Fewer Ill Students Can Visit the School Nurse

The quiet monotony of testing students’ eyes and ears came to an abrupt halt for school nurse Jan Hargreaves on a recent day with the ring of her cellphone. A fight between two girls at a high school 10 minutes away had left one student with a badly injured eye.

Seconds later, her phone rang again. An asthmatic fourth-grader at another school 10 minutes in the opposite direction wasn’t responding to his medication and was gasping for air.

Hargreaves bolted out the door, preforming triage in her mind. As she drove to the high school, Hargreaves dialed the elementary school and ordered a rattled assistant there to call paramedics for the boy.

“I had to choose between a kid with a fractured eye socket and one struggling to breathe,” said Hargreaves, who is responsible for about 9,000 students at 10 Riverside schools. “It is ridiculous what they are asking us to do. It’s really unsafe. I don’t think parents have any idea about the level of medical attention their kids are getting at school.”

There was a time when most schools had a nurse at the ready for playground bruises and classroom fevers. Today, a severe shortage of school nurses in California has led to a system of care that health officials say leaves children at risk.

Nearly one of every 10 students in California -- more than 600,000 children -- attend schools in districts with no nurse on staff. The state’s remaining 5.7 million students are overseen by about 2,800 nurses -- a third of what national and state nursing groups say is needed.

Filling the void are minimally trained, unlicensed staff members such as secretaries and attendance officers who handle not only runny noses but an ever-increasing number of children with chronic illnesses that require potent medications and daily treatments.

“It’s a game of roulette,” said Penny Stone, director of health services at Riverside Unified School District. “I’m scared every day.”

Unlike other states, California has no law mandating that districts have nurses, except for special education students who are legally entitled to medical care at school. For all other children, schools must screen only for spinal curvature and sight and hearing loss, tasks that districts often hire private companies to perform.

The dramatic decline in California school nurses dates to 1978 when the passage of tax-cutting Proposition 13 greatly reduced school funding.

Today, as the state’s ongoing fiscal crisis continues to squeeze school budgets, hiring nurses is not a top priority, administrators say.

“It would be nice to have a nurse around,” said Jay Wilbur, superintendent of the 16,600-student Paramount Unified School District, which has no nurses on staff. “But as dollars have been reduced and budget decisions had to be made, the district decided they weren’t essential.”

Only a few small districts in the state meet the recommended ratio of 750 healthy students to one nurse. More typical is Riverside Unified, where five nurses are responsible for about 40,000 students on more than 40 campuses.

In Orange County, where there are only 180 school nurses for half a million students, the Children and Families Commission has spent $4 million over the last two years to hire and help train an additional 27 nurses. The commission also assists districts in recruiting, a challenge in the face of a deepening nationwide nursing shortage.

“We’re all competing for the same few nurses,” said Gayle McLean, who oversees 35 nurses at the 62,000-student Santa Ana Unified School District. “It’s very difficult to find nurses that are well-qualified with the specific skills needed for schools.”

In the Los Angeles Unified School District, 580 nurses tend to 746,000 students. Individual schools have tapped into discretionary funds that would otherwise be used on educational programs to pay for two-thirds of the district’s nurses.

Demands on nurses are particularly great in poor neighborhoods where many children don’t have health insurance, said Karen Maiorca, Los Angeles Unified’s nursing director.

With so few nurses, most districts have cobbled together a network of care that relies heavily on school staff members. Nurses have largely assumed the role of supervisor, frequently racing from school to school to tend to emergencies.

The amount and quality of training that districts require for health assistants varies dramatically, said Linda Davis-Alldritt, nursing consultant for the California Department of Education. Many districts, she said, rely on secretaries and other staff with no training. Others staff each school with a health assistant trained in CPR and first aid.

State law prohibits assistants from administering injections or making medical assessments. But assistants are allowed to dispense medicine and to perform intricate procedures such as suctioning tracheal tubes, feeding students through gastronomy tubes and administering drugs to cancer patients -- tasks that a hospital employee with similar training would not be permitted to do.

As medical care has improved and federal laws have expanded the rights of ill and disabled children to attend public school, health officials say the number of such cases has steadily climbed.

“The type of children coming to school today has changed dramatically,” said Maiorca, whose staff cares for about 4,000 students with seizure disorders and dispensed nearly 344,000 doses of prescription medicine last year. “If we could have a nurse at every school, students would be a lot safer.”

State agencies don’t track cases of children dying or suffering serious injury because of care received -- or not received -- at school. But school nurses and administrators say close calls and lawsuits are common.

In 1996, an 11-year-old boy near Fresno died during an asthma attack while school staffers struggled to operate a breathing machine.

His mother sued, and, in 1999, a jury awarded her $9 million, which the courts later reduced to $2.2 million.

Nurses express frustration that untrained staff often fail to recognize subtle symptoms of serious illnesses, make errors administering medications or wait too long to call nurses in emergencies.

“Sometimes I feel like we are given too much responsibility,” said one assistant, who asked that her name not be used out of concern for her job.

Cathy Owens, a veteran nurse at Murietta Unified School District, recalled how a health assistant assumed a student was on drugs when she found him acting disoriented and incoherent.

Instead of calling Owens, the assistant called campus police. But the student, in fact, was diabetic and suffering from low blood sugar. Owens and paramedics were not notified until the boy almost lost consciousness. He recovered.

“You do the best you can,” Owens said. “You prioritize and put the kids with the most serious needs at the top of the list, but there are a lot of things that don’t get done.”

On a recent day, Hargreaves, the Riverside nurse, found the health assistant at a middle school trying to juggle a steady stream of pupils in the health office while also filling in for an absent secretary.

A young boy waited until the visibly frazzled assistant could unlock a cabinet to give him his medication for hyperactivity. As she went back to answering phones, she pointed out to Hargreaves a boy who was quietly sitting, shoulders slumped, in a chair. He had come to the assistant complaining of a cough.

After an examination, Hargreaves immediately called one of the boy’s relatives.

“He coughed up blood and had a lot of fluid in his chest,” Hargreaves said later, shaking her head at the assistant’s lack of urgency.

“She should have called me immediately.”