School nurses are essential members of the academic team in public schools, but many schools in Maine fall short in the number of nurses they employ.
The American Academy of Pediatrics recommends a ratio of one school nurse per 750 healthy students as well as a minimum of one full-time nurse in every school building. The National Association of School Nurses believes a “one ratio fits all” approach to school nursing is inadequate and recommends staffing ratios that consider the school population’s socioeconomics, chronic disease and complex health issues.
In Maine, it is especially important to focus on population acuity because many districts serve impoverished populations with complex health needs. The Robert Wood Johnson Foundation ranked each Maine county based on health behaviors, clinical care, social, economic and physical and environmental factors. Only four counties — Knox, Cumberland, York and Sagadahoc — earned a “healthy” rating, with Cumberland ranked as the healthiest in Maine.
Interestingly, many schools in Cumberland County have some of the best school nurse ratios in the state (Falmouth, 3.75 full-time nurses, one in each school, with a total of 2,095 students; Yarmouth, four full-time school nurses, one in each school, with a total school population of 1,550). Washington County ranked as the least healthy in the state and has some of the worst ratios. The Eastport School Department, for example, only has one nurse who travels to each of its seven schools once a month.
Because of the population health status of the majority of Maine districts, some ratios may need to be as low as 150 students to one nurse, the school nursing association’s guidelines state.
After collecting nurse ratio data from districts across Maine, I found only a handful of districts that fully adhere to the academy and association recommendations. Some schools have ratios as high as one school nurse to more than 1,300 students. School nurses in some districts cover three or more schools and drive 30 to 45 minutes between schools. The greatest ratio disparity is found in Maine’s largest high schools.
Given the national attention on adolescent mental health prevention and treatment, we may be missing an opportunity to address our population’s mental health needs by failing to adequately staff nurses in Maine’s high schools. In 2015, only 10 percent of young people over age 12 who needed substance-use treatment received it, and Maine was ranked among one of the states in the U.S. with the highest percentage of people suffering from mental, behavioral or emotional disorders.
Maine has the highest rate of babies born with neonatal abstinence syndrome in the nation. Many children born with the syndrome need additional physical, emotional and family support to ensure positive academic and health outcomes.
Maine also leads the nation with a significant increase in overdose deaths from heroin and opioids. Children attending Maine schools are orphaned every year because of this deadly epidemic. The loss of a parent is among the worst adverse childhood experiences, and it can negatively influence a child’s lifelong health. School nurses can serve to reduce the impact of these experiences through assessment, surveillance, prevention, referrals and care coordination.
Some argue that the schools’ goal is to focus on education, not health. But there is a direct link between health, safety and ability to learn.
School nurses focus on primary, secondary and tertiary prevention interventions, which decrease absenteeism and increase academic achievement. School nurses dismiss students from school three times less frequently than other school personnel. School achievement gaps created by chronic absenteeism between students with and without chronic conditions such as asthma can be reduced significantly by the presence of a full-time school nurse.
One experienced school nurse told me in an email, “When I care for a child who has a medical challenge, I so fight for that child’s right to have a school day like every other child. I never want a child to be defined by diabetes, ADHD, Autism, Cancer.”
For many children and adolescents, the only access to health care is at school from the school nurse. Nurses often report that children will intentionally come to school sick because their parents want the school nurse to assess them. Some children suffer all weekend until they can go to school Monday to be evaluated by the nurse.
The correlation between poverty and academic outcomes is well known; the same is valid for poverty and health outcomes, so why not blend the two? When schools appropriately staff nurses and empower and enable them to lead school health, nurses can focus on reducing the risk of injury and disease and promoting well-being, leading to decreased absenteeism and improved academic performance.
Critics who argue it’s not the school’s but the parents’ responsibility to provide health care to students may be missing the bigger picture. School nurses who focus on population health can develop and implement policies to limit the spread of disease and outbreaks, benefiting not only the school-age population but the community at large. School nurses who can identify physical and mental health needs and provide appropriate care coordination and referrals may help to prevent violence at school.
But with such high student-nurse ratios in Maine, many school nurses spend their time “putting out fires” rather than taking a preventive approach.
Maine needs to re-examine school nurse ratios. As one nurse said, “Because of inadequate ratios and the limited number of schools who employ a full-time nurse in each building, increasingly more care is transferred to school secretaries or teachers. This practice is dangerous and places student’s health at risk.”
School nurses report their “hands being forced to train unlicensed personnel to care for and administer medications and treatments; duties that should be performed by a nurse because of the need for assessment and clinical judgment.”
In Maine, school nurses report to principals and superintendents, who are formally trained in education, not health. Because of the current infrastructure, there is significant disparity in nursing ratios across districts and how much influence nurses have on population health and health services.
As a state, we must develop new payment structures for school nurses so schools do not need to choose between the cost of curriculum and teachers and students’ health. Does it make sense for school nurses to report to professionals without health education and credentials? A new method to pay for school nursing and health services, as well as a new organizational model consistent across school districts, would ensure the health and safety of Maine’s children is a top priority, while also directly benefiting academic outcomes.
School nurses can have a significant financial benefit. A cost-benefit analysis of school nursing services in Massachusetts found that for every dollar spent on school nursing services $2.20 was saved. The Massachusetts health program prevented an estimated $20 million in medical care costs, $28.1 million in parents’ productivity loss and $129.1 million in teachers’ productivity loss. As a result, the program generated a net benefit of $98.2 million to society.
When a full-time school nurse is present at every school, principals have an extra hour each day to focus on academics rather than the health needs of children, and teachers have an extra 20 minutes each day.
Children and adolescents in Maine deserve a high-quality education, and that requires Maine’s political leaders and schools to prioritize emotional and physical health. Maine should adhere to national ratio guidelines and stop transferring nursing care to teachers, secretaries and principals. Policymakers should consider alternative funding sources for school nurses to prevent budget cuts that eliminate or reduce school nursing services.
New models could not only improve emotional, physical, health and academic outcomes, but may also prevent school violence and lead to significant savings for Maine residents.
Kelley Strout is an assistant professor of nursing in the School of Nursing at the University of Maine in Orono.
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