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School nurses make do

Often short-staffed, local nurses forced to work quickly
By: Andrew Westrope, Staff Writer
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If one believes the old adage about healthy bodies and healthy minds, then the number of nurses on staff at some local schools, like many across the state, could be disconcerting.

The National Association of School Nurses recommends one nurse for every 750 students, and more than that for children with special needs. It’s a ratio every school nurse seems to know, yet very few in California are familiar with in practice. According to the most recent statistics from the California Basic Education Data System, California’s student-to-nurse ratio is the 45th highest in the nation at 2,187 pupils per nurse. (Vermont is first with 396, and Michigan last with 4,411.) The result, some school nurses say, is an inability to meet more than the most basic and urgent student medical needs.

As one of two credentialed school nurses at Placer Union High School District, Sandra Medlin said her part-time hours mean the school effectively staffs 1.5 nurses for 4,229 students, a ratio of about one to 2,819.

“The ratio is not good in terms of health and safety of our students, so every day, the other nurse and myself triage what needs to be done,” she said. “There’s so much more that we could do, but we’re able every day to do the basic stuff that we’re required by law to do, and that’s mainly it.”

Funded mainly by the district’s general fund with help from Medi-Cal subsidies, Medlin appreciated that the district recently increased its effective nursing staff from 1.4 to 1.5 full-time positions by increasing the number of paid part-time hours.

Even so, she and the other school nurse, Pakou Thao, are forced to divide their time among the district’s schools not based on population but on individual needs. Most of their job involves writing health care plans for particular student needs, training staff on first responder duties like how to administer an EpiPen or when to call 911, or assessing symptoms when regular staff cannot. The district also staffs two classroom health aids with health-related backgrounds for tube feedings, simple wound care and other basic work, plus one licensed vocational nurse dedicated to a single student.

Medlin said most of the patients she sees are special education students who require special medical assistance and a nursing assessment every three years. Though she and Thao are always available by phone, she said, the district cannot afford enough nurses to take temperatures, apply Band-aids and administer other basic treatments – they train staff members for that.

Medlin knows the level of care isn’t optimal, but there are ways to make it better without spending. For instance, she wants parents to know their kids can keep medication at the school office, which can help students with chronic migraines or other conditions avoid absences. With more staff or more hours, she would also like to increase home visits to work with families of students who  are struggling with a particular condition, as she only has time for four or five of those a year.

“My goal as a school nurse is to get kids in school. They can’t learn if they’re not in school,” she said. “A lot of times, if we pick up on a lot of medical absences, I’ll call parents and try to find out what’s going on and maybe work with the doctors.”

The only nurse for Auburn Union School District’s 2,193 students, Becky Dittemore said she has help from a health assistant at each school site, although they do not have professional health backgrounds. Still, she said the district can’t afford more nurses with the necessary degree and credentials or attract them from more lucrative jobs in hospitals. And as a former district nurse in Marysville, she’s seen worse.

“We got cut down to one school nurse for 10,000,” she said. “Especially in a lower socioeconomic area where I was before, it really deprives the kids, because they really need more of that one-on-one in other aspects, like family life.”

Dittemore recalled an era when school nurses had time to administer more in-depth care, spending days at a school to establish personal connections with student patients and even giving psychosocial care as needed. In her current role, she said some students are used to communicating with the health assistant and do not even recognize her as the nurse. That being said, a few of the most important aspects of Dittemore’s job cannot be done by a secretary, teacher or paraprofessional.

“They can do the daily scraped knees, putting Band-aids on, something that doesn’t take a lot of assessment. But truly, a nursing process is assessment,” she said. “That’s when it comes down to … ‘How deep is that cut?’ and that comes down to our learning.”

But the shortage isn’t everywhere. Lead nurse Nancy Miller of the Placer County Office of Education said she has no complaints about the staffing at her office, which mostly serves students with unique medical needs and therefore staffs more nurses than its fellow districts.

She said her office pays six registered, credentialed school nurses and seven more licensed vocational nurses to serve 450 students ages 3 to 22. Though she did not have an overall figure for Placer County’s nurse-to-student ratio, she acknowledged there are fewer nurses on district campuses, and the ones who remain cannot afford as many hours on-site as they might have decades ago.

“When you have one nurse for a whole district, that’s a lot of work,” she said. “The districts are definitely looking at models for how to serve (students) cheaper, because registered nurses are more expensive than licensed vocational nurses. There are a lot of districts in the rural counties way up north that don’t have school nurses, because there isn’t anybody, and how do they serve these really rural places? They may serve with an LVN. That doesn’t really meet the education code, but they’re doing their best.”

The county office shares one of its school nurses, Tracy Castro, with Placer Hills Union School District. Castro is stationed at the district 45 days a year, or about one and a half days a week, to care for its 866 students. This includes writing emergency care and individualized education plans, conducting hearing and vision screenings, training staff and responding to emergencies as needed.

Sheree Palma, lead nurse at Loomis Union School District, also feels comparatively “pretty good” about her district’s nursing staff of three part-timers for 2,579 students. Still, she doesn’t get to spend as much time on each campus as she would like, and the need for care is obvious.

“Parents send their child in to see me, because they have such high deductibles. ‘Should I pay my health insurance, or should I put food on the table?’” she said. “I do see a lot of kids that their parents have sent them in to see me because they have limited insurance.”

But for all its stresses, Palma said the work can be its own reward.

“People stop me in the grocery store and ask me about, ‘What’s this rash?’ or ‘What about this and that?’” she said. “It’s a really fun job.”