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School nurse shortages grow as budgets shrink

Among nurses’ responsibilities is caring for the estimated 3 million children with food allergies

Reports of districts eliminating school nurses or replacing them with unlicensed staffers are increasing nationwide, and student health care is suffering as a result, nursing advocates say. Among nurses’ responsibilities is caring for the estimated 3 million children with food allergies—a number representing an 18 percent increase from 1997 to 2007, according to the Centers for Disease Control—and the 7.1 million children with asthma.

Just 45 percent of public schools have a full-time registered nurse, according to a 2007 study from the National Association of School Nurses (NASN). Another 30 percent of schools have a nurse who works part time in one or more schools, while 25 percent have no nurse at all.

There has been no comprehensive study since then, but anecdotal reports show that more school nurses are losing their jobs as budgets are cut and health services are a low priority, says Carolyn Duff, president of the NASN.

Nurses act as health care providers and educators, and care for conditions such as obesity or asthma.

The preventative care provided by nurses keeps students healthier, which means less absences, Duff says. “School administrators cannot accomplish their mission of enabling students to reach their full academic potential without providing school health services,” she adds. School nurses also coordinate services for students with chronic illnesses like asthma and train teachers on appropriate emergency responses.

Administrators in schools that share nurses have to call for an ambulance for non-emergency situations more often than do districts where each school has its own nurse. Districts that share nurses also have less health education, Duff says.

Recommended ratios

NASN recommends a nurse-to-student ratio of one-to-750 for students without chronic illnesses. But 33 states were above that average in 2010, the association found. Vermont had the lowest nurse-to-student ratio at 396 students per nurse at the time, while Michigan had the highest, at 4,411 students per nurse.

To determine how many nurses are needed, administrators should consider the number of students eligible for free or reduced-price lunch who may have less access to outside health care, and the number of emergency services calls from the school each year, Duff says.

No federal legislation mandates school nursing, and as of 2005 only 14 states had established student-per-nurse ratios, according to the American Nurses Association. With no nurse on duty, the responsibility for administering medications and treating students falls on administrators, educators and staff who may not have enough training.

Cutback consequences

The School District of Philadelphia is facing severe cutbacks in every area, including nursing. Two years ago, budget cuts led the district to lay off 100 nurses, and those remaining now rotate between buildings.

Questions over this practice arose after the September death of a sixth-grade student who suffered an asthma attack in a school where no nurse had been on duty that day. She went home, and died shortly afterwards on the way to the hospital emergency room.

In an interview about recent budget cuts, Philadelphia Superintendent William Hite told DA the district was investigating the events leading to the girl’s death. The district meets the state-mandated ratio of one nurse per 1,500 students, so hiring more nurses is not a priority, he says.

The ratio of nurses in Philadelphia schools was 1 to 950 students before the cuts two years ago. And the reduction has led to poorer student health services, according to a May 2013 Education Law Center of Philadelphia survey of school nurses, parents and special education advocates.

Seventy percent of respondents reported that medications and/or treatments were being administered by teachers or aides rather than by nurses, and 52 percent reported that children were not receiving urgent medical care. Another 36 percent said children were not receiving their treatments at prescribed intervals.

“What happened in Philadelphia is incredibly sad,” Duff says. “Aid is missing for a good part of the day when the nurse is somewhere else, and that is frightening.”

To strengthen care for students, districts can work with regional health care providers to share the funding burden for school nurses. A partnership formed in 1996 between the Austin ISD in Texas and Seton Healthcare Family was the first public/nonprofit health collaboration of its kind.

Seton Healthcare provides more than 70 full- and part-time registered nurses and 50 full-time school health assistants to the district of 84,000 students. School health assistants maintain the health office and treat students under the direction of the nurse.

A NASN-backed bill now before Congress would provide Department of Education grants to districts to lower nurse-to-student ratios.