How School Nurses Affect Policy, Drive Change to Improve Child Health

The economy of Elko, Nevada, a small city in the northeast corner of the state, relies heavily on the state’s gold mining industry. The story of an Elko mine’s hiring boom turned out to be a gold strike of a child health policy opportunity for Martha Dewey Bergren, DNS, RN, NCSN, PHNA-BC, FNASN, FASHA, FAAN. Bergren, who in 2003 received her DNS and in 1992 received her Master of Science in Child Health Nursing from UB School of Nursing, served as a Change Leadership Coach for Elko’s school nurses while a member of the lead faculty for the Johnson & Johnson School Nurse Leadership Program based at Rutgers University.

“The mine was constantly hiring, and most of their new hires were young families relocating from out of state,” Bergren said. “But the kids can’t start school until they fulfill Nevada’s immunization requirements.” Getting their vaccines proved to be a long and complicated process.

“We found that the Elko primary care physicians required a full physical to establish a new patient before giving vaccines, yet the average wait to get in was two months,” Bergren said. Other obstacles were that new-hire health insurance had a wait period before coverage started, the local urgent care center did not offer vaccines and there was not a health department in the county.

“Kids were missing an incredible amount of school, sometimes several kids in one family, because they couldn’t get their vaccines,” Bergren said. The Elko school nurses in her coaching cohort acted by mobilizing their school districts to give the vaccines themselves. The nurses that held a school-based clinic one weekend vaccinated 338 children – but this wasn’t a long-term solution.

The nurses went on to lead a collaboration among Elko City Council, the mining company, local physicians and the nonprofit Immunize Nevada to develop a multifaceted sustainable solution: The mining company altered their health coverage to accommodate vaccines without the waiting period, physicians began to allow walk-in same-day immunizations, and the urgent care center also began to offer immunizations.

“The existing relationships within this smaller community was really key in bringing all these stakeholders together,” Bergren said. “Everyone wanted what’s best for the kids.”

That sentiment has been the common denominator in Bergren’s nearly 50-year nursing career, which she began in 1976 as a primary care nurse in Children’s Hospital of Philadelphia.

Bergren has gone on to teach, consult, conduct research; author or co-author 59 articles, 12 books or book chapters, and countless briefs, clinical guidelines, and commentaries, while also speaking at engagements from coast-to-coast and in Asia and Europe. Yet, she is far prouder of the child-centered policy impacts on communities where she has worked either as a school nurse herself or as an educator or mentor to school nurses.

“There are so many ways to provide service as a nurse, but I always knew I wanted to be a school nurse; it was a calling,” Bergren said. “But I don’t think of it as ‘school nursing,’ – I think of it as policies that impact child health.”

Her experiences have taken her across the country to roles in both school nursing and child health nursing education; along the way she has noted how the disparity in resources between urban and suburban school districts impacts child health.

“I’ve seen a very well-appointed school nurse’s office in one well-funded high school, then traveled just 30 miles to visit a school nurse whose office was located in a converted basement utility closet that lacked a sink or toilet,” Bergren said. Furthermore, suburban schools typically have one dedicated nurse per school while in urban school districts a single school nurse is responsible for an average of four-to-five schools.

The inequalities, she said, are also evident in lunch menus, after school sports, and recess time, as well as access to overall community health care. “School nurses have been fighting these battles and are uniquely positioned to call out structural inequities to get policymakers to see the differences,” she said.

Much of Bergren’s work in nurse education and child health policy has been in identifying how to empower school nurses to be change leaders in their communities. As a longtime member of the faculty of the University of Illinois at Chicago College of Nursing, she has spent years observing how policy in the Chicago public schools impacted child health – and how shifting policy there often precedes nationwide change.

Another project she mentored through the Johnson & Johnson school nurse leadership program focused on population health in Oakland, California. Particularly, children with asthma.

“The nurses mapped all the elementary schools in the district and discovered that the children with the worse exacerbations of asthma were attending schools located close to the freeway,” she said. The proximity to emissions created a cascade of issues – asthma events caused absences and emergency room visits, which in turn caused parents to miss work. Knowing which populations of children to target for intervention was vital.

“We were able to help those parents understand the resources available and streamline their access to them,” Bergren said. This included relying on local respiratory nonprofits to help make sure asthma medications were always available, and then being alert to worsening asthma events to head off emergency room care.

School nurses have been at the forefront of child health topics ranging from school start times to recess; in the latter, shifting it to occur before lunch to encourage students to eat more and, in some schools, advocating to get it reinstated altogether. Next is addressing disparities in discipline policies and how they contribute to the school-to-prison pipeline.

“Former United States Secretary of Health and Human Services Donna Shalala once said, ‘Nurses need to see policy as something they can change,’” Bergren said. “I drive this home to my students, teaching them that with planning and skills, you can change any policy out there.”

-Terra Osterling