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

[halohg, RN]

Do the kids come with a pass? If not start there, with a pass you have prepared, with details of why they are coming. Second send a ziplock with some mixed sized bandaids, include a note of 'when to see the nurse' with instructions of what to do for non emergencies prior to sending to the nurse, such as for headache complaints, ask how long?, ask if they are hungry? give water, head on desk, wait 15-30 prior to sending. For stomach ache, sent to the bathroom, give water, ask if hungry, assess how long the pain has been going on, and wait 15 minutes after hydrating before sending. Etc. for sore throats, old cuts, bug bits, chapped lips, and also review reasons to send without a delay. If it continues get these numbers together and present to administration to reinforce the rules of when and how the health office is to be used.

[moreoreo]

Do the kids come with a pass? If not start there, with a pass you have prepared, with details of why they are coming. Second send a ziplock with some mixed sized bandaids, include a note of 'when to see the nurse' with instructions of what to do for non emergencies prior to sending to the nurse, such as for headache complaints, ask how long?, ask if they are hungry? give water, head on desk, wait 15-30 prior to sending. For stomach ache, sent to the bathroom, give water, ask if hungry, assess how long the pain has been going on, and wait 15 minutes after hydrating before sending. Etc. for sore throats, old cuts, bug bits, chapped lips, and also review reasons to send without a delay. If it continues get these numbers together and present to administration to reinforce the rules of when and how the health office is to be used.

We do use passes and the teachers are good about filling them out. You'd be shocked how even the most reasonable teachers will write things like, "neck hurts, says she hurt it at home yesterday, I told her she could use an ice pack" (I talked to child about it and sent back without one). I have supplied bandaids as well.

I will make sure to include headaches, stomach aches, sore throats, old bug bites/bruises/invisible injuries, and paper cuts in my note. I'll also mention I don't extract fully embedded splinters or pull loose teeth.

Luckily our principals are aware. Our new one heard that our school was known for "a lot of nurse visits." Supposedly it was not like this before I started so I feel somewhat responsible and I am going to change that! I am glad to be a good resource but the health office should not be a distraction for the school.

[Windchaser22]

I ran some numbers on cough drop requests (not there for illness). >150 requests with one legit referral last year. Two days total of class time missed. Crazy!

[moreoreo]

I ran some numbers on cough drop requests (not there for illness). >150 requests with one legit referral last year. Two days total of class time missed. Crazy!

omg our one saving grace is not supplying cough drops/mints/OTC meds (without MD order). We would never see the end of it!

I have written up an email to send to staff and am pretty proud of it. I am going to make a strong appeal to our district nurse to allow me to actually send it to them. I think the root of our problem is that the teachers are unaware of the situation bc I am not permitted to email them freely. Not that every single one would care but I know a few would be shocked by the numbers, especially from last year. I think that informing them and supplying them with some problem solving tips (i.e. reminding that not every minor complaint should automatically be sent) will shrink our visits to more reasonable numbers. "School whose students see the nurse a lot" is not a reputation I think they would want for our school!

[ohiobobcat]

I have written up an email to send to staff and am pretty proud of it. I am going to make a strong appeal to our district nurse to allow me to actually send it to them. I think the root of our problem is that the teachers are unaware of the situation bc I am not permitted to email them freely.

Why are you not allowed to email teachers without permission? Or am I reading that correctly?

It sounds like you have a good plan. I also talk to the teachers during one of our staff meetings about appropriate reasons to send a student to me, although nurse visits not really abused in my school by the teachers. I do know most teachers at my school don't ask why students are coming to see me if a student asks to go to the nurse. I think that could and should be different at the elementary level.

[WineRN]

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.

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.

[KKEGS, MSN, RN]

I had this problem last year at my elementary school as well and my health aide and I did send an email to the teachers with some problem solving advice and bandaids. It also served to make them aware of the problem. We were seeing 50 to 60 kids a day and our record was 80. I had a couple teachers email me back and thank me for letting them know. They had NO IDEA that we saw that many kids.

I think the pass idea is also good practice. Something else we experienced were teachers who had no clue that their students were not, in fact, just going to the bathroom or going to another classroom like they were supposed to be doing and were instead coming to visit us in the health office.

Recess and lunch time are always tricky. Those were definitely the majority of our visits during the day. Sometimes we heard on the walkie talkie that a playground monitor was sending us a student but a lot of them were coming to us at the end of recess because they didn't want to go back to class. If you are seeing repeat offenders talk to the teachers or the parents. Some parents also have no idea how often their little darlings are skipping class to come to the health office.

We also encouraged the teachers to not send students before 10 am or after 3 pm unless it was a true emergency. Our school hours were 9:15 to 3:40. That cut down on the kids coming to the health office straight off the bus or coming to us with 10 minutes left of the school day.

[moreoreo]

Why are you not allowed to email teachers without permission? Or am I reading that correctly?

I am allowed to email individual teachers at will but have been instructed to CC our lead nurse every time, and it's been implied that any staff-wide emails need to be approved. It's not a requirement just for me but for each building RN in my district, as far as I know. We are not given much free reign which is a double edged sword--I'm glad for the guidance and supervision as a newbie but sometimes it just feels like my hands are tied.

As it turns out I have not been encouraged to send my email (I am being told that advising on when to send/not to send is a liability issue... which I am happy to take on, because I cannot seriously be the only one to clear papercuts in my school, but OK) but am having a meeting with our principals next week so we can discuss the statistics and ideas for how to improve the situation. And I have been invited to bring my email along for consideration. The district nurse offered to look it over to see what she thought--I was so discouraged by her initial response that I did not send it to her yet but will certainly bring it to the meeting.

There are still some teachers who will ALWAYS over send, but a lot did respond in a positive manner.

It's funny because my oversenders from last year are awfully quiet this year (knock on wood) but the rest have increased. I remind myself that some classrooms are also more demanding in general than others which might cause the teacher to look for an outlet! One of mine this year is a temporary sub who has sent me 18 of her 20 children in the first 1.5 weeks of school. Today she sent me 6 happy and well children in the first two hours of the day so we had a conversation. I don't know that she really realized it was unusual to send so many.

We also encouraged the teachers to not send students before 10 am or after 3 pm unless it was a true emergency. Our school hours were 9:15 to 3:40. That cut down on the kids coming to the health office straight off the bus or coming to us with 10 minutes left of the school day.

I think this would help for my school, too. I get almost 10 kids in the first .5 hour of school most days and all of them go to class unless febrile because "it's still so early in the day to call it quits" (and no one puts up any fight). And any child who comes in the last 20 minutes seems to feel pretty silly when I explain that their parent could not possibly get to them any sooner than dismissal time

Thanks all for your thoughts, encouragement, and advice. I do love this role and my job and do not want to throw in the towel. I know it can be better and will be!

[mercurysmom]

My kid was drawn to the nurse's office like a moth to a flame. He received meds every day and also had snacks available (metabolic disorder). He never faked actual illness, fortunately, since that usually ended with stuff that he avoided at all costs. Boredom often became hunger, so he needed to take a leisurely trip down to her office. Math made him particularly hungry. When we amended his IHCP, we sent cans of Pediasure to the math classroom, and he could only go to the nurse's office if he had anything going on besides hunger/thirst. His visits dropped by more than 50%. Imagine that!

So Hubby and I are those parents who worked with the school to keep his butt in his seat and cut down the social visits. :-D Meanies!!!

mm

[BSNRNHS]

I inundate the parents with emails in the first month of school. ie:

"Dear mom and dad, Your son Johnny reported to the clinic today to complain of pain in his shins. He had just been outside on the playground and I think he was playing soccer. He has no visible signs of injury, and was bearing weight equally on both legs. I talked to him about stretching before sports. He verbalized understanding. I don't think this will be any issue later today, but just in case he forgets to mention a clinic visit to you, I wanted to give you an opportunity to follow-up with him this evening as well."

The last sentence is key. For me--it takes a lot of time on the front end, but serves to have the parents get with the kid and get on the same page fast. Soit pays dividends the rest of the year. Plus, it creates a paper trail. Plus, I cut and paste whatever I type to the parent into the note. Easy peasy!

[moreoreo]

So Hubby and I are those parents who worked with the school to keep his butt in his seat and cut down the social visits. :-D Meanies!!!

Mean love is good love! A new 5th grader at my school commented (after I called parent for pick up) that he was relieved bc the nurse at his last school was "mean" and I quickly defended her bc "sometimes we have to be mean to help you stay in class when you can" (and immediately wondered whether he will become a "frequent flyer"). You gotta guide them to love them and sometimes that requires some meanness!

BSNRNHS, I which I could email parents! Most of the time when I call I just end up leaving a voicemail which states only that the student saw me and to call back. I doubt most of the parents listen to the message. I have certainly learned that letting a parent know that their child has been in X number of times this week does help cut down on visits in most cases! Either with a visit to the doctor if legitimate complaints or a firm talk if invisible ones. At my school the other issue that makes this tricky is that most of our parents speak Spanish, which I speak as well but not natively. Most of the time I am glad just to communicate what happened. But it's a great point that we have to put the onus on the parents bc the teachers can't help sending if Johnny keeps complaining!