Wouldn’t Now Be a Great Time to Have School Nurses?

(Bloomberg Opinion) -- School nurses are already on the front line battling epidemics, from asthma to obesity to teen suicide. Now, as the coronavirus epidemic forces schools to shuffle sports schedules and debate whether to cancel proms, school nurses would seem to be ideal leaders to help guide the response, from offering prevention tips to correcting the kind of misinformation that inevitably courses through the classroom rumor mill.

Yet school nurses are in a less-than-ideal position to offer such guidance because, nationwide, their ranks have been devastated. Only three out of five schools employs a full-time school nurse and a quarter of all schools have no nursing staff at all.

It shouldn’t have taken the coronavirus to lay bare the long-term cost of this kind of penny pinching. Long before Covid-19 started spreading in China in January, U.S. school budget cuts were forcing administrators and teachers to administer insulin to diabetics and Narcan to victims of drug overdoses because there was no health professional around to do it.

Delaware is one of the only states that requires a certified school nurse in every school, according to the National Association of School Nurses. In Washington, D.C., a law requiring a full-time school nurse in every public and charter school went into effect in 2018. Tennessee is now considering legislation that would require one nurse per every 750 students, up from the current ratio of one to 3,000.

Many states that already have mandated or recommended levels of nursing care in schools do not follow their own guidelines, according to the school nurse association. For example, Oregon recommends that school districts provide one nurse for every 750 students, but only four out of 197 districts meet the recommended ratio. Washington, D.C. has been slow to enforce its own new law. In Pennsylvania, which requires one nurse per 1,500 students, many districts opt to pay a fine rather than meet the nursing mandate.

Meanwhile, a bill pending in the Iowa legislature would effectively remove an already weakly enforced mandate that districts provide “access” to one school nurse for every 750 students.

School nurses are coping with complex problems like asthma and obesity, which affect 8 percent and 18.5 percent of children, respectively, and probably pose a greater long-term risk than the coronavirus. Higher rates of obesity are associated with increased rates of diabetes among children, and the need for nurses to measure blood sugar and administer insulin during the school day.

In 2016, the American Academy of Pediatrics increased its recommendation for school nurses to at least one per school from an earlier recommendation of one nurse per 750 students.

The recent wave of teachers’ strikes, which included a demand for more school nurses in several cities, has focused attention on the school-nursing shortage. The Los Angeles Unified School District met the strikers’ demands for more school nurses by agreeing to phase in 300 full-time nursing positions by the 2020–2021 school year. Similarly, last fall, a teacher’s strike in Chicago produced a commitment from the city to hire hundreds of school nurses. In recent years, the city’s schools have relied on a chaotic deployment system, in which an average of five nurses cycle through any given school during a three-month period, with about 300 nurses staffing more than 500 schools.

Chicago, the third-largest U.S. school district, illustrates the costs associated with a lack of school nurses. A survey of school nurses there identified multiple barriers to caring for kids with asthma, a leading cause of school absenteeism, according to a study published last year in Public Health Nursing. These included a shortage of nurses and “other trained health-care personnel in schools” and a lack of medications. In 2015, nationwide, 219 children under the age of 18 died of asthma.  

Without school nurses, children also are more likely to seek emergency care. The number of children who landed in the emergency room because of allergic reactions alone more than doubled between 2010 and 2015, in part because schools did not have nurses on staff.

The costs of school nurses typically are borne by school districts, which have been slow to increase funding that was gutted during the financial crisis of 2008. And, even when districts agree to hire more school nurses, low salaries often make it difficult to fill vacancies. While nurses, on average, earn $65,000 a year, more than half of school nurses earn less than $51,000 annually.

Shortages of school nurses are especially acute in rural areas, according to Laurie Combe, president of the National Association of School Nurses.

One bright spot is the spread of school-based health centers, especially for families in poor communities. Nationwide, the number of such health centers doubled to 2,584 during the 2016–2017 school year since 1998-1999, thanks in part to funding from the Robert Wood Johnson Foundation. School-based health centers also receive state and local funding.

The political climate may be shifting in favor of more school-based nurses. Several Democratic presidential candidates, including former Vice President Joe Biden and Senator Bernie Sanders of Vermont, proposed added federal spending on nurses and other school-based support services. Policymakers also increasingly recognize the physical and psychological health effects of poverty.

In the meantime, states and local districts should require all schools to have at least one full-time nurse on staff. As an interim measure, states could also follow the lead of Texas, which passed a law last year requiring schools that do not have a full-time nurse and a counselor on staff for 30 days or more to notify the public so that families who have children with a chronic illness, and who rely on a school nurse for treatment, can make alternative plans.

Even as the U.S. prepares for the coronavirus pandemic, it is time for government at all levels to address the long-simmering health-care challenges in schools.

To contact the editor responsible for this story: Jonathan Landman at jlandman4@bloomberg.net

This column does not necessarily reflect the opinion of Bloomberg LP and its owners.

Andrea Gabor, a former editor at Business Week and U.S. News & World Report, is the Bloomberg chair of business journalism at Baruch College of the City University of New York and the author of "After the Education Wars: How Smart Schools Upend the Business of Reform."

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