The typical workday for Carolyn Duff and Beth Mattey is what you might call hectic.
Duff, who serves as president of the National Association of School Nurses, is the nurse at an elementary school with 425 students in South Carolina’s Richland County School District One. One-third of those children are international students and about 60 percent of them are on free- or reduced-price meals, a common indicator of student poverty.
“My typical day, I start running from the minute I get to my school,” Duff said. “Often I have parents waiting to see me when I unlock my office door. Usually, they’re there because their child has been sick for the past couple of days and they don’t know what to do.
“I fill my days with students. If I’m not treating them for something, I’m pulling them into my office to do vision and hearing screenings. I work with a partnership outside of my school and, through that program, I can connect my uninsured students with vision care, dental care, episodic care. … It’s not a medical home I’m connecting them to, but if a child fell on the playground and has an injury and needs to be seen, through the partnership I can provide free care for that.”
Mattey, president-elect of the association, is the nurse at the 1,100 student Mount Pleasant High School in Delaware’s Brandywine School District.
“When I got there (at school) today, I had two students who came in just after I came in,” Mattey said. “One had a really bad headache, had a bad headache all night. … I checked him out. I had another student, she had brought in information because she’d been to the doctor about an injury that she had. We had to make accommodations for her.
“Then we had a meeting. I meet with the counselors and the psychologists … every other week to talk together about students who are at high risk so we all know that we’re concerned. When we do see them, we’ve got our antennas up a little more, do a little more digging on referral. … Then I needed to check on the young man I sent home the other day because of asthma. I needed to check and see if his asthma was better, if he was under control.”
These pretty typical days exemplify the overwhelming need many schools have for registered nurses on site to help take care of a growing number of students with chronic medical conditions. Even though the need may be great, full-time school nurses are a vanishing breed due to steep funding cuts many school districts faced following the Great Recession.
The National Association of School Nurses recommends one registered nurse for every 750 students in the general population. For students who require daily services, the group recommends one nurse for every 225 students. That ratio drops to one nurse for every 125 students if the children have complex medical needs.
But, the nurses association notes, only 45 percent of all public schools have a full-time school nurse on site. Duff said the association did an informal survey in 2011 and found limited pockets where states such as Pennsylvania and Maryland had been eliminating school nurses.
“The concern was more about the reduction in services or in quality of services due to the replacement of RN positions with unlicensed health aides or licensed practical nurses or licensed vocational nurses,” she said.
One state that has been hit hard with education budget cuts recently is Pennsylvania. In Philadelphia, a report by the Education Law Center says, the school district faced a budget shortfall of more than $700 million in 2011. The district laid off more than 100 school nurses during the 2011–12 school year as part of its efforts to close the budget gap.
“I think everything in Pennsylvania is defined within the reality of budget and lack of resources,” said Rep. James Roebuck, who represents part of Philadelphia and is minority chair of the Education Committee. “It makes no sense to me that you can have a situation where the (nurse-to-student) ratio is, I believe, 1-to-1,500 students and where there is not a nurse in every school building every day.
You can’t get sick on the day the nurse is not there. … It doesn’t make a lot of sense, but it’s become the reality we live with.”
Tragedy struck in Philadelphia last year when, according to Forbes, a 12-year-old girl died on her way to the hospital from an asthma attack that began at school. No nurse was on duty at the school at the time.
“There’s not really been a major legislative reaction,” Roebuck said. “There’s no legislation I’m aware of that’s moved forward, no systematic effort to address the lack of qualified nursing personnel. We have a situation that hasn’t changed very much despite the fact that a child died.”
Mattey said Delaware is the only state in the country that has a statute requiring at least one nurse for each school.
“An elementary school may have 500 students and one nurse,” Mattey said. “I’m in a high school with one nurse with 1,000 students. While we have a nurse in every school, the number of students per nurse isn’t really at the recommended level.”
But, Mattey noted, the Delaware legislature has been very supportive of school nurses. This legislative session, Rep. Earl Jacques introduced House Bill 263, which requires state funding for school nurses. Currently, some districts have to cover the gap between the amount of funding they get from the state formula for a nurse and the actual cost of the nurse’s salary if there is a shortfall.
“We had a case in our state about a year ago where we had a student, I think she was about 12 years old, had a cardiac arrest,” Jacques said. “Luckily, we had a school nurse there in that building who brought her back. That child is alive today because of that school nurse.
“My bill will make sure the state pays. That way, there’s no question as to how it’s being done. We wanted to be sure there’s nowhere where they have an administrator, a teacher or someone (else) performing the role of school nurse.”
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Working Together for Healthier Students
In 1996, the Austin Independent School District was in a tough spot. Facing a budget deficit, the district decided to eliminate all of its school nurse positions.
“The superintendent at that time had to make some tough decisions and begin cutting programs and services that were not required by state law for the district to provide,” said Tracy Lunoff, assistant director of comprehensive health for the school district. “In Texas, currently and in the past, health services are not required by law. It is not required for nurses to be on campus.”
But for some in the Austin community, that idea didn’t sit well.
“When different people in the community heard about the decision to cut all school nurses, they were concerned because they realized many times, school nurses are a stop gap before families begin to access EDs (emergency departments) for health care ,” said Sally Freeman, director of Children’s/Austin Independent School District Health Services.
The Seton Healthcare Family, which has 13 hospitals in the Austin area, stepped up and contracted with the school district to provide school nurses and school health assistants for the district. It was the first public/private collaboration of its kind.
“At the time, Seton provided the majority of the funding, resources and services, whether it was in capital or in-kind donation, to continue the health services program since the district was in a budget crisis,” said Lunoff. “Throughout the years, the district has really taken on about 95 percent of the financial burden to fund the continuation of the contract.”
Seton still has some significant in-kind pieces, including all of the human resources, liability insurance and staffing benefits.
Lunoff said a registered nurse and school health assistant work together as a team in the schools. The number of nursing and school health assistant hours each of the district’s more than 100 schools receives is based on the number of students enrolled, the number of students case-managed for health conditions, the number of medically fragile students and the overall health status of students at each school.
“In our model, we end up with about one staff member, I believe, to about 1,200 students there,” Lunoff said. “It’s trying to balance out the costs versus what’s safe for the children. … We’d love to meet that 1-to-750 (students) ratio that the National Association of School Nurses recommends, however, the district at this point in time is not able to put forth the extra funding to do that. So let’s find other ways we can maximize our services.”
Freeman said the school district places a priority on the health of its 87,000 students, of which more than 61 percent come from economically disadvantaged homes.
“We focus on the whole child,” she said. “We know the importance of focusing on health as well as academics. Our vision and mission is to optimize the health and well being of students by coordinating education, prevention, primary care, public health services and advocacy. In doing that, we understand that if children are not feeling well or have a chronic medical condition, it can affect their ability to perform well academically or attend school.”
Austin school district officials have been going over next year’s budget and once again, they’re looking at a significant deficit. Freeman believes the district will continue to fund student health services despite the budget situation.
“The district has continually, throughout our bleak budget years, said these are the buckets that are really important to the district to maintain these levels of funding, Freeman said. “One of those buckets has been the health and safety of students.”
Freeman would like policymakers to know that maintaining, or even improving, student health provides lasting benefits.
“I would like to ask them to really think about the whole child and the value of education in our society,” she said. “It probably has shifted from when they were in school. … We have so many social and economic barriers and challenges.
“Using an innovative model such as ours … opens doors for services that help to create healthier children, who can go on to be healthier adults and taxpayers. So it’s not just a benefit to the district. It’s a benefit to the community and our nation as a whole.”
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