The 17-year-old boy who came into Cathy Owens' nursing office at Murrieta Valley High School in Riverside County was gasping for breath. He had no history of health problems. After quickly examining him, Owens' 35 years of experience kicked in.
"He was not able to breathe, and there was no heart rate going," she recalls. "All I could think of was he was suffering from anaphylaxis."
Often the result of a severe food allergy, anaphylaxis can be lethal if not treated within minutes. Owens grabbed a dose of epinephrine — the standard first line of defense — and injected it into his leg, stabilizing the boy until paramedics arrived.
Had Owens not been there for that boy 10 years ago, she says she is certain he would have died. But across the country, more schools are taking that chance as budget cuts leave them with inadequate funds to hire nurses. As a result, healthcare professionals worry that students' lives are being put at risk.
"Kids need services while they are at school," said Nancy Spradling, executive director of the California School Nurses Organization. "Those services are not just to make them feel better, but to allow them to continue to live."
Only 45% of public schools across the country have a full-time nurse, according to a 2007 study conducted by the National Assn. of School Nurses, or NASN. Another 30% rely on a part-time nurse, leaving 25% with no nurse at all.
The situation varies greatly from state to state — and even from school district to school district — because federal guidelines regarding nursing in schools are far from comprehensive. For instance, some states require school nurses to have a master's degree in nursing, while others mandate that they receive a special certification to work in schools, said Amy Garcia, NASN's executive director. Some states don't set any standards for school nurses.
Though 32 states have increased the number of nurses in schools over the last decade, a report issued by NASN in 2009 found that only 12 met the Department of Health and Human Services' recommendation of one nurse for every 750 healthy students.
Vermont had the best ratio, with an average of one nurse for 311 students, and Michigan had the worst — one nurse for 4,836 children. Nationwide, the average is about one nurse for every 1,378 healthy students.
The problem isn't a lack of qualified nurses, Garcia said, but a lack of funded positions.
In some states, the money needed to pay school nurses has been redirected to classrooms to make up for cuts to education budgets. In California, that has been happening since Proposition 13 was passed in 1978.
"The way that schools were funded was drastically changed," Spradling said. As school districts saw their budgets shrink, "nurses were one of the very first things cut."
California, once a leader in student healthcare, now ranks among the 10 worst states in the country, averaging one nurse for every 2,187 students in 2009, according to NASN.
Even in cases in which school officials want to hire more nurses, they often find themselves unable to offer competitive salaries. According to data from the Educational Research Service, a nonprofit organization in Alexandria, Va., that collects information about U.S. schools, the average salary for school nurses in 2009 was $46,476. In the same year, the federal Bureau of Labor Statistics reported that the average salary for registered nurses was $66,530.
In some cities, the pay gap is only part of the problem. Uncertain funding also makes it difficult for schools to recruit the nurses they need.
"In parts of the Bay Area, nurses don't want to work for a school district," Spradling said. "If you're only going to be making $60,000, and there is no job security because the district has a history of letting its nurses go every other year, wouldn't you rather make $110,000 in a hospital setting?"
The dearth of nurses has left many schools struggling to cope with rising rates of childhood illnesses such as asthma, food allergies, diabetes and seizure disorders.
The prevalence of asthma in children under 18 increased from 3.6% in 1980 to 9.6% in 2009, according to the Centers for Disease Control and Prevention. Food allergies in this age group rose from 3.3% in 1997 to 3.9% in 2007. And though historical data on diabetes in children is thin, the CDC reports that approximately154,000 children now have the disease — a figure which, by most accounts, is on the rise.
"When I first started as a school nurse, we didn't have one insulin-dependant diabetic in the school," said Owens, who is now the lead school nurse in Murrieta Valley Unified School District. "We now have nearly 100 in our district."
To cope, some school districts are training secretaries and teachers to give medications to students. That solution doesn't sit well with the nursing community. Allowing unlicensed, non-medical school staffers to administer drugs like insulin is too dangerous, some say.
"Insulin is something that you have to calculate, and it's easy to make mistakes," Spradling said. "Even in the hospital setting, insulin doses have to be checked twice — if someone gets too much insulin they can go into very low blood sugar and die."
Registered nurse Suzi Shriver works full time in a school district in eastern Idaho, where she shuttles between two schools. As a result, she sometimes finds herself in the uncomfortable position of having to rely on colleagues with no medical training.
"I had a boy from the high school and I thought he had broken his arm, but it was time for me to take care of my diabetics" at another school, Shriver said. She enlisted the help of a secretary to care for the children with diabetes, but added that "it puts me between a rock and a hard place. I ended up delegating something I didn't really want to delegate."
Untrained school staffers also lack the know-how to recognize when children need to be sent home — and when they don't.
"When there is a school nurse," Garcia said, "children aren't sent home because they have a math test stomachache."
Congress isn't likely to do much to increase the ranks of full-time school nurses. A provision that would have addressed the issue was cut from last year's healthcare reform legislation, Garcia said. States also appear ill-equipped to pick up the slack, leaving it up to local communities to find ways to make school nurses a priority.
In the meantime, parents like Brian Wilson are running out of options. Wilson's 9-year-old son, Jake, is diabetic and needs a minimum of five shots of insulin each day, including at least one at school. The elementary school down the street from the Wilson home in Emmett, Idaho, doesn't have a full-time nurse, so Brian drives Jake to another school 15 minutes away that does.
If Jake recognizes that his blood sugar has dipped too low, he can eat something to get back on track, Wilson said. If not, his son — like any diabetic — loses the ability to think clearly. "If nobody else recognizes it, he's going to drop too low and pass out somewhere," he said.
In two years, Jake will enroll in the town's only middle school, which currently has a nurse on campus for five to 10 hours a week. Wilson and his wife, who both work full time, are hoping that will change. If it doesn't, the family will be stuck.
Wilson mentions a friend in Boise who, when faced with the same dilemma, had to quit his job in order to make trips to his child's school every two hours.
"There's no way I would have time to do that — I'd have to close up my business," said Wilson, who owns a computer repair shop about 10 miles from the middle school. "If there's no nurse, there's no nurse. We'll just have to figure out what to do."