Little voices

Why every school needs a full-time registered nurse

 
May 19, 2014 -- Over the past year, news items have continued to highlight the importance of school nurses to the health and education of U.S. children, often with a focus on reversing the widespread staffing cuts that threaten students. On August 20, 2013, the Associated Press put out a good general overview by Carolyn Thompson. That piece gave readers a sense of how school nurses help ensure that the next generation is healthy enough to learn. It discussed the independence required of school nurses and the great range of duties involved, including annual health screenings, counseling and mental health services, and chronic care for conditions like diabetes and ADHD, ending with a note about pending federal legislation that would help schools get closer to safe nurse-to-student ratios. On October 18, 2013, Salon published a long, powerful piece by Jeff Bryant about cuts in school nurse staffing. In particular, Bryant pointed to the death of Philadelphia 6th-grader Laporshia Massey from an asthma attack, a tragic event that is hardly an outlier. Bryant argued forcefully that the prevailing political environment has often meant a short-sighted focus on adding security guards at the expense of health and social services, resulting in the criminalization of relatively minor student misconduct. And today, Reuters ran an excellent report by Genevra Pittman on a new study in JAMA Pediatrics by researchers at the Centers for Disease Control finding that a Massachusetts program placing RNs in schools had "more than paid for itself by averting medical costs and lost work for parents and teachers." The study authors noted that the actual savings were likely much greater, since averted emergency department visits and hospital admissions were not considered. We thank all those responsible for these pieces, which provide more compelling arguments for ensuring that all schools have nurses available to protect the nation's children.

More than tummy aches

Thompson's AP overview, "School nurses have come a long way since 1902," focuses on school nurse Jane Zakrzewski ("Nurse Zak"), who works at a suburban Buffalo primary school. The piece notes that although Nurse Zak still deals with bruises and tummy aches, modern

school nurses also see things like life-threatening food allergies, behavioral and emotional issues and, in today's culture of inclusion, conditions that would have kept children out of the mainstream in the past. Now, school nurses might suction tracheostomies, clean gastrostomy tubes, monitor wearable insulin pumps, keep track of inhalers and EpiPens, give medicine for ADHD and seizures and dispense birth control.

Stepping back, the piece says that things have changed since Lina Rogers Struthers became the first school nurse in 1902, in an effort to control "contagious diseases like diphtheria and scarlet fever" in New York City. Nurse Zak is one of about 74,000 RNs now practicing as U.S. public school nurses. Carolyn Duff, president of the National Association of School Nurses (NASN), explains:  "Students that are healthy stay in school, have fewer absences and they learn better, and students that are well educated become healthier adults." The piece goes on to report that school nurses' screenings can catch hearing and vision problems, and nurses can influence school policy on issues from concussion management to hand washing to environmental concerns like air quality. And the report explains that school nurses today spend a lot of time on counseling and mental health services, such as listening to concerns about relationships and drugs, as Nurse Zak notes. They also, in some jurisdictions, provide condoms and safe sex advice. Quoting Duff, the article stresses that school nurses must be unusually independent and adaptable to different people and new issues. The piece closes with some data about the wide range of nurse-student ratios in different states, with NASN recommending "a 1-to-750 ratio for well students and 1-to-225 ratio in schools with students who require daily services." But more than half of the nation's schools don't have a nurse on site all day every day, according to U.S. Rep. Carolyn McCarthy, D-N.Y., a school nurse herself for more than 30 years. McCarthy has reportedly introduced legislation to give grants to help states hire more school nurses.

This piece has no earth-shattering revelations or dramatic hook, but it does a fine job of laying out the great range and importance of what school nurses do for students, in light of the complexities and stresses of the current school setting. Once readers have absorbed all that, it seems only logical that the ratios be increased, as the final parts of the piece discuss.

Crimes and misdemeanors

Bryant's long Salon article is really an advocacy piece, arguing strongly for more school nurses and fewer school security guards, as the headline and subhead make clear: 

"School nurse cuts killed my daughter": Laporshia Massey died because our priorities are wrong

A Philly sixth-grader's death from asthma could have been prevented. Why do we cut nurses and add armed guards?

Massey died of an asthma attack that a school nurse might have identified and stopped from killing her, except that "funding cuts to the nation's eighth largest school district had left most children bereft of full-time school nurses who know what to do during an attack of a life-threatening disease." Surveying other recent press stories about these issues, Bryant notes the common refrain that cuts to school nursing basically come down to a shortage of funds. And he does not dispute that funds are limited, noting that Pennsylvania's current austerity budget has meant huge cuts to non-teaching staff, including nurses, a trend seen nationwide despite the high percentage of students who attend with disabilities or chronic conditions that non-nurse staff are not trained to handle. But he wants to explore what funds are being spent on in schools today. One large and growing answer seems to be school guards, especially in the wake of the Sandy Hook shooting. However, Bryant suggests that the main result of that seems to be increases in arrests and misdemeanor charges for relatively minor offenses. Bryant pleads for different choices, holding up as a positive counterexample one poor Philadelphia school that reportedly achieved a 90% drop in violence not by adding "aggressive security guards," but through "noncoercive, nonviolent conflict resolution" and "engagement coaches, who provide support, encouragement, and a sense of safety."

Although Bryant's long piece provides relatively limited specific information about school nursing, his use of the nurses as a key example of the apparent shift in funding priorities from the humanitarian toward the authoritarian is powerful. He does argue that students need nurses and other care-giving staff in light of the high percentage who now attend with serious chronic health conditions. And his main example--the tragic case of Laporshia Massey--clearly conveys that school nurses can save lives.

Saving money

Pittman's Reuters story leads with the powerful headline "School nurses save money: study" and with the JAMA Pediatrics study's core finding that a "Massachusetts program that put full-time registered nurses in schools more than paid for itself by averting medical costs and lost work for parents and teachers." Pittman notes that school nursing has been cut back in recent years to save money. But she quotes Li Yan Wang, who led the research by the Centers for Disease Control and Prevention's Division of Adolescent and School Health, as saying that the new study suggests that "from a societal perspective, the benefits of school nursing services may well exceed the cost for those services." Researchers studied 22 procedures that full-time school nurses perform, "from testing blood sugar to administering physical therapy." They compared the costs for the nurses to the costs for those same services at clinics or hospitals, lost wages for parents who would have to take time off work to get their kids the care, and teaching time lost when teachers had to try to do things school nurses do. The study found that in the 2009-2010 school year, Massachusetts had paid $79 million for school nurses at 933 schools, while the relevant outside care would have cost $20 million, the lost parent productivity $28 million, and the lost teacher productivity $129 million--a savings of more than twice as much as the nurses cost. Study senior author Anne Sheetz adds that those savings are "just a drop in the bucket" because they do not include "big savings" from averted emergency department visits and hospitalizations. Sheetz also briefly explains the range of things modern school nurses do, including teaching the rest of the school community about issues like allergies. The piece closes with quotes from two local physicians who attest to the value of school health programs, with pediatric allergist Michael Pistiner noting that the study "may put getting a full-time school nurse back on the priority list."

Like the Salon piece, the Reuters report does not have a lot of detail on what school nurses do, but what it does have is powerful:  a study by CDC researchers in a prestigious journal explaining in detail, with estimated dollar amounts, just how school nurses can actually save money by preventing a range of bad outcomes that would otherwise occur. In fact, that is a key problem in the valuation of nursing care generally--it is very difficult for most people to see the value in preventing things from happening, as opposed to the seemingly more dramatic and important tasks involving in making them happen. (For a more basic example, consider whether the best known team athletes tend to be offensive or defensive players.) To many people, it may look like nurses are mostly just hanging around talking, fiddling with equipment, and cleaning up, not making countless skilled assessments and working quietly to stave off disaster.

We thank those responsible for these pieces, all of which help tell the public why every school needs a full-time registered nurse.

See the original research: JAMA Pediatrics, July 2014, "Cost-Benefit Study of School Nursing Services," Li Yan Wang, MBA; Mary Vernon-Smiley, MD, MPH; Mary Ann Gapinski, MSN, RN; Marie Desisto, RN, MSN; Erin Maughan, PhD, MS, RN; Anne Sheetz, MPH, RN.