When Kittra Roberson came to her neighborhood elementary school in her nurse’s scrubs to pick up her son, who was feeling sick, she was surprised to find she was the only nurse in the building.
“I didn't know they didn't have a nurse. I thought they had one. Didn’t you guys have one a couple years ago?” Roberson asked the school’s receptionists.
Last year, Lakewood Elementary in Durham had a nurse who was scheduled to come twice a week. This school year, there's no designated day that a nurse is consistently at school. Their nurse's time is stretched across four schools in the district.
When a child has a medical need, that responsibility frequently falls on the school's two receptionists.
The National Association of School Nurses recommends at least one nurse all day, every day in every school building.
School nurses have become a vital resource as schools reopen their doors to more students during the pandemic, but most public schools in North Carolina don't have a full-time nurse on site ― not this year, or any other year.
A new bill in the North Carolina General Assembly seeks to bring a trained medical professional to every public school to relieve support staff who have been left with a heavy burden.
Medical Response Often Falls On Front Office Staff
About 60% of all medical procedures conducted in schools are performed by school employees who are not nurses. That’s according to a 2017 legislative report by the North Carolina General Assembly’s Program Evaluation Division.
At Lakewood Elementary, that burden falls on Shahidah Muhammad and Noemi Mondragon. Their primary duties are as receptionists and administrative assistants. Plus, Mondragon handles bilingual support for the school’s majority Spanish-speaking families. Medical administration has been added to her duties.
“I have to keep up with, ‘Who needs an epi pen? Who has allergies?’" Mondragon explained.
Both Muhammad and Mondragon received basic training in medical administration from the school district, but they don't feel they have the background to deal with a true medical emergency ― like if someone had a heart attack on school grounds.
Muhammad points to an empty nurse’s office: “If you can see in the health room, there's a defibrillator. That's an overwhelming amount of responsibility for us.”
“You don't get training for the defibrillator,” Mondragon added. “I asked the nurse once, and she said, ‘Don't be nervous, the instructions are on the box.’ And that actually made me more nervous.”
The most serious issues they have dealt with include: helping a diabetic student inject the right amount of insulin; responding to a child having a seizure; calling 911 and then a child's Spanish-speaking family to talk them through an emergency.
Then there are day-to-day issues. Roberson came to pick her up her son because he had a headache, which is COVID-era protocol. About the same time, another little girl slipped and fell in mud. It's the kind of thing that happens at an elementary school all the time.
“Broken arms, things happen, bloody noses,” Muhammad said. “And then COVID.”
COVID-19 Exacerbates An Existing Problem
After a couple weeks of being open for in-person learning, Lakewood Elementary had its first reported case of COVID-19.
Principal James Hopkins said it raised many questions about how to best respond. So he requested for the school district's lead nurse to have a Zoom meeting with teachers and staff to answer questions and ease anxieties.
“There's nothing in the world like having a health professional on site to address any questions, concerns, to support my secretarial staff who are essentially doing the work of the nurse,” Hopkins said.
During the COVID-19 pandemic, the school is required to have a “care room,” where a child who has any symptoms must wait until a guardian picks them up.
The responsibility of staffing the care room often lands on the principal, assistant principal and support staff.
Hopkins says he'd be happy to have a part-time nurse at school more often to assist with these duties, but it's not always enough.
"The day we need a nurse we don't have it, the day we have the nurse we don't have any issues."
House Bills 347 and 348 Call For A Nurse In Every School
A group of lawmakers in the North Carolina House have proposed two similar bills to require and fund more school nurses.
House Bills 347 and 348 propose to put one nurse in every public school in the state at the cost of $102 million in recurring annual funds.
Both bills have mostly Democratic sponsors. House Bill 348 has two Republicans signed on as sponsors. The relative lack of Republican support doesn’t bode well for the proposal.
Representative Gale Adcock, a Democrat from Wake County, is a primary sponsor of House Bill 348. She says she’s hopeful more lawmakers will recognize the need.
“What I know about all of my colleagues in the House is that they care about children. They care about schools,” Adcock said.
Adcock is a longtime family nurse practitioner and a former school nurse herself.
“When I was a school nurse, I had three schools and they were in very different geographic parts of the county,” Adcock said.
That was about thirty years ago that Adcock remembers driving across Wake County every week, and she says the problem hasn't gotten much better.
The National Association of School Nurses currently recommends at least one full-time nurse for every school building.
Fewer than half of North Carolina schools meet that standard, and most school nurses divide their time among multiple schools. Rural, low-income school districts tend to fare worse, Adcock says.
And among charter schools, only 22% have a full-time nurse. Data on school nurse capacity can be found in the North Carolina Annual School Health Services Report Brochure 2019-2020.
The North Carolina State Board of Education has recommended a ratio of one nurse for every 750 students, following an older recommendation by the National Association of School Nurses. But North Carolina doesn’t even achieve that, instead having a ratio of roughly one nurse for every one thousand students.
When a school has a full-time nurse, Adcock says she or he can help address underlying issues before they become an emergency.
“If the nurse is there, you have a constant, consistent, trustworthy source of education about not just COVID issues, but about all kinds of health related issues,” Adcock said.
That kind of wrap-around holistic support educators want to give children comes with a price tag.
The Cost Of Providing Every Public School With A Nurse
The General Assembly's non-partisan fiscal research division calculated the cost of House Bill 348, which covers all public schools, including charter and lab schools.
The $102 million price tag amounts to about 1.5% of the total K-12 education budget in North Carolina, and is roughly equal to a third of what the state spends on teacher assistants.
Adcock says one criticism the bill has received is that school sizes vary, and some schools already have a full-time nurse, so the bill wouldn’t provide every school the same nurse-to-student ratio.
Still, she calls the bill “a good start” at addressing schools’ urgent needs.
Adcock says even if House Bill 348 doesn’t advance, she’ll urge lawmakers on the House Appropriations Committee to consider the proposal. She plans to ask budget writers to hit the $102 million price tag “on the nose,” but adds that she hopes the General Assembly will get as close as possible.
Perhaps this legislation’s biggest obstacle is that many North Carolinians may not realize how many schools don't have their own full-time nurse.
“It's almost like oxygen,” Adcock said. “You don't pay attention to it until you don't have it.”
