The School Nurse May be the Only Source of Healthcare Some Students Have

Andrea Wickstrom, BSN, RN

Halfway through my first year as an elementary school nurse, after the newness and excitement of having my own office started to wane, I found myself complaining to the Health Services supervisor of the district about the regular and multiple extra visits from a group of students that were not school-onset illnesses or injuries, but rather maladies that should be taken care of by parents or primary caregivers outside of the school day. Couldn’t the students see that my plate was full of learning a new building nurse position, the constant flow of health office visits, phone calls, attendance tracking, medication administrations, documentation, and handing out endless icepacks? Also, that crazy little thing we call.......COVID-19?

Of course not. They were kids.

My rant continued as I gave example after example. She listened without interrupting, but when I was finished, she immediately and directly informed me, “You are their only source of healthcare.”

Wait. What?

I, the school nurse, am multiple children's sole source of healthcare? How can that be? Isn’t it a federal law that everyone has insurance? I am already responsible for so much here- How can this be put on me, too? I was angry.

I chewed on it for a few days- it was never far from my mind. I was forced to admit to myself that I was thinking too narrowly about what fit within the confines of the school nurse’s office. Wasn’t the primary reason for a nurse to be present in the building to help promote and maintain student health so they optimize time in classroom learning? As far as these students knew, one went to the trusted nurse to get fixed what hurt. Guilt began to creep over me the next time I saw their sweet little faces with their big owies. It wasn’t their fault.

How Many Children Do Not Have Healthcare Coverage?

In 2021, the United States Census Bureau reported 5% (or 3.9 million) of children under 19 years old did not have any health insurance. This staggering statistic is apart from the 36 million children who are already covered by Medicaid (MA) and the 8 million on the Children’s Health Insurance Program (CHIP).

Many of the students who are uninsured have parents who do not know the process or what is available to them. If the case is that the parents are undocumented, they are less likely to seek assistance for their children because of a mistaken belief that their lack of citizenship disqualifies their citizen children from government aid. In addition, the parents that are undocumented fear deportation if they apply. Language and poor health literacy certainly are also barriers that prevent the pursual of benefits.

What Can the School Nurse Do to Help Close the Gap for Students Without Healthcare Coverage?

For students who do not have medical and dental insurance, lack of access to comprehensive healthcare is a given. In turn, learning is directly affected. Not only do frequent absences or feeling poorly in the classroom reduce instruction time, creating a negative impact on education, but unresolved health problems continue and become more complex.

The school nurse may be the first and only consistent source of health services. They have the platform to help address barriers to access by supplying direct care, care coordination, and case management while at school. During training or through time and experience, most school nurses are made aware of the common referrals and resources- the school social worker, free vision exams and glasses vouchers, vaccine clinics, and dental care events. These are easy and convenient to communicate. But is there more we can do?

The Not-as-obvious Interventions

Listed below are some lesser-known tactics that the school nurse could pursue:

Check the school's enrollment forms that ask if students have health insurance
Review the list of those who have free or reduced meals at school, as this may exemplify more areas of need
Utilize virtual visits from the health office if your district takes part, which may supply free charity visits for the uninsured
Send health coverage program information with students when they go home sick and hand it directly to caregivers- this is a motivating time for them to look at it
Utilize community-based organizations and non-profits for other resources
Educate staff on efforts and how to refer students
Schools, and thus school nurses, are one of many “qualified entities” that can enroll children who appear to be eligible for Medicaid or SHIP through the “presumptive entity option,” which is for a temporary period until a final eligibility determination is made (The students do not have to supply a Social Security Number to receive a presumptive entity determination)
Approach school and district leadership to suggest an advocacy team be created

We all know nurses just do not have enough time in the workday to complete everything that we need and want to. Perhaps if there were a team and process in place to identify and aid all students in need of obtaining or keeping healthcare insurance coverage, both the classrooms and the nurse’s office would see an affirmative transformation in students’ education and wellness. After all, isn’t that what we are here for?

References/Resources

Children's Health Coverage Outreach: A Special Role For School Nurses

Position Brief - Student Healthcare Access - A Right and Not A Privilege

Uninsured Rate of U.S. Children Fell to 5.0% in 2021

Implementation Guide: Medicaid State Plan Eligibility/Presumptive Eligibility/Individuals above 133% FPL under Age 65/Presumptive Eligibility

Enroll Children by Engaging Partners

Guide to School-Based Outreach for Health Coverage Enrollment