In 1897, health authorities in New York City hired doctors to examine public school students for infectious diseases—not to treat them, but to identify children who would be sent home so as not to infect their classmates. Five years later, in the wake of an outbreak of infectious eye diseases that prompted officials to send home thousands more children, local nurses volunteered to provide actual treatment. The effort was an eye-opener in more than one sense.
Permitted into the schools on a trial basis, nurses began solving a public health problem with long-term implications for children’s health and education.
“Many of the children needed only disinfecting treatment of the eyes, collodion applied to ringworm, or instruction as to cleanliness,” reported one of the nurses, Lina Rogers Struthers. Struthers went down in history as the nation’s first school nurse, and in the 118 years since, the profession she pioneered has become an increasingly critical, if often overlooked, component in the nation’s health care system.
Today’s school nurses deal with chronic conditions, life-threatening allergy and asthma events and epidemics of various sorts; they connect students to substance-abuse treatment, mental, behavioral and reproductive health services; they screen for vision, hearing and other problems that might impair learning; they ensure immunization compliance and administer first aid; and so much more.
According to the latest edition of Charting Nursing’s Future, the Robert Wood Johnson Foundation (RWJF) publication series focused on policy ideas with the potential to transform patient care, despite school nursing’s long track record of success, “policies related to school health service vary dramatically, and half the nation’s schools lack a full-time registered nurse.” The brief, “Unlocking the Potential of School Nursing: Keeping Children Healthy, in School, and Ready to Learn,” describes dramatic disparities in the availability of services and highlights promising policies and funding strategies.
The ‘Hidden System of Health Care’
Despite school nurses’ central role in the health of students, policy-makers seem largely unfamiliar with their contributions or potential, according to Julia Graham Lear, Ph.D., founder of the Center for Health and Healthcare in Schools at the George Washington University School of Public Health. The tens of thousands of school-based counselors, nurses, psychologists and social workers caring for children on a daily basis are, she says, a “hidden system of health care.”
Not surprisingly then, health care reformers and public health professionals interested in making better use of school nurses face a patchwork of state and local policies on nurse staffing and practice, as well as inconsistent and sometimes fractured systems of financing.
In all, some 66,000 school nurses are at work in the United States, but from state to state, coverage ranges from comprehensive to inadequate. In some jurisdictions, students have direct access to registered nurses. Others have no nurses on site, and first aid and other duties fall to secretaries and health aides, sometimes supervised by off-site nurses. A small minority of schools employs nurse practitioners, who provide primary care and related services in school-based health centers.
The varying approaches are often driven by funding, rather than by concerns about students’ needs or quality of care. But the data on effectiveness are mounting. Research shows that the daily presence of school nurses advances the twin goals of improving health and educational outcomes, particularly where nurse-to-student ratios are at workable levels. Milwaukee Public Schools recently added additional registered nurses, with the goal of a 1-to-750 nurse-to-student ratio, and made impressive gains in immunization rates, identification of asthma and life-threatening conditions. The changes also allowed teachers who had previously handled health matters to return their focus to the classroom. School staff had reported spending an average of 13 hours a day per school on health matters, at an estimated annual cost of $133,000 in salary and benefits—almost twice the cost of hiring a nurse.
Finding the Dollars
Data notwithstanding, for school systems commonly forced to choose which educational necessities to forego, identifying funding for school nurses is a difficult challenge. The federal government provides some funds, but mostly to support education for children with disabilities—and not enough even for that purpose. Medicaid payments contribute a small share of the needed resources, but with limited impact, and rarely for services for students not diagnosed with disabilities. Insurance companies benefit from the care provided by school nurses—because they help prevent or treat conditions that might otherwise necessitate an insured trip to the doctor or to an emergency room. But the companies rarely, if ever, reimburse schools for such services.
That leaves communities and local school districts in need of other sources of revenue. The Charting Nursing’s Future brief profiles a disparate group of funding approaches, including a taxation mechanism, publicly and privately funded grants, as well as partnerships with a health care provider, an insurer and a nursing school. This patchwork of funding streams highlights the absence of sufficient, dedicated funding for school nursing services in most of the nation. Some examples:
- Outsourcing Care. In Texas, the Austin Independent School District contracts for school health services with the Seton Family of Hospitals, which acts as a safety-net provider to the community. Some 73 registered nurses and 55 school health assistants work in teams to provide coverage to 112 schools.
- A Dedicated Tax. In 2002, voters in Miami-Dade County, Florida, authorized a dedicated tax linked to property values to fund children’s services, and established The Children’s Trust to administer the funds. One of its programs, Health Connect in Our Schools, has placed nurses, nurse practitioners, social workers and health aides in 131 of the county’s schools, in partnership with the school system and the health department.
- Health Plan Initiative. In Minnesota, the St. Paul Public School system has partnered with UCare, an independent, nonprofit health plan, to provide asthma education to UCare-member students who attend public schools. UCare sees the outreach effort as a cost-effective investment in asthma control.
- Partnering with Nursing Schools. Nurse practitioner students and faculty from Regis College of Nursing and Health Professions provide school nursing services to the cash-strapped Archdiocese of Boston, helping to create, equip, staff and secure corporate funding for a wellness center at a private high school with a high rate of overweight students.
- Multiple Funding Streams. Schools in Mississippi have developed a patchwork of funding streams. The state’s School Nurse Intervention Program awards grants to place school nurses in some underserved districts. In other districts, increased attendance has brought in enough additional state dollars to fund a school nurse. Some districts partner with hospitals for nurses, while others use funds from the federal Early Periodic Screening, Diagnosis and Treatment program. Finally, the state’s school nursing program also receives significant support from the Mississippi-based Bower Foundation.
Looking Ahead: Policy Initiatives
Policy-makers have an important role to play in ensuring access to school nurses, as “Unlocking the Potential of School Nursing” makes clear. The brief highlights a number of potential policy approaches that are gaining traction at the federal level. They include:
- Federal legislation to provide competitive grants to states with nurse-student ratios better than one nurse per 1,000 students;
- Comprehensive national data collection that would allow for gauging the intensity of school health services and their impact on student health, as a step toward developing stronger policies; and
- Creation of an office within the U.S. Department of Education that would provide school nurses, school social workers, school psychologists and others with a point of contact dedicated to identifying best practices, providing technical assistance and offering professional development opportunities.
The value of school nursing is clear to at least some federal policy-makers. U.S. Representative Lois Capps, D-Calif., a former school nurse, says, “When children receive the support they need to remain healthy and focused on learning, the entire classroom benefits. Increasing the presence of nurses in our schools can be a critical element in achieving this goal.”
U.S. Senator Olympia Snowe, R-Maine, agrees, “A school nurse is the only consistent contact that millions of children have with a health care professional, yet half of the nation’s schools lack a full-time registered nurse. We need to make sure that all children have access to a nurse in their schools.”
Secretary of Education Arne Duncan concurs. “We know that students need to be healthy to learn,” the brief quotes him saying. “School nurses play a vital role in making sure children are healthy and ready to learn.”