Reciprocal Rewards

School nurses can be a valuable resource, sounding board, and ally for athletic trainers—if you know how to nurture that relationship.

By Shelly Wilson

Shelly Wilson is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 12.6, September 2002, http://www.momentummedia.com/articles/tc/tc1206/rewards.htm

Frank Mastrangelo, LAT, EMT, Assistant Director of Student Life at Lawrence Academy in Groton, Mass., knows what a school nurse can mean to an athletic trainer. Years ago, when he was applying for a job, the school administrators sent him a list of whom he’d meet during his interview day—and left off the nurse. They said he’d meet her if he got the job.

“I said, ‘No. This is the person I’m going to be working with on a daily basis. I want to interview with her. I want to speak to her, know who she is, and find out what her beliefs are.’”

If you’ve never thought of interviewing the school nurse before taking an athletic trainer’s position, you’re not alone. Many athletic trainers don’t realize how great the rewards are of forging a strong working relationship with your school nurse. An amiable relationship with the nurse can ensure you are informed of what care student-athletes are receiving in your absence, as well as the quality of that care.

Also, an extra set of hands is always helpful, and a good working relationship with your school nurse may allow you to more easily filter non-injury cases like colds and rashes out of the athletic training room and up to student health services. What’s more, a school nurse’s protocols and contacts can make your treatment of the many injuries you do manage more effective and efficient.

“Building a relationship with my nurse definitely made my job easier,” says Mastrangelo. “Since she was a nurse practitioner, I could send stuff up to her and get things moved along quicker. For instance, she can write out an X-ray order, and that saved me hours waiting in the emergency room. When I wanted a kid to wait and see the orthopedist, the nurse could give him medication, which is beyond my protocol.”

Here’s how to get off on the right foot with your school nurse, enhance existing relationships, and gain a resource, an advocate, and a sounding board in the process—to the benefit of you and your student-athletes.

Trust & Respect
One of the biggest obstacles to a fruitful working relationship between you and your school nurse is misunderstanding each other’s role, education, and training. As with many other healthcare providers, school nurses sometimes perceive athletic trainers as tape jockeys or boxing staff. And athletic trainers can be just as misinformed about the school nurse’s role.

“There’s no question some athletic trainers have this perception that the nurses are still wearing their little caps, giving shots, and making sure everyone has ginger-ale and crackers when their stomach’s not feeling well,” says Mastrangelo.

To move past these inaccuracies and stimulate mutual trust and respect, athletic trainers say it’s incumbent upon them to promote their knowledge, philosophy, and training. “When it comes to scope of practice, we don’t have as much free reign to handle things as a nurse does,” says Mastrangelo. “But we’re much more knowledgeable and more detailed about the injuries we deal with. And they need to know that.”

The most direct method of forging a positive relationship is to schedule a chat about each other’s backgrounds. “When I first arrived at Carmel, I met with the nursing staff and said, ‘Hey, let’s sit down and talk about what each of our areas of expertise are and how we can make this a win-win for both the nursing and athletic training staffs,’” says Tim Drudge, MS, ACT/L, CSCS, Head Athletic Trainer at Carmel High School in Indianapolis, Ind., and Operations Coordinator at St. Vincent’s Sports Medicine Center.

“The discussion broke down a lot of barriers and put them more at ease because it was an eye-opener. It let them know what we do, what we’re capable of, and what our education is as athletic trainers.”

Spending time together on the job is another approach. At Bourbon County High School in Paris, Ky., Head Athletic Trainer Heather Mattocks, MS, ATC, invited her school nurse to shadow her for a few days.

“Even in trying to talk to her about what I do, she still thought that athletic trainers did a lot of taping before the game,” says Mattocks. “So I simply asked her if she’d be interested in helping out. I let her know what the schedule is throughout the day, and what times are hectic, but told her to come by whenever she wanted to.

“She spent two or three days with me,” Mattocks continues. “She got to see what we do on a daily basis, the madness after school when you have 20 athletes and one athletic trainer, the acute care we provide, and the rehab part of our job. And then she traveled to a game with me and got to meet the doctors on the field. So she got an insider’s look, which was nice, and I was grateful that she was willing to do that.”

And when the nurses can’t make it to you, taking the show to them can achieve the same ends. “During our initial meeting, I’d indicated to my nurse that if she and her assistant nurses needed any help in terms of orthopedic injury education, I’d be more than willing to do that,” says Drudge. “So she put together an in-service for me to give an orthopedic presentation to her staff on things that I look for in certain situations. It gave them athletic training tricks of the trade to use in their practice every day, with the general school population as well as with student-athletes they see.

“When I finished the in-service, I felt they had a really good grasp of what I did and how capable I was from a medical standpoint,” continues Drudge. “And funny enough, not two weeks later, she got an e-mail from one of her associates at one of the elementary schools saying, ‘I tried the thing Tim showed me and I found a scaphoid fracture.’”

Your paperwork can also send a more subtle message about your capabilities and training. “I used a three-part form,” says Mastrangelo. “A copy went to me, the parent, and the health center. That way, the nurses were always informed when a kid was injured. But when I wrote out a form, I made certain to put down my suspected findings. And when I got a doctor’s note in, and the doctor had put down exactly what my suspected findings were, I’d copy that note to the nurse and she’d say, ‘You thought it was a torn ACL and it was.’ That looked good for me and made the nurse think, ‘This guy does know what he’s talking about.’”

Avoiding Encroachment
Explanation and demonstration can reduce confusion associated with what you do, but some nurses’ concerns over professional boundaries can also limit the extent he or she is willing to work openly with you. After all, two medical professionals caring for a client base that overlaps can breed conflict. That’s why it’s important to show your respect for the care being given by nurses, even when it’s not what you would do. This diplomacy, say athletic trainers, is one of the best ways to alleviate encroachment concerns.

Drudge took this approach when he discovered he and his school’s nurses had different opinions about how heat should be used on injuries. “When I first got there, there were some situations where they were still applying heat to acute injuries,” he says. “And that’s since changed. It wasn’t a situation where I said, ‘That’s absolutely wrong.’ I said, ‘Okay, I can appreciate where you’re coming from. But here are some articles I’ve found in my professional journals that have helped me. Take a look, and tell me what you think.’

“It’s about being a good professional and knowing how to overcome conflict,” Drudge continues. “If you know how to approach the situation and diffuse the volatility, rather than going at it head-on, saying, ‘it’s my way or the highway,’ then everybody is going to keep their guard down and be more open to discussion.”

Mattocks agrees, opting to use compromise to change nurses’ minds rather than argue over whose approach is most suitable. “For example, one day my nurse saw an athlete who happened to sprain an ankle in a pick-up game on the basketball court,” Mattocks says.

“She saw him initially and wanted to do your basic ice and elevation and keep the athlete on crutches for from seven to 10 days. But as an athletic trainer, that’s not something that we’d do for a basic ankle sprain. So I compromised with her and said, ‘Okay, I’ll give you two or three days. But if you don’t mind, after that, will you let me see what we can do with this athlete, because he wants to play on Friday night? And fortunately, she was willing to do that, because I didn’t say, ‘You’re completely wrong.’

“And that was a big stepping stone, because it showed her I wasn’t going to cross the line, and that we can work together. I gained a little respect from her. Since then, because we have developed a working rapport, she’ll say, ‘This is out of my league. I don’t know how to deal with this, so here you go. Have at it.’”

Athletic trainers say that besides showing respect for the nurse’s opinion, it’s equally important to include the school nurse in the care of your student-athletes.

“You have to ask them if they can help you out when you come up against problems,” says Brian Robinson, MS, ATC/L, Head Athletic Trainer at Glenbrook South High School in Illinois, “because if you walk in there as if you know everything and have all the answers, that’s going to create problems. You need to check your ego at the door and say, ‘Let’s work together on this.’”

Mastrangelo agrees. “Send your nurse those one or two kids who you’re not sure of,” he says, “because that’s going to make him or her say, ‘He’s relying on me for information.’ And that makes him feel good.”

“There have been situations with allergies or medication, skin irritations, or rashes that I’m not familiar enough with that I refer to her,” adds Mattocks.

A Team of Two
Breeding familiarity and professional respect with your school nurse is an important first move, but it takes more to build the all-important personal interest in each other’s professional welfare that brings about the best care for the student-athletes. To do this, athletic trainers must consciously practice interaction and assistance under more casual conditions.

“Interaction outside the school is valuable,” says Mastrangelo. “Because something as simple as getting a bite to eat or a drink where you can shoot the breeze creates a friendship and bonding.”

Mattocks, for example, volunteers for non-athletic school events and committees in order to get to know her school nurse better. Mastrangelo has found this approach helpful, too, going even farther and finding interaction opportunities that aren’t school related.

“One thing we did is tag-team on activities that were of interest to her or me,” he says. “For example, we went to several local conferences on eating disorders. It certainly was not a topic at the top of my priority list, but it was a way to get to know her better. And it worked the other direction, too. If a conference or workshop came up for athletics that I thought she might like to see, she was usually interested in going. And it was an opportunity for both of us to get out.”

Sometimes, just going out of your way to informally interact can cement your relationship. “I make an effort to talk to my nurse at least once a day, just to say hi,” says Israel Pena, ATC/L, LAT, Head Athletic Trainer at Weslaco (Texas) High School.

“I make a point to talk about something other than school or somebody being hurt, because it helps to avoid what I call the ‘grim-reaper’ complex—when people see the athletic trainer coming and automatically think it’s bad news.

If you are constantly butting heads with your nurse over care, when she sees you coming, she’s going to put her guard up. But when my nurse sees me coming, she doesn’t know if we’ll be talking about a kid, her dog, or how her son’s doing. And that makes things a lot easier.”

Many athletic trainers also improve the relationship by making a point to offer their help to the school nurse regularly, along with gestures to make his or her job easier. That means stating you’re available for assistance, escorting injured students from the gym next door to the nurse’s office rather than making him or her walk down, and volunteering to help out with their pet projects.


Collaboration & Advocacy
So in your hectic schedule handling hundreds of athletes a year, where’s the pay-off for taking on one more task—and an interpersonal one at that? It comes in two forms: collaborative care for the student-athletes and an athletic training advocate to school faculty and administration.

Simply put, two heads are better than one (See Sidebar, “Power in Numbers” at the end of this article). And sometimes, working together can help a student-athlete in ways an athletic trainer alone can’t.

“Last year, we had an athlete come down with a shoulder problem,” says Robinson, “but he also had all the symptoms of Marfan’s syndrome—the long arms, the huge hands, the kind of deformed chest. But because he was white, he didn’t fit the racial profile for the condition. So I contacted the nurse and asked if there was anything in her records about this kid. There wasn’t, but she dug a little bit deeper and actually called the parents to say, ‘Not to alarm you, but this is our concern.’

“We found out that the student-athlete did have a history of heart problems,” he continues. “In fact, the doctor told the parents about five years ago that the kid had an irregular heartbeat. So the parents had him examined again and discovered that he did have a condition that needed to be observed—nothing that precluded him from athletics, but I was glad to find it out then rather than later. So the school nurse can be a very valuable part of the medical team.”

Mastrangelo also found that a different set of eyes can sometimes offer a clearer perspective on a situation. That’s because last year, when his school’s star hockey player suddenly broke out in a rash between the first and second period, he was sure something serious was wrong.

“We couldn’t figure out what the heck was going on,” he says. “He wasn’t in pain and his vital signs were fine. So I called the nurse at home, and she zipped down here and popped him some Benadryl. The rash cleared up, and he was back on the ice. Meanwhile, I was thinking this kid might have some medical problem. But she suggested it might have been from the detergent in the school laundry. And I realized she might be right. There’s always stuff that she picks up on that I don’t.”

A nurse as an ally can also act on your behalf and defending your interests to others. At Lawrence Academy, Mastrangelo’s nurse pushed the administration to make his position full-time. And in Pena’s former position, the school nurse helped diffuse tension among school staff over his arrival.

“I went into my previous position during a very sensitive situation,” says Pena. “When the former athletic trainer was let go, that person burned a lot of bridges. And since I was only the school’s second athletic trainer, there was still skepticism about what an ATC can do and is capable of. But she was my advocate and was supportive. And she helped put out a lot of fires before they started.”

A good relationship today can also help the athletic trainer who fills your shoes (not to mention the profession) tomorrow. For example, when the school began hiring Mastrangelo’s replacement for this school year, it was the school nurse who stepped up to help ensure the new athletic trainer would be fairly compensated.

And finally, one athletic trainer discovered the importance of both collaboration and having an ally when a student-athlete became pregnant. It was the school nurse who made it possible for the athletic trainer to help the athlete continue competing.

“The nurse had first knowledge of the situation,” says the athletic trainer, who is being left anonymous to protect the privacy of the student-athlete. “Recognizing that I needed to know about it, she was able to persuade the child, the child’s mother, and the administration (which has a strict confidentiality rule), to bring me in the loop. And it was important that I knew because of how far along the student-athlete was in her pregnancy.”

Because of the nurse’s advocacy, the athletic trainer was able to explain to the player that she didn’t necessarily have to quit her sport. What’s more, the two professionals worked in concert to help the student-athlete finish her season safely.

“We did a lot of research together,” explains the athletic trainer. “With the patient’s and her mom’s approval, we were allowed to talk to some physicians about do’s and don’ts. We educated ourselves and the athlete. Then, we worked as a team to reassure the administration, because it had a lot of liability questions and concerns that we understood but they didn’t. We also jointly did a lot more monitoring of her during practices and games, which gave the athlete a little more sense of security. She was able to finish her season and has since received a scholarship to play in college.”

Professional Happiness
Ultimately, a strong, working relationship with your school nurse can help you provide better care for your student-athletes and create a potential advocate in the main building. And having another medical professional for comfort and empathy on campus can also substantially contribute to your personal job satisfaction.

First, your nurse is someone who can relate to your healthcare stories when family or other school colleagues can’t. “I can’t really go home to my wife and have a conversation about Johnny blowing out his ankle,” says Mastrangelo. “But the nurse has an idea of what I’m talking about. And she gets my medical humor when nobody else does.”

What’s more, the school nurse understands the broader spectrum of your duties, and can offer support. “It’s one thing to talk to a coach about kids, but when it comes to medical stuff, it’s nice to have somebody who’s on your wavelength,” says Robinson. “Also, I have three athletic trainers with me here. But if anything goes wrong, as head athletic trainer, it’s my fault. My nurse manages a staff of three as well. And there are times when it’s nice to be able to sit and talk with somebody [who understands] the difficulties of running a program.”

Even when there are no problems, the school nurse can be the healthcare sounding board that you need. “I went to my nurse with a lot of questions I just couldn’t answer or with situations where confidentiality was important, because she was more familiar with being an intervener,” says Pena. “And then there were times when I knew what to do with a case, but needed someone to tell me to do it. Since I’m a young athletic trainer, she’s been my ‘what-do-I-do?’ person. And that relationship has helped me. Just being able to pick someone else’s brain adds to job satisfaction.”

For Drudge, it all boils down to a simple equation: Modest Effort equals Great Reward. “For ATCs who’ve never spoken with their school nurse, I think they’ll be surprised at how well their efforts and interest will be received,” he says. “If you establish a good line of communication and educate them about what you do, then hopefully you’ll get some reciprocal communication and education. ”



Sidebar: Power In Numbers

One of the best reasons to make headway with your school nurse is the impact that two medical professionals acting in a coordinated effort can have on a school administration. Whether it’s safety issues for student-athletes you want resolved or health issues for the student body, sometimes two unified voices can get the job done quicker than either party working separately.

“It helps your cause to have that additional person on your side when you want to implement changes or institute a new policy—like making sure coaches are first aid- and CPR-certified,” says Frank Mastrangelo, LAT, EMT, Assistant Director of Student Life at Lawrence Academy in Groton, Mass. “And having somebody on your side in the field who knows the importance of that change will be beneficial, rather than you squawking alone to the principal or school board.

For instance, we’ve had nutritional concerns about our cafeteria in the past, and having two voices go to the people in charge and saying, ‘This is what we think should happen and this is why,’ is much more effective than having one person do it. And she does carry some weight, because people see her as THE school nurse—the one who oversees the whole health program, including me.”

Other projects more ATCs and nurses are successfully pursuing together are the acquisition of automatic external defribilators (AEDs). “My school nurse involved me in her efforts to get AEDs placed in the school,” says Tim Drudge, MS, ATC, CSCS, Head Athletic Trainer at Carmel High School in Indianapolis.

“First, she invited me to be on the original committee to educate school administration, because there was some apprehension from area school corporations to even have AEDs on site. They felt that if they were on site, now they were responsible. And now that we have five AEDs, she’s asked me to be part of the policies and procedures committee that will decide how and when they’ll be used, and under what circumstances.”

Heather Mattocks, MS, ATC, Head Athletic Trainer at Bourbon County High School in Paris, Ky., has also been working on the AED issue with her school nurse, and the two are beginning to make some progress, thanks to her school nurse’s specialized background. “We have a fairly large group of disabled students in our school system,” she says. “And she has a special-education and health disabilities background. So we’re trying to approach it from that angle, and she has the experience to emphasize that this audience may have an increased need for that equipment.”