Paula Apa-Hall is among the many school nurses who look back wistfully at the days of splinters, skinned knees, and runny noses.
One of two school nurses in the West Linn-Wilsonville (Oregon) School District, Apa-Hall is responsible for 3,800 students in seven buildings. The population she serves includes children with physical disabilities, diabetes, feeding tubes, catheters, emotional disorders, and life-threatening allergies.
I triage by phone and e-mail, Apa-Hall told Education World. Some days end in tears; other days I'm beaming because things worked out. If I weren't an optimist, I wouldn't still be here.
While Apa-Hall's assignment is particularly challenging, she is not alone in feeling stretched thinner than a Band-Aid.
At a time when more children with chronic medical conditions are enrolled in public schools than ever before, many districts are eliminating or not expanding nursing positions because of budget cuts and fierce competition in the job market for nurses -- forcing many schools to fall back on school personnel to provide medical services. The lack of nurses not only impacts chronically-ill students, but overall student performance by keeping more children healthy. And some fear cutbacks and outsourcing care to non-medical personnel could have life-threatening consequences.
"I'd like to have a nurse in every school [nationally] so we can go back to nursing and teachers can go back to teaching and kids are safe and healthy," Apa-Hall said. "Districts nationwide look at classroom personnel as the top priority -- and I agree -- but kids who don't feel well can't concentrate and don't learn as well if they feel sick."
The school nursing shortage in the U.S. has evolved from a scheduling problem to a serious health and liability risk, nurses told Education World. The U.S. currently has no national standard for the number of nurses per school or child. We see a wide disparity between the states in terms of the number of students per nurse, Amy Garcia, a registered nurse and executive director of the National Association of School Nurses (NASN) told Education World. In Vermont, there is one school nurse for every 298 students; in Utah, the ratio is 1 to almost 6,000 students. The average caseload per school nurse in the U.S. is 1,150 children. Only 45 percent of U.S. schools have a full-time nurse, and 25 percent have none, Garcia added.
As student health needs increase, it puts students and districts at risk, noted Apa-Hall. "We have to explain to people why nurses are important to academic success and to keep kids safe in school," she said.
On the positive side, 40 percent of states improved the nurse-student ratio over the past year. So it's not all doom and gloom, Garcia noted. "We are seeing some superintendents who understand school nurses' effect on attendance and students' ability to learn."
NASN and its affiliates at the state level currently have proposals in Congress and in state legislatures to require all school districts to have at least one registered nurse per 750 students in the general population -- that is, children without chronic medical conditions. The ratio for students with serious chronic conditions -- such as those requiring ventilators -- should be 1 to 1, NASN maintains.
Current economic conditions, though, could put some of the recent progress in jeopardy. School budget cuts are trimming the school nursing ranks, and a nationwide nursing shortage is making it harder to hire school nurses when jobs are available. The private sector can offer nurses higher salaries than school districts and even throw in signing bonuses.
Another problem districts are encountering is that many school nurses are becoming overwhelmed. The stress of having to monitor so many serious medical conditions in so many children is driving school nurses from the field.
"I've been a nurse since 1971 and have worked in an intensive care unit and an emergency room -- and I felt safer there than in a school," said Donna Kosiorowski, the supervisor of school health services for the West Haven (Connecticut) Public Schools. "[In a hospital,] you could call for a doctor or someone else to help. In a school, you are on your own, and have no one hooked up to heart monitors or other equipment, so you don't have the means to help you diagnose the problem."
Apa-Hall agreed. "Some people leave the profession because of the risk -- the kids are getting sicker -- they are afraid of the severity of the illnesses," she told Education World. "I'm seeing fabulous nurses leave because of fear of the liability and the risk. It's difficult to do such a huge job with such limited resources."
Once more of a first-aid station, many school nurses' offices now are operating like medical clinics. The nurse's role has changed because now they are seeing children who previously did not go to school in public schools, said Garcia. "We see kids on ventilators, with asthma, obesity, and closely-monitored diabetes. Thirteen percent of kids now are on medication for more than 90 days. The work has become much more complex."
Ensuring a safe environment and inclusion to the greatest extent possible for special-needs students has become the primary role for many school nurses, added Susan Marley, a nurse at The Chatsworth School in Reisterstown, Maryland, who has worked as a school nurse for 24 years. "We're not just responsible for first aid; we're planning for kids with chronic health needs so they can participate in school," she said. "Really, we are the facilitator and advocate for kids with chronic needs."
"At the same time, it can be difficult working as the only health professional in an education environment. We're not in medical setting," said Kosiorowski. "They all have an education perspective. It's like traveling in a foreign country -- we have to understand each others' language."
The current economic and social conditions also are straining school nurses' offices. When parents lose jobs and health benefits, the school nurse may be the only source of medical care for many sick children. Apa-Hall said she often spends time helping families apply for the state's free medical insurance program for children.
In some cases, nurses are filling in for busy working parents. In fact, an August 2008 survey conducted by NASN found that 72 percent of school nurses have students in their schools with a known history of severe allergies or prior use of epinephrine -- which is the first-response drug for a severe allergic reaction -- whose parents have not provided the school with auto-injectable epinephrine for their child.
At Marley's K-5 school, about 80 of the 425 students have individual education plans (IEPs), and maybe even more have special needs. "We have so many who are medicated, and in some cases it's not working," she said. "We have a clinical social worker because of the large numbers of kids with mental health issues, like ADHD, bipolar disorder, and depression." If parents have trouble getting children to take their medication daily, Marley said she does it. She also closely monitors a kindergartner with diabetes, including checking to see what she eats and calculating the insulin dosages. If the kindergarten class goes on a field trip, either Marley or a parent must go along.
"Our role used to have more to do with health and safety; now it's more of a care-giver," Marley explained. "There is a fine line between helping and enabling. There are some situations where you want to help parents stand on their own two feet. But some parents leave for work at 6 a.m. and don't have time to administer the medication."
In terms of the general school population, school nurses' influence in enhancing student performance often is underestimated by educators, some of the nurses said. Nurses are there to help students be healthy and ready to learn, Garcia noted. "Nurses are a benefit to teachers; teachers have enough to do without worrying about health issues."
"Nurses do need to do a better job of explaining their role in the education setting, and stress that they are a valuable asset when it comes to learning outcomes," said Kosiorowski. "It's partly nurses' own fault that educators don't realize the effect of nurses on learning," she said. "By having a nurse in the building, it helps support kids and helps return them to classrooms faster. Sometimes educators don't understand what we're doing. We have to keep repeating the message that health and learning go together, and make sure children's health care needs are met so they can achieve what they need to do in classrooms."
And the more time nurses spend in schools observing and interacting with students and parents, the better chance they have of spotting and solving problems early, added Apa-Hall. Currently, her job demands don't leave her time to do health screenings or check students' blood pressure, hearing, sight, and weight. "If I'm in the schools, I get to know kids, get to know the issues. I can see kids who are hungry, over-tired, have allergies, or appear abused," she told Education World. "I can see potential health issues that teachers are not trained to recognize. I talk to parents more when I'm in the building. There are kids with eating disorders or who have wheelchairs -- and there are a lot of kids with health needs most people are not aware of."
Few, if any, school board members would dispute that nurses are valuable assets to schools, said Brenda Z. Greene, director of school health programs for the National School Boards Association. But with school budgets in the red and tax bases eroding, many communities are focused on keeping their districts solvent and preserving teaching positions.
The money issue is critical, Greene told Education World, as is the competition in the job market for fewer available nurses. "Trained personnel are very costly. As boards are cutting teaching positions, it's hard for them to say they can maintain nursing positions."
In some areas of the U.S., local hospitals and health departments have been making nurses available to schools to take up the slack, Greene noted. "If there is a groundswell of feeling for this [for more school nurses], then there could be a change," she added.
A solution to the personnel and funding shortage has to come from a multi-disciplinary group, Kosiorowski said. "We [nurses] have to articulate better what we do and gather data about outcomes," she said. "Unfortunately, a solution will come when tragedy occurs."
Because the number of nurses often has not kept pace with the increase in students with special needs, responsibility for student first aid and routine care such as administering daily insulin injections and dispensing medications -- even changing catheters -- is being outsourced to teachers, administrators, and even clerical staff members.
"The problem with unlicensed personnel is that they don't know what they don't know," noted Garcia.
While not ideal, training school personnel to handle some health-related tasks is a compromised way of making sure children's needs are met, Greene told Education World. "I think parents understand the financial constraints that schools are under and try to work with them. [Non-medical] people can learn to do things in a safe way. But you have to have people who are willing to take on the commitment and be thoroughly trained."
Oregon, for example, does not require school nurses and ranks 49th for the ratio of nurses to children -- the state average is one nurse for every 3,500 students. The state has very liberal delegation regulations, Apa-Hall said, so nursing duties can be assigned to administrators, teachers, paraprofessionals, and secretaries. These tasks could include dispensing medication as well as changing diapers, inserting catheters, mixing glucagon for diabetic emergencies, changing feeding tubes, dispensing food and medication through feeding tubes, and even administering emergency seizure medication, which needs to be done rectally. "It's difficult for them to handle all these tasks," Apa-Hall said.
In addition, six people per building serve on an emergency response team (ERT) whose members are trained in CPR, first aid, and how to use a defibrillator, she said. One adult has to be trained in these skills for every 60 children in a school. Team members undergo a full day of training, then have review sessions throughout the school year. Before school starts, ERT members review the medical conditions of students in their buildings and discuss them with the classroom teachers, she said. Part of her job is to do refresher training with the ERTs during the year, said Apa-Hall. She does find time a few days a week to visit schools.
Some states have gone as far as to develop new positions to fill in the gaps. In Maryland, Marley said, some schools have licensed medication technicians, who are certified to dispense medication under the supervision of a nurse. They also are trained in first aid. The position was created by the state because so many facilities needed medication distributed -- including schools, day care centers, and nursing homes, she said. Fairfield County, Virginia, schools have similar personnel -- although budget cuts may force them to be eliminated, Greene said.
And in tight economic times, not having any alternatives to nurses can put schools and families in a bind. In November 2008, a Sacramento, California, Superior Court judge overturned a 2007 rule that permitted trained school staff members, in addition to school nurses, to administer insulin injections to diabetic children, because there were not enough nurses. Some parents of diabetic children in schools with no regular nurse, though, were dismayed by the ruling, because they did not know how their children could continue to attend school if the district could not afford to hire more nurses. If their child's insulin levels needed correcting, that could mean leaving their jobs and rushing to school on short notice to give the injections themselves.
School boards in other states are keeping an eye on the California decision to see where it leads, said Greene.
Nurses told Education World they are aware of the competition for school systems' shrinking pool of money, which is why they favor directives -- and funding -- for school nursing coverage from the federal level. Communities should not have to choose between teachers and nurses, they said. "A lot of people want to see a nurse in the building but don't want to give up teachers," Apa-Hall added. "And they shouldn't have to."
Greene, however, said that decisions about nursing levels and allocating funds are best left at the local level. "I think what goes on has to be determined by the needs of the schools and the districts."
There are several sources of funding for nurses, according to Garcia. "It's how schools choose to allocate funding," she said. "Kids have to feel good to learn. We have to take care of the 16 percent who need daily care. Federal money can pay a portion of the nurse's salary."
More professional recognition, better working conditions and salaries, and benefits on par with other educational staff members also will help attract strong applicants to the field, said Kosiorowski, adding that many school nurses need summer jobs to survive. "School nurses will have arrived when we are as important when we are there as when we are not there."
"School nursing has to be viewed as an investment in students," added Garcia. "Healthy students learn better. School nurses are partners to make sure that happens."
Article by Ellen R. Delisio
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