Image of child receiving eye examKelly Oswald regularly helps the diabetic students at her school draw blood and determine whether their glucose levels are within normal range or whether further steps must be taken to stabilize them.

And in the course of her school week, she knows she may be called on to administer medication to a child having a seizure or determine when it’s too cold outside for an asthmatic child to go out for recess.

That’s in addition to dispensing the usual daily round of prescription medications that a school full of children in varying degrees of ill health bring with them from home.

Oswald is not a nurse. She’s the school secretary at the 100-student Kit Carson School in the town of Kit Carson in Cheyenne County, a sparsely populated community on Colorado’s eastern plains.

“I did work as a certified nursing assistant years ago, so it doesn’t bother me,” said Oswald, a veteran secretary who has seen the gamut of school health emergencies in her years at the school.

But at another school in the county, the school secretary quit rather than do the daily blood draws that a diabetic student required.

“She said it wasn’t her responsibility to take that child’s blood and determine if the child was OK,” said Kelli Adamson, a public health  nurse in Cheyenne Wells who contracts with the local school district to provide limited nursing coverage for two schools.

“School secretaries get a lot of stuff put on them,” Adamson said. “I’m always available by phone, but I’m not always available to run to the school when they need me. It makes it tough.”

School staff required to pick up the slack

Across the state, in urban, suburban and rural districts alike, school secretaries – along with principals, teachers, coaches, bus drivers and other campus adults – are sometimes reluctantly picking up the slack for overburdened school nurses who continue to see their numbers shrink, even as the demands placed on them grow.

Indeed, one study in Milwaukee showed that when additional school nurses were hired, other school staff saved a cumulative average of 13 hours a day that previously had been spent on health-related issues.

“The problem is that kids are requiring more and more services, and their needs must be met in school,” said Kathy Patrick, the Colorado Department of Education’s principal consultant for school health services and a state school nurse consultant. “Parents expect those needs to be met.”

Gone are the days when school nurses administered aspirin and bandaged minor scrapes picked up on the playground. Today, about one child in four comes to school with some chronic ailment that potentially will require medical care during the course of the school day.

Some require much more than the simple administration of pills. There are feeding tubes to be suctioned, catheters to be cleaned, ostomy bags to be emptied, injections to be given and some meds must be administered rectally.

“Years ago, kids that were that severely ill were either kept at home or in the hospital,” Patrick said. “Now they leave the hospital and go right back to school. It’s a whole different situation than it was 10 or 15 years ago.”

Colorado loses nearly 50 school nurses in two years

Yet very few school districts can muster the funds to put a nurse in every building, or even have a nurse on campus part-time every day.

School nursing positions are near the top of the list to be cut when budget cuts must be made. Between the 2007-08 school year and the 2009-10 school year, Colorado lost nearly 50 school nurses, going from 518 to 470.

The Healthy People Consortium, in its Healthy People 2020 10-year agenda, recommends a ratio of one full-time nurse for every 750 students. Only 15 states meet that standard. Colorado, with a ratio of one nurse for every 1,982 students, ranks 39th in the country.

“And when you look at the rural areas where they’re responsible for multiple districts, even though they may not have as many students, they’re on the road driving hundreds of miles a week,” said Patrick.

The answer – as any overworked executive who has tried to be in multiple places at once will tell you – is to delegate. The law allows for unlicensed individuals to perform certain medical tasks, as long as the individuals are trained and the tasks are completed under the supervision of a registered nurse. That’s what happens with many of the students with special needs.

“We screen what can be delegated and what can’t be,” said Paulette Joswick, director of health services for Douglas County schools.

A recent health survey of the district’s roughly 60,000 students showed that 32,880 listed some sort of health problem, and many of those children take multiple medications.

“We would not ever delegate anything that would be dangerous for an unlicensed person to do,” Joswick said. “One thing we do delegate is the care of a child with diabetes. But we spend a lot of time with the person who will be doing that care.”

Caring for diabetic students a huge challenge

In fact, Colorado is among the nation’s models with its Diabetes Resource Nurses program, which connects highly qualified school nurses and public health nurses to school districts for consultation. But providing direct care for a diabetic child can be a time-consuming job that requires constant vigilance.

Christy Lindenschmidt, a school nurse who serves 11 widely-dispersed schools in seven different school districts in Kit Carson and Yuma counties, recalled one recent incident that could have ended in disaster. A diabetic middle-schooler was supposed to drop by the school office before lunch to have his glucose level checked. He didn’t, and the office staff didn’t follow up.

A school nurse in Douglas County gives a shot at a school flu clinic, another nursing task.

“They got busy and the kid never got checked,” Lindenschmidt said. “One of them had to run to the bank, and this wasn’t at the top of their priority list. When the kid finally got checked later in the day, his glucose was in the 650 range, which could be life-threatening. That’s a very high number. We spent the rest of the day getting him back to normal.”

Some fear such lapses may occur more and more frequently as not only school nurse positions are cut but also school support staff.

“We have far fewer nurses than we used to have, but the people in the front office have also been cut,” Joswick said. “You do have kids who are sick and who need medical attention, but the people left are busy. Medications are forgotten. Kids are not getting immediate care. We need more people whose job it is to do that.”

Elizabeth Clark, a school nurse for the past 16 years, tells another frightening story: A middle-school student with a pacemaker complained to his teacher that he wasn’t feeling well and was dizzy and asked to see the school nurse. But the nurse wasn’t there and the teacher declined to let the student leave class.

When the student became more insistent, the teacher checked with the school’s designated health para-professional or assistant. They discovered that the nurse had drawn up a health plan for the boy, and in it had noted that dizziness could indicate that his pacemaker wasn’t working properly.

“They called his parents to come and get him, and by the end of the day he was in Children’s Hospital because his pacemaker had failed,” said Clark. “He could have died if the nurse hadn’t had a written plan for his care.”

Citing budget shortfalls, Greeley cuts nursing staff in half

Clark, the 2010 Colorado School Nurse Association Administrator of the Year, spent 16 years working in Greeley schools until that district, facing critical budget shortfalls, cut its nursing positions by half, from 12 to six. Clark resigned and now serves in the Brighton school district.

“In Greeley, we went from one nurse for every 2,300 students to one for every 5,000,” she said. “Rather than serving three or four schools and being in a school one day a week, now they’re there maybe one day every two weeks. That puts kids at risk.”

Greeley school board member Bruce Broderius said the situation is “not satisfactory.”

“But I don’t have a good alternative,” he said. “The state’s broke, we’re broke, and kids get the short end of this thing. It’s not fair, it’s not right.”

Yet he couldn’t rule out even more cuts to the district’s nursing staff in the future.

“So far it’s been OK,” Broderius said. “I wouldn’t rate it any better than that. It may be that one of the things that gives us a little sense of OK is that we do have a major hospital in our community, immediately available. We have ambulance service and the like, so in the worst case we’re only a few minutes from some medical support.”

Parents mistakenly assume a nurse will be present

“Parents think there’s a nurse in every school,” Clark said. “But the reality is, it’s a health para-professional, maybe with no health background at all. Maybe it’s a parent with some first aid and CPR training. That’s a message we need to get out to parents. If your child has a significant health need, you should check to see what the availability of the school nurse is.”

Elaine Gantz Berman, a member of the Colorado State Board of Education, doesn’t foresee any improvement for the situation anytime soon. Rather, nursing positions are likely to continue to be cut or go unfilled since nurses generally are in high demand and school district pay is hardly lucrative.

“I don’t think, in the foreseeable future, the legislature will get to a point where it will be mandating more nurses in schools or improvements in the nursing ratio, just because of the budget situation we’re in,” she said. “I think we’ll just have to be more creative about making making sure students with chronic health care needs get those needs met.”

Boulder Valley schools – with a nurse-to-student ratio of 1 to 3,500 – has recruited some licensed practical nurses to help with the load, and has also trained emergency response teams at each school to work under the supervision of RNs.

“On a day-to-day basis, if a child falls on the playground, it’s these first-aid trained emergency response people who go out, stabilize the child and make decisions about calling 911,” said Susan Rowley, health services coordinator for the district.

“But every year, the number of kids with diabetes or serious allergies keeps going up,” she said. “The number of students we have with seizure disorders is relatively stable, but they’re kids who often need medications on an urgent basis.”

Across the state, nurses insist that they do provide the care that is most urgently needed, and that incidents in which children’s lives are truly endangered by a lack of trained care providers are rare. Critically-ill children do have health plans in place so that school personnel aren’t left in the dark about what to do in an emergency if the nurse isn’t there.

What’s not getting done, they say, are the less urgent tasks that contribute to children’s overall health. Vision screenings  are done – in accordance with state law – but the follow-up calls to parents whose children need glasses don’t get made.

“There’s no opportunity to ask parents if they took their child to the doctor, and if not, why not?” said Clark. “I know health education doesn’t get done. When I started, I went in the classrooms to do hand-washing and tooth-brushing units. There’s no time for that anymore.”

By the numbers

  • Colorado ranks 39th in the nation for its ratio of one school nurse for every 1,982 students.
  • Colorado lost nearly 50 school nurses between 2007-08 and 2009-10, dropping from 518 to 470.

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