No school nurses left behind

Once a comforting presence in most public schools, full-time nurses are increasingly scarce. Now teaching assistants, secretaries and other nonmedical personnel are trying to care for sick children -- with often tragic results.

Published September 29, 2005 6:28PM (EDT)

On June 2, 2005, 15-year-old Clare McKenna was gripped by an asthma attack in the middle of her class at City Honors High School in Buffalo, N.Y. Within seconds McKenna -- an avid volleyball and softball player -- was gasping for breath. The teen collapsed as two friends helped her to the nurse's office, where her asthma medication was stored. Terrified, the students struggled to carry her the rest of the way. When they finally reached the office, however, the door was locked and nobody was inside.

Unfortunately, this was business as usual. In its last round of budget cuts, the Buffalo Public School District had slashed nursing staff from 40 full-time employees down to 15, which meant some nurses could only spend as little as 45 minutes a day at one school. Slumped on the floor, McKenna began to hyperventilate. School staff, looking frantically for the key to the health office but unable to find it, called 911, then Clare's mother. Ann McKenna raced to meet her daughter at the hospital as ambulance workers used a nebulizer to blow life-saving medication through an oxygen mask into Clare's lungs.

It was her daughter's fifth asthma attack at school. "I was praying, 'Dear God, please help my daughter,'" McKenna says. "I found myself thinking, Is it going to take a death for this community to start taking children's health issues seriously?"

But even children's deaths may not be enough to expand nationwide funding for school nurses. A full nine years before McKenna's close call, fifth-grader Philip Hernandez, who had asthma, began having trouble breathing in class. He made his way to the nurse's office at Lee Richmond Elementary School in California's Central Valley: By the time he reached it, he was in the middle of a full-blown asthma attack, according to court documents. The nurse, however, was at another school. Paramedics arrived and found Phillip on the floor in her office, surrounded by school staffers, his face and lips a purplish hue and his pulse failing. The paramedics tried to revive him, to no avail. The youngster died on May 13, 1996, four months shy of his 12th birthday.

School nurses -- once available every day in most public schools -- have virtually disappeared as a full-time presence in many schools around the country. At the same time, chronic illnesses among schoolchildren have mushroomed. Although there are no precise figures, experts say anywhere from 10 to 15 percent of schoolchildren suffer a chronic health condition, many of which require treatment during the school day. In West Virginia schools, for example, more than 16,000 children required healthcare plans in 2002, more than double the number six years earlier. These illnesses include life-threatening asthma and food allergies, diabetes, seizure disorders and cancers as well as mental health problems like severe depression and attention deficit hyperactivity disorder (ADHD).

It's well-known that the academic testing demands of the Bush administration's No Child Left Behind program has forced many already financially strapped school districts to make deep cuts in music, art and physical education. There's been little outcry over the impact the legislation has had on school nursing -- perhaps because few parents realize that a school nurse may be at their child's school as little as once a week, if at all.

But in this era of high-stakes testing and local budget constraints, "unless there is big pressure from parents and other community members, student support services such as nursing become vulnerable, because any extra money goes to academic support," says Julia Graham Lear, the director of the Center for Health and Health Care in Schools, based in Washington.

In place of nurses, teachers and other medically untrained staff are being put in the thankless position of overseeing the illnesses and emergencies of schoolchildren -- sometimes with severe or tragic consequences. Government reports say the nation has 60,000 full-time nurses to cover the approximately 90,000 elementary and secondary schools. Just how much time they spend at a school, however, is unclear. "Our best guess is that some schools have a full-time nurse, many have a part-time nurse, and many have no nurse at all," Lear says.

The likelihood that school nurses are often unavailable is particularly alarming because of the sheer number of children taking regular medication. Nine million students, about 13 percent of children between kindergarten and 12th grade, take medication regularly for at least three months during the year, according to a recent report by the Centers for Disease Control and Prevention. The types of medication can run the gamut from several kinds of inhalers and inhalation therapy by machine for asthma, to insulin pumps, glucagon or insulin injections for children with diabetes, to suppositories for children with seizure disorders and epinephrine for children with food allergies. Some schools allow children to medicate themselves. Because of budget constraints, the immediate health needs of schoolchildren are often put in the hands of school secretaries, minimally trained health clerks, teacher's aides, teachers and other school staff who lack medical training. If caught in a bind, they try to page a school nurse, who may be miles away.

Cory Sanfilippo is often mistaken for the school nurse by parents at Sutter Elementary School in Santa Clara County, California, where she works as a school secretary. "I always correct them," Sanfilippo says. But it seems to be a constant misconception. Sanfilippo takes her job seriously: She answers the phone, writes school reports and letters for the principal, responds to parents' questions, deals with children who've been sent to the office because they're misbehaving or have wet their pants, signs off on package deliveries -- and gives medication to students.

Because the school nurse is on campus only once a week, it falls on Sanfilippo to hand out medication to students and deal with emergencies. She's skilled in cardiopulmonary resuscitation, injecting epinephrine to prevent shock in food-allergic children, and has used her own familiarity with the care of a diabetic grandmother to help her respond to the needs of children with diabetes at school. But Sanfilippo is uncomfortable with the role she's been forced to assume.

"I'm lucky that we haven't had a near-death experience. My greatest fear is: Is today going to be the day?" says Sanfilippo.

On any given day, Sanfilippo will have to deal with five to 15 children coming to the office because they need their medication or they don't feel well or because there's an emergency. "We have asthma big time," she says. "We have some visually impaired this year and 13 students that have autism. We have severe allergies to milk and peanuts and bee stings, five or six kids with EpiPens (injection pens to prevent anaphylactic shock), and a couple of children with cancer in remission."

Hard-working and conscientious, Sanfilippo distributes medication, making sure that the children swallow their pills or get the right number of puffs of an asthma inhaler. It's at this point that she enters an unknown -- and dangerous -- zone: "I can tell if a child with asthma is having trouble breathing, but I cannot tell what stage of distress a child is in," Sanfilippo says.

Sanfilippo's worries are well grounded. Mistakes are more than three times as likely to occur when an unlicensed person and not a nurse is responsible, according to a 2000 University of Iowa survey, whose results were reported in the Journal of School Health. Unfortunately, the vast majority of school employees handing out medications have no medical background, the report continued. The randomized national survey of 649 school nurses in 49 states showed that more than 75 percent of school nurses had to delegate medication administration to school staff lacking medical training, referred to as "an unlicensed assistive personnel."

The types of errors included "missed doses, overdoses, giving the child the wrong medication or not writing down that medication had been given."

Seeing those problems first-hand is Juanita Hogan, a school nurse in Pittsburgh, Pa., who circulates among four to six schools each week. She has seen the risks to schoolchildren when medically untrained staff that work in her absence are at the helm: "I had a student on Ritalin [for ADHD] at a school I visited once a week," says Hogan, a nurse practitioner. "The following week he had a protrusion on his tongue," indicating he was on too high a dose. The doctor, she explains, should have been notified immediately that the medication was at a toxic level and should be stopped. "That was very dangerous," Hogan recalls. "The child could have had trouble swallowing, choking and breathing."

In another survey compiled by the California School Nurses Association in 2003, a nurse who covers eight schools had trained a school aide to hand out medication. After a student with a seizure disorder died, she looked at his medication card, noting in horror that the student wasn't called in by school staff to take his medication, as he was supposed to, and had missed seven out of 15 doses. "I saw this omission three weeks late when I checked his card," writes the nurse. "The parent had not been notified of the omissions. He had a seizure when home alone ... He hit his head on a sharp table corner and was found dead by his parents."

This crisis in school medication errors has received little publicity, although teachers have pleaded for help in state hearings. "I sat in a room and watched a teen pass away, " says Curtis Washington, a science teacher at Mills High School in Millbrae, Calif. Pausing to compose himself at the California State Board of Education hearing in February 2003, he recounts the death of a student who suddenly fell unconscious during badminton practice in 2001 -- there was no on-duty school nurse, and paramedics could not revive him. "Would that have been different if there was a school nurse?" Washington asks. "I don't know. But that's a question I have to live with.

"We talk about how we have to have qualified teachers," Washington continues, his voice rising. "If I mess up on a lesson, I could have a negative impact on a child's future, but if we mess up their medical care or their medication, that child may not even have a future."

It's hard to understand why healthcare services in schools would not be automatically guaranteed. In fact, laws and regulations on the issue are a tangled maze, differing from state to state and even district to district. Only Delaware and the District of Columbia, for example, require that there be at least one nurse for every 750 students. States also interpret federal mandates differently. In some states children with severe chronic health conditions and those with learning disabilities are covered by section 504 of the federal Rehabilitation Act, so that schools are required to provide them with health services. Other states allow a child's chronic health condition to be covered by section 504 only if that child also has a learning disability.

Even if schools try to maintain health services for students, many have been forced to make cuts in those services in order to pay for programs to meet the test scores demanded by the Bush administration's No Child Left Behind program. A recent report by the National Conference of State Legislatures, for example, said that "in the best-case scenario, federal funding marginally covers the cost of complying with the administrative processes." However, the February 2005 report continues, "states still face a separate set of costs to reach the law's standards of proficiency." If states choose not to comply with the law, they lose massive amounts of federal school funding.

Yet schools also lose funding -- because of decreased enrollment -- if children have absences or drop out due to illness. Dr. Pat Cooper, the superintendent of schools in McComb, Miss., thinks the tie between health and performance is obvious: "No Child Left Behind is going to leave a lot of children behind if we don't start looking at the health needs of our students," Cooper says.

When Cooper became superintendent nine years ago, he looked at the high dropout rates, absences from the district's seven schools, and poor test scores. He found a significant link between the health needs of the children and poor performance. "I decided that we had to stop investing in stuff and start investing in people," Cooper says. "We had good teachers, great training, good textbooks. But we realized part of the problem was we weren't reaching kids because the kids weren't in school." The district was plagued with asthma, type 2 diabetes and childhood obesity issues, which cut into students' attendance. Such illnesses are more common among low-income children, which Cooper says describes the majority of students in his district.

Cooper worked with community and health experts to come up with a five-year plan to meet students' health needs and get them back in school. "First we hired two nurses in each school -- not as window dressing, but to treat kids and to do prevention," Cooper says. Daily attendance rates began going up, he says and, consequently, so did the school district's money from the state.

Cooper didn't stop there. He eventually hired master's-level social workers to help manage the emotional and mental health needs of students. Since the majority of students in his district are poor, the schools qualified for a Medicaid-funded clinic on-site. In the McComb School District, dropout rates were 30 percent when Cooper came; now they're down to less than 2 percent, he says.

Dr. Cynthia Mears, who started a school-based health clinic in an immigrant neighborhood in Chicago and three in other states, says that in order to get a clinic or even school nurses in each school, you have to have a champion like Cooper. "The problem is that healthcare isn't always high on a school district's agenda, because they have to answer to test scores," says Mears, who is on the American Academy of Pediatrics School Health Committee. "But you have to have healthy children if they're going to learn."

Regrettably, students in many parts of the country are not as fortunate as the students in McComb, Miss. In Buffalo, this September, Clare McKenna began her sophomore year at City Honors School. Although her mother, Ann McKenna, has worked furiously on state legislation to fund school nurses, her daughter started school with no nurse on-site.

Although Buffalo has one of the highest asthma rates in the nation, New York Gov. George Pataki vetoed a bill in early August that would have funded a nurse in each school in Buffalo and surrounding areas lacking school nurses. It was a bill championed by parents like McKenna, who was outraged by its veto. "We have this beautiful, vital child who goes to a wonderful school that's provided her with perfect potential," McKenna says. "But if kids' primary health concerns are being ignored, how safe are our schools?"

McKenna's advocacy has finally paid off. City Honors High School gained a full-time nurse on Sept. 19, after the local school board agreed to increase the number of nursing positions to 20. Most schools in the district, though, have not fared as well. "Right now I have some schools that don't even see a nurse," says Sue Ventresca, director of health-related services for the Buffalo Public Schools, who says she's hopeful that more money will be found. Presumably, the schools left without nurses feel the same.

By Laurie Udesky

Laurie Udesky is an award-winning San Francisco based reporter. An earlier article she wrote for Salon, “No School Nurses Left Behind,” earned an award from the Association of Health Care Journalists.

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