School Nurses Searching for Guidance
What is the topic that is leaving so many elementary school nurses searching for guidance?
Who should change a child that has had a toileting accident.
Why is this even a concern? Most children have successfully achieved this milestone by the time they reach kindergarten, but there is still a small segment that has not. In fact, when my girls were young many schools required children to be toilet trained before entering school. Apparently, that is no longer true… at least according to the sisterhood of school nurses.
It is a hot topic in at least one national school nurse support group. With many weighing in on how inappropriate it is that children are not already trained. Or, then there are the punitive statements of “lazy parents, expecting us to do their job”. That is the attitude that really gets to me.
First, is changing a wet or soiled child a nursing task? No. It is not. It is a developmental task, a social task, an activity of daily living (ADL) task, but it is not a nursing task. And at least one state has issued a memo to all: “Superintendents of Schools in Districts receiving Universal Prekindergarten Grants (UPK) and/or Statewide Universal Full-Day Prekindergarten (SUFDPK) funding; Superintendents of School Districts with Kindergarten Programs Pre-K Program Contacts for Agencies receiving Statewide Universal Full-Day Prekindergarten (SUFDPK) funding”
The memo clearing states “toilet training is a significant developmental milestone in a child’s life…” It also exhorts all to treat each child as an individual, to be gentle, calm and caring, but above all, be respectful of the child (I would suggest we extend our demeanor to the parents as well).
After the short memo reminding readers about the developmental readiness and toileting guidance, the memo has a Q & A section. The questions include things like: must a child be toilet trained (no) which goes hand-in-hand with denying entry into school (no, you can’t deny entry); are there special considerations (yes); and my personal favorite, who is responsible for clean-up duties (it is not the school nurse); an important question for parents, can a child be sent home from school for a toileting accident (no); can a parent be called to come and change their child (no—suck it up buttercup and change the child).
Yes, this question is included in the memo, and it comes up every time the toileting issue in this nursing group is raised. Like presidential elections, there is a great divide between the nurses that either call the parent to come in and change their child, or they call the parent to pick up the child and those of us that feel it is a no-no to call parents for this task.
So… what are the reasons we shouldn’t call parents to pick up their child or should come in and change their child?
A child is sitting around in soiled clothing while waiting for the parent. This is demeaning, degrading and can impact the child’s physical and emotional well-being. It causes undue hardship on the parent; it disrupts the learning process and can start setting up the child for failure in school. It’s rude and uncaring. We are supposed to be caregivers, not soul-destroyers. So… when you are tempted to pick up the phone and call the parent ask yourself, is this really best for the child and family? Ask yourself, would I want to be on the receiving end of this call? Do I know the real reasons this child is not, yet toilet trained? Telling ourselves the reason is because the parent is “lazy,” is, well…lazy on our part. I will now jump off my soapbox, wash my hands and move on.
I get it, nurses are often sole providers of medical care for children in their building and nobody’s got time for changing a child that has had a toileting accident. In programs where there are aides in the classroom, that is the person that is delegated to do the task. This guidance memo even addresses who should do it. “Toileting is not required to be performed by a nurse - see attachment C of our Provision of Nursing Services in School Settings - Including One-to-One Nursing Services to Students with Special Needs. The school should determine who is best to assist a child in toileting as it is a local decision and should be a shared responsibility to best support student needs. To ensure the safety of children, school districts should inquire with their insurance company to identify the number of staff who must be present when assisting with toileting.”
I’ve worked in a preschool setting for much of my career. My earliest years I was on a site that had two classrooms. I was embedded in one of the classrooms and I cheerfully took turns with the TAs that did the toileting. We had set times in the day when we toileted all the children. Some of our children were already trained when they started, others learned during the school year. It was part of everyone’s day. Later when I was moved into an office, I would still go and help with toileting on occasion. But at no time was it my responsibility and once I moved to a site with many more classrooms it was never expected that I would take part in toileting the kiddos.
In other words, I was lucky. I had plenty of support from aides that, reluctantly or eagerly, took on the task of doing the essential work of assisting children with an important developmental milestone. It is time for nurses to let administrators know who disruptive it might be to drop essential nursing tasks to take care of changing a child. The wet/soiled child might have an unduly long wait as changing them falls lower in the priority list that true nursing tasks. Let them know that perhaps they should check with the school lawyer or insurance about number of adults that need to be present when a child is being cleaned following an accident of this nature. If you are not in NY state, perhaps your state education department has addressed this issue. But hover over the underlined words for the link to the NYSED policy.
Remember: toileting is not a specialized task that requires a nurse. This is something that other responsible adults can do, leaving you to do the specialized tasks that only you can do in the building.