Health and Development | Education | Child Health + Development | Issues

More Than Band-Aids: Demand for School Nurses Increases, but Funding Doesn’t Follow

The latest on Washington school nurse-to-student ratios, nurse availability, needs on the rise and next steps

From the time of the first bell, Kari Asadorian is on the move.

A registered nurse assigned to Seattle’s Cascadia Elementary School, Asadorian is responsible for 775 students, handling everything from playground spills to daily medication. Because Cascadia is labeled as one of Seattle’s 18 “medically fragile” schools — one that serves students with severe health conditions, where a full-time nurse is required — Asadorian also assists students in wheelchairs with basic needs.

Asadorian, who wrote health care plans for 80 students this past fall, considers herself luckier than many school nurses. She works full time at Cascadia and has regular help from a licensed practical nurse, who accompanies special needs students on the bus each day and can take care of, for example, a recess injury if Asadorian is with another student.

“There’s always something to do,” she says, pausing periodically to meet with students as they enter the health room.

But at some schools, nurses aren’t always available. Largely because of funding, nurses in some districts must divide their time between buildings, while licensed practical nurses, substitutes and trained assistants fill in the gaps. In many schools, teachers and office staff dole out Band-Aids on days when there is no nurse staffing. And in many districts, increasing nurse caseloads and limited resources mean outside funders — mostly PTAs — step in to cover some services.

Now, pending a long-awaited increase in funding for schools following the 2012 Washington State Supreme Court’s McCleary decision, school nurses from around the state are banding together to develop new guidelines for staffing. Recommendations could come in March.

So, how does your child’s school compare to other schools in the state, and will its nurse staffing change soon?

The bottom line: There is “no one size fits all” for nurse-to-student ratios, says Robin Fleming, director of the Office of Superintendent of Public Instruction’s (OSPI) Health Services department. Demographics and health needs should play a role when determining how nurses are assigned.

Every student that comes to school has a right to be here and access their education. Their health shouldn’t get in the way of that, and we need to know how to react if they need help.

Need on the rise

The National Association of School Nurses and the American Academy of Pediatrics have recommended one nurse per 750 students, but here in Washington, the state nurses association suggests that ratio doesn’t take into account the very issues Fleming mentioned. In other words, such an assignment might work in some areas, but not in others.

Every school nurse is expected to handle a laundry list of duties: administering first aid and care for sudden illnesses, annual vision and hearing screenings, dispensing medication, and developing care plans for students with severe and life-threatening conditions.

But in recent years, the demands for those latter services — plans and medication — have skyrocketed, while the process for assigning nurses to buildings has remained unchanged. More students suffer from food allergies, diabetes, seizure disorders and mental health conditions, all of which can require daily services.

According to data maintained by OSPI, student health conditions have risen 75 percent since the 2005–2006 school year. During that same period, the number of registered-nurse hours in school buildings decreased 40 percent. “How sick kids are and how in need they are — that has definitely gone up, and that increases the workload,” says Terri Helm-Remund, president of the School Nurse Organization of Washington and a registered nurse who cares for approximately 450 students at West Seattle Elementary. “Every student that comes to school has a right to be here and access their education. Their health shouldn’t get in the way of that, and we need to know how to react if they need help.”

Who should pay?

In 2011, a Pierce County jury found the Bethel School District negligent in the 2008 death of a fifth-grader who suffered a fatal allergic reaction; the school nurse wasn’t present when the girl died, and care plans weren’t followed. The tragedy represents the worst-case scenario of insufficient nurse staffing and resources.

Most parents assume their child’s health needs, emergency and otherwise, will be met at school, and they often don’t know that a school nurse may have to split her time between more than one building, says Eden Mack, legislative chair of the Seattle Council PTSA and parent of three children in Seattle schools.

Mack’s twins, enrolled in kindergarten at Lawton Elementary, suffer from severe asthma and food allergies and have health care plans on file. The school nurse works at Lawton on Mondays and half-days on Fridays, so the school secretary is available to help administer the children’s inhalers during the rest of the week.

“It’s a safety issue, and it’s pushing responsibilities onto people who aren’t trained medically. The secretary shouldn’t be in the position of doing the nurse’s job, because she has so much work just doing the day-to-day work of the school,” Mack says. “It’s scary, as a parent, to be in this situation.”

The Lawton PTA helps pay for extracurricular activities, but not hours for the nurse. Mack says she is considering asking the PTA to set aside funds, but, she adds, PTAs shouldn’t be put in that position.

“We’re getting exhausted of having to fund the basics of education,” Mack says of PTSAs and PTAs in general. “People feel like it’s something they can do, so they step in and do it. But the expectation is ballooning.”

“Our top issue is fully funding education so that local PTAs, parents and teachers do not pay for something that is the State of Washington’s paramount duty,” says Kathryn Hobbs, executive director of the Washington State PTA. “The Washington State PTA does not support, endorse or encourage local PTAs to pay for nurses or staff.”

Filling the gap

As it stands now, Washington school districts decide how to utilize their nurses in much the same way they determine how many teachers they need — by enrollment and budget. That often means a school nurse might work in more than one building, with a trained staff or volunteer available for certain duties when the nurse is out.

But it is only the school nurse who is permitted, for instance, to write a school-based care plan for a student with a life-threatening condition. School nurses must be certified, have a bachelor’s degree in nursing and maintain continuing education requirements. Often, secretaries can be trained to perform basic duties in a nurse’s absence, while a “parent-designated adult” can help diabetic students check blood sugar and administer medication. For the past decade, Seattle Children’s Hospital has offered a class for such volunteers; attendance over the past year has doubled.

Of the 71 certificated nurses who work for Seattle Public Schools, 31 are assigned to their buildings full time; that includes all comprehensive high schools, and several middle and elementary schools where the “medically fragile” designation require them. The city’s Families and Education Levy helps fund services such as school-based health centers and additional nurses to, for instance, accompany special needs children on a field trip. And at some schools PTA money is available.

Although not every school is likely to get a full-time nurse, adds Katie Johnson, Seattle Public Schools manager of Student Health Services and former interim Health Services director for OSPI, the district demonstrates a “strong commitment to student health,” whether in its services to medically fragile schools or through the support and resources available to nursing staff.

Rural districts, though, tend to lack such services. In 1999, the state established the School Nurse Corps, setting aside about $5 million every biennium to pay for nursing services in small school districts. The money is administered through each of the nine educational service districts, financing, for example, one nurse to serve some 1,200 students spread across six school districts in Mason County. In some areas, the school nurse may be the closest health care provider.

“In many of the districts we serve,  it’s not unusual at all for parents to wait until they know the nurse is at school, and send their child in to have their child looked at,” says Lynn Nelson, Nurse Corps administrator for a five-county region in southwest Washington. “Some of it has to do with a lack of [health care] providers in the community, and some of it is about poverty and lack of transportation for parents.”

Nurses hope the efforts of the statewide staffing work group, along with potential funding from Initiative 1351 and enforcement of the McCleary decision, will trickle down to student health services. Maybe, says Lorali Gray, School Nurse Corps administrator for counties in northwest Washington, there can be support for other wraparound services, such as family advocates and counselors.

The effort to come up with nurse staffing guidelines also aims to identify duties that registered nurses must do, and what can be handled by a licensed practical nurse or health assistant. It comes at the same time that health reform is under way; OSPI is working with the state Health Care Authority to find ways in which the federal government might help fund nursing services, Fleming says. Nearly half the students in the state are eligible for Medicaid.

It’s the whole kid that we want to look at. Our goal is to keep them in school and make sure they’re successful.

More than Band-Aids

Of Washington’s 295 districts, only Shoreline has committed to assigning one full-time nurse to each of its schools, according to OSPI. The district categorizes nurses as classified employees, the same category as instructional assistants, cafeteria workers and bus drivers, and they are subject to a different pay scale than teachers and librarians, who are considered certificated employees. (Some districts consider nurses certificated employees.)

Shoreline district spokesman Curtis Campbell says the district set aside $781,000 this year for nurses at all 14 of its school buildings — a staffing ratio it has maintained for at least 20 years.

“It’s always been a high community priority that there be nurses in the schools during the school day,” he says.

Shorewood High School nurse Paula Williams has worked at the elementary, middle and high school level in Shoreline since 1999. In her eight years at Shorewood, she’s seen student health needs increase, along with her responsibilities.

“It’s not just the numbers that we see; it’s that the kids are getting more complicated,” Williams explains. “They have more issues at home, maybe family or financial issues. Each kid we see doesn’t necessarily need a Band-Aid, but you might have to do things like help them find a dentist.”

Williams recorded about 1,500 student visits to the health room in the 2009–2010 school year; five years later, there were more than 2,000. Despite the increased demands on her time, Williams enjoys her job. She feels fortunate to work in her building full time.

“If I were going from building to building, I wouldn’t have this level of patient and student contact,” Williams says. “It’s the whole kid that we want to look at. Our goal is to keep them in school and make sure they’re successful.”

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