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A Band-Aid Solution

As nurses are squeezed by growing workloads and shrinking budgets, the burden of medical care increasingly falls on teacher’s aides, secretaries, and other support professionals.


By Rebecca L. Weber

As children walk to their classrooms at Cherokee Elementary in Alexandria, Louisiana, Sharon Scott greets each one with “good morning,” calling many by name. Some kids are still Monday-morning sleepy, and others are speedwalking down the halls. A few, like Sam, a fifth-grader who was diagnosed as a diabetic before he was school age, get more personal. “I’m his school mom,” Scott says as they hug. Chase, with spiky hair that was bleached some time back, also checks in; he’ll see her later in the day, when it’s time for his inhaler. Dressed in primary red pants, a bright yellow Dr. Seuss shirt, and black Mary Janes, Scott stands with her hands clasped behind her back. This is perhaps the calmest moment of her day.

Classes begin and Scott heads to the nurse’s station, a euphemistic name for what’s essentially a long closet outfitted with storage cabinets and a sink. The windowless room has no ventilation; a small fan Scott bought with her own money whirs away. She makes do without a computer or even a chair for herself—there’s barely room for the patient seat and the cabinets, drawers, and mini-fridge that hold prescription medicines, Epi-Pens, antiseptic wipes, inhalers, files, and fruit juice bottles.

ESP Sharon Scott’s role includes medical duties.

Scott spends most of her seven-plus hour days standing here, attending to students with chronic and acute medical needs. She has 37 students’ individual medical plans on a neatly written list—which keeps growing. Most of the kids refer to her as the nurse, but she was never trained as one. Scott was hired as a teacher’s assistant, and she is still responsible for making copies for the school’s first-grade teachers and reading the after-school bus announcements. But most of her time is spent attending to the medical needs of Cherokee’s 700-plus students.

Increasing medical needs are straining the ability of school districts across the country to retain adequate numbers of school nurses. But while the percentage of medically fragile children with chronic conditions such as asthma is rising, many states and school districts are slashing health care budgets. Without school nurses present, the burden of medical care increasingly falls on the shoulders of some of the lowest-paid employees at the school: teacher’s aides, secretaries, and other support professionals.

The education support professionals (ESPs) who bear this ever-increasing medical load typically were hired to perform other roles—but the “and other duties as assigned” clause kicks in. David Clark, an organizational specialist in Florida, once sat in on training where support staff were instructed how to give a shot. A peach was used for the model. “These people, who generally are underpaid and underappreciated, with limited medical background, are being put in a very difficult position,” he says. “What stuns me is that for the amount of money they’re paid, and the status that they’re denied, they’re literally asked to do a life-or-death thing.”

Since Scott has been at Cherokee, the student population has swelled from about 450 to over 700. But the school’s other paraprofessional who shared medical duties with Scott was cut because of budget constraints. “I had the most medical training—and I use that term loosely,” says Scott. So now everyone, she says, refers to her as the nurse. Even the district RN calls Scott “the real school nurse.”

On her weekly visit to Cherokee this spring morning, she and Scott are searching through the locks of a morose little girl with a stylish bob. The adults keep the talk cheerful: What a lovely haircut; it’s got good body. The student, who had been sent home the previous week for head lice, is relieved to hear she can return to school.

Next, an asthmatic boy comes in before his PE class. He was diagnosed just a few weeks ago, so Scott coaches him with his inhaler. After taking a dose, he has trouble holding it in. “Pretend you’re sucking on a straw,” Scott advises, and he giggles, losing the rest of the dose. He tries again with a straight face.

Another, younger girl on the verge of tears takes her turn, gripping the chair seat tightly. She keeps her eyes on the floor, ignoring the comments about her lovely blond highlights as Scott searches her hair for nits.

“I worked on her hair so long, she fell asleep,” her mother says. “If it couldn’t be sprayed, it got doused with bleach.”

“It’s so hard to spot them,” says Scott. When her daughter is given the OK to go back to class, it’s hard to say who is most relieved.

That sense of relief rarely extends to Scott. “There are times when you don’t feel qualified,” she says.

Nurse Norma Nikkola’s district has lost five of its seven school nurses over the past few years. Even a principal now serves as a backup.

Even in places where nurses are more readily available, their workloads are changing. Norma Nikkola works in a small Ohio town that, over the past few years, has lost five of its seven school nurses. One of her assistants now dispenses medication and does regular tube feedings. Even the principal has been trained as a backup.

The National Association of School Nurses (NASN) recommends at least one school nurse for every 750 students with general needs. (The ratio changes dramatically when considering students with substantial or profound disabilities.) Some states and districts are increasing the number of nurses to keep pace with medical needs, but others aren’t. As a result, nurses like Nikkola often worry about the quality of care they can provide.

“A lot of people don’t know what school nursing has become, with asthmatics, diabetics, overweight kids,” she says. “We’re overwhelmed with individual health care plans, screenings, paperwork. We don’t have the opportunity for hands-on care, for follow-up, or counseling. We can’t be used to the fullest extent of our training.”

While nurses increasingly share their workload with other staff, they remain responsible for the outcome—and should be the ones deciding who can handle what, argues NASN President Sue Will. “The nurse is the one who needs to determine what will be delegated to a paraprofessional,” she says. “Health problems change day to day and across the school year. You need somebody with a medical background and licensing.”

By early March in central Louisiana, azalea blooms are already turning into lush, deep green bushes. The pollen count is climbing; mosquitoes are out looking for fresh blood. Gym class meets daily, and the outdoor track is concrete. But when scraped-up kids come to Scott, she directs them to wash the wounds, or instructs them to ask their parents to cut off torn skin when they get home. State law prohibits nurses and other staff members from administering any topical medications or antiseptic. At one point, Band-Aids were banned because of adhesive allergies, but now the school allows Scott to use the latex-free bandages she picks up on her own time.

A silent, sandy-haired little boy sits folded into himself as he holds a baggie of ice on his pale, thin arm. His teacher spotted the big, ugly welt near his wrist, and walked him down to the nurse’s station, where Scott calls his father.

When his father—a handsome, burly man with the same face as his son—walks in a bit later, the boy smiles. Dad produces a well-used tube and squeezes out pink ointment.

“Has he always been allergic?” Scott asks. She keeps detailed files on all students with medical histories, but this is the boy’s first visit.

“Yeah, look at this scar. He’s got a little eczema, too. Do y’all want this?”

“We can’t put on any ointment.”

“It’s not like the old days!” the parent replies. “I used to get all swabbed up.”

“These people, who generally are underpaid and underappreciated, with limited medical background, are being put in a very difficult position.
David Clark, organizational specialist in Florida
While barred from administering some medications, ESPs like Scott are still expected to perform other, often complex medical procedures, including tube feedings and urinary catheterizations. Over the years, Scott has assisted or performed the latter procedure for a half-dozen children. Her training consisted of a video and a nurse who “walked us through it,” she recalls. “Seeing a video and actually doing it are two different things.” At one point, she had to train a second-grader to do it herself. “I remember feeling very inadequate to have to train this child to do this,” she says. “If a child cannot do it, I believe a medical person should. In most cases, they were paralyzed from the waist down—they had no feeling, and cannot say, ‘Ow, you’re doing that wrong.’”

It’s past time to check in with her school’s five first-grade teachers to see what assistance they need with photocopying, laminating, and the like. “I’m sometimes not doing them justice,” she says. Nor does Scott’s salary do justice to the work she does—after nearly three decades of experience in the same district, her salary is capped at just below $15,000. Many of her peers are only able to get by with food stamps or live in subsidized housing.

But Scott loves taking care of children, especially the one-on-one time with those with chronic health problems. Nine-year-old Tristan has a variety of physical and mental needs, but he’s mainstreamed and his needs are relatively minor compared to some of the special ed children she’s worked with in the past. While he always had a bit of an unusual gait, Tristan was recently diagnosed with cerebral palsy and now wears leg braces. His cleft palate impairs his ability to eat and swallow—he’s the only student who chews his pills. (“Ooh, bitter!”) But he knows the drill: Pills, then a little reward.

“Where are the Spider-Man stickers?”

“I don’t have any. You can have a bunny sticker.”

“I'm scared of the Easter Bunny.”

“No, he’s not scary. You can have a sticker.”

“I’ll have chocolate chips.”

Scott changes the subject. “How’s the brace?”

“Not great.”

She gives him his pills.

“They’re yuck,” he says. He demonstrates that he’s already strong and healthy: he flexes and pats his bicep.

“Have you had any water? Drink, drink. Hey, let me see.” He swallows all the water, sticks his tongue out, then up.

Tristan chooses a sticker that she places near his shirt pocket. He then hops out, bunny-style.

Photos top: John Ballance; bottom: Peter Wine

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