I first met my children’s school nurse earlier this year, when our district invited parents to preview the puberty video our fourth and fifth graders would soon be watching. After the video, the district nurse gave a presentation. Her closing remarks made my jaw drop: “Please email me if your student is going through something major. I have 3,800 kids at six schools, so it’s hard to keep track sometimes.”
Like many parents, I was surprised to learn my children’s school does not have a full-time nurse. But my district is not an outlier. According to the National Association of School Nurses (NASN), only about 40 percent of all U.S. schools have a full-time nurse; just 35 percent have a part-time nurse, and 25 percent have no nurse at all.
School nurses fall into two types: There are registered nurses (RNs) and licensed practical nurses (LPNs). RNs have a baccalaureate degree from an accredited nursing program, while LPNs typically complete a year of coursework and work under RNs’ supervision. Both treat acute problems like fevers and sprained ankles; help manage allergies, asthma, and other chronic illnesses; and provide services such as blood glucose monitoring. Nurses educate students on healthy lifestyles and work with families to establish guidelines — including Individualized Education Programs (IEPs) and 504 Plans — to accommodate a variety of health conditions.
In short, school nurses keep kids healthy and ready to learn. They’re vital to our education system. Yet they seem to be disappearing.
When kids need help managing chronic conditions, a shortage of school nurses can leave families scrambling to find a solution. Stephanie Prince Alexander, a copywriter and mother of two, spent months researching the Denver Public Schools for her 4.5-year-old daughter, who has Type 1 diabetes, wears an insulin pump, and needs continuous monitoring. Though the family’s neighborhood school does not have a full-time nurse, a few others in the district do. Prince Alexander asked if her daughter could be guaranteed a spot at one of them.
District officials said no; they could not make an exception for any student. They advised Prince Alexander to use the SchoolChoice enrollment system and see if she could secure a spot at a school with a nurse. If not, the district would train a school employee to administer insulin — a prospect that worried Prince Alexander. “My child could have a seizure, slip into a coma, or even die from mismanagement of her disease,” she says.
Prince Alexander’s daughter landed at a school with a part-time nurse. Creating a care plan that ensures her daughter is safe and staff are comfortable with their responsibilities — even when the nurse is not there — has taken some time. “It’s definitely impacted our family,” says Prince Alexander.
For kids with numerous, complex medical needs, like cerebral palsy and a feeding tube, attending a school without a nurse is not an option. “Rates of absenteeism are way up,” says Christine Schindler, Ph.D., R.N., a professor at Marquette University College of Nursing and a nurse practitioner at Children’s Hospital of Wisconsin. Dr. Schindler cares for children with multiple, serious health conditions, and says a school nurse is a key partner in keeping these kids in the classroom and out of the hospital.
The projected U.S. nurse shortage has received a lot of media attention, but schools are struggling for other reasons, according to Linda Aiken, Ph.D., R.N., director of the University of Pennsylvania School of Nursing's Center for Health Outcomes and Policy Research. She says one major factor is the lack of funding, which has traditionally come from education budgets, not Medicaid or other health insurance programs. In many schools across the country, particularly in urban districts, there are simply not enough budgeted positions. The problem worsened with the economic downturn in the early 2000s, which prompted many districts to eliminate nursing jobs.
Different aspects of the school environment also make it challenging to recruit and retain nurses. In a large study of various factors in the nursing work environment, Dr. Aiken found that 46% of school nurses surveyed were dissatisfied with their opportunities for advancement. Unlike hospitals, “Schools are really not offering the same level of continuing education opportunities or tuition benefits for nurses,” she says. In addition, while nurses in health care settings benefit from an on-site network of colleagues, school nurses often cover multiple buildings on their own and are much more isolated.
“We’re seeing more kids with health conditions that need support,” says Lisa Kern, M.S.N., R.N., N.C.S.N., Supervisor for Health Services for Pasco County Schools in Florida. Today approximately 25 percent of children have a chronic illness such as asthma, epilepsy, hypertension, food allergies, or diabetes. Schools must be equipped for a wide range of needs, from students who use wheelchairs, to those who have tracheostomies or take medication for seizures, Kern says.
Mental health problems are also growing. Kristy Klinkhammer, an L.P.N. caring for approximately 600 students in Tennessee’s Dyersburg City Schools district, has seen more kids with anxiety and depression over the past few years. Kids who are struggling tend to visit the nurse frequently without any medical symptoms, she says. In a given year, an estimated 13 to 20 percent of children experience a mental disorder — such as attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, or substance abuse.
With increased needs in the student population — and without a matching increase in staffing — today’s school nurses are carrying dangerously high caseloads. In the past, “Once you became a school nurse, you stayed, because the job was so fulfilling,” says Nina Fekaris, M.S., R.N., a past president of NASN who served as a school nurse in Beaverton, Oregon for nearly three decades. But now, Fekaris observes many school nurses leaving positions after only a couple of years because they can’t practice safely and fear losing their licenses.
Though NASN recommends that all students have daily, direct access to a registered nurse, there are no federal laws governing school nurse requirements, and coverage varies widely. Some schools without full-time nurses share one nurse who covers multiple campuses. As a Cluster School Nurse in Fulton County, Georgia, Judy Reddick, R.N. oversees the care of roughly 6,000 students at three elementary schools, one middle school, and one high school. Reddick depends heavily on unlicensed assistive personnel (UAP) — clinic assistants at each school who support her role. Assistants typically don't have a medical background, so Reddick trains them extensively to ensure they’re prepared to handle both acute problems and chronic conditions like diabetes and asthma.
In addition to training assistants, Reddick monitors communicable illnesses in the school community and conducts preventive care programs such as vision screenings. She also works with families, hospitals, and school staff to establish “reentry” plans for students who are returning to school after a major medical event — for example, a new Type 1 diabetes diagnosis or a broken arm. “We sometimes feel a little pulled thin,” says Reddick. “I wish we had more time to spend one-on-one with the students.”
While assistants can help with specific duties, they must work closely with the nurse. Brandi Singh served as a part-time health and safety assistant at a Gresham, Oregon elementary school. Working under the supervision of the district nurse who covered five schools, Singh received training to administer over-the-counter medications and prescription drugs including EpiPens, inhalers, and medications for ADHD and diabetes. But for serious injuries, like head trauma or broken bones, Singh called the nurse for back-up.
Other nurses who cover multiple campuses don’t have designated assistants. In her role, Fekaris was responsible for one high school and three elementary schools and was always available on her cell phone. Front office staff fielded students’ medical concerns and called her if they needed help.
At the 25 percent of schools with no nurse at all, students’ medical needs might fall completely on the shoulders of teachers, their aides, and secretaries.
The specialized training and skills of nurses make a critical difference in the quality of care students receive. “As a nurse, my big concern is that the knowledge and expertise I acquire during nursing school and years of experience cannot be taught or delegated away,” Fekaris says. Assigning medical tasks to staff members who lack such training and may be managing other responsibilities is “asking for trouble.”
Though the job can be difficult and emotionally draining, what keeps many school nurses coming back is the opportunity to make a lasting, positive impact on children’s health. Reddick sees a lot of students with asthma who aren’t using their inhalers correctly when she first meets them. After she teaches them how to use their medication properly, “it really makes a big difference in how well-controlled the symptoms are,” she says. That simple skill not only leads to better health — it also saves lives.
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