Unkindest Cuts
School nurses mark 100th anniversary, but they're fighting for their jobs in a nationwide budget crunch that's slowly squeezing them out

By Cathryn Domrose
July 30, 2003

At a conference in January, organizers passed out paper and asked California school nurses to write down anecdotes to show the state Board of Education what was happening in schools when nurses weren't there.

One nurse wrote about a student who often missed half the required doses of his seizure medication, administered by time-pressured aides. One day, the student went home, hit his head during a seizure and was found dead by his parents, who had assumed he was receiving all his medication.

Another wrote about a clerk who offered an inhaler to students who came to the office with stomachaches. In an elementary school, one nurse wrote, an office worker panicked when a student with epilepsy had a seizure. Instead of giving the student medication provided by the student's physician, she administered an injection with an epinephrine pen used for allergic reactions.

In another case, a nurse spotted a student sitting in the hall. Office workers assumed he had been sent to them because he was a discipline problem or on drugs. The nurse recognized he was a diabetic about to go into a coma and administered medication.

Nurses wrote of medications being stolen, of secretaries or clerks mixing up medicines and giving them to the wrong students, of doses of medications like Ritalin being inadvertently changed.

"These were anecdotes that we pulled together in a three-hour period," said Nancy Spradling, executive director for the California School Nurses Organization. "These are things that the average parent, the average community member and certainly the average legislative member is completely unaware of."

A shrinking budget

This year, a faltering economy is forcing many states to cut money for education. School districts in a number of states are considering slashing already strained budgets for school nurses. Some schools already have no nurses. Others have a nurse who visits a few hours per month or per week.

The proposed cuts come as more students require medication for conditions like asthma, seizures and diabetes; students with complex chronic health conditions are being mainstreamed into classes; and new studies are showing that future risks for health problems like high blood pressure and Type 2 diabetes can be affected by exercise and diet patterns in school-age children.

As states cut their public health and mental health programs, in some places, schools must pick up the slack, referring children to programs, or in some cases, taking care of the health problems themselves.

In other words, just when school nurses are needed more than ever, their already thin ranks are being depleted. Nurses are fighting back by lobbying legislators, establishing public education campaigns, fighting dismissal through their unions, even running for school board positions, but they face an uphill battle.

Many school boards and educators who control education budgets don't understand why health is important, or would rather cut nurses than teachers. Parents may not realize their school does not have a full-time nurse and relies instead on a health clerk or a school secretary to hand out medications and to call 911 in an emergency.

Beyond boo-boos

As school nurses say over and over, their job consists of much more than bandages and boo-boos. "The reality is, that is a very small part of what the professional nurse does in the school setting," said Marilyn Morgan, RN, a school nurse with the Flagstaff (Ariz.) Unified School District.

As a result of a 1975 law mandating that children with special health care needs be included in regular school populations, children with increasingly complex health conditions have been attending U.S. schools, according to the National Association of School Nurses.

About 1.7 per 1,000 children younger than age 20 have Type 1 diabetes and increasing numbers of children are being diagnosed with Type 2 diabetes. Many of these children must take insulin. An increasing number of students and school workers have life-threatening allergies, which, if triggered, require an injection of epinephrine. Students with severe asthma who require nebulizer treatments also are increasing.

Nurses report regularly seeing children with feeding tubes, tracheal tubes, catheters and ventilators. They have students with heart defects, muscular dystrophy, cancer and cerebral palsy. They must draw up individual health plans for these students, explaining their care, how to give them the best educational experience and what to do in an emergency.

In most states, they train nonmedical assistants, sometimes health clerks, sometimes secretaries and instructional aides, in how to give medications in their absence.

School nurses also are responsible for state-mandated screenings, keeping students up-to-date on immunizations and creating preventive health programs. As school counseling services are cut, they often are responsible for counseling and mental health programs. They also may teach health classes and help students learn healthy habits.

In some areas, the school nurse is the first or only contact a family has with the health system. Morgan recently saw a student with a possible case of strep throat whose parents waited over the three-day weekend so she could see the school nurse. "Her mom and dad just couldn't afford to take her to the doctor over the weekend," she said. "That's what we're here for, to make sure the kids get seen, to help reduce those barriers to receiving medical services."

Becky Rendon, MSN, RN, president of the Texas Association of School Nurses, has treated teachers, cafeteria workers and bus drivers, as well as students at the middle school in San Antonio where she works.

School nurses say they value the hands-on time they spend with students, school workers and community members. Some teach health classes, develop prevention programs and do counseling. But in a growing number of school districts, nurses have little time for anything but drawing up individual health plans, conducting mandatory screenings and training people to give medications, said Janis Hootman, Ph.D., RN, president-elect of the National Association of School Nurses and nursing supervisor for the Multnomah Education Service District in Portland, Ore.

The National Association of School Nurses recommends one school health nurse to no more than 750 students in the general school population, one nurse to no more than 225 students in schools that include children with special medical needs, and one nurse to no more than 125 students in schools that have large numbers of severely chronically ill or developmentally disabled students. For medically fragile students, the ratio should be based on individual needs.

Few states come close to meeting these guidelines, and some are light-years away. In California, one of the states hardest hit by the economic crisis, schools average one nurse per 2,517 students, said Linda Davis-Alldritt, MA, RN, PHN, school nurse consultant for the California Department of Education in Sacramento. Only 5 percent of California schools have a full-time nurse; one-quarter have no nurse at all, Spradling said. The other 70 percent have a part-time nurse who may visit one day a week or a few hours a month, she said.

"And those numbers are getting worse," she said.

For the children

One district, which has two nurses for 8,000 students in 11 schools, recently voted to cut one of the nurses. The nurse, Susan van Ouwerkerk, RN, health services specialist for Moorpark Unified School District in California's Ventura County, requested a hearing through her union and eventually got her job back.

The student population includes 221 students with asthma, 44 with life-threatening allergies, eight with diabetes, 19 with seizure disorders, one with cystic fibrosis, four with heart defects and two with cancer.

Van Ouwerkerk recommended that any school nurse who receives a layoff notice request a hearing and fight it. "I realized that I had to do it for the kids," she said, "because if I didn't stand up, the kids would have had one nurse for 8,000 students."

No one knows what the nurse-to-student ratio is in Oregon, another state whose education budget has been hit especially hard. The state does not have a school nurse consultant to gather that kind of information, Hootman said. Some districts have a nurse for every 3,500 or 4,000 students, she said. Others might have one per 1,800 students. None come close to the recommendations of the National Association of School Nurses, she said.

"Unfortunately, we've hit rock bottom," Hootman said, describing education budget cutting so severe that schools have shortened the number of days in the school year. Some districts are deciding to hire nurses for fewer days as well. "The economy is so challenging right now that everybody is having to make hard decisions," she said. "Right now, they're just looking to keep schools afloat."

In Iowa, the situation is not as drastic, but could become so, school nurses report. In 2001-02, the state had one nurse per 877 students, but the situation varied widely from district to district, and the number of school nurses decreased last year for the first time since the 1980s, said Charlotte Burt, MSN, RN, school nurse consultant for the Iowa Department of Education in Des Moines.

"Probably that's an indication of what's happening now," Burt said. Forty percent of the school districts reported ratios of at least one nurse per 750 students, she said. The other 60 percent had fewer nurses per student.

School nurses across Iowa, responding to an e-mail request from Barb Allen, RN, president of Iowa School Nurse Organization, reported everything from supportive school boards and no fears of cuts to overworked and dangerous conditions that seemed to be getting worse.

"My health associate was eliminated due to budget cuts," wrote Diana Duffy, RN. "I cover three buildings and approximately 1,000 children. I have kids with diabetes, requiring blood glucose checks and monitoring of snacks, and kids with cystic fibrosis, who require enzymes before eating, monitoring of caloric intake, weight monitoring and nebulizer treatments. I have kids who require tube feedings, asthmatics requiring nebulizer treatments, not to mention the others who have injuries or other occasional health needs.

"Routine screenings are not done as often as a result of staff shortages, so some kids who may need glasses, etc., may not be discovered until later. The secretaries cover for me when they are able, but don't have the assessment skills or knowledge base to do much more than dispense meds and provide basic first aid."

Many Iowa nurses reported difficulty in establishing prevention and health education programs, saying they felt like they were constantly responding to crises and "putting out fires."

Most schools in Texas have at least one nurse, Rendon said. In rural areas, a nurse might visit two or three schools. "A lot depends on the district and how their nurses are valued," she said.

Because of budget cutting, some districts have opted not to replace retiring RNs or to replace them with LVNs. "That's our biggest concern," she said.

Even states that have traditionally supported school nurses are fighting threats from budget cuts this year.

School nurses in New York, where 99 percent of the districts have a school nurse and the ratio is one nurse for every 600 students, excluding New York City, Buffalo and Rochester, are pressing the Legislature for a law mandating school nurses to ensure against future cuts.

In Delaware, which has a state law requiring one nurse for every 40 "teaching units"-traditionally about 40 students each-nurses are concerned about growing class sizes and want to change the ratio to one nurse per 35 classes.

In Massachusetts, where a state advisory committee has recommended ratios of one nurse per 500 general population students and where almost all schools have at least one nurse, the governor cut state funding for school nursing by nearly 40 percent in January. Nearly 500 school nurses were laid off.

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.

"I understand the mandated states are faring better" with retaining nursing positions, Hootman said.

Many school nurses say they feel discouraged by the situation. A few have decided to retire or find other jobs. But many others say they feel it's more important than ever to stay in school nursing, even if it means reduced hours or more work.

If budget cuts in her district go through, Morgan, who now works with 510 students at one elementary school, may have to take charge of two elementary schools, essentially doubling her workload.

It makes her nervous, she said, to think of leaving her medically fragile students in the care of people who are not nurses, even though she will be available by phone.

It makes her sad, she said, to think she no longer will have time to mentor nursing students and show them the wonderful experiences of nursing and of school nursing in particular.

But she said that she will continue to do the best she can to provide her students and her community with some access to health care. "We're not just dealing with the pediatric population," she said. Mothers often ask her to look at their babies or see if a grandparent needs to go to the doctor.

"We really are dealing with cradles to grannies," she said. "That is such a wonderful feeling to have that kind of respect from your community."

Rendon recalled a day when a man pulled into the parking lot of her San Antonio middle school, driving erratically. He was having a heart attack. She was able to stabilize him and get him proper care. He told her, "I knew if I pulled into the school, somebody would help me. I knew there would be a nurse."

Not in all schools, she wanted to tell him. Not anymore.

Contact Cathryn Domrose at kaguilar@well.com