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Schools

School nursing a juggling act

By THERESA BLACKWELL
Published May 15, 2005

	[Times photo: Carrie Pratt]
	Marie Amato, a full-time nurse at Cross Bayou Elementary in Pinellas Park, talks to Alexis Banks, 4, a prekindergartener, after preparing to feed her lunch recently. Alexis, who is in the school's pre-K program for the deaf and hard of hearing, uses feeding and breathing tubes. Amato's credo: "A little love, a little concern for 30 seconds. Make them feel special in that little way."

Since the end of last school year, a third of the registered nurses who work in Pinellas County schools have quit. Fourteen registered nurses have left full-time school positions. That's twice as many as in the previous two years combined. The turnover also is higher than in surrounding counties.

Nearly all those who left have been replaced, and Pinellas school administrators say they provide the best care possible with the resources they have.

But former nurses say the pay is too low and the responsibilities are too great. Most schools are covered by registered nurses assigned to visit five schools a week. On average, each nurse with five schools is responsible for 4,350 students, according to a Times analysis. When nurses are not at a school, nonmedical employees follow their written instructions if a student needs care.

Some former school nurses say they felt overextended and worried about putting students at risk.

"I think it's playing with fire," said registered nurse Donna Sewell, 44, of St. Petersburg. A former Pinellas school nurse, Sewell now works in home health care.

Schools need more nurses, said Laura Leveroos of Clearwater, whose son Devin has diabetes.

"Especially in this day and age, when more kids are diabetic," she said. "You can't say it's up to him to do it, because when (his blood sugar level is) high or low, he needs assistance."

A registered nurse comes to Devin's school, Palm Harbor University High School, once a week.

That's true for 110 of Pinellas County's 137 public elementary, middle and high schools. One day a week, a registered nurse not only cares for students but also trains clerks, teacher aides and other nonmedical employees to cover the other four days.

They learn to monitor blood sugar levels and follow instructions to help diabetic children stabilize those levels. They use EpiPens to inject epinephrine for allergic reactions, give Valium rectally to stop seizures, hand out inhalers, operate steam nebulizers for asthma, and give eye drops, eardrops and oral medications.

"It's amazing what we're asking the school staff to learn," said Jodi Shingledecker, a registered nurse and an acting school nurse coordinator.

At Forest Lakes Elementary School in Oldsmar, the office staff already is busy, principal Bob Evers said, and giving out medications without making mistakes puts a lot of pressure on them.

"It's a full-time job in a hospital," Evers said. "It needs to not be another ball that the office staff has to juggle."

School health officials agree that every principal would love to have a nurse every day, but nurses are assigned based on the medical needs of the students in the schools.

"It would be wonderful to have more (nurses)," said Marlyn Dennison, the school district's director of organizational, instructional and student support. "But I think we are meeting our needs."

Twelve schools have a registered nurse every day. Most are centers for exceptional students or have students with complex medical needs like feeding tubes.

Nine schools share a registered nurse with one other school. Eight of those nine have many low-income students, and the Pinellas County Health Department pays for the extra staffing.

Six schools are covered by licensed practical nurses, who must work under the supervision of registered nurses. Pinellas County officials say they do not, as a practice, use licensed practical nurses as school nurses. Only registered nurses can prepare student health care plans.

The rest, 110 schools, see a nurse one day a week. Sometimes schools see them less often. A nurse's regular schedule can change when there is a student with an urgent need at another school or when the nurse is assigned to cover a sixth school temporarily.

While turnover has risen this year, administrators say the demand for nurses is growing everywhere. Generally, they say they have not had trouble replacing nurses who leave. School nurses work a shorter day, are considered full-time employees and receive year-round benefits.

"Everyone would like more money, but some people like the job because they don't like to work shifts and they don't like to work weekends and they don't like to work holidays," said nurse coordinator Marcia Izzo, who temporarily acted as supervisor of nurses after a previous supervisor left.

Still, school officials would like to have more money available for nurses. The School Board's goals for this year's legislative session included increasing state funding for school nurses. It didn't happen.

Meanwhile, Pinellas school health services officials say they have recommended raising the starting pay for registered school nurses. Currently, it is $18.18 per hour. For nurses who cover five schools a week, working six hours a day, 10 months a year, that comes to $21,600 annually.

By comparison, registered nurses with Morton Plant Mease Health Care make an average of $50,000 per year, including shift differentials, a spokesman said.

While school administrators say they have discussed ways to increase nurse staffing, they note that years ago school nurses covered 10 schools each. That dropped to five after the school district received a cut of a big tobacco lawsuit settlement.

Today nurses identify students who are most at risk, and school personnel are taught to err on the side of caution. Even with a nurse on campus, emergencies require a 911 call.

"I think we keep the students safe," Izzo said. "I think we keep them healthy."

Registered nurse Sharon Artman quit on March 29 after five years as a Pinellas school nurse.

"I doubled my salary with a new job" in home health care, said Artman, 51, of Largo.

Artman said she was paid $21,400 and loved her job. But with about 3,400 students, she felt stretched.

"I had five schools, and then they gave me a sixth school," she said. "And I just didn't feel safe."

Leaving students in the hands of nonmedical school employees worried former school nurse Donna Sewell. In an emergency, she said, nurses are trained to look at the patient as a whole, assessing many indicators. A secretary, she said, can't do that.

"They are not trained as nurses, and they should not have to act as nurses," Sewell said.

Brooker Creek Elementary School principal Nell Chapman said her staff is relieved when the nurse arrives on Tuesdays because they "feel like she's better able to make decisions, dispense medicine and call parents."

"If a child breaks their arm and their bones are sticking out, you know we are not doctors or nurses," Chapman said.

Often injuries are not so obvious, Sewell said. Many times, she urged parents to take their children for X-rays of fingers that turned out to be broken. Injuries like that, Sewell said, might lead a coach to say, "You're faking it."

In a lawsuit the School Board settled for $18,250 last fall, parent Audrey Landry contended that the Safety Harbor Middle School staff didn't take her son's injured knee seriously enough after he fell from wet pullup bars.

There was no nurse at the school that day, according to court records. In court pleadings, Landry said her son complained of pain after his fall in December 2000, but a coach said, "You're okay. Walk it off." She said her son limped to the office, back to class, then back to the office again before she arrived to pick him up. His knee was swollen to three times its normal size. His injury is permanent and painful and limits his activities, Landry contended. She declined to comment for this story.

School Board attorney John Bowen said the boy was not required to walk around the school and was given ice at the office. It doesn't appear anything different would have been done if a nurse had been there, he said.

In another incident at Osceola High School last October, a mother complained that her son did not receive prompt medical treatment after his jaw was broken in a fight.

Student Theodore Reed said he held his jaw in place as he and the other boy discussed the incident with assistant principal Angela McCloud. McCloud said Theodore did not complain of pain and she didn't see a lot of blood, so she talked with the boys for half an hour before calling their homes.

There was no nurse at the school that day. Theodore said he tried to tough it out for a while and received ice when he complained of pain. Two hours passed before his mother arrived and took him for emergency medical treatment. Doctors wired his jaw together.

While registered nurses with five or six schools in Pinellas average 4,350 students, state statistics for last year show that the county's overall average is lower. That's because the schools that had a nurse more than once a week brought the county average down to 2,935 students per nurse. That's close to the state average of 2,898 students per nurse.

Florida, however, lags behind most states and has no mandated standards for school nurse staffing.

Vermont leads the nation with 294 students per nurse, according to a fall survey of the National Association of School Nurses. Only four states had more students per registered nurse than Florida - which had the most students per nurse in the South.

The federal government's Healthy People 2010 program has set a goal for half the nation's schools to have no more than 750 students per registered nurse by 2010. But that's a goal, not a requirement.

When Pinellas County's staffing from last year is compared to nearby counties, only Citrus and Hernando counties had more students and schools per nurse. But those ratios don't tell the whole story.

In addition to their registered nurses, school administrators in Pasco, Hillsborough, Citrus and Hernando say they assign more licensed practical nurses, certified nursing assistants and health aides to schools than Pinellas does.

In Pasco, along with a registered nurse for every two to three schools, each school clinic has a health assistant trained in CPR, first aid and communication, said Marilyn Koop, supervisor of nurses.

Hillsborough's ratio of registered nurses to students is close to Pinellas', but Hillsborough has more than 10 times as many licensed practical nurses, and five times as many certified nursing assistants and health aides trained in CPR and giving medications. Hillsborough administrators try to keep the workload at no more than 3,000 students per nurse.

"You get past that, and it does get dangerous," said Karen Brown, Hillsborough's supervisor of school health.

None of the four counties has seen the kind of turnover that Pinellas has this year, administrators in those counties say.

In Pasco, school nurses are classified as professional, instructional staff and are paid on the same scale as teachers. Another reason they stay, Koop said, is the workload.

"We as nurses are always trying to fix everything we come in contact with," she said. "If you give us such a huge assignment that we can't make a difference, we are going to leave and find someplace where we can."

Times researcher Caryn Baird contributed to this report. Theresa Blackwell can be reached at blackwell@sptimes.com or 727 771-4305.

[Last modified May 15, 2005, 01:21:24]