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School Nurses Seek Checkup of Rules: Group Hopes to Reduce Professional-Student Ratio in State's Public Schools.

Posted on: Sunday, 2 April 2006, 12:00 CDT

By Steve Esack, The Morning Call, Allentown, Pa.

Apr. 2--Kathy Halkins stopped talking when the boy wobbled into her spotless office at Liberty High School in Bethlehem.

"May I help you, dear?" Halkins asked.

"I don't feel good," he replied, after giving an obligatory cough and sitting down next to Halkins, the school nurse.

In the next chair, a distraught girl sobbed when health assistant Vicky Bearer, switching from English to Spanish, asked if something other than her head hurt.

"Sometimes when I speak in their own language, they tell me," Bearer, a registered nurse, said after the ill girl left for home. "She wasn't ready."

Then another student bounced in and waited for them to retrieve the medicine the student's Individual Education Plan -- the school district ordered road map that guides his learning -- said must be taken twice a day.

The patients -- three of the 245 students that entered Liberty's nursing station that week and a few of the more than 60,618 students served districtwide so far this school year -- highlight the new role of a school nurse.

School nurses no longer simply apply ice, put on bandages and take temperatures. They are part counselor, part teacher and part emergency-room physician because of the changes in family life, medicine and state requirements. They have become the primary health provider and health information source for children in some families who have no medical insurance or limited English skills. They must administer a wide array of drugs -- typically paid for through Medicaid or private health insurance -- for both physical and mental afflictions for students who may have left hospital settings and special schools to attend regular public schools. But federal and state governments are not doing enough to help local schools cover the increased cost of students' health needs and increased supplies and paperwork, according to experts.

Even though Pennsylvania has one of the best laws governing school nursing in the country, nurses, faced with more demands, have been lobbying Harrisburg to cut in half the nurse-to-student ratio of 1-to-1,500, established by the May 9, 1949 passage of the Pennsylvania Public School Code.

More newborns are surviving premature births and more children are surviving cancer and other debilitating diseases "Yet we haven't done anything to improve the health services that are provided to the students while they are in school," said Halkins, president of the state chapter of the National Association of School Nurses.

According to the state Health Department, in 2003-04, the last year available for data, nurses in Lehigh County schools administered 86,693 doses of doctor-prescribed medicine (including insulin, antihistamines and psychotropics). Nurses in Northampton County dispensed 115,383 doses.

Julia Lear, a national health care expert at George Washington University's School of Public Health, said she is not sure if there is a crisis of more students with more health problems and less medical coverage since statistics vary from community to community.

But national statistics show medications play a larger role in students' lives than they did 20 years ago. Since more households have two parents working, Lear said, schools have become more responsible for administering medications and maintaining a child's health than they did two decades ago.

With the increased costs, Lear said, state and federal governments are not doing enough to help local school districts, which are spending most of their resources trying to meet the academic requirements of the No Child Left Behind law.

"There's no federal mandate you have to have a school nurse, and no federal funding explicitly directed to school nurses," said Lear, director of the university's Center for Health and Health Care in Schools. "For the most part, local school districts are on their own."

Funding less than in 2000

Gov. Ed Rendell's proposed 2006-07 budget calls for the state Health Department to spend $38.8 million for "School District Health Services." It is the same amount the state allocated this year, but it is $1.62 million less than the state allocated in 1999-2000, the eight-year high.

Stanley J. Majewski Jr., Bethlehem's assistant superintendent for finance and administration, said the state subsidy covers less than 30 percent of the district's nursing costs.

Pennsylvania is one of 33 states with laws governing school nurses, according to a 2004 report by the General Assembly. The report said Pennsylvania is one of only five states that has established a law requiring a maximum student-to-nurse ratio.

The state's funding is used in part to reimburse school districts for some of their nurses' salaries, medical supplies and dental and medical services. But often it is not enough, and that is holding up a vote on a bill by state Sen. Joe Conti, R-Bucks that among other things would reduce the nurse-to-student ratio to 1-to-750, a figure recommended by the National Association of School Nurses and the U.S. Department of Health and Human Services.

The bill, introduced in May 2005, has been in committee since Nov. 14, 2005.

Kirsten Kenyon, Conti's legislative director, said the ratio needs to be reduced because a key part of the bill would increase the demand on nurses she said already are overworked. The bill, which was written after a 15-year-old Bucks County boy died of an undetected heart condition, would require schools to give physicals to students in fourth, eighth and 11th grade, as compared to existing law requiring them of just sixth- and 11th-graders.

"We're trying to come up with some money," Kenyon said. "Plus the whole [Public School code] section hasn't been updated since the 1950s. it's time to bring it into the 21st century."

Nurse as primary care provider

Bobbie Malcolm, head of the Allentown School District's Health Services Department, agreed. She said Allentown's changing demographics have brought higher poverty levels and more transient students to the district's 23 schools.

"Often, we are used as their primary-care source because their parents are unable to get their own primary-care provider," Malcolm said. "The original law to have school nurses was written in 1949, and the last time it was revised was 1956. I think it's a little antiquated."

A reduced nurse-to-student ratio would help school districts handle the medical and emotional needs that were once the realm of hospitals and parents, she said.

"One nurse for 1,500 students," Malcolm said. "If you put 1,500 students in one room, you'll see how big that number is."

Not everyone is behind the bill.

Robert Thornburg, Parkland School District's director of student services, said the bill is too rigid, even for Parkland, which has a nurse in each of the district's 10 buildings.

"We have increased medical demands as a result of a number of things, amount of students requiring medication, the number of students having diabetes and other special needs, and the [Individual Education Plan] governs everything," Thornburg said. "But I think the bill is a little strict, even for us."

More mandatory work

Under the Public School Code, nurses are required to track immunization records. They must test vision and hearing, screen for tuberculosis and scoliosis, and check height and weight measurements in all public, private, parochial and charter schools that lie in a given district's boundaries.

This year, Pennsylvania mandated that nurses calculate height and weight measurements into Body Mass Index, which uses height, weight, age and sex to determine proper growth. Under the new state law, nurses must mail the results to parents to let them know if their child is at optimum weight, underweight or overweight.

The Individuals with Disabilities Education Act, and its predecessor, the Education for all Handicapped Children Act of 1975, opened public schools to more physically and mentally disabled students who previously would have been homeschooled or attended a special school. The laws also brought more medical issues -- tracheostomies, feeding tubes, shunts, catheterization -- into schools, according to the 2004 legislative report.

Part of the increase in students' physical ailments, and less noticeable learning disabilities, can be traced to medical advancements in neonatal care in the last decade, according to a 2003 article in The Journal of the American Academy of Pediatrics. The article detailed a study that found premature babies have more physical, learning, behavioral and neurological impairments than children who were born of normal birth weight.

Hallam Hurt, a pediatric neonatologist at The Children's Hospital of Philadelphia, said not all all premature babies (about 12 percent of U.S. births, according to the March of Dimes) have physical and mental problems once they reach school. But she said the study shows premature babies face more grade retention and special-education needs, adding to nurses' and schools' responsibility.

"For the preemies there are issues, and I feel for the school nurses who also have to field everything from inner-city turmoil and lots more kids with special needs," Hurt said. "I don't envy schools trying to deal with it."

steve.esack@mcall.com 610-861-3619

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Copyright (c) 2006, The Morning Call, Allentown, Pa.

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Source: The Morning Call, Allentown, Pennsylvania

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