Scouting out communicable diseases and quarantining children who have them are functions almost as obsolete in today's school nurse's job description as starched white uniforms and stand-up caps.
Although still concerned with minimizing infectious diseases and preventing their spread through schools, today's school nurses have taken on responsibilities that an earlier generation of their kind couldn't have imagined.Rep. Paula Julander, D-Salt Lake, a nurse herself, understands the needs and recognizes the dearth of school nurses in Utah schools. She is sponsoring HB77, a bill that would increase the number of school nurses practicing in Utah schools by almost 600 over the next five years. Wednesday morning, the bill was reported out favorably by the House Education Committee, despite concerns about the $2.6 million price tag for the first year. The cost would increase to $20.9 million for 1995. After listening to a number of nurses and teachers who attested to the critical nature of school nursing, committee members wanted to keep the issue alive in case money can be found to finance it.
The statistics that inspired HB77 include 44,000 students in grades kindergarten through 12 who have identified handicaps; approximately 2,100 handicapped preschool-age children who were added to the system by federal mandate last year; approximately 24,000 children under 14 with asthma; diabetes that affects 0.12 percent of all American children up to age 14 and 0.35 percent of those 15-24; 6,570 children identified as abused or neglected; dental caries in 31 percent of children; 3,692 injuries reported by schools in a year's time; and a death rate due to unintentional injury of 22.5 Utah children per 100,000, higher than the national rate.
To deal with these problems and many more, Utah has 48.8 full-time-equivalent nurses. They serve 435,700 students, with one nurse to every 9,000 students - 12 times the ratio recommended by the American Nurses Association.
"I believe healthy children learn better," said Julander. "I'm willing to try this more than one session if necessary." Her caution relates to a fiscal note on the bill. The first-year infusion of nurses would cost $2.6 million, and the total bill would be almost $21 million.
A second reality that could affect the measure is a shortage of nurses in Utah. The Utah Nursing Resources Study Task Force has estimated the need for nurses by 1993 to be more than 1,570, said Norma Matheson, who has been involved in the study for several years. The study did not include the call for school nurses, nor did it consider the Middle East war, which has decimated nursing ranks in some hospitals.
Sandee Oliver, school health nurse consultant in the State Department of Health, said many nurses inquire about school jobs and it may be that some inactive nurses would be interested in jobs where the time demands match family needs.
The shortage of school nurses means "secretaries and principals are making decisions that could be very dangerous," said Oliver. HB77 is backed by the Coalition to Promote Utah School Health.
Carol Pia, who spends her time in the trenches as one of three school nurses serving approximately 78,000 Granite District students, has no illusions about the demands made on her small crew.
Besides routine health problems (head lice occupies a disproportionate amount of a school nurse's time), "We have four children in the district who have central venous lines - catheters that go into the vena cava, the largest vein in the heart, to administer chemotherapy, nutrition or other intravenous fluids. We have children who require gastrotomy feedings. We have children with heart pacemakers and children who are on oxygen."
Because three nurses cannot possibly be in each of the district's schools every day, some medical responsibilities are delegated to teachers or other school personnel, she said, but always under supervision of the nurses.
The Granite nurses have trained teachers to monitor and use gastrotomy tubes or equipment to deliver oxygen, be alert to seizure disorders, administer medications, watch for failure of heart pacemakers and other routines that used to be confined to hospitals or nursing homes. Each child with a medical condition has a written regimen that is carefully followed, Pia said.
In some instances, parents have requested "do not resuscitate" orders, so if a child were in a terminal condition, the teacher would not be expected to respond - a touchy decision with which many are uncomfortable.
"I was trained to teach," said Julie Cunigan, a teacher. "I don't know these things." Nevertheless, as a teacher in Granite's Hartvigsen School, where many of the district's most severely handicapped children are taught, she does do gastrotomy feedings and other procedures vital to her students' well-being.
The delegation process concerns nurses. "When we delegate a procedure, if it is not performed well, our licenses can be at stake," said Pat Shifflett, one of Pia's co-workers. Even more to the point, they are concerned that children may not get the kind of care they need. If they fear that a special procedure cannot be performed well enough by another person, they do not delegate the responsibility.
The nurses would like to spend more time helping children stay healthy, but preventive health is another luxury for which they haven't sufficient time.
More telling than any of the statistics when the Deseret News visited Hartvigsen School, however, was an incident that interrupted the interview. Pia was called from the room to help a child who had about a quarter-inch of the tip of a thumb amputated when a door slammed on it. In the great majority of Utah's schools, no nurse would have been available.
Proposal to add nurses
HB77 would reduce the ratio of students to school nurses over five years as follows:
Fiscal year Ratio New nurses hired Cost
1991 1/5,000 73 $2,628,000
1992 1/3,500 108 3,888,000
1993 1/2,000 208 7,488,000
1994 1/1,500 281 10,116,000
1995 1/750 581 20,916,000