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School Nurses Overlooked as Critical Caregivers

BY DEBORAH BALSHEM

Since 2000, the federal government and the National Association of School Nurses have recommended a school nurse-to-student ratio of 1 to 750. The national average dwarfs that figure at 1 to 1,187. And a look at Florida is even more grim, with an average school nurse-to-student ratio of 1 to 2,639 — more than double the national average and nearly four times greater than the federal guideline.

Critics allege the absence of qualified nurses — or the decision by a financially pressed school district not to hire them — is leaving unlicensed staff members to dispense medication, treat injuries, diagnose illnesses and handle emergencies, potentially leading to medication errors and other dangerous mistakes and oversights.

The Journal of Issues in Nursing recently reported that the use of unlicensed assistive personnel in schools "has resulted in life-threatening situations and even death in some instances." The results of a 2000 survey by the University of Iowa revealed that "mistakes are more than three times as likely to occur when an unlicensed person and not a (school) nurse is responsible."

Kathleen Rose, RN, MHA, NCSN, president of the Florida Association of School Nurses (FASN), knows all too well the potential threats. She is the sole school nurse responsible for more than 4,000 students at four different schools in southwest Florida.

"The Florida education system doesn't recognize the value of school nurses. There is a perception that school nurses give vaccinations and hand out Band-Aids, when the reality is there are large numbers of students with complex physical, mental and emotional problems. Students in wheelchairs, students on oxygen," she stressed. "The situation will only get worse as more children with special needs are mainstreamed into the public school system."


Unsupervised Treatment
According to the Florida Department of Health (DOH), in the 2004-2005 school year, 995 school nurses cared for more than 2.6 million students — of which more than 400,000 had reported health conditions ranging from allergies and asthma to seizure disorders, cystic fibrosis and cancer. The average student health room visits per day: 83,178. The average medication doses per day: 17,685. (See sidebar for local statistics.)

"I've talked to nurses who have seen school secretaries dispensing medication from a desk drawer — medications that should be in a locked medicine cabinet and not easily accessible," Rose said. "They hand the students the pill and a cup of water and send them on their way, not even checking to verify if the student actually took the medication. Some of those pills will become fertilizer for a potted plant outside the clinic."

No minimum education requirements are in place for school nurses in Florida. Certification by the National Board of Certification of School Nurses is recommended but voluntary. In the Sunshine State, a nurse who provides school health services can be a licensed practical nurse, registered nurse or advanced registered nurse practitioner. Rose pointed out that there is a "large disparity in education among the three."

With the evolving role of school nurses, it is more important than ever to be trained in the unique aspects of school nursing, Rose added, such as case management, advocacy, educating students and staff, initiating emergency and individualized health plans for students with chronic medical conditions and reporting cases of child abuse. As elementary students graduate to junior high, problems with drugs, alcohol and sexual activity start to surface and continue though high school.

"Mental health counseling, especially for suicidal thoughts, is crucial in high school when students have a perfect ideation of love. When it's time to say good-bye, they have no life experiences to say 'OK, this will get better.' Nurses have psychiatric training and are better equipped to identify these students and get them the proper help."

The importance of the school nurse simply cannot be overstated, Rose added. "School nurses play a multi-faceted role in the school setting. The bottom line is a healthy student learns better. School nurses should not be considered 'guests' in the system."

'One Nurse, One School'
Although many factors contribute to the shortage of school nurses, many believe the problem is a lack of federal and state legislation mandating school nursing. Currently, in Florida, the decision to set standards/ratios, hire school nurses and procure funding is the responsibility of each school district.

Only Palm Beach County has a health care district tax that provides for one nurse per school. In the 2004-2005 school year, Palm Beach's school nurse-to-student ratio was just a hair above national guidelines, at 1 to 806. Compare that to Orange County's ratio of 1 to 2,914.

Florida Sen. Frederica Wilson wants all counties to follow Palm Beach County's lead. So much so that the outspoken, former Miami school principal sponsored a bill in this year's legislature appropriately titled the "One Nurse, One School Act."

"When I was a little girl, my elementary school nurse was Nurse Mann. She helped thousands of children with a variety of illnesses. But she was much more than just a nurse. She was someone all the kids felt comfortable going to with our problems," Wilson recalled. "Unlike some of the counselors at our school, Nurse Mann was keenly aware of our overall symptoms–whether we were losing weight, or were so tired that we kept our heads down on the desk. She recognized the small symptoms that often made a big difference."

When Wilson herself became a teacher and then a school principal in Miami for 12 years, she witnessed the deterioration of school health services at point-blank range, sharing one nurse with four other schools at times. At that point, she said, "it became my dream to have a Nurse Mann in every school."

Funding Up in Smoke?
The "One Nurse, One School Act," SB 418, establishes procedures and criteria for the awarding of state matching funds for the delivery of school nurse services. The bill's stated intent of funding a school health nurse in every public school creates a need for approximately 2,723 additional nurses.

The bill also provides for a computer for each nurse and central staff, and allocates $75,000 in general revenue funds for a statewide school health summit. The total cost of the bill is estimated at approximately $130 million for fiscal year 2007-2008 and $148 million for fiscal year 2008-2009.

The bill is unlikely to pass, however, since it was temporarily postponed in committee on March 22 and had not resurfaced as of April 17. Among naysayer concerns was the potential financial impact on the state.

The bill specifies that it is the intent of the legislature that tobacco-settlement revenue be used to pay for state matching funds. However, in a Professional Staff Analysis and Economic Impact Statement prepared by the Florida Senate, analysts state that tobacco money " … would not be a likely source of funding for the requirements of this bill because the recurring revenue from the tobacco settlement is appropriated for other health and human services programs. In addition, the 2006 amendment to the state constitution, which requires the legislature to fund a tobacco prevention program from the tobacco settlement funds, will be funded for the first time in fiscal year 2007-2008."

Other detractors wonder how additional school nurses will be recruited at a time when a general nursing shortage continues to plague Florida and the nation — a notion Wilson dismisses as fear.

"When there was an air-traffic controller shortage, everyone said, 'We'll never have enough.' Yet we met the demand. Florida is addressing the nursing shortage. Many community colleges have created nursing programs. If you step back and do nothing, you'll never have progress," she said.

And even though Wilson expected the bill likely wouldn't pass the first time around, she is confident that the bill itself is progress. "You have to start a conversation. And this bill has people talking," she said. "Almost every adult I speak to says, 'Yeah, I remember my school nurse.' When enough people start talking, the legislature will find it topping their agenda."


May 2007

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