The Kansas Legislature’s in-house auditors released an efficiency study of Topeka’s Auburn-Washburn USD 437 in July, part of a series of school district audits commissioned by lawmakers looking to cut public education costs for kindergarten through 12th grade.
One of the auditors’ findings was that the district could save about $68,000 in salary and benefits and the state could save an additional $9,000 in pension contributions if Auburn-Washburn replaced four of its 10 school nurses with “health aides.”
Brenda Dietrich, who was in the process of retiring as Auburn-Washburn’s longtime superintendent, floated the idea to the district’s parents.
It was not well-received.
“A lot of our families in the school district have medical backgrounds,” Dietrich said. “They’ve just come to expect to have a nurse in every building.”
But that’s not a reality in many districts, and with state budgets tight and legislators increasingly focused on making sure more K-12 funding goes to the “classroom,” nurses are among the non-classroom staff that could be in the crosshairs.
Dietrich said the medical professionals who live in her district understand that the job of a school nurse is not what it was 50 or even 20 years ago.
Chronic conditions like asthma and diabetes are on the rise among children, as are serious allergies. The movement to mainstream kids with disabilities means there are now far more students in public schools who rely on things like well-functioning feeding tubes, tracheostomy tubes and catheters not only to keep them learning but to keep them alive.
“When I was in school I don’t remember a child with a disability in any of our classes, and now it’s very common,” Dietrich said. “It’s a good thing, but you’ve got to have professionals who can take care of those kids in your buildings.”
Nurses also help form individualized education programs (IEPs) for students with disabilities in special education and screen children for vision, hearing and obesity-related problems.
Most districts are not flush with nursing staff.
The total number of school nurses in Kansas did not recover to pre-recession levels until last school year and, because of increases in enrollment, the ratio of students to nurses is still not back to where it was in 2008.
Even so, Dietrich said cutting the number of nurses is “absolutely” a discussion going on in other districts across the state, and it may be one Auburn-Washburn has to revisit soon because of the ongoing budget crunch at the state level.
“I think it will be something the district will have to consider going forward as revenues continue to decline,” Dietrich said. “But I think it’s going to be one of those things where there is nothing left (to cut).”
According to data from the Kansas State Department of Education, there were 701 registered nurses and licensed practical nurses in the state’s public schools during the 2008-2009 school year. The following year that number dipped to 680 and stayed below 700 until last year, when it rose to 715.
The ratio of students per nurse last year was about 690:1. That’s less than the previous five years but still does not match the 674:1 ratio of the 2008-09 school year.
Kansas’ student-to-nurse ratio remains far lower than some other states, and it’s within the general recommendation from the National Association of School Nurses of one nurse for every 750 students.
But Chris Tuck, a school nurse and health director of Topeka’s Seaman USD 345, noted that the one-per-750 recommendation assumes the 750 students in question have no disabilities or chronic illnesses.
“Those are regular ed kids,” Tuck said. “I don’t know of a single school that doesn’t have kids with an IEP.”
The national association recommends ratios of one nurse for every 225 students for populations that require daily professional nursing services.
Tuck, who until recently was on the national association’s board of directors, said the Seaman district of about 4,000 students had 31,762 health room visits last year.
Like Auburn-Washburn, Seaman has a nurse in every building. But Tuck said that’s a luxury many school districts can’t afford.
A survey the national association conducted in 2013 found that 62 of the state’s 286 school districts had no full-time nurse in the entire district.
No state standard for health aides
The staff who audited Auburn-Washburn for the Legislature suggested that district officials substitute “health aides” for some of their nurses, noting that some “peer districts” had more health aides and fewer nurses.
Health aides must work under the supervision of district nurses, but those nurses are not required to be in the same building. And while school nurses are licensed and regulated by the Kansas State Board of Nursing and subject to the board’s training and education requirements, there are no minimum training requirements for health aides under state law. Each district sets its own.
Tuck said in her district health aides must be trained in first aid and CPR. They’re especially valuable to nursing staff when it comes to managing immunization and health screening records, she said.
But in a different setting, like a hospital or nursing home, they would not be allowed to do things like dispense medications or perform tube feedings.
“They can’t do the job of the registered nurse,” Tuck said. “Not legally or safely.”
In a school setting, the health aide can do those things if a licensed nurse delegates those duties. In some Kansas schools, nurses who feel stretched thin are deputizing teachers to dispense medications.
Tuck said she’s aware of the current Legislature’s emphasis on prioritizing classroom spending over other K-12 costs, but she hopes it does not come at the expense of nursing staff.
“If a child is not healthy and they do not feel safe, it isn’t going to matter if they’re sitting in that seat at school,” Tuck said. “What we do as school nurses is we support teachers to educate the kids.”
Andy Marso is a reporter for KHI News Service in Topeka, a partner in the Heartland Health Monitor team.