Small Steps for Big Vision: A Conversation with Mary Noga

An audience measures attention. Understanding transforms people.

August is Children's Eye Health Month, and families everywhere are heading back to school. In this episode, we sit down with Mary Noga, Clinical Assistant Professor and Director of the School Nurse Certification Program at University of Illinois Chicago, to talk about the Small Steps to Eye Care Action Plan she implemented at Indian Prairie School District 204, where she previously served as Health Services Coordinator, and why the gap between a vision screening and a completed eye exam matters so much for a child's ability to learn and thrive.

Guest

Mary Noga, Clinical Assistant Professor and Director of the School Nurse Certification Program at the University of Illinois Chicago

Hosts

Sylvia and Gabby

In This Episode

00:00 Welcome And Why Vision Matters
02:02 Growing Up With Low Vision
07:10 Meet Mary Noga And The Gap
10:23 Small Steps Action Plan Explained
21:04 Barriers That Block Eye Exams
30:55 Partnerships That Boost Follow-Through
37:40 Inclusion Tools And Back To School
45:45 Resources And Closing Thoughts

Mary's Bio:

Mary has been a nurse for 19 years, and has worked as a school nurse for the past 18 years.  Mary recently completed her Doctor of Nursing Practice in Advanced Population Health Nursing. Mary's advocacy and service focuses on children's vision and eye health and removing barriers and improving access to eye care.  Mary has previously worked as the Health Services Coordinator and Licensed School Nurse in a large suburban school district in Illinois. Mary currently serves as the Director of the School Nurse Certification Program and Clinical Assistant Professor at the University of Illinois Chicago.  Mary is dedicated to educating the next generation of school nurses and being the voice for children with visual impairments.

A Note on A.I.R.

This platform works to shift how we see one another through A.I.R. (Access, Inclusion, & Representation)™. This episode is a reminder that access starts early, and that something as ordinary as a vision screening can shape a child's whole experience of school.

Resources

• Small Steps for Big Vision website, https://nationalcenter.preventblindness.org/small-steps-for-big-vision/ 
• Small Steps Action Plan, https://preventblindness.org/document/small-steps-to-eye-care-action-plan-a-conversation-guide/

Bold Blind Beauty On A.I.R. features thoughtful conversations that challenge assumptions, broaden perspectives, and celebrate the richness of disability experiences, rooted in A.I.R. (Access, Inclusion, & Representation)™.

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May Bold Blind Beauty always be known not for the noise it made,
but for the understanding it cultivated.

Music Credit: "Ambient Uplifting Harmonic Happy" By Panda-x-music  https://audiojungle.net/item/ambient-uplifting-harmonic-happy/46309958

Thanks for listening!❤️

Transcript

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Welcome And Why Vision Matters

Sylvia 0:02

Hello everyone and welcome back to Bold Blind Beauty on Air. AIR. We're so glad you're here with us today. On this platform, we work to shift how we see one another through access, inclusion, and representation. As families head back to school this month, exciting times, we're also marking Children's Eye Health Month. It's a good time to talk about something that really shapes a child's entire education experience. How well they see, what happens when they can't see well, what can teachers do when they need to include students with visual impairments in their classrooms? How can parents advocate for their children? Today's guest is Mary Noga. Mary is a clinical assistant professor and director of the School Nurse Certification Program at University of Illinois in Chicago. Mary has spent her career in school and clinical nursing, and she brought the Small Steps to Eye Care Action Plan, which is part of the National Center for Children's Vision and Eye Health at Prevent Blindness into her school district's workplace. I'm Sylvia Perez and I'm joined by Gabby Mandanka today, co-hosting with me. We'll be talking to Mary about what this toolkit provides, what it looked like to put it to work in her school district, and why that follow-through from screening to the complete eye exam matters so much. So let's begin.

Growing Up With Low Vision

Sylvia 2:02

We're going to start with how our experiences, mine and Gabby's, as children who were with visual impairments, impacted us. So Gabby, what was what was challenging for you about navigating school as a child with visual impairment? What could have made that experience better for you?

Gabby 2:25

I feel like for me, a good chunk of my time in school, there could have been more conversation or more more. I guess as a child, it's hard to have the conversation around what accessibility really is and how to advocate. But I wish that there was more options available when it came to what I was actually provided. It took some time for me to get just classroom materials, whether that would be books. And that was when I was reading physical copies. You know, I wasn't on Audible or had voice stream reader to do these things. Like I preferred to just have like the physical textbooks. And so that's what they provided me with. And so oftentimes I wasn't specifically behind in the class, but I did feel behind because I wouldn't have full access to my materials or technology that I needed. Um, and so I I feel like what could have made it better was the school having prepared for that way before I even entered the class. And that's the one thing I I would say that was hard for me was feeling like, okay, how am I gonna figure this out by myself? And, you know, while while everybody else is like chugging along and doing these assignments and whatnot. So um, but overall, I would say like there were other experiences that counteracted that. But yeah.

Sylvia 3:50

It's super disappointing for me to hear and to see what still happens because I was in school starting kindergarten probably 30 years before you gave me. Which is so scary to say. But I mean, so much longer before. And so, really, when when inclusion was just starting to be a thing, and um my parents, they didn't know what they didn't know, I didn't know what I didn't know. Um so I had enough vision to see close up, but it was all the other things like being included in recreation and you know, making me feel like I belong there, and I think that was a really big thing is inclusion and and making you feel like you belong. Right. I think that's a such an important thing for teachers, um, you know, and the whole system to really work on.

Gabby 4:42

Definitely. I I 1000% agree with that.

Sylvia 4:45

What do you think teachers could do to help you feel supported and included in the classroom, Gabby? I would say just different alternatives.

Gabby 4:56

And I think now when I think about just kids that are in school, I feel like there's so many more options. But for me, you know, I just had a Perkins braille writer and the physical textbooks. I I didn't have a braille note or, you know, an iPad to help me figure it out. And so I feel like even just saying, like, hey, a lot of this stuff is visual, let's come up with an alternative way for you to do this assignment. And I think that took a lot of time for the teachers to finally figure out. But I think once they did, you know, it became kind of like, okay, now we know what to do. But of course, then once they figured that out, it was already like I was moving on to the next year, you know. And so I think again, it goes back to the preparation before the student with a disability steps into the class, you know, what what materials will they need? And again, I think that goes, especially for children, goes back to, you know, having that conversation with a parent and saying, hey, you know, what are the things that this child will need in order to help them succeed throughout the year? I think those were those are some of the things I would have wished that a teacher would have, you know, kind of done differently. But I will say I had a a para professional and and she worked really hard with me. So I feel like she definitely knew how to, you know, go the extra mile and help me out in those moments when I couldn't access the materials like everyone else.

Sylvia 6:22

Okay. I so I'm I'm even gonna go a little bit further. So for me, just even where I sat in the classroom and I needed the natural light, but I also have a tendency to look out the window. But I needed that, but they would sit me in the front of the classroom, close to the board. I could stand with my nose on the board and not see the board. And so understanding, like really, um, I think so much is focused on that book and those close-up things, and they don't think about the far away things so much. And I think that's a big deal. I can't wait to hear Mary's take on that. I know. Um, there's so many, like you said, so many great tools, but we I was pre-computer, pre-all technology. So let's get Mary involved, Gabby.

Meet Mary Noga And The Gap

Sylvia 7:10

Yes, we're asking Mary some questions. Mary, you're on the you're on the ball now.

Mary 7:14

All right.

Gabby 7:16

Yes. So, Mary, I know you've worked uh as a school nurse and are now the clinical assistant professor and director of the school nurse certification program at University of Illinois, Chicago. What led you to National Center for Children's Vision and Eye Health, Small Steps for Big Vision at Prevent Blindness, and what were problems you were hoping you would help solve?

Mary 7:46

Sure. So I've been a licensed school nurse in Illinois for, gosh, this is my 18th year. And um I was also doing my Doctor of Nursing practice in advanced population health over the last several years. So I did my clinical internship hours with the National Center for Children's Vision and Eye Health. And over the last two years, um part of that was developing the small steps to eye care action plan. We also did a pilot with some schools across the country. And then once we um solidified what that would look like, um, I did a quality improvement project using that small steps to eye care action plan at the preschool, in the school district that I was working in as the health services coordinator last year. The essential gap that we identified, at least within our district, was that in Illinois, you do have a vision screening mandate for preschool through 12th grade. So we had a lot of data collected already from our school district and our vision screening program that showed we had a lot of children at the preschool level that were failing that vision screening. And we were sending home a letter and a treatment form per the Illinois Department of Public Health's guidelines, expecting the parents to then follow up with that failed screening with an eye doctor and go get an eye exam. And based on the data that we collected, we were only getting about 30% of our parents to follow up with that eye exam. So there was a big gap in knowing whether or not that child actually had an eye condition because the screening's pretty basic. And then those students who didn't return the eye exam, you know, that's almost 70% of this of the families that didn't seek that eye care.

unknown 9:39

Right.

Mary 9:40

Those children were going through school not knowing whether they actually had an eye um concern that needed to either be treated or monitored, you know, by an actual eye care provider.

Sylvia 9:50

Yeah. And they and they could be doing poorly in school and it not being recognized that it's a vision issue.

Gabby 9:58

Exactly.

Sylvia 9:59

Exactly.

Gabby 9:59

Definitely. For listeners who aren't familiar with it, can you walk us through what the action plan actually includes? For example, the step-by-step follow-up process, conversation starters, and discussion prompts, uh, our scheduling and appointment checklists, or any other relevant information.

Mary 10:22

Sure.

Small Steps Action Plan Explained

Mary 10:23

So just to give you a little bit of an idea of the background on how vision screening works and how this new guide really assisted us, um, traditionally we just send a letter home and a treatment form home to a parent whose student has failed that vision screening. In Illinois, all preschoolers have to be screened. So, starting at age three, that's a mandate. The small steps action guide came into play for us in our quality improvement project because it gave us an actual conversation guide that looked at structural and social determinants of health that may be barriers for parents and/or caregivers when you know coming to schedule that that eye exam. So a series of questions is asked by our school nurses who are our vision screeners in the school districts in Illinois that look at a variety of topics. Some of those included do you or a family member have transportation to go to an eye exam? Have you noticed anything or eye concerns about your student? And just kind of start that conversation with the parent. Do you have any concerns about your child wearing glasses? And then also, do you have any concerns about the cost of an eye exam? And let me help you understand your concerns. Or do you have any concerns about your insurance or do you not have insurance for eye care? So these questions would lead us to, depending on their answers, other questions such as, you know, do you need help finding an eye doctor? Um, or will you need a transportation to your appointment? Do you need a translator? So we're looking also at that access point for people who don't speak English.

Gabby 12:07

Right.

Mary 12:08

And do you have a work schedule that precludes you from taking your student to an eye exam? Do you need an eye appointment later in the day? So really it became a conversation guide and a script for our nurses to be able to have a more comprehensive follow-up phone call with the parents. Uh, we also added into that conversation some educational tools that we sent home to the parents in advance that were also developed by Prevent Blindness to help parents understand what kinds of clues they could be looking for in their three and four-year-olds don't read yet. So, what can you look for in your student that might indicate that they have an eye concern? Um, so that was really kind of the crux of what we did with the um action plan itself. And then we added in some additional elements to it as we learned from our first set of parents, like what were the most common areas of concern? And then we added things on to those um concerns to supplement sort of the case management of these parents and children to make sure that they got the care that they needed.

Sylvia 13:17

What what were some of the most common ones, Mary?

Mary 13:21

So the most common one for the group of parents we dealt with was that they could not or did not know of an eye care provider that would see children under the age of five. That was our number one, I guess, identified barrier. The second barrier was they did not have insurance that would cover it or didn't know where their insurance was accepted.

unknown 13:45

Right.

Mary 13:46

And really those were the biggest in terms of the group of parents that we dealt with. The other piece was they didn't think that or never occurred to them that their child who was three or four years old would have an eye condition because they hadn't really noticed any concerns with their student. And so really that parent education piece was huge in helping parents understand, you know, what kind of eye conditions can take place in a three or four-year-old and why it's so important that we address them now before they enter the school system, the formal educational system, you know, being kindergarten, at least in Illinois.

Gabby 14:24

So I love that. It makes me think, you know, I did the aspect program, and one of the things that my group did was we started working on a project uh was based on, you know, kind of children's eye health. And we had these conversations about income and how families would be able to get to these appointments with their child or any of those things that could come into play. So I I love how you how everything is set up. Small Steps for Big Vision was originally designed with Head Start and early childhood programs in mind. What did it take to adapt it for your school district's students and families?

Mary 15:07

So there's two pieces to this: the Small Steps for Big Vision Toolkit, which is the, I guess, larger umbrella, um, where the small steps for eye care action plan falls underneath. And the whole point of the program was to educate parents on eye conditions so that they would have that background knowledge to follow through. I think for our district, it wasn't really that hard to fit into our vision screening program because it's already a mandate in Illinois, and many of our nurses are trained and certified as vision screeners already through the state. So adding on a more in-depth case management approach to follow-up for these families was really the only thing we had to do. We had to make this um, and it will continue moving forward to be a part of our referral process, um, which um, because we're a larger district, we have about 20 screeners. And, you know, school nurses are already advocates for students and children with health conditions and uh disabilities. So it's really a natural progression for the school nurses to want to have a tool that helps them be better case managers for students with, you know, uh potential visual impairments. I think the broader aspect of that is, and my goal is really educating school nurses on why paying attention to students with potential visual impairments is really um key as the nurse. You know, many times the nurse is the first person who recognizes any kind of health condition or disability student. And I think there was a gap also in our nurses not understanding the broader concept of case management and not just sending home a letter and then letting it go. Right. So that was a bit of a challenge for us. But you know, having the materials from blindness and from the small steps, you know, toolkit in general really made it a lot simpler for our nurses to adapt some of these tools into our process. Um and I think it was it was a very successful program for us. We raised our referral return rates from 30% to 65% in a three-month period.

Gabby 17:28

So that's amazing.

Mary 17:34

You know, by school nurses to help these families bridge those gaps is going to increase not only access to the care, but earlier identification of visual impairments will lead to hopefully you know better program planning, like you had said, Gabby, for teachers. And there's a big collaboration between teachers and the school nurse already going on through special education. So I think you know, my goal and in leading this project forward and beyond just the school district is to make sure that the education of school nurses in the program that I'm teaching now includes a broader program in understanding how visual impairments affect students and how the school nurse can be an integral advocate for um those areas of need. So absolutely. Thank you.

Sylvia 18:26

Spectrum of visual impairment is often daunting for everyone, is just understanding that, and especially, you know, the parents, you know, oh, my child could see. Um, you know, I I I am super guilty, is that I was I am very visually impaired. And when my daughter was nine, um she she we took her to the eye doctor, and and because our pediatrician recognized, oh, she might be a little, she, you know, maybe maybe you better go see the eye doctor. And when she they put glasses on her, she went, Wow. And so she needed those way before that moment, clearly. So yeah.

Gabby 19:10

For sure. Definitely.

Sylvia 19:11

So I think parents really, if their kids are doing fine, they just don't connect all those dots. So oh, that maybe you know, they have the letter, oh, but but they seem fine. Why do I do that? So it's great that you've taken that step further.

Gabby 19:28

Definitely, I agree. So, Mary, when a child or parent doesn't realize vision is impaired, how does the action plan for nurses and educators step in early to guide families from initial signs to a full exam?

Mary 19:49

Well, so one of the things, at least in Illinois, is um we do have an eye exam mandate for kindergarten. So even in preschool, ages three and four, while they can still attend school and not have that mandated eye exam, the small steps action guide helped us to identify early who some of those three and four-year-old students might be who need additional assistance either visually or just need that eye exam, maybe just need glasses. Um and to bridge that gap early before they get to kindergarten is really a way to advocate for those students in the event that they do have a visual impairment going into kindergarten. The school nurse can then follow up with that next level prior to that student entering the grade and help um bridge the gap for any additional accommodations or modifications of materials for that student. So, really, it was a natural addition to our program and our process in our district, but um could really be adapted in any district that has a vision screening program where the schoolers are involved with that you know, sort of advocacy piece.

Gabby 21:01

And now I'll pass it to Sylvia.

Sylvia 21:03

Okay.

Barriers That Block Eye Exams

Sylvia 21:04

So, Mary, let's let's discuss implementation, the referral exam gap, and equity of access. In your experience, where does that follow through tend to break down the most? I think you've kind of mentioned that, but go into what helps has helped to really bridge that gap into a little bit more detail.

Mary 21:35

Sure. So I think the most important piece to bridging that gap, at least in our district, was creating community partnerships with local eye care providers. We were very fortunate. I connected with a optometry school in our um county that had a pediatric eye clinic, and they saw children from birth. Really too adult. And they also had a special needs clinic for students with sensory issues or autism or nonverbal. So that was one of the biggest pieces that really helped us in our quality improvement plan because the number one reason parents didn't take their children to the eye exam is they didn't know where there was an eye doctor that would see their child that young. So I spent quite a bit of time interacting with that university and setting up their an actual connection to their referral coordinator, helping them set up appointments. That was one of the hardest pieces, I think, for some of the parents with a language barrier was being able to make those on their own, not knowing if the person answering the phone is going to be able to speak Spanish or Russian or whatever language was their native language. So, you know, bridging that gap and the case management part of school nurses being involved in this and looking at those gaps on an individual basis, not just as a whole, and helping those parents bridge the barrier. So whether it was finding a translator or making that appointment for the parents or directing them to the appropriate resource, our district was very, very fortunate and generous in the if there was a transportation issue, we provided Uber services to those families. The other piece was educating the parents on their Medicaid insurance. Many of our families are Medicaid, and many families on Medicaid didn't understand that they get a free eye exam and a free pair of glasses every year. And so they didn't know that their insurance already covered it. So a lot of them who were concerned about the cost didn't realize that it wasn't going to cost them anything. So parent education was huge, not only in understanding that their child had an potential eye condition, but helping them understand their insurance and all of the, I guess, little tidbits that go along with it. One of the pieces to the community partnership that we developed was their referral coordinator would help us not only get the appointments that were convenient for our parents, but would also help bridge some of those barriers for us. So they did have a caseworker that would help with the Medicaid piece. They also had translators. So we, if we didn't have to use our own translator, they could use theirs. And that was really the most successful part of this. Once we found that outside provider and bridged that with that partnership, we saw our referral return rate go from like 27% over a two-week period to 42%, just because we gave the families what they needed. The other piece to that was when the nurse called and used the small steps action guide as their conversation piece. They also had sent home a packet to the parents in advance, not only with the letter stating that their child had failed the screening, you know, the treatment form that needed to be filled out, but we included parent education materials that were developed by Prevent Blindness. And at the time of the nurse's phone call, uh they reviewed that parent education materials with the parent. And that gave the parent an opportunity to ask questions, to truly understand, you know, why does vision matter so much at an in a three or four-year-old? And allowing those parents to answer those questions or ask those questions and have the nurse answer them made the, I guess, urgency of the parent to get that eye exam more important. So that was really a huge piece to our success, was just sort of a comprehensive package that the nurse provided to the parents.

Sylvia 25:58

That's awesome. So you so you sent the package, and I'm I'm guessing you sent it in in English, or if you knew they had a different language, you could send it in that language as well.

Mary 26:09

Yes, so it was twofold. We sent home uh in the student's backpack a hard copy of the packet, and then we also sent it to the family's email on file. Um, if we knew that the family, you know, was either Spanish speaking or um and and Prevent Blindness provides the packet in Spanish already. Um that was that was doable. Now, some of the other languages, you know, we have 37 languages in our district. So we did not have access to the small steps action plan in every single language, but you can use a translator also. If you open up the small steps action guide in like a a PDF or even in like a Google Sheets, you can use Google Translator to read.

Sylvia 26:54

Or throw it in an AI. Yeah.

Mary 26:57

I mean, there's a lot more tools nowadays than if you follow them. So if if it were a huge barrier, we can certainly send documents to our translator as well. And they will read the documents on our behalf. So it it is an extra effort on the on the part of the nurse, but we we even kept track of how much extra time it took for the nurse to do this. And honestly, on average, it was really only one extra phone call. And the average or the longest time it took parents or nurses on the phone was about four minutes. So really it's doable and it's feasible for the nurses to take that, take this on as an extra piece to that referral process.

Sylvia 27:39

And you and you have results. I mean, it really showed results.

Mary 27:45

Yeah, well, it was very, very uh rewarding for the nurses too to feel like they actually could provide a comprehensive program for those parents.

Sylvia 27:53

So, since bringing this action plan into your district's work, what have you seen change? Where it's in staff or how referrals are made or how you know families respond.

Mary 28:06

I mean, I think the biggest piece is a change for the nursing staff. So they do have to learn how to use this new action guide. But I think the the bigger piece is we bridge the gaps for the parents. And that is really where this will be the most useful in our district. I mean, we screen 7,500 kids a year, and it's about a 10% referral rate. So 750 kids need an eye exam. And if we can get more than 50% of those kids to at least go see an eye doctor, then we're catching a significant number of children who could potentially have visual impairments that go undetected. So, really, I mean, it's it has multiple facets to it, and and um, it's really been a rewarding program for us, and I think the nurses really enjoyed using the plan, which makes it a lot easier to integrate into our systems.

Sylvia 28:58

It gave them a direction, yeah, instead of instead of um, well, I just didn't get a response. Well, here's a whole strategy. Yeah. Right.

Gabby 29:07

Okay, Mary, what recommendations would you give to anyone who wants to advocate for vision health in their own school districts? And what should they focus on first?

Mary 29:18

Well, I think that, you know, having having been an advocate for the blind and visually impaired community already, I kind of had an advantage to really know where to go with some of these tools and and how to use them to bridge the gaps. I think if you're maybe a new school nurse or new to vision screening and not really understanding children's vision, that's your first step. And the National Center for Children's Vision and Eye Health has an amazing website with many, many materials, many webinars. The small steps to big vision toolkit is also on the National Center for Children's Vision and Eye Health website, as well as the National Um Association of School Nurse website. So there's a lot of educational material out there. And I think that's the first step is getting that outreach to the school nurse community to understand the importance of children's vision. You know, it's an aspect of what we do on a daily basis. Um, if you look at the special education system in our country, which is a federal mandate, uh, vision and hearing screening is part of that case study evaluation that you do on any student who might need special services. And I think that school nurses really need to understand the importance of not just putting down the date that the student passed or didn't pass the vision screening. It's really digging into pull out that eye exam that that parent might have turned in or dig a little deeper into understanding, even if it is a minor visual impairment or just low

Partnerships That Boost Follow Through

Mary 30:55

vision, truly understanding how that impacts a student's education is really the the role of the school nurse. And that's what we do. So, you know, I think that any district can adopt this, even if you are a district that doesn't do the screening yourselves, but maybe the health department does it for you and then gives you the referrals to follow up on. I think this tool really will help you navigate how to help these families get what they need and not just like one of you said, just sending the letter home and saying, not my problem anymore. I don't know that. I don't think that is how nurses operate. I mean, we are trained to bring our patients back to independent living. And vision is one of those aspects that we have to pay attention to. So I think it's a really simple tool. It's very well outlined. It's very the directions are pretty specific and really follow, easy to follow. So really anybody could pick this up who is advocating for children's vision issues and and utilize it.

Sylvia 31:58

Where can parents find the best resources? Are those that same website or not?

Mary 32:04

Mm-hmm. So, I mean, the you had mentioned the Head Start program. So the small steps to big vision toolkit is on the National Center for Children's Vision and Eye Health website. It is geared toward parents, and it is a whole bunch of videos and you know, forms and documents that parents can read and go through. Even school nurses who work in preschools could present that information to at like maybe a parent information night in a preschool.

unknown 32:33

Yeah.

Mary 32:33

It's very well done, it's very well written. Um I think it's just a resource that we need to get out there to make sure people know it exists. And I know that they do a lot of um outreach and advocacy work, you know, as um an organization. And again, it's on the National Association of School Nurse website. So the tools are there. We just need to direct the parents to the tools.

Sylvia 32:55

And that's often the case. That's just often the case. People don't know, you don't know where you need to go. Like, you know, if if there's something you don't know about, you just don't even know something exists.

Gabby 33:05

Exactly.

Sylvia 33:06

Until all of a sudden you need it. And then it's really often difficult to figure out where things are.

Gabby 33:12

So And I think this is important because, you know, it's when parents are trying to help their child navigate this, you know, the last thing I'm sure they want to think about is like, okay, I have to research all these things. And I think knowing that this is a tool that exists that they can just keep tucked away for for whenever they feel like they need to refer to it is really important to help them through anything with, you know, teaching their child about vision loss or helping their child through through the adjustment period of vision loss as well, I'm sure.

Sylvia 33:45

So access, inclusion, and representation shapes how we talk about disability at bold blind beauty. So, where do you see those same principles, Mary, um, showing up in school help work?

Mary 34:00

Well, um, I think that we've come a long way in providing resources and access for students. I know your stories maybe did not indicate that as much. Evolution is a great thing. And I think, you know, school nursing has become a lot more complicated over the years as well, for as long as I've been doing this. I think more and more accessible type learning materials have really helped the blind and visually impaired community. You know, having the access to technology now with iPads and screen readers and speech to text and um, you know, even software like JAWS that you're using, um, those are all tools now that maybe didn't previously exist. Now they do have to be taught to, right? And I think, you know, the teachers of the visually impaired, and we call them vision itinerants in our districts, and they should be in every district because that is a federal mandate that we support under a special education category of visual impairment, that they do have um one-on-one or or they're taught how to use those tools. So I know working in our district, you know, if you're looking at access, our teachers of the visually impaired always start with braille because braille is early literacy.

Sylvia 35:23

That's how you're I love that.

Mary 35:26

Yes, no, I think it's it's so easy to just go to an iPad instead or just audible instead, but there's a burn a brain connection that you make by learning Braille.

Gabby 35:40

Absolutely.

Mary 35:41

And so thankfully, the system still teaches Braille, and I think they still highlight that as being equivalent to someone who is cited learning to read. Yeah, that's sort of the access part. I mean, in schools nowadays, inclusion is a mandate, so everyone is included in regular mainstream classes as appropriate. Any kind of special education is usually pushed into the classroom. So the teachers of the visually impaired will go in and spend time in the classroom one-on-one with students. They do some pull-out minutes, they call it, where they might pull them out of the classroom. If you're teaching someone Jaws where obviously the screen reader is speaking out loud, you want to do that in an area where the student can learn it without, you know, sort of being distracted by what's going on in the classroom and vice versa, right? So those are so some of the inclusion things that are going on. Um, I also know that you know there are some visually impaired students that I'm aware of who participate in a lot of the after-school activities now.

unknown 36:42

Right.

Mary 36:43

Um we have kids, we even have students that are participating in in sports, whether it's through Special Olympics or um even some of our students who might just have low vision but not blind, they're able to participate in sports now because they they have to be allowed to do that. We can't discriminate against anyone's disability anymore. And as long as it's safe for them to participate, then we do have students that are doing that. I think a lot of times it's the willingness of the people in the building or in the school to recognize that just because you might have low vision or you're blind, that doesn't mean that you can't still access everything. It just has to be adapted to how you learn it.

Sylvia 37:26

And sometimes it's fun for the other kids to figure out those adaptations too.

Mary 37:31

Yeah. Well, and I'm always amazed at our our truly blind students who have white canes and you know have to access the building at how

Inclusion Tools And Back To School

Mary 37:40

confident and how quickly they become adapted to the building. And those kids walk around that building like no different than any other student. And they navigate the stairwells and they they go through the lunch line and they get what they need. And I think the younger that you learn some of those skills, maybe the easier it is because you don't really know any different. But that's um I mean, I happen to work in a very, very inclusive you know area. Uh, we have a lot of resources in the county that I live in. Um, our investment in special education in our districts is very, very well done. Um, so that's um really of an advantage when it comes to um adding new tools to the system because we already have teachers and administrators that are very, very supportive of that too.

Sylvia 38:27

So yeah, sounds like it. What would you say really makes an impact for children who are visually impaired as they start a new school year?

Mary 38:38

You know, I think having a one-on-one adult that they can rely on or even appear, I think helping them to feel part of the regular school community. Um, obviously, you know, walking into a you know really big high school, for example, can be very, very intimidating if you can't see your surroundings, or even if you are low vision and and still can see, but maybe need some help, you know, navigating, connecting a peer-to-peer so that they feel like associating with someone their own age and identifying their adult resources as well. Typically, we the school nurse is one, the social worker, uh, maybe a guidance counselor. Um, we usually do like a meeting at the beginning of the year with the parent and the student and the families, and we ask, you know, how how how do you want to be supported?

unknown 39:29

Right.

Mary 39:30

There's got to be some individual, um, some kids want more help than others, and we don't want to blanket what we do for every single student. We want the student to tell us what they need as well. That's awesome.

Gabby 39:41

That's important.

Mary 39:42

Yeah. And we do have orientation and mobility specialists on staff and occupational therapists on staff. So we really create a comprehensive individualized education program for those students if they qualify or need special education services. If they don't, they qualify for accommodations under section 504. Yes. Um, and so I think it's it's a matter of how the school approaches it. I mean, I will admit I've had to kind of put my foot down for some kids who've come into the district with some visual needs, and certain people weren't on board thinking, well, they don't really need special education. I'm like, yes, they do, you know, and that's the role of sort of the nurse. Like, we're the advocate. Sometimes we're the squeaky wheel that gets the grease at the table. And um, you know, I'm not saying every teacher walks out of their teacher preparation program and knows how to work with students with visual impairments because they don't.

Sylvia 40:40

They don't. They don't.

Mary 40:44

So I think just a school in general taking uh sort of a wraparound approach to someone. I mean, you don't see a large population of the students with visual impairments. I think in a district our size of 26,000 kids, I think we have maybe 20. So that's a pretty small population, but there's really no excuse to not have those services ready to go when that you're only dealing with a small population of the of the student body, too. So I think teachers who can prepare in advance. I think Gabby, you had said that teachers really didn't understand how you learned and what you needed. Um and I think that um teachers need to be educated more about what are the resources for people who are blind or visually impaired. So how can I change my curriculum or how can I modify it? Or nowadays, thankfully, we have you know accessibility laws when it comes to the internet and things are starting to turn around there, which you know that's that's a big process, but you know, teachers don't know what they don't know either. So that's correct. Thank you.

Sylvia 41:51

So uh the final question I'll ask, and anything else you want to share, but how can parents, teachers, and schools ensure the success of students who have visual impairments? And I think you've talked a lot about that, but anything else?

Mary 42:08

You know, why I guess one of the um sort of examples over the years that I think really kind of speaks to this is the parents need to be on board.

unknown 42:18

Yeah.

Mary 42:19

And you know, we've had children come over from other countries where there is no such thing as special education. You know, they they they don't look at a visual impairment as something that needs to be supported. It just is what it is. Just a very different, you know, medical system in other countries. So we've had students come over from other countries where the parents didn't even ask for any assistance, and we didn't know that the student had a visual impairment until they walked in the door, and you see some observable signs of someone who's struggling to see. And then we ask the question, oh yeah, well, they had a mini stroke when they were an infant, and they're they can only see, you know, low vision, low light, or or whatever the diagnosis might be. Right. They never thought to ask for help because they come from a country that doesn't have a system in place. So really getting the parents on board with understanding that special education is not a bad thing. Um, sometimes parents think, well, I don't want my kid labeled as somebody with a disability. Well, we don't advertise that. Nobody wants a label. Um, a lot of that falls on how how well of a program you have in place, the special education.

Sylvia 43:34

How you communicate, right?

Mary 43:37

And helping parents understand that the purpose is to give their child the tools and to level the playing field. I just think that um, you know, my husband is visually impaired, he's blind from uh retinitis pigmentosa. And I think that as an adult navigating the world too, we owe it to, and he's still working and accessing, you know, the work world and trying to live an independent life. One of the things that we need to do for children is making sure that we're planning for their transition outside of the school system. Um, and understanding, and I guess having that perspective of you know, being with someone who's out in the work world and understanding what it takes to navigate that, we need to make sure that we're incorporating some of those tools, especially into kids in the high school level, so that they have those tools when they leave high school and not have to learn them on the job. That is going to make them more employable. It's going to make them more successful and get more people with visual impairments employed too.

Sylvia 44:44

So well, and like you you didn't say these words, but it's just the truth. Transition for a kid who's visually impaired, especially one who's blind, really start when they start walking because it is all about developing the skill that they're gonna have for life. And that's why I mentioned earlier, um, and I didn't mention on the podcast, but that four to twenty four, number four TO 24 app is so good because it it does exactly that, tells you all the activities that that um you kids should be doing or can be doing at to start really getting ready for adulthood at different ages.

Gabby 45:25

Yeah, definitely.

Mary 45:26

Hopefully, bring that back to our um vision itinerant team because that that's a huge um bonus for kids for sure, especially because resources, just resources, and making sure people have those.

Sylvia 45:40

Mary, that's awesome.

Gabby 45:42

Yes, thank you, Mary, so much for

Resources And Closing Thoughts

Gabby 45:45

just I think just the work that you're doing and just taking us through all of it today. I I think that definitely the fact that a child's vision shapes so much of how they experience school, and it's easy for that to go unnoticed until someone is actually paying close attention. Thank you again, Mary. Thank you so much. You're welcome. Thank you for having me. Thank you to our co-host, Sylvia, for leading such a thoughtful conversation. If you'd like to learn more about small steps for big vision, we'll include a link in the show notes. If this episode gave you something to think about, we'd love for you to subscribe, leave a review, and share it with parents, caregivers, or educators who could use it. Until next time, thank you so much for choosing, understanding, and understanding with us.