the presentation, this number drops to 30-50 which is extremely beneficial for not only my mental sanity but also to prepare for the school year/immunization time/etc. I have found that it is key to get it done in the first month to avoid school nurse headaches!

Good luck!

CoastalSchoolNurse