Just an hour into the school day, the health room at Tacoma’s Birney Elementary School was already getting a steady stream of visitors.
By the end of the morning, registered nurse Joyce Ells had helped a gap-toothed first-grader through the drama of tooth loss and reassured another child that an eye infection was getting better.
She also gave a kindergartner with a queasy tummy a fresh T-shirt, a toothbrush and toothpaste to freshen his mouth, and some TLC while he waited for his mom to come pick him up.
“People think we just hand out Band-Aids,” Ells said.
While that’s part of her job, the registered nurse is also responsible for overseeing health plans for students with complex medical needs, training other staff in basic care, and teaching proper hand-washing and tooth-brushing to the youngest students.
Ells has worked for Tacoma Public Schools for 18 years, following a career as an Air Force nurse. In addition to working at Birney one day a week, she spends one day a week at the Science and Math Institute and the other three days at Baker Middle School.
“I see a wide range of kids, with a wide range of needs,” she said.
Some adults may remember the days when every public school included a full-time school nurse. But Robin Fleming, who oversees school nursing programs for the state Office of the Superintendent of Public Instruction, says those days are long gone.
Fleming said systems like Tacoma’s, with nurses covering more than one school, are typical. But she said as more students come to school with serious chronic health conditions, there may be motivation to return to the staffing models of years past.
State data show that the number of students with conditions such as asthma and diabetes has increased over the past decade.
“These are conditions that can interfere with kids’ ability to learn,” Fleming said. “If you can’t breathe, or if your blood sugar is so low that you’re feeling foggy, you are not connecting with learning.”
She said the state is looking at ways to increase federal dollars that could be used to enhance school nursing programs. Student health services also could be in line for more state funds as the Legislature overhauls education spending in response to the McCleary Supreme Court decision.
Right now, Fleming said, the National Association of School Nurses ranks Washington state as having the eighth-highest school nurse caseload.
She said national recommendations from the association, the Centers for Disease Control and the American Academy of Pediatrics recommend one school nurse for every healthy 750 students, with even lower ratios for students with complex medical problems.
Statewide, Fleming said, “we are not even close.”
The Tacoma School Board recently heard a review of its nursing staffing model and decided to stick with what it has.
The review was prompted by a consultant’s report that made recommendations about special education programs, such as exploring whether these students’ needs could be met by relying more on lower-paid licensed practical nurses.
Tacoma’s nursing staff includes 22 full-time equivalent RNs and 12.1 LPNs
RN’s have a higher degree of education and broader scope of practice compared to LPNs., who must work under the supervision of RNs. (For example, only an RN can write a health care plan for a student with a complex medical condition.)
Each of Tacoma’s five comprehensive high schools has a full-time RN, while at the smaller alternative high schools they work part-time. Middle schools are staffed by a combination of RNs and LPNs.
There are eight elementary schools staffed by RNs one to three days a week, and LPNs on other days. Those eight schools (Skyline, Lowell, Franklin, Fawcett, Edison, Larchmont, Northeast Tacoma and Lister) are considered regional hubs, providing licensed nursing care for students with serious conditions such as seizure disorders or diabetes.
Tacoma’s other 27 elementary schools are staffed by RNs one to 2 1/2 days a week, and by health clerks the rest of the time. (Health clerks do not hold a state nursing license, but are trained in basic first aid and may be trained to administer medications.)
Elizabeth Goldberg, the district’s health services administrator, recommended that the district continue its current staffing model, which has been in place for at least eight years.
The issue of school nurse staffing is being debated nationwide. In recent years, districts across the country have cut on-site health services and nursing staffs.
A study published last year in the Journal of the American Medical Association that looked at school nurses in Massachusetts found that for every dollar invested in school nursing, society would gain $2.20. The savings were reflected in lower medical costs and more teacher productivity.
For Fleming, Washington’s school nursing manager, the message is clear.
“As nurses in schools become more understood and more valued, people are going to realize that we can’t afford not to have one in every building,” she said.