Who's Playing Nurse?

Public schools without registered nurses could be a lawsuit waiting to happen.

If you have kids in the Arizona school system, there's a good chance nobody adequately trained will be around should they get hurt.

Of the 2,000 public schools in Arizona, only about 900 have registered nurses on site. The other schools have licensed practical nurses, health assistants or even school secretaries performing some "nurse" duties. It's part of a nationwide trend where less than half of the country's public schools employ a full-time nurse.

"Our position is that there should be a registered nurse at each school site on a full-time basis," says Paul Karlowicz, president of the Tucson Education Association. "But there is an understanding that there is a cost to that, and (there's) a tight budget."

Still, a national survey released this month shows that most parents want to see more health care services provided in schools.

"Many parents are under the false impression that a school nurse is on the premises all the time, or that their child has access to needed health care services at school," says Dr. Julia Lear, director of the Washington, D.C.-based Center for Health and Health Care in Schools. "But that isn't the case. In fact, many of the nation's 90,000 public schools do not have a full-time nurse on staff."

The study found that more than 85 percent of parents look to their schools to "not only educate their children, but also to help keep them healthy, safe and ready to learn."

CHHCS cites "school-based health centers" as a growing provider of comprehensive physical and mental health services in the wake of a nurse shortage--but not as a solution to the problem. Nationwide, there are approximately 1,500 such centers--a 650 percent increase since 1990 and a 9 percent increase over the past two years. And, in a March 2003 letter, Catherine Eden, director of the Arizona Department of Health Services, endorsed the role of the Arizona School-Based Health Care Council to expand, stabilize and advocate school-based health care in Arizona.

"The school-based clinics are not intended to replace the school nurse," says Phil Lopes, executive director of the Arizona School-Based Health Care Council. "What the school-based clinics are there for is to provide primary care to uninsured kids."

With some 200,000 uninsured kids in Arizona, there are 97 school-based health center school sites with nine in Pima County. Because they are staffed by nurse practitioners, they can prescribe, treat and diagnose problems. But if they are funded by the federal or tobacco tax money, these centers can only treat uninsured kids, leaving the rest of the student body subject to the school system's nurse shortage.

According to Lopes, most of Arizona's school-based health centers are in elementary schools, even though high schools are where they are needed most.

"Not only in Arizona, but elsewhere in the country, there's a political problem with being in high schools, because there's a perception that all we are doing is handing out condoms," says Lopes.

The specifics of school health care varies from school district to school district. (TUSD officials did not return several phone calls, so information was obtained from the district's Web site.)

TUSD requires a doctor's order for all prescription medications and some over-the-counter drugs (including inhalers), as well as a completed "medication permit" to be in hand. And no student is permitted to take medication independently on campus. TUSD policy also requires an adult to bring and pick up medication at the health office.

"When parents desire their children to use cough drops, the child must remain in the health office during their use due to the possibility of choking. The teachers have 20-plus children in their classrooms and cannot be expected to watch a child for possible choking on a throat lozenge," according to TUSD's Health Services Web site. "When it is determined that a TUSD student should be sent home as a result of illness or injury, a parent/guardian who has legal custody will be notified and asked to come pick up the child from school."

Annette Ferebee, deputy director of CHHCS, says some policies prohibit health providers and teachers from even touching kids.

"So you do have some conflicts between what kids need during the school day and what's either available or able to be provided. It's a system that tries to give kids what they need and also protect themselves."

This comes at a time when most health experts acknowledge that the needs of students are becoming more complex.

"It's not just a nurse sitting in an office and passing out Band-Aids," says Mary Freeland, an registered nurse and president of the School Nurses Organization of Arizona. "So there still needs to be lots of education to the community as to what exactly school nurses do."

The nationwide shortage of nurses and nursing educators is also an issue. And even if there were more teachers, why would anyone want to live on a school nurse salary?

"It's about half of what we could make at a hospital," admits Freeland.