School Nursing: Burnout and Renewal

Purple_Scrubs, BSN, RN

I work for a large urban school district. The district as a whole, and my school in particular, is host to a large number of students from low socioeconomic backgrounds and various minority groups. One of the first things my principal told me was that I am the only healthcare provider that many of these kids see. Such an awesome responsibility to fall on one person's shoulders. While I loved my job and working with the kids, a slow insidious stress began to creep into my life, much without my notice.

The transition from being one of a team of healthcare providers to being THE healthcare expert on campus can be difficult. There is no one else to grab and say, "Hey, come take a look at this rash". While my supervisors at Health Services were always supportive and merely a phone call away, it is not the same as having a brain to pick in the building. I am the one who decides which rashes need a doctor's examination. I am the one who determines if that hurt wrist is a possible fracture or simply a strain. I am the one who decides which head bumps need medical intervention versus an ice pack and a hug. It all falls on my plate, the good outcomes and the bad.

As I learned to deal with being THE nurse, I became aware of the many other stressors of school nursing. Parents are a funny group. You have the ones who will scream that you did not call them for little Johnny's scraped knee. On the other hand, there are those whose phone numbers are disconnected or who tell you they are at work and cannot take little Suzy to the doctor when her asthma is acting up (and you have been asking them to provide an inhaler and permit for school use since August). Thankfully, most parents fall somewhere in the middle of this continuum.

Teachers are another funny group. The vast majority are wonderful and truly appreciate having a nurse in the building. Then there are those who all but demand for a parent to be called for a student who claims he vomited in the bathroom, with no signs of illness and who has been in my office for near an hour with no fever and no repeat episodes. There is that one who will have students call home themselves (on the teacher's cell phone!!!) before sending the student to the nurse for assessment. Some are happy to place a band-aid on a paper cut, while others will send a student to the clinic for every complaint and every invisible ouch imaginable.

Of course, there is the stress of that great unknown. When will "it" happen. Every parent, teacher, administrator, and school nurse's nightmare. The true emergency. We know it is bound to happen sooner or later. Will that kid with a sore neck coming around the corner have meningitis? Will that boy who bumped his head at recess start to seize? Will the little girl with asthma and still no inhaler at school have a severe attack. What if a child with undiagnosed allergy gets a bee sting? What if a teacher's shortness of breath after climbing the stairs turns out to be an MI? Of course, I am educated and well prepared for all of these uncertainties. That does not mean I am ready to face them.

So as my first full year as a school nurse wore on, I found myself feeling more and more negatively about my job. I would vent daily to my husband about uncaring parents, teachers with no idea what I really did, and "frequent flyers" who surely must think I was born yesterday. I stopped putting band-aids on well scabbed and healing cuts; those kids are just looking for attention. I became skeptical of any child who claimed to have vomited; I started to require that I must see the vomit or it does not count. I all but gave up on getting some kids what they really needed, be it a pair of glasses or a winter coat; if the parent does not care, why should I? By the time December rolled around, I was nearing the end of my proverbial rope.

The Friday before Christmas break was a busy one for the entire school. Between plays and class parties and the kids' sheer excitement of having no school for two weeks, there was little merriment for teachers and staff. We were all weary warriors just trying to survive the day. Or so I thought.

I was desperately trying to finish up documenting my vision and hearing screening results before the holiday, as is required by state law and my district, when the teacher's assistant for a bilingual Pre-K class rushed into my office.

"Nurse, nurse, we need you in the hallway!" Here we go, I thought. This particular Pre-K class had a knack for lunchtime vomiting, usually with no underlying illness other than a pathological distaste for fish sticks. I dragged myself from my chair and into the hallway joining the cafeteria and office. The class was lined up nicely with the teacher at the head.

"One . . . Two . . . Three!" the teacher counted, upon which the class chimed, almost in unison, "Merry Christmas, Feliz Navidad!". A tiny girl handed me a plastic candy cane filled with M&Ms and threw her arms around my waist. At that, several other little ones demanded a hug of their own and swarmed around me.

"OK, OK, everyone gets a hug! How about a group hug?" The class closed in on me like ants to candy, holding tightly to my waist and each other. The teacher and her assistant laughed out loud at the sight.

"We just wanted to thank you for everything you do for us," the teacher said. I blinked to clear my eyes and gave a last squeeze to the closest children.

"Thank you all, you have made my day," I replied.

The day ended uneventfully and I gleefully headed for home with a long stretch of days off before me. As I unwound over the next two weeks, I reflected on myself, my job, and my nursing philosophy. I had entered school nursing not because it was easy, without stress, or even less stressful than the toxic environment at the hospital I had left. I entered school nursing to make a difference in the lives of children. I knew that I had done that.

There was the girl who was at first distrustful and did not want to come to my office at all, who ended up confiding to me that her grandmother was dying. She ate lunch in my office that day, unable to face her peers in her distraught state. We ate in silence until she opened up and shared her feelings about her grandmother. At the end of lunch she said she felt strong enough to return to her classroom. I told her I knew she was.

And what about the boy who had no idea how to use his inhaler properly or why he needed it. I spent time each day teaching him about his condition and how to take care of himself. Weeks later his mother commented to me that she had learned so much from the things her son was telling her about our talks.

There was the parent who was eight months pregnant when she slipped and fell in the cafeteria. I sat and held her hand while we waited for the ambulance. I consoled her daughter when her mom was taken to the hospital for precaution. Thankfully, all were OK and a gorgeous baby boy has joined the family, none the worse for wear.

Of course, there were the hundreds of tears I had hugged away, the boo-boos I had healed with a little compassion and a band-aid, and the kids who knew that no matter what, there was at least one grown up in their lives who would take care of them when they hurt. I had indeed made a difference in many lives. Perhaps not every day, and not without added stress to my life, but yes, I make a difference.

To this day, I cannot pass by that Pre-K class without at least one or two hugs from smiling kids. Whenever I start to recognize those first pangs of burnout, I think about that simple act of gratitude and it keeps me going. Oh sure, my rule that I need to see vomit before it "counts" still stands, but I am quick to give a band-aid for even the smallest scratch if it makes a child feel better. I try to see my job as not just to heal the visible wounds, but to try and heal the hidden ones as well. Sometimes all that takes is a little attention from a grown-up who cares.

School Nursing: Burnout and Renewal

About Purple_Scrubs, BSN, RN

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