Nurse shortage puts school kids at risk
Baker had just arrived at another school a couple of miles away to help Logan Rice, a 10-year-old diabetic crashing from a sugar low.
Now, as the secretary at the other school pressed the phone to Gavin’s chest, Baker could hear the scratchy wheezing. She had been ordered by the principal to stay by Logan’s side. Should she stay with Logan, or leave to help Gavin?
Problems like this are becoming more common at schools across the nation, a USA TODAY examination of school nursing found. At some schools, a lone nurse, often a part-timer, is forced to juggle multiple medical demands. At others, there are no nurses on staff.
An analysis of 2004 Census data by USA TODAY showed roughly 56,000 nurses worked full time at schools. That’s one for every 950 students, a ratio that fails to meet federal guidelines that call for one nurse for every 750 students.
As a consequence, thousands of children with asthma, attention-deficit disorder, food allergies and other increasingly prevalent health problems must rely on teachers, other school staffers or the telephone.
“I tell everyone, ‘If there’s ever an emergency, don’t even bother trying to find me — just call 911,’ ” says Kate Earnhart, the lone school nurse for 7,200 students in Tuolumne County, Calif.
That’s what school staffers in another California school district did when Albert Lee, a 17-year-old senior, collapsed during badminton practice five years ago. Mills High School, in Millbrae, Calif., had no nurse then, and has none now. Albert, a senior, died of cardiac arrest.
“I think about it every day,” says Curtis Washington, a physics teacher who watched Albert die. “Maybe a school nurse might have looked into his eyes and seen a clue to what was going on. I look at the faces of the students I have now and still see his face.”
Sometimes, school nurses make deadly mistakes. Last year, in Washington, D.C., a school nurse sent an ailing 13-year-old girl with cerebral palsy home on the school bus with an urgent health note. The girl died en route.
And in a case still pending in Atlanta, a school nurse was charged with failing to report suspected child abuse after the death of an 11-year-old student whose parents were charged with the murder last year.
Concerns about who is at school to oversee the health needs of students have prompted some parents to push for changes. In California, the American Diabetes Association and families of four students filed a federal lawsuit in October alleging that the state school superintendent and two large school districts failed to meet the health needs of diabetic students.
“A student with diabetes cannot take a break from diabetes when he or she boards the school bus in the morning,” says L. Hunter Limbaugh, a committee chair at the American Diabetes Association whose daughter has diabetes.
And in Utah, where the nurse-to-student ratio is estimated by a school nurses group to be the worst in the nation, a parent has launched a petition drive to seek state funding for more nurses. Paula Tuck’s 10-year-old daughter, Michaela, suffered seizures in September after she panicked during an asthma attack at school and accidentally overdosed on the medication in her inhaler. Her school had no nurse on duty that day.
“Schools without nurses are putting children in harm’s way,” says William Sears, a pediatrician and author of more than 30 books on child care. “If we can’t afford school nurses, we’ve got our priorities skewed.”
Rep. Lois Capps, D-Calif., a former school nurse, agrees. She worries that staff members at schools without nurses might fail to spot illnesses among students or find themselves hamstrung during emergencies. “It’s a ticking time bomb,” she says.
Staff makes mistakes
No one is certain how many school nurses are registered or licensed, work full or part time — or how many health aides, secretaries or teachers are asked to fill in. That’s because there are no authoritative counts.
Estimates by the National Association of School Nurses, a non-profit trade group, suggest the nurse-to-student ratio may be even worse than Census statistics show: one for every 1,461 students. That’s roughly half as many nurses as the federal government says schools need.
Almost half of schools nationally — 47% — fall short of the federally recommended nurse-to-student ratio, a Centers for Disease Control and Prevention survey shows.
And students at some of the nation’s larger schools have no nurses at all. Among them: the 3,400 students at Lynwood High School in Lynwood, Calif.
Why are the staffing levels so low?
Within the nursing profession, school nurses aren’t paid particularly well. The median salary was about $36,000 last year, according to a 2004 survey of more than 4,000 school nurses by the school nurses association. That’s about $20,000 a year less than the median salary for a nurse on staff at a hospital or clinic, according to Salary.com, a website that tracks wages.
The absence of qualified nurses — or the decision by a financially pressed school district not to hire them — leaves unlicensed staff members to dispense medication, treat injuries, diagnose illnesses and handle emergencies. It can also lead to errors.
University of Iowa researchers found that almost half of about 600 school nurses surveyed in 2000 reported “medication errors” at the schools in which they worked.
The nurses weren’t the ones making most of the mistakes. Secretaries, teachers and health aides often were to blame for giving students the wrong medicine or missing their doses, the survey found.
In the Los Angeles Unified School District, 86% of the medical doses administered last year came from staff members who weren’t licensed to be nurses, the California School Nurses Organization says.
The consequences are potentially deadly.
In a survey taken in 2003 at its annual conference, the California nurses group asked attendees to describe medication errors made by health aides that they knew about. The survey was done anonymously so that nurses might be more open in their responses, says Nancy Spradling, executive director. It showed that 22 nurses knew of medical errors and theft of medications.
One nurse feared mistakes by office staff led to the death of a student who had a seizure disorder. About three weeks after the student died, the nurse wrote, she checked the student’s school medication card and saw that the boy had missed seven of 15 doses because school staff failed to call him in to give him the medicine.
The parents had not been notified, the nurse wrote. She believed that might explain why the student had a seizure when he was home alone. The student hit his head on a sharp table corner “and was found dead by his parents,” the nurse wrote.
USA TODAY’s efforts to identify the student were unsuccessful.
No money for nurses
To be sure, most kids are healthy and resilient, and tragedies such as Albert’s death in Millbrae remain exceptions.
Nevertheless, the sheer frequency of health issues, and a rise in the number of children whose families lack health insurance and primary care, is enough to keep even a full-time nurse busy.
In Utah, for example, every half-hour a student suffers an injury significant enough to cause him or her to miss a half-day or more of school, reports the Utah Department of Health. Every three days, the injury is so severe that a student loses consciousness.
“Schools were never developed hundreds of years ago thinking of children coming with such complex health conditions,” says Janis Hootman, former president of the school nurses group. “Most people don’t realize that schools are now being asked to do things for which society is not providing resources.”
Despite the federal recommendations on the ratio of nurses to students, the Department of Education has no plans to enforce them. “State and local officials determine staffing needs,” says Susan Aspey, press secretary for the department. “We don’t dictate hiring decisions.”
Most states also refuse to mandate that nurses be hired and instead rely on the same loose guidelines that the federal government sets. That leaves the decision up to school districts, which often struggle to find money to meet the most basic federal and state mandates for teachers and curriculum.
Some schools hire security guards to keep peace in the halls and strangers from the building. Others develop elaborate plans for bioterrorism attacks.
But many school administrators say they cannot afford to keep a nurse on staff, especially given the demands of the government’s No Child Left Behind program, which links federal funding of schools to improved standardized test scores.
“I don’t like going without a school nurse,” says Scott Johnson, district administrator for the Siren (Wis.) School District. “But I don’t like cutting a teacher, either.”
In the past three years, Dearborn, Mich., has cut school nurses at its 32 schools from nine to five. “We depend on secretaries to take care of minor medical needs,” says John Artis, superintendent of Dearborn Public Schools.
In Baldwin County, Ga., three of the seven school nurses were laid off this year. The district’s superintendent says he had little choice, though he has since rehired one of the nurses. “It’s all about money,” says Gene Trammel, whose district has seven schools.
In California, the number of schools with full-time nurses fell from 7% in 1998 to 5% in 2003, according to recent state Parent Teacher Association surveys cited in the American Diabetes Association lawsuit.
For Salem, Ohio, nurse Patty Baker, having to choose between treating Logan Rice, the diabetic boy, and Gavin Ward, the asthmatic, underscored her frustration. Even though the school principal at Prospect Elementary School had ordered her not to leave Logan, she says she knew she had no choice but to go.
After treating Logan — stabilizing him with glucose tablets and sweets and checking to see that his blood sugar level was improving — she asked a teacher to watch him and drove 2 miles at close to 50 mph through the streets of Salem, she recalls. Then she ditched her car in the no parking zone outside Buckeye Elementary School and ran inside.
“I could hear him wheezing in the hallway as I entered,” she says of Gavin. Baker recalls strapping him into a nebulizer — something the secretary said she wasn’t comfortable doing. About 40 minutes later, after two treatments, Gavin was breathing normally.
Memories of that day still haunt Baker. “I wanted to march into the superintendent’s office and say: ‘This is unsafe — someone is going to die,’ ” she says.
Now under a new superintendent, Salem has boosted the total hours of its three part-time nurses this school year. But there’s still one day each week when Baker works alone, covering 2,400 students at seven schools.
“You’re talking about scarce resources,” says Stephen Larcomb, the new superintendent. “No one will ever be completely satisfied.”
For one, Gavin’s father, Mike Ward, a high school business teacher. “It’s like not putting in a traffic light,” Ward says, “until there’s a serious accident.”
Complex health issues
Severe asthma, such as the kind Gavin suffers, has become one of the greatest threats to student health. It affects almost one in 10 students. That means about two students in every classroom are asthmatic. During the 2002 school year, a CDC study showed, students across the nation lost roughly 14.7 million school days to asthma.
The number of students with breathing problems continues to rise. In 1998, roughly 7 million children ages 5 to 17 had been diagnosed with asthma at some point in their lives, according to the CDC. By 2004, the CDC reports, that number had risen to more than 7.4 million.
More school nurses might help keep those students in the classroom. Asthmatic students who attended schools that had full-time nurses averaged three more school days annually than did asthmatic students at schools with part-time nurses, a 2003 study in 16 elementary schools in Toledo, Ohio, shows.
The issues are broader and more complicated than asthma. Every day, more than 3.5 million schoolchildren take medication at school. That includes 200 types of prescription drugs — about three times the number taken in the late 1980s, University of Iowa researchers found.
The number of children allergic to peanuts and tree nuts, though small, doubled from 1997 to 2002, according to a study by doctors from Mount Sinai School of Medicine and the Food Allergy & Anaphylaxis Network.
A 1999 U.S. Supreme Court ruling requires public school districts to provide medical care short of a doctor for students with disabilities. That means someone at school may have to know how to handle devices commonly used by severely disabled students, such as tracheostomy tubes, ventilators and feeding pumps.
Emergencies happen frequently, and calls from schools to 911 are not uncommon. In Florida schools, 6,007 calls were made to 911 for injuries or illnesses during the 2003-04 school year, according to the state’s Department of Health.
An emergency call — and a school nurse — helped save the life of Maribel Ruiz last fall. The 10-year-old had no history of health problems. But while running laps in gym class at Highland Elementary School in Las Cruces, N.M., she stopped breathing and collapsed on the soccer field.
Ellen Williams, the school nurse, heard the voice of school physical education teacher John Coats on the walkie-talkie. “She’s not breathing,” he screamed.
Williams, 55, dashed out of her office toward the soccer field, yelling for the staff to call 911. When Williams got there, she and Coats began CPR. Nine minutes later, the ambulance came.
Maribel survived; she had a serious but previously undetected heart condition. Today, she has a defibrillator in her chest. Says Lucina Ruiz, Maribel’s mom: “Without the school nurse, my daughter wouldn’t be alive today.”
‘Kids at serious risk’
Children’s advocates say such cases underscore the urgency of the situation. “It’s criminal for a school not to have a nurse,” says Ted Lempert, president of Children Now, a children’s advocacy group. Without school nurses, he says, “we’re putting a large number of kids at serious risk.”
Few know that better than Curtis Washington, the teacher from Millbrae, Calif.
Decades earlier, when Washington was a first-grader, he slipped on the school floor and sliced off a large piece of one ear on a sharp, metal edge of a counter.
A quick-thinking school nurse picked up the ear, put it in ice and rushed Washington to a surgeon, who successfully sewed it back on.
Washington has never forgotten that day. Or the day he watched the 17-year-old student die.
Perhaps that’s why he was darkly philosophical when he testified about the need for nurses before the California State Board of Education two years ago.
“If I mess up my lessons, I can have a negative impact on a child’s future,” he told the board. “If we mess up the medical care, maybe a child doesn’t even have a future.”
Contributing: Paul Overberg, Tom Ankner, Bruce Rosenstein