Bozeman, Mont. (H24N). In one local middle school, there are five insulin-dependent students. At a high school in the same district, there is a student with cystic fibrosis and another with muscular dystrophy.

The role of the school health system is changing as more children with chronic illnesses are mainstreamed and require daily medical attention.

Kathy Sheriff, RN, and one other registered nurse cover an entire school system in rural Montana, mostly via cell phone and pager, each acting as a consultant for eight schools, and answering questions on a referral basis from school health monitors.

Many school health monitors are unlicensed and lack formal training in health care. Yet, these monitors distribute prescription medicine such as Ritalin and Haldol, an anti-psychotic, to students. Experts estimate that at almost every school, staff must assist with asthma inhalers and attention-deficit disorder medications daily.

"Many of the mountain states are at the beginning stages of establishing school health programs," said Sheriff, president-elect of the Montana Association of School Nurses. "School health has been a battle with people fighting us, thinking we are doing unclothed physicals and providing contraception, which we don’t do. Every district is so different it is hard to evaluate [how we are doing]. It is improving slowly. I would give the Bozeman area [as a whole] a 5 on a scale of 1 to 10."

But Sheriff says some metro-area districts are doing much better than that. "One of the big things this year is accountability; we are evaluating medicine distribution, making sure it is done safely."

"The Northeast has better coverage than most other places," said Judith Harrigan, RN, education coordinator for the National Association of School Nurses, adding that schools in the West are much further behind. "Our recommendation is a minimum of one registered nurse per 750 students, with one building being the preferred model. It is common to see one nurse per several thousand students traveling from facility to facility, making it difficult to cover the needs of students."

In Blackfoot County, this is the first year there is a clinic monitor in each of the district’s 18 schools. Susan Hale, a spokeswoman for the district, says that one-third of the monitors are registered nurses or licensed practical nurses (LPNs). The rest are clinic assistants. Six district-level visiting nurses supervise the monitors. Hale says parents and school administrators are thrilled to have the monitors because previously, a diabetic school employee with no health care experience handled the administration of insulin.

"We are seeing dramatic increases in asthma, just a tremendous surge, and increases in diabetes, and the other thing is that with changes in legislation, more children with significant technology needs – IVs, ventilators and tube feedings – are attending school right along with their peers," Harrigan said. "The biggest concern we have is that unlicensed people are being relied upon to make judgments and administer medicine and decide what to do with ill and injured students, and they don’t always have the background or experience to do it properly."

School nurses in the state and nationally say school districts often opt for LPNs instead of RNs because they have lower salaries. But legislatures, school administrators and often LPNs are not aware that LPNs are not allowed to work unsupervised, the nurses say.

School health monitors are used in many school districts and are seen as an improvement because registered nurses generally train them. The monitors are a new position, funded in part by money the state received from the national tobacco settlement fund. The state used nearly $30 million from the settlement to beef up school health systems. But many say the new legislation is inadequate.

"I don’t think it is enough," said Janet Singleton, RN, clinical liaison for the health services program of the Butte City Public Schools. "It is very gray and very limited. There are no ratios for caseloads in the bill. A nurse can only take care of so many kids, and they are concerned about liability exposure. Throughout the state it is a big problem."

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