UPSTREAM PUBLIC HEALTH Unhealthy Schools: The Alarming Decline of School Nurses in Oregon ?21 Since 2010, the school nurse to student ratio in Oregon has rapidly grown. In the 2014-15 school year, Oregon had just one registered nurse or certified school nurse for every 2,178 students. The recommended ratio encouraged by state law is 1:750. School nurses play an important role in providing a complete and healthy education for our children. Healthy kids simply learn better. When kids are home sick from school with an asthma attack or in constant pain from dental decay, they aren’t getting the full benefits of classroom instruction. High rates of chronic absenteeism in Oregon schools have raised alarms, but the news coverage has missed an important part of the story: We are not providing the basics our children need in order to stay healthy and stay in school. School nurses provide a wide range of services from organizing immunization clinics and promoting healthy eating to developing individualized health plans and helping students inject insulin and epinephrine. In the absence of a school nurse, students go home from school at greater rates and may not receive the care they need, and medical services are delegated to teachers or classified office staff, who lack appropriate training, and who are often overburdened themselves. Ultimately, the lack of school nurses does a disservice to our children’s health and education while costing the state money. The problems and stories outlined in this report can be addressed in order to give our students the complete care and education they deserve. But to do so, we need to make major investments in funding our kids’ health and safety at school. In order to meet the 1:750 ratio encouraged by Oregon state law, the legislature would need to make an investment of $58 million per year. In order to ensure that every school building has a school nurse – a standard set by Massachusetts, a leader in school funding and educational outcomes – Oregon would need to invest $78 million per year. The Role of School Nurses School nurses don’t just treat cuts and bruises that our kids get on the playground. According to the National Association of School Nurses: “School nursing, a specialized practice of public health nursing, protects and promotes student health, facilitates normal development, and advances academic success. School nurses, grounded in ethical and evidence-based practice, are the leaders that bridge health care and education, provide care coordination, advocate for I’ve been a school nurse for the last 30 years, and I’ve seen how much our health care system has fundamentally changed. Now we’re playing catch-up for issues that happened at birth, or through the cycles of poverty and violence. Consequently, students not only have a number of physical issues but mental health and behavioral issues as well. As nurses, we are trained to see and understand this kind of big picture. I once identified a pair of sisters with chronic head lice. In working to treat their condition at school, I found out that their head lice came from dirty clothes – and the reason their clothes were dirty is because their water at home had been shut off. “It’s fun,” the little girl said, “like camping.” They also didn’t have electricity, because their single parent just couldn’t make ends meet. Had we just sent those kids home until they were treated, we would’ve missed that important underlying issue, and I’m confident they wouldn’t have returned to school at all. We do the best we can for our students, but I wish we were able to do more. I wish I could sit down with all of my graduating seniors who are diabetic or who have severe allergies and talk them through managing their condition on their own: Do you have a primary care provider? Do you have a pharmacy? Have you ever ordered insulin and supplies for your self? When I talk to my school nurse colleagues on the East Coast, they’re shocked that I can’t meet with all of my students with asthma to provide disease management, coaching and education. In Oregon, we don’t even know if our students have an inhaler, let alone if they know how to use it. We just don’t have the nurse capacity to provide our students with the level of care that they are afforded in many other parts of the country. I worry because I know that thousands of students with major underlying issues are simply going unnoticed and untreated. Nina Fekaris, MS, BSN, RN, NCSN, School Nurse Westview High school, Beaverton and President-elect of the National Association of School Nurses quality student-centered care, and collaborate to design systems that allow individuals and communities to develop their full potentials.” I’ve been a school nurse in the Salem Keizer School District for the last 16 years. I primarily work with students who face adversity in their lives and in their education -- teen parents, kids who have been expelled from their mainstream high school, and students from low-income families that haven’t gotten the same health care access that many Oregon children have. In my work, I’m responsible for 6 schools and thousands of students -- and their newborns or toddlers -- that I am responsible for. And I’m not a full-time nurse. I work 4.8 hours a day, driving miles between each building, just to serve the students and because they deserve to have some basic access to health care. The first week back at school is usually the worst because so many students haven’t gone to the doctor over the summer or received care since they last saw me. I spend hours each day getting updated medical records, trying to find time when I can meet busy parents who don’t have regular days off, and working to get students enrolled in Medicaid. We’ve created a system where students are forced to come to school sick so they are able to stay enrolled in social services and potentially get the only health care they have access to in a school nurse. Unfortunately, the reason students are profoundly sick is because they don’t have the care they need. Ultimately, we could be keeping students so much safer and healthier if there were more school nurses. There would be better attendance, higher graduation rates and better student performance. If there were more of us we could have so many more proactive conversations about parenting, chronic diseases and preventable conditions. We could actually be a part of their education, instead of just desperately trying to keep them in school. Cindy Hoffert, School Nurse Salem Keizer SD In Oregon, a “school nurse” must be a certified and licensed registered nurse (RN) with a bachelor’s degree. Districts occasionally hire licensed practical nurses (LPNs) to provide nursing support, but they can only work under the direction of a doctor, RN or dentist and do not provide the full range of services needed. Certification as a Professional School Nurse provides assurance to school districts that a nurse has specific expertise to address schoolage issues in the educational setting. By the most stringent definition, only RNs with this certification are “school nurses.” Typical health services provided for free to all students by school nurses include: • Providing case management of students with chronic and/or severe health needs such as diabetes, seizures, asthma, allergies, mental health disorders, and feeding tube and ventilator dependency in the school setting; • Providing direct care to students for acute conditions, from sprains to scrapes to stomachaches; • Managing school immunization programs; • Conducting population-based health screenings; • Providing health instruction and promotion with individual students, staff, and classes; and • Collaborating with the primary care providers of students with complicated medical needs. In addition, much of school nursing involves seeing past symptoms to root causes. Many upset stomachs are really caused by stress and dread. Kids come to school hungry because they don’t have food at home. They are upset from bullying or abuse, or are experiencing homelessness. Children come to school nurses with physical symptoms, but skilled nurses are able to identify these and other underlying problems and work to get kids the support they need so that they can succeed in school. That support can range from mental health services for the student to social services for the family. The Consequences of Oregon’s School Nurse Shortage Oregon now has one of the worst school nurse shortages in the country. School nurses must often split their time between several buildings and districts and typically take on a more supervisory role, with teachers and support staff at schools routinely called upon to provide medical care, including insulin dosing and injection, administering anti-seizure suppositories, urinary catheterization, and medical emergency crisis response. These classified school support staff include office staff and secretaries, or classroom staff, instructional assistants and aides. Both classifications are providing medical services to students with little to no training or direction. In many cases, it is the parent of a child, not a health care provider, who gives non-medical staff instructions for delivering care. Students with serious medical conditions who would be tended by a team of providers in a healthcare setting are instead getting treated by a teacher or secretary with no formal medical training. For example, administrative assistants in Oregon are asked to juggle their regular job while helping children inject their insulin, often even without the direct supervision of a registered nurse. Lack of supervision by trained health care providers is putting students at risk of negative health outcomes, and putting schools at risk of legal liability. School nurses also help keep children at school. One study in Kentucky also found that students were more than three times as likely to get sent home when they were seen by an unlicensed school employee, instead of a school nurse. In a recent report, the Chief Education Office concluded that the presence of school nurses, case management, and schoolbased health centers significantly help reduce the rates of chronic absenteeism. It’s no wonder that Oregon has some of the worst rates of chronic absenteeism in the country, and that student illness is the leading cause of missing school. A large body of research shows students from economically disadvantaged families are more likely to develop chronic diseases like diabetes and heart disease, as well as mental and behavioral health disorders. Due to the social determinants of health, it can be concluded that chronic absenteeism tends to be worst among students from economically disadvantaged families. These are the students most in need of care from school nurses, and therefore the students hurt most by staffing cuts. The Current State of School Nurses in Oregon In 2009, the Oregon Legislature passed a law requiring districts to provide the following levels of nursing services: • One Registered Nurse or School Nurse for every 225 medically complex students. • One Registered Nurse or School Nurse for every 125 medically fragile students. • One Registered Nurse, School Nurse, or Licensed Practical Nurse for each nursing-dependent student. Medically fragile students are those who “may have a life-threatening health condition and who may require immediate professional nursing services.” An example would be a six-year-old student who is newly diagnosed with diabetes. Medically complex students are those “who may have an unstable health condition and who may require daily professional nursing services.” A student with medically stable epilepsy would be in this category. Medically dependent students require one-on-one around the clock care. These are often students with a condition that severely limits their capacity both physically and mentally. In 2014-2015, 31 school districts did not have enough nurses required by law to care for medically complex, medically fragile, and nursing-dependent students. For example, the Greater Albany School District enrolled 9,399 students in 2014-15. By law, they should have at least 1.86 nurse FTE to cover their one nursing dependent student and 193 medically complex students, but instead report only one LPN and 0.1 RN. (A 0.1 FTE is equivalent to an employee who works two days a month.) Of course, there are also 9,205 other students who need access to a nurse at school in the Greater Albany School District, not accounted for in that 1.86 FTE. In addition, Oregon law (ORS 336.201) encourages school districts to provide one Registered Nurse or School Nurse for every 750 students by 2020 following the calendar below: • • • • One Registered Nurse or School Nurse for every 3,500 students by July 1, 2014 One Registered Nurse or School Nurse for every 2,500 students by July 1, 2016 One Registered Nurse or School Nurse for every 1,500 students by July 1, 2018 One Registered Nurse or School Nurse for every 750 students by July 1, 2020 On average, in the 2014-15 school year, Oregon had one Registered Nurse or School Nurse for every 2,178 students. But the overall average hides the fact that many districts completely lack nurse support. In 2014-15, 136 districts had fewer than one Registered Nurse or School Nurse for every 2,500 students, including 85 districts that reported no Registered Nurses or School Nurses at all. In the table below, we outline current enrollment and nursing levels in school districts around the state, and analyze how many more nurses would be needed to meet the needs of medically dependent, fragile, and complex students, in addition to meeting the recommended ratio of meeting the health needs of the other students in the district. School Districts 2014-15 student enrollment 2014-15 LPN FTE 2014-15 Certified School Nurse FTE 2014-15 RN FTE Nurses needed to meet legal requirements for students with medical needs, plus national recommendation for one nurse for every 750 other students 2014-15 Total Nurse FTE Beaverton SD 48J 39,686 1 7 12.25 20.25 80.2 Eugene SD 4J 16,891 3 7 8 18 78.3 Portland SD 1J 46,620 3 4 35.1 42.1 72 Salem-Keizer SD 24J 40,698 0 12 2 14 56.9 Hillsboro SD 1J 20,884 4.18 6.4 0 10.58 37 North Clackamas SD 12 17,130 2 2 6 10 33 3,111 0 2.6 0 2.6 28.6 Tigard-Tualatin SD 23J 12,676 0 7 1 8 26 Bend-LaPine Administrative SD 1 16,866 0 5 5 10 23.6 Reynolds SD 7 11,702 3 2.61 4 9.61 20.9 Gresham-Barlow SD 10J 12,020 2 1.47 5 8.47 19.3 Medford SD 549C 13,628 0 3.6 0 3.6 19.2 David Douglas SD 40 10,917 2 0.44 3.6 6.04 17 Springfield SD 19 11,046 0 4 0 4 16.2 Greater Albany Public SD 8J 9,399 1 0.1 0 1.1 14.1 Oregon City SD 62 8,036 1.5 0.6 2 4.1 13.9 Redmond SD 2J 7,329 0.88 2.5 2.5 5.88 13.8 Corvallis SD 509J 6,625 0 6 0 6 13.5 West Linn-Wilsonville SD 3J 9,220 0 2 1 3 13.4 Lake Oswego SD 7J 6,916 2.5 2 1 5.5 13.3 Forest Grove SD 15 6,101 0 2 0 2 13.3 Sweet Home SD 55 2,402 0 0 1.6 1.6 12.4 Lincoln County SD 5,237 0 2 0 2 12.3 Silver Falls SD 4J 3,776 0 3 0 3 10.7 Sherwood SD 88J 5,190 0 1.75 0 1.75 10.2 Grants Pass SD 7 5,935 0 1 0 1 10.2 Coos Bay SD 9 Source: Oregon Department of Education In addition to these numbers, during the 2014-15 school year, 40% of school districts had no nurses at all and 59% of school districts had less than 1 full time equivalent registered nurse. This is an average of one certified school nurse for every 4,664 students, and one registered nurse for every 2,178 students. The Cost To achieve the ratio of one school nurse for every 750 students, as recommended by the Oregon State Legislature and the National Association of School Nurses, the cost would be between $58 million and $72 million more per year.1 This is approximately $126 per student. This cost is not included in the Quality Education Measure’s total breakdown of school costs. If Oregon were to provide a nurse in every school building, as Massachusetts does, based on an average cost of $83,259 per nurse (including salary, benefits, and taxes), it would cost around $78 million per year. Paying for nurses is a smart investment. When school nurses are available, not only do students and schools benefit, but one study estimates that every dollar spent on school nurses provides $2.20 in benefits to society, saving these later costs in publicly subsidized medical insurance and programs. Further, it allows teachers and office staff to actually do their job. One study found that having a school nurse saved an average of 20 minutes a day for teachers, 45 minutes a day for clerical staff, and an hour for the school principal. The cumulative impact across an entire school district, or an entire state, is significant. Investing in student health will pay off many times over. 1 Funding for school health in Oregon is primarily funded out of the local school district’s general fund with limited amount of reimbursement statewide from Medicaid billing options. There are a few districts that have alternative arrangements with local partners to provide funding for school nursing services. In a recent survey to district business managers, 81% of districts report using general fund monies for school nursing while 22% report supplementing with Medicaid Administrative Claiming reimbursement, 10% use direct billing reimbursement. Some use multiple forms of funding to support school nursing. According to a recent survey facilitated by staff, this is consistent with funding models across the country. I’ve been working as a special education assistant, primarily with students with severe autism or some kind of medical need, for over 20 years. The demands for help continue growing year after year, while funding continues to fall. Everyday I work with students with special needs who need physical therapy several times a day so their muscles don’t atrophy, or occupational therapy, helping them eat so they don’t aspirate their food. I and many staff in my same position have had to perform duties such as put in catheters, help students change and use the restroom, administer oxygen several times a day and lift and transfer students from their wheelchairs. Our office assistants consistently help students take their medication while juggling phone calls and paperwork. I am not trained to provide medical services. But I do all of this work because my district only has one half-time time nurse for some 3000 students. Because there aren’t enough school nurses, occupational and physical therapists and health services staff, about 50% of my job is filling in for that work, instead of the special education work I was hired to do. There are times when there are simply not enough trained staff available to help feed one student, change another, and do the actual educational learning with the other students in my class. If we had more school nurses and support staff, or even the ability to call-in additional help from a school nurse, our staff wouldn’t be getting hurt, students would be better taken care of, have more consistent care, and there would be so many more opportunities to actually teach my students. Gloria Lundin, Special Education Assistant EA4: Dallas School District Unless you are the parent of a student with special health needs, most people have little conception of what school nurses do and what we are asking our teachers, education assistants and secretaries to do in our absence. Conclusion School nurses have the expertise to see the big picture, plan and coordinate care in the school setting and provide a bridge in making sure that health providers, teachers, parents and students are all on the same page about how their health condition is managed at school. Decades of disinvestment from Oregon schools have had numerous negative consequences for our state’s children. The recent decline in school nurse positions – during a period of economic growth no less – has put our state far behind in providing a complete and healthy educational environment. So much of our work is care coordination and when you have to split your time between 5 or more schools and over 3,000 students or more, depending what district you work in, you just don’t have the time to provide that kind of detailed care. I am lucky to be able to work as a full time nurse at Roosevelt High School. Because of that, in addition to working with students on their individual health plans I am also able to do some health promotion and prevention in terms of healthy eating and lifestyles. But that is because I am here every day and able to build relationships with students, teachers, family and administrators. We could do so much more if we only had enough school nurses to meet the needs of our students. Nicky Zimmerman, RN, MSN School Nurse at Roosevelt High School, Portland But there is no reason to believe we can’t solve these problems. The legislature has set forth required staffing ratios and a task force has been convened in order to make recommendations for improving the state of school nursing in Oregon. However, the critical piece of the puzzle has not yet fallen into place, and that is funding. With insufficient funding, school nurse FTEs will continue to go down and down, not only putting Oregon at the very bottom of the nation, but also flagrantly breaking the law, putting some of Oregon’s most vulnerable children at risk. The time has come for the legislature to remedy this problem by adequately funding school nursing programs. Doing so can improve the health and educational outcomes for our state’s children, and they deserve nothing short of a full commitment to funding this important part of their education.