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"If there's ever an emergency, don't even bother trying to find me -- just call 911"

                                         -- A school nurse responsible for 7,200 students

December 13, 2005 -- Today USA Today ran a massive and influential report on the shortage of school nurses, including a very good main story and five shorter related pieces. The main ideas are that U.S. school nurses are vital but severely understaffed, and that given the serious health issues today's students confront, their health is at risk. The report covers much of the same ground as Laurie Udesky's Golden Lamp Award-winning September 2005 piece in Salon, even using some of the same anecdotes. The earlier article seems likely to have been a strong influence on this one. But the USA Today piece, while less probing in some ways, surpasses the earlier one in giving readers a better sense of what it's like to be a school nurse confronting this short-staffing, and in showing the different ways school nurses affect patient outcomes. The new report appears to have led to recent coverage by NBC's "Today Show" and other prominent news entities. We commend authors Bruce Horovitz and Kevin McCoy, contributors Paul Overberg, Tom Ankner, and Bruce Rosenstein, and USA Today for bringing these important issues to a broader public.

Horovitz and McCoy start their piece with a harrowing story about Ohio school nurse Patty Baker. Last spring, Baker was reportedly helping a 10-year-old diabetic who was "crashing from a sugar low." She got a call from a frantic secretary at another school. An eight-year-old asthmatic boy was wheezing and could barely breathe. The principal at the diabetic's school "ordered" Baker to stay there. She did not. She stabilized the diabetic boy and rushed to the other school, ran inside, and strapped the asthmatic boy into a nebulizer, which the secretary felt she could not do. After two treatments, the boy was breathing normally. Baker is now "haunted" by this, and she is quoted saying she "wanted to march into the superintendent's office and say 'This is unsafe--someone is going to die.'" The piece reports that the school district has increased its school nurse hours, but there are still only three part time nurses for 2,400 students at seven schools--and one day each week, Baker covers them alone. The current superintendent points to "scarce resources." The asthmatic boy's father, a high school teacher, has a different take: "It's like not putting in a traffic light until there's a serious accident."

The USA Today piece uses powerful anecdotes to show the effects of the choices U.S. school districts are making, in a harsh budget climate where their very existence is linked to test scores, and more nurses can mean fewer teachers. Baker's situation is increasingly common. And some schools--like a high school in Lynwood, CA with 3,400 students--have no nurses at all. An anecdote also included in Udesky's Salon piece is about a Millbrae, CA high school senior who collapsed during badminton practice five years ago and died of cardiac arrest. Mills High School "had no nurse then, and has none now." The physics teacher who watched the student die, Curtis Washington, is reportedly haunted by it. Testifying before the California State Board of Education, Washington reportedly said: "If I mess up my lessons, I can have a negative impact on a child's future...If we mess up the medical care, maybe a child doesn't even have a future." Prominent pediatrician William Sears is quoted as saying that a school with no nurse is putting students "in harm's way," and that if we can't afford school nurses, our priorities are "skewed."

The piece reports that Census data show about 56,000 full time school nurses, one for every 950 students, well below the one-to-750 ratio the federal government recommends. But the National Association of School Nurses estimates the ratio is more like one school nurse for every 1,461. And a study by the Centers for Disease Control and Prevention estimates that 47% of schools fall short of the recommended federal nurse-student ratio. In California, PTA surveys showed that just 5% of schools had full-time nurses in 2003. Kate Earnheart, a school nurse responsible for 7,200 students in Tuolumne County, CA, is quoted as saying: "I tell everyone, 'If there's ever an emergency, don't even bother trying to find me -- just call 911.'" And as the article shows, emergencies and injuries are common. The Utah Department of Health reports that every half hour a student in that state suffers an injury serious enough to cause her to miss a half-day or more of school.

The situation is especially serious because of the increasing numbers of students who attend with serious chronic health conditions, including asthma, diabetes, attention-deficit disorder, and food allergies. More and more children lack insurance and primary care, further increasing the burden on nurses. Asthma alone affects almost one in 10 students. A 2002 CDC study found that asthmatic students had lost about 14.7 million school days because of their condition that school year. One of the shorter side pieces tells the story of a Buffalo student who apparently barely survived an asthma attack, after she found that the part-time school nurse had left for the day. In addition, about 3.5 million U.S. school children take medication at school, including 200 types of prescription drugs. The California School Nurses Organization reportedly says that 86% of the "medical doses" last year in the Los Angeles Unified School District were administered by non-nurse staff members. The consequences of missing doses can be tragic. One anecdote, also included in Udesky's Salon piece, concerns a California boy who apparently died after having a seizure and hitting his head at home. The non-health care staff the school nurse had assigned to call the boy in for his anti-seizure medication had repeatedly failed to do so. Such medication errors are increasingly common, as short-staffed nurses are forced to rely on secretaries, teachers, health aides and other unlicensed persons. Congresswoman Lois Capps (D-CA), herself a nurse who formerly worked as a school nurse, notes that staff at schools without nurses might fail to spot student illnesses.

Another critical point the USA Today piece makes in passing, though the Salon piece hit it much harder, is that school nurses can actually improve students' performance, not only by keeping them alive, but by keeping them healthy. Healthy students will likely have better attendance, better focus--and better test scores. The USA Today piece notes that more school nurses "might help keep [asthmatic] students in the classroom," since such students who attended schools with full-time school nurses averaged three more school days annually than asthmatic students at schools with part-time nurses in a 2003 Ohio study. Thus, even if you believe that kids deserve no greater health protection at school than any adult worker without a nurse, it's clear that there are real educational advantages to more school nurses.

And it would seem that a lack of school nurses can also have unforeseen economic effects. The more school time kids miss, the more parents may have to miss work or incur child care expenses they cannot afford. Another potential economic effect is school district liability. One of the side pieces tells the story of an Iowa school district that settled a lawsuit brought by the mother of a student who had attended with a breathing tube following a serious injury. Though there was supposed to be a nurse on hand to suction the tube when needed, none was there one day. The girl could not breathe, and she suffered severe brain damage. Another side piece tells the story of a $2.23 million judgment awarded in 1996 after an 11-year-old California student with asthma died after reaching the nurse's office to find no one there who could help him with the nebulizer. The nurse was at another school.

The piece gives a couple anecdotes of school nurses making mistakes. An "ailing" Washington, DC student with cerebral palsy apparently died on her way home on the school bus with "an urgent health note" from the nurse. And an Atlanta nurse has reportedly been charged with failing to report suspected child abuse after a young student was allegedly killed by her parents. Presumably the idea is to show that understaffed nurses can make deadly mistakes, or that in general school nurses have responsible jobs that we should take seriously, though the piece might have made that clear.

But of course, the piece does a very good job of showing the difference nurses can make in patient outcomes, including through pro-active teaching. One of the side pieces explains how the Waltham, MA, school district's nurses are improving student health through a number of aggressive initiatives, including walking clubs, a nutrition task force, and an allergy support group. (That piece suggests that Waltham is a model for school nursing, with a 1:500 nurse-student ratio and nurse pay comparable to that of the teachers. One key? "Waltham has the financial wherewithal for such services" with a "median family income [of] $64,595," (which compares favorably to a US median family income of $44,500).) Another anecdote is about a 10-year-old New Mexico girl who collapsed and stopped breathing during gym class, apparently as the result of a previously undetected heart condition. School nurse Ellen Williams rushed out to the field, asking staff to call 911, and began CPR with the physical education teacher. The student survived. Now she has a defibrillator in her chest. Her mother, Lucina Ruiz: "Without the school nurse, my daughter wouldn't be alive today."

Why aren't there enough school nurses? The basic reason, of course, is money. Here again, Udesky's Salon piece was more aggressive in pinpointing specific government policies and choices that led to the shortage. But USA Today does include some good points. It quotes Janis Hootman, apparently former president of the national school nurses association, as noting that most people don't understand just how much nurses have to do in the modern school environment--a problem pieces like this one help address. The piece notes that many school administrators feel they can't afford nurses. They "struggle to find money to meet the most basic federal and state mandates for teachers and curriculum," including the "demands of the government's No Child Left Behind program, which links federal funding of schools to improved standardized test scores." In many cases, they must pay for security guards and bioterror plans. An excellent chart accompanying the article lays out the requirements for school nurses in all 50 states; it appears that only Delaware requires a nurse for every school. Many states, including Florida, Texas, and Iowa, don't seem to have any school nurse requirements at all. And even the nurses schools do have are paid astonishingly little money for the challenges they face today. The piece reports that a 2004 survey found the median US school nurse salary to be $36,000, about $20,000 less than the overall US average nursing salary.

The piece reports that some parents are trying to do something. Recently, the American Diabetes Association and the families of several students filed a federal suit in California alleging that school officials had failed to meet diabetic student needs. In Utah, parent Paula Tuck started a petition drive to get more state funding for school nurses. Her daughter had seizures after panicking about an asthma attack and overdosing on her medication. Tuck's daughter's school had no nurse that day. Indeed, a school nurses' group estimates that Utah has the worst nurse-student ratio in the nation. According to the side piece telling this story in more detail, Utah school nurses have been trying for years to increase their numbers. The piece might have included more discussion of what school nurses in general have done to try to address the problems the piece describes.

On the whole, this lengthy report does a very good job of showing why school nurses are so important, and explaining some of the ill effects of not having enough of them. We commend the reporters and USA Today.

See the article "Nurse shortage puts school kids at risk" by Bruce Horovitz and Kevin McCoy in the December 13, 2005 edition of USA Today.

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