Not enough helping hands

Mary Vinson's morning visitors at Bull Run Elementary School in Centreville, Va., walked in with a bloody nose, a lost tooth, a sore throat and a tender hip. Then came the case of the conk on the head.

After a tower of plastic cubes came crashing down on 9-year-old Cal Meunier in class, two buddies escorted him to see Vinson, the school's clinic room aide. She gave him an ice pack, told him to rest on the only available cot and shifted attention to other students.

Three needed medicine for asthma, lactose intolerance or attention deficit disorder. An achy girl waited for her parents. And the ugly flu season was just beginning.

"I feel like we are pretty well trained, and we are pretty well set up to do what we need to do," Vinson said. "There are just certain times when it would be nice to have a little extra help -- or perhaps some guidance on how to deal with a parent who refuses to pick up their child when the child is getting sick every five minutes. You do what you can."

School nurses and health aides are expected to do more than ever, as children needing tube feedings and catheterizations require help alongside those with the skinned knees. A mix of factors -- federal laws ensuring fair education for disabled children, medical advances, busy working parents -- has resulted in more students coming to school with chronic illnesses.

School health professionals say the increased demand highlights a concern they've had for years: whether there are enough medically trained people in schools to handle the load.

Inadequate numbers"If state legislators were to walk through the halls of an urban elementary school and see the type of medical conditions taking place, they'd be astonished," said Joni Tanaciev, a health official for the American Federation of Teachers, which represents 15,000 school nurses.

About three out of four schools have a full-time or part-time nurse, often someone who juggles health care, teaching and training responsibilities in more than one building. And one third of schools have a clinic aide, whose duties include triage for the sick and hurt.

Those numbers are climbing, according to the Centers for Disease Control and Prevention. Yet almost half of schools don't have the recommended ratio of one nurse for every 750 children.

The National Association of School Nurses, in surveying its members, found that half of them are assigned to one school. Most of the rest shuttle between two and nine schools, if not more.

"If there is only someone here one day a week, you can't build relationships with students," said Maureen Knowles, the nurse at Nathan Hale Academy in Toledo, Ohio. "I've had children come to me because they know me and trust me. If you simply stop in once a week to check 610 immunization records, you aren't going to have time to develop that rapport."

There are other problems when school health care is lacking or nonexistent, school nurses and their union say. Schools miss signs of broader health trends, with some sick children ending up at the emergency room for basic care. And school workers such as secretaries and teachers -- given varying levels of training -- are asked to help provide care.

About 97 percent of schools let staff administer prescription drugs, and at least one study reveals that delegation doesn't always work. A University of Iowa researcher found medication errors were three times more likely when nursing duties were delegated to staff.

"You always believe that if something happens to a child, an injury or illness, that someone will be there to help," said Sue Will, a school nurse in St. Paul, Minn., and president-elect of the National Association of School Nurses. "I think some parents are shocked if they find an injury was handled by someone with minimal or no training."

Vying for dollars

Large majorities of parents say it's important for schools to treat chronic illnesses, administer medications and teach healthy living, according to a 2003 poll funded by the Robert Wood Johnson Foundation. The only solid argument against school health care among parents was that it could take money away from other school priorities in tight times.

Elaine Brainerd, director of a coalition of health groups known as the National Center for School Health Nursing, said: "At some school board meetings, what we've faced is, 'OK, we'll have nurses, and we'll cut the arts program.' Well, no, I don't want to cut the arts program. But everything is vying for those dollars. It's a really tough sell."

Yes it is, particularly when schools are trying to cover costs such as teacher salaries and textbooks, said Dan Fuller, a lobbyist for the National School Boards Association.

"School nurses are a necessary part of school," he said. "The problem is, a lot of parts of school are necessary that may be closer to the classroom and the education of children."

Officials in Fairfax County, Va., home of Bull Run Elementary, say they've found an approach that works. The health department provides one nurse for every three or four schools within Fairfax, the largest district in the metropolitan Washington, D.C., area. And every school has a clinic room aide, such as Mary Vinson, who's done the job for 17 years.

On the day when Vinson juggled head injuries, medications and calls to parents, her boss, nurse Diane Blackwell, was there to help.

More must be done nationwide, according to the American Federation of Teachers, which is lobbying at the school district and state level to get a full-time nurse in every school. At least 14 states require some school nursing, and others are considering the idea.

Meanwhile, about 1,500 schools have opened comprehensive health centers on site, typically broad community efforts designed for poor children who have no other primary care.

"We are doing better," said Lani Wheeler, a medical officer in the school health division of the CDC. "But the most important thing is looking at individual communities, individual schools. Because any child who can't get the treatment they need -- that's a huge problem."

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On the Net:

National Association of School Nurses: http://www.nasn.org

American Federation of Teachers: http://www.aft.org/healthcare/schoolnurses/