Nurses' Offices Overburdened
The Washington Post
June 25, 2008
Caseloads for school nurses exceed federal guidelines in much of the Washington region at a time when campus clinics serve growing numbers of students with severe disabilities or chronic conditions such as diabetes and asthma.As health-care needs multiply, school nurses are struggling to keep up and finding less time for preventive education on public-health issues such as childhood obesity or substance abuse. Many still dispense bandages and bags of ice, but they also counsel pregnant teens and manage complex medical plans for children with seizure disorders or feeding tubes. Schools often hire unlicensed aides for help.
"Children today come to school with conditions and treatments that would have kept them at home or in the hospital years ago," said Amy Garcia, executive director of the National Association of School Nurses. "We are concerned about the safety of these children and their ability to be ready to learn."
The association and the federal government recommend at least one registered nurse for every 750 students -- a target some local government officials say is hard to meet in a time of increased budget pressures. The ratio in the Fairfax County school system, the area's largest, is one for every 2,800.
Since 1993, the portion of students with chronic medical conditions has more than tripled in Fairfax schools, rising from 8 to 27 percent. Nursing positions have doubled in that time, but a 2002 task force report for the Fairfax County Board of Supervisors and the county's School Board noted "severe understaffing." A follow-up review to be released soon made similar findings.
Montgomery County has one nurse for every 1,600 students; Prince William and Arlington counties have one for every 1,000.
Other systems fare better: Alexandria schools have a 1-to-600 ratio. Prince George's County schools have a ratio of 1-to-700. D.C. officials could not supply a precise ratio, but staffing levels indicate the city's schools meet the federal guideline.
Nationally, the ratio is about 1 to 1,150, with the average nurse tending to students at two or more schools, the school nurse association reports. About one in four schools has no nurse, with responsibility for care given in many cases to teachers or school secretaries.
In some states, scarcity of medically trained staff has become a safety issue. In Utah, which the association reported had the nation's leanest supply of school nurses in 2007, with one for every 5,500 students, a 10-year-old girl overdosed on asthma medication three years ago at a school without a nurse or health aide available. Her mother has campaigned since for the state to fund a nurse for every school.
Fairfax relies on unlicensed aides for most day-to-day needs while nurses coordinate care for more complex cases. County health officials, who run the program, said it keeps children safe, with emergency calls low and school attendance rates high.
Still, the limited supply of school nurses is a public-health concern for a generation of students whose life expectancy, scientists say, might be shorter than their parents'. Nurses could lead efforts to prevent obesity, asthma, diabetes or substance abuse. But many are too overwhelmed by immediate needs to try.
With millions of children uninsured nationwide, many students wait until Monday to get help for a hacking cough that developed over the weekend. They are more likely to have untreated or undiagnosed conditions. The widespread inclusion of students with disabilities in the public school mainstream has also increased demand for care. Nurses perform or monitor procedures such as changing catheters or suctioning tracheotomy tubes.
Some area school systems and health departments are bolstering services. The District, through a partnership with Children's National Medical Center, expects to staff a full-time nurse in nine of every 10 schools this fall, up from 37 percent of schools in 2006. The District also is renovating school health facilities, some of which have lacked running water or secure storage for medications, according to a 2006 D.C. Department of Health report. Its $19 million annual school health budget is funded partly by Children's Hospital.
The Prince George's budget for the just-ended school year included $13 million to provide a nurse in every school. Montgomery increased its school health budget from $18 million to $21 million for the coming fiscal year, helping to fund four campus health centers with doctors or nurse practitioners where students can get physicals or mental-health care.
Fairfax's $10 million school health budget will increase little in the fiscal year that starts July 1. Rosalyn Foroobar, director of patient-care services for the Fairfax County Health Department, said the agency is requesting funding for a dozen more school nurses in coming years.
Foroobar said a 1-to-750 ratio is hard to maintain in a system with nearly 200 schools, some of which serve 3,000 students or more. Nurses are assigned by need, she said. Centers for severely disabled students have a dedicated nurse, and more than a dozen medically fragile students usually have full-time nurses (through separate funding).
Fairfax Board of Supervisors Chairman Gerald E. Connolly (D) acknowledged the number of students per nurse is "way too high. But the question is resources." He said that the county cut many services this year and that school nurse staffing will have to be "addressed over time."
For now, 59 registered nurses supervise more than 200 clinical aides assigned full time to the schools. The nurses manage about 45,000 health-care plans, many for conditions ranging from severe food allergies to spina bifida, epilepsy or cancer.
One May morning, visitors to Saratoga Elementary School's health clinic in Fairfax County included a smiling kindergartner clutching his front tooth, a headachy second-grader resting behind a curtain and two students with juvenile diabetes, stopping in for a pre-lunch blood-sugar check.
Under the supervision of clinical aide Cathy Jimmo, Nasara Moore, 10, and Tyler Nichols, 12, pricked their fingers, read the numbers on their monitors and injected doses of insulin through the skin on their stomachs.
Saratoga Elementary shares nurse Diane Allen with another elementary school, a middle school and a high school.
Allen assesses students and creates and monitors their health plans. She also trains teachers and other personnel to perform emergency procedures, including administering rectal valium in case of a prolonged seizure or injecting epinephrine to stabilize a student who has a severe allergic reaction. If she had time, she said, she would focus more on preventive care, including hand-washing, breast cancer screening and nutrition.
Aides are trained to provide first aid, medication and care for chronic medical issues. Jimmo's medicine closet has 45 inhalers, four asthma nebulizers, nine epinephrine pins for allergic reactions and a shelf of Benadryl, eye drops and prescription medication.
Jimmo refers to a detailed flip chart with directions on what to do in an emergency. She also draws on her experience raising six children. She is generous with hugs and affection, calling children "sweet love" or "precious," and student portraits fill her bulletin board.
Jimmo had four diabetic students in the just-ended school year. She is adept at interpreting monitors and reading body language to determine whether blood-sugar levels are high or low.
Shelbee Williams, who fretted at first about leaving her insulin-dependent daughter Nasara at school, said she has been reassured.
Williams recalled that Allen noticed a frequent dip in Nasara's blood sugar that led the mother to adjust her insulin pump.
"It's nice to know they realize how critical her care is," she said, "just like I do."
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