Inside the school nurse’s office at Kennedy Elementary School in Hastings last Thursday afternoon, a diabetic student came in for his routine blood sugar test. It was one of six that he does under the supervision of the on-site nurse, Kim Meier, each day to gauge how he’s doing and strategize for the next segment of his day.
“Are you going to have raisins today?” Meier asked, referring to the school snack scheduled for that afternoon. “You’ll need insulin with that because it’s a lot of sugar.”
Weighing his options, the student decided he’d just have the snack he’d brought from home instead. Then he headed back to class.
His teacher keeps a handwritten reminder of his testing schedule attached to the lanyard she wears around her neck. It’s not always easy staying on top of this important task while managing a classroom with more than 20 students. But it gives her peace of mind knowing there’s a nurse on site, capable of managing her student’s health needs and willing to call her classroom with a reminder to send him down for testing whenever the day gets hectic.
“It’s nice to have the support,” she said, noting she also relies on Meier to help manage the health needs of other students in her class who have asthma and severe allergies.
At the charter school she worked at before, the teacher said there wasn’t a licensed nurse on hand. Rather, she was responsible for addressing the health needs of her students — even when it took her outside of her comfort zone. For instance, she once had to administer an EpiPen to a student who started vomiting because of a severe allergic reaction while in her classroom, she said. Not only was the episode stressful, but she also had to stop her instruction until the child’s parent was able to come and pick up the student.
Across the state, teachers and other staff — from secretaries to paraprofessionals — are being asked to fill the role of a school nurse. State law requires that a district with 1,000 pupils or more employ at least one full-time-equivalent licensed school nurse. That allows for a lot of variability in how districts staff their health offices to meet students’ health care needs. Some do have a licensed school nurse — or at least a licensed nurse, who may lack the specialized licensure — assigned to each building. And some don’t have any licensed nurse on staff at all. Districts seeking middle ground have adopted a roving nurse model, where a licensed nurse travels between buildings in the district and other staff fill in when the nurse is not on site.
In Minnesota, leaders in the profession say they’d ideally like to have at least one school nurse in each school building. But even that seems like a lofty goal at this point. According to Erika Yoney, the school health consultant with the Minnesota Department of Health, there’s roughly one school nurse for every 4.7 school buildings serving students statewide. Put another way, that’s roughly one full-time, licensed school nurse for every 1,700 students in Minnesota — a ratio that places the state near the bottom, nationwide.
The low ranking is familiar, given the state’s 792:1 student-to-counselor ratio that’s gotten more attention in recent years. Now here’s a look in the lesser-known role of school nurses: what, exactly, they are responsible for these days — beyond the Band-Aids and ice packs — and why those in the profession hope state lawmakers and school administrators will invest more to ensure this pillar of the student support team remains intact.
One nurse, four buildings
Crystal Genelin has been working as a school nurse in the Le Sueur-Henderson Public Schools district for the past five years. She shares one full-time position with another school nurse, only working for the district on Mondays. They are responsible for providing nursing services to students at four buildings: three district buildings (with 1,031 students, according to 2017 enrollment data reported to the State Department of Education), plus one local private school building. To cover the most ground, they hold office hours at all three district buildings each day and stop by the private school as well, when need be.
On a recent Monday, before winter break, Genelin started her day at Park Elementary School in Le Sueur. By 8:15 a.m. her desk phone was ringing with a parent calling for a consult: Should she send her kid, who had been vomiting that morning, to school?
Genelin advised that she stay home for now and maybe come to school around noon if she started feeling better and didn’t have a fever.
From there, the steady stream of foot traffic through her office never ceased. A parent came into her office to drop off a new prescription medication for her child — who already takes a few other pills every day — so Genelin could lock it up in a cupboard and write up instructions for the secretary or other staff member who would administer this medication later on, when she’d no longer be in the building.
“Basically they’re working under my nursing license to administer that medication,” she explained.
Next, she had a little boy come in with a sore throat, a girl in need of a Band-Aid for a cut on her hand and another boy with chapped lips in need of a Q-tip with some Vaseline. With each visitor, she took time to investigate their symptoms and offer health care advice in ways an elementary student could understand, then logged each visit in a binder on the counter to keep track of health trends and personal care records.
In a separate binder, she had individual student records noting the specific health-care needs of three kids in need of EpiPens, 15 in need of inhalers, and a handful in need of medications. At the high school, she helps monitor three diabetic students as well.
At 9:20 a.m., she vetted a mother’s questions about having her child’s vision and hearing screened, to check for any barriers to learning. It’s a task that school nurses take part in, en masse, before the start of each school year. But there are some kids who slip through the cracks or need follow-up screenings, if they suspect there may be an issue. For instance, Genelin says that because she flagged one little boy’s vision during a screening, his parents brought him into an eye doctor and he was prescribed glasses — a scenario that may have otherwise resulted in a prolonged barrier to his learning. Throughout the year, she also plays a key role in developing Individual Education Plans for students with specialized health needs.
By 9:25 a.m., she’d called down a boy whose mother had called in asking for the nurse to check him out. Genelin checked his jaw and the inside of his ear — the two sources of pain — and told him what she suspected: a possible infection. As a school nurse, she’s not legally allowed to diagnose any ailments. But she can say what looks suspicious and advise a student or parent to follow up with a doctor. So she called up the default Spanish interpreter — a secretary who actually had the day off work, but was still willing to take calls — and relayed her message for the boy’s mom.
Eight minutes later, she got a phone call from a teacher, letting her know that a student with Celiac disease had mistakenly been given a bite of a granola bar. Genelin told the student’s aide that “she’ll probably start puking” and — with no immediate danger to the student’s health — advised her to call the child’s mom to see what she wanted them to do next.
Just as she was getting ready to leave for the high school building, a little boy walked in, saying he had a headache and a sore throat. With no clear signs of a fever or strep, she let him choose a cot to lie down on for a bit to rest.
This is the sort of thing that, when a student develops a habit of coming in with repeat ailments but no fever, may end up signaling an underlying mental health issue.
“That’s when we’ll start asking about their situation: ‘Are you being bullied? Is anyone being mean to you? Did anything happen at recess that upset you?’ ” Genelin said. “We’ll talk to their teacher and go from there.”
Sometimes they loop in the school counselor or social worker to see if there are some unresolved traumas at home or frustrations with certain subjects that they may be avoiding, she added. Before packing up her bags, she made a note to swing by the thrift store on her day off to pick up some more pants of all sizes — the stash of spare pants she had on hand in the office for bathroom accidents had already been depleted.
Monitoring health outbreaks
Upon arriving at the middle/high school building, Genelin stopped by the front desk to get an update on attendance records. Bracing for a later-than-usual flu season to hit the district, she’d been keeping close tabs on how many students were out with influenza.
“I think we’re in for a rough season because that flu shot’s not effective,” she said, noting public health data shows flu season hadn’t really hit her region yet.
Apart from a boy in with a hurt ankle, she found a bit of time at her high school office to get caught up on paperwork. She wanted to draft an influenza newsletter to send out to parents soon — the same protocol she’d take with any pending outbreak, whether it be head lice, pink eye, or any other contagious health condition. And there was at least one updated student immunization record lying on her desk, to be entered into the computer and filed away.
“We spend a lot of time communicating with public health about things that are going on in the school,” she said.
After her lunch break, she’d head over to Hilltop Elementary, where she’d spend the rest of her workday. It’s not easy losing time during each transition, she says, but everyone seems to be pretty understanding and flexible. And based on what she’s hearing from her colleagues in the region, it’s not all that uncommon for nurses to rotate among buildings and oversee nonlicensed staff who fill in for them when they’re off-site.
“In the rural areas, down here, it’s very common to have kind of a mixture because we have so many buildings we’re covering. When you have only 1,000 students, it’s hard to justify because a nurse costs just as much as a teacher — we get paid on the teachers contract,” she said.
The key to making this assignment sustainable, at least for her, was in setting some firm boundaries early on, so as to not overextend herself. Her predecessor left suddenly after 10 years because of burnout, Genelin suspects. So she said no to serving on multiple district committees and delegated some scattered tasks like restocking sanitary pads in the bathroom dispenser. But, if the staffing resources were available, she’d like to be able to spend more time focused on follow-up care and phone calls to parents who brought home a sick or injured student.
“We can make sure you’re following all the laws, and that staff are adequately trained to meet medical needs of students,” she said. “We can make sure we don’t have life-threatening issues, and do the very basic screening things that we do. However, there’s a lot more that [school] nurses should be doing and want to be doing for kids.”
A patchworked landscape
According to the most recent state data, Minnesota public charter schools and traditional public districts employed 542 full-time equivalent licensed school nurses during the 2016-17 school year. Those positions were shared among 605 school nurses, some of whom job shared, like Genelin and her colleague. That means that, at a minimum, they’re a registered nurse with a valid bachelor’s degree and two licenses: one from the state Board of Nursing and another from the state Professional Educator Licensing and Standards Board (formerly known as the state Board of Teaching).
By way of comparison with other staff positions that fall under the umbrella of “student support services,” there were 1,130 school social workers, 728 school psychologists and 1,328 school counselors statewide last school year.
Beyond licensed school nurses, schools across the state employ both two-year RNs and licensed practical nurses, but no state data exists on those categories. Nor does the state track how many nonlicensed “health aides” — also known as health paras, health techs, health assistants, or maybe just the secretary who wears two hats — are currently serving in lieu of someone with nursing credentials, says Yoney.
“It becomes a funding issue — especially in those smaller districts,” Yoney said, noting that in some of these smaller rural districts, things are complicated further by the fact that they need to ask for variances because they can’t even find a qualified school nurse to hire. “They’re having to get a little more creative. So we’re seeing a whole variety of ways those needs are met.”
For instance, a smaller district may hire an RN with a two-year degree, but no license from the state Professional Educator Licensing and Standards Board. Or it might contract with a different agency, such as a local public health provider who might come in just a couple of hours a week to take care of the bare minimum: training staff, writing up health plans for students with more specialized needs, conducting screenings, and managing new medications that students have brought in.
“I think for families to just understand what the [staffing] situation is, is important, so they understand who’s seeing their child and providing care,” Yoney said. “We have this myth around ice packs and Band-Aids around school nurses and what they do. I think with all the advances in medical technology, school nurses are providing really significant medical interventions every day. The level of students who are able to participate in the school day with significant health needs has really changed.”
Not to mention, those with a background in nursing are trained to assess health ailments with any eye toward root causes and preventive measures that can be taken. And they’re well-equipped to respond in a moment of crisis, says Susan Nokleby, president of the School Nurse Organization of Minnesota.
“In school nursing, we’re trained to look for causation — and then to ameliorate those kinds of problems, and make sure the kids are in the classroom learning,” she said.
She’s worried that many of the smaller districts — those with fewer than 1,000 students — are taking a bit of a gamble when they choose not to hire at least one licensed school nurse.
“My concern is: ‘Who’s training on the EpiPen? Or how to manage diabetes? And who’s liable?’” she said, noting most districts cite budget constraints as justification for going without. “Well, I think a lawsuit could be very expensive.”
In her experience as a school nurse, Nokleby has pretty much seen it all. She spent nearly a decade working in a district in Greater Minnesota, north of the Twin Cities, where she was the sole licensed school nurse overseeing students at 10 different buildings — including all district buildings, plus local private schools and a juvenile training school. When she started out, she had just nine kids with diabetes to help manage. By the time she left, she had 21 kids with diabetes spread across her territory. And that was just one of the many increasing demands that ultimately led to her leaving for a job with a workload that felt more manageable, and safer. Currently, she’s working at a level IV school, serving a caseload of about 250 students with special needs.
“I’m still very busy, but it’s a different busy. I’m not running all the time — nervous about coverage,” she said. “So I’ve gone from one end of the spectrum to the other. And I can tell you which one works better, I believe.”
In her current position, she says she has the opportunity to get to know her students and their families better and to even indulge in an aspect of school nursing that many never find the time to focus on: health education.
If all districts were to heed to the 1:750 ratio recommendation for students in the general population that the National Association for School Nurses advocates for, more nurses might be able to do the same. But, that ratio “didn’t win hearts,” as Nokleby puts it. Minnesota’s 1,000 student minimum threshold, she says, makes its school nursing law “one of the weakest in the nation.”
Given the variations in how Minnesota schools staff their health offices these days, she suspects a lot of confusion exists among parents — and even school staff members — around who is actually licensed and who is simply filling in.
“I do think a lot of people believe they have a nurse in their child’s health office,” she said, advising people to simply “go ask.”
One nurse, one building
Another reason Nokleby would like to see all districts commit to staffing each school building with one licensed school nurse has to do with equity. She says she’s worked with a number of undocumented students, who may not have otherwise been connected with proper health care. Given her professional connections, she’s been in a position to help connect them, along with students living in poverty, with clinics that offer things like free eye exams and glasses, or affordable dental care. She’s also there to help encourage preventive care — an awareness piece that children growing up in households that have experienced generations of poverty may not have otherwise considered.
In the Hastings Public Schools district, Mary Ellen Fox, the district’s health services coordinator, has enough staffing resources to run a “smart choices” committee, focusing on student wellness outreach.
She serves as the district’s sole licensed school nurse. But she oversees eight other RNs and LPNs who all work under her school nurse license — one assigned to each school building. That’s how it’s been for as long as she can remember; and she’s been with the district for 13 years. Her district doesn’t employ any health aides.
“I would say all districts are strapped,” she said, speaking of their finances. “This district has said, ‘We really want to make sure there’s a nurse in each building because they know that it could create problems to not.’”
Adding to the list of care ideally administered by a nurse, she noted her nurses have helped make health accommodations for kids with cancer, kids with diabetes, kids who have seizures and — more so at the middle and high school levels — kids who come in with so much anxiety that they’re coming down with a stomach ache or something more severe like hives.
“There’s a lot of anxiety out there these days,” she said. “I think school nurses are pretty much on the front line for that.”