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The governor's proposed budget includes no funding for school nurses, who receive some money from a grant program intended to supplement state funds for school health care.

But Massachusetts school nurses have a close relationship with their legislators, said Marcia Buckminster, PNP, RN, director of school health services for the Framingham Public Schools and Massachusetts representative on the board of directors of the National Association of School Nurses. In response to heavy lobbying by the nurses, both houses of the state Legislature have reinstated funding for school nursing in the budgets they plan to send to the governor. Buckminster is hopeful that the laid-off nurses will be rehired.

"It always goes well for us," she said, referring to similar budget situations. "We feel we have done an excellent job of educating the legislators."

Raising awareness

Nurses in other states are following her lead not only with legislators, but also with education boards, parents and the general public. Nurses in Iowa have learned to speak in the language of educators, Allen said. They use terms like "student achievement" and "increasing test scores." School officials "sit up and take notice why you start talking about things that will improve student achievement," she said, like providing breakfast and improving nutrition.

Nurses in Flagstaff are fighting budget cuts in part by pointing out how they save the district money by helping to keep kids in school, Morgan said.

In California, school nurses are doing everything they can to raise public and government awareness, Spradling said. Besides collecting anecdotes, she has asked school nurses around the state to give her statistics on their student populations and services they perform. She has set up exhibits for the state school board. She has worked with the state Parent Teacher Association to raise parent awareness.

"The majority of parents have no clue," she said. Parents see a health clerk in the nurse's office, she said, and assume they have a full-time credentialed school nurse.

Some districts seem to get the message, she said. Others do not.

Roberta Williams, RN, PHN, is a school nurse for the Lodi (Calif.) Unified School District, an agricultural community in the Central Valley. She and 14 other nurses serve about 28,000 students, including 2,358 asthmatics, 50 with Type 1 diabetes, 148 with heart disease, 1,220 with life-threatening or severe allergies and two with organ transplants.

On a typical day, she treats nosebleeds, writes health care plans, works with children who forget to take their medicines, examines insect bites, does vision screenings and makes countless referrals for families who have no insurance or access to health care.

Part of her position is funded by a grant obtained by the elementary school where she works full time. "The principal at this site really sees health as a priority," Williams said. Her district also seems to understand its importance. A school board advisory committee charged with looking into ways to trim the budget not only advised keeping the current nurses, it recommended hiring more.

But even when parents have testified to their school boards about how their children would not have been prescribed glasses if it hadn't been for the nurse, or how a nurse discerned a medical condition unnoticed by anyone else, some districts still have eliminated nurses, Spradling said.

Without a state mandate providing a minimum number of nurses, many school nurses face an almost impossible situation, many school nurse leaders said. In Oregon, the state Legislature understands the need for nurses, Hootman said, but can do nothing because it simply has no money to spend.

Allen reports a similar situation in Iowa. "Our Legislature has turned a deaf ear to anything that would even come close to costing the slightest amount of money for education," she said.

Twelve states had school nurse mandates in 2001, according to the National Association of School Nurses. The mandates varied from at least one nurse to every 3,000 students in Tennessee to at least one nurse per school in Connecticut, Massachusetts, New Jersey and Rhode Island. Most had mandates of one nurse per 1,000 or 1,500 students, well above the association's recommended minimums.