Nurses working at ratios three to five times what the state recommends

TRIBUNE PHOTO: JONATHAN HOUSE - Benson High School nurse Laurel Merz serves two schools, but Multnomah Education Service District nurses serve up to seven schools. Merz says she worries about her students when she's not in the building.

Here’s a riddle for you: When is state-provided health care not billed through the health care system?

Answer: When it’s provided by a school nurse.

Just like teachers and janitors, school nurses are paid for through the State School Fund. But there is a movement this session in the Oregon Legislature to start to change that. Senate Bill 698 would establish a State School Nursing Consultant in the Oregon Health Authority, someone who would establish guidelines and protocols for school nurses across the state. The bill would also set up a task force to explore other ways to fund school-based health services, such as through public health agencies or even billing private health insurance.

School nurses are rare in Oregon — there are fewer than 300 full-time equivalent nursing positions statewide. A 2011 national study ranked Oregon 47th in the nation for the number of school nurses, though the ratios are up for debate. A 2014 state report says there is one nurse for every 2,119 students. But advocates say when they survey their nurses, they find the ratios are much higher than that. Nina Fekaris, president-elect designee of the National Association of School Nurses and a school nurse at four schools in Beaverton, says she has 4,200 kids in her charge.

National organizations such as the American Pediatric Association and others say ratios should be more like one per 750 typical students, and far more for populations with significant medical needs. Oregon law encourages school districts to meet this ratio by 2020.

Fekaris, the Beaverton school nurse, says other states coordinate school-based health care through public health agencies, which allow them to apply for federal grants, such as a recent one for asthma prevention in youth.

“But in Oregon there’s no way for those dollars to get translated into the schools itself,” she says, adding: “The Department of Education kind of gets hammered about, you know, why aren’t there more school nurses? But, you know, the Department of Education shouldn’t really be responsible for funding health care. At least not all of it.”

Fewer nurses, yet more complex needs

In Portland, children with medical needs are more common than in other parts of the state because parents move here to access specialized medical care. That means the need for more school nurses can be felt even more greatly.

“There are students with very complex health needs all over the state, but the majority tend to be around the metro area,” says Margo Lalich, director of School Health Services at Multnomah Education Service District, which is the umbrella government providing the vast majority of nursing support to the eight school districts in the county. Without a statewide coordinator, the resources that MESD creates tend to become templates for the rest of the state, according to Lalich.

School nurse Laurel Merz is one of the lucky ones. She has only two schools to serve — Benson High School and Sabin (K-8) School. School nurses at MESD can have as many as six or seven schools to serve, and up to 3,700 students on their caseload.

“For me, it’s less about the number of students and more about the number of schools,” Merz says of her caseload. She says that the one day a week she is at the elementary school, she worries about her high schoolers and vice versa. Merz says one time, she switched her regular day and just happened to be at the school when a student came in with a serious emergency health issue.

“I don’t know — if I hadn’t been there with my door open — who she would have gone to or what she would have done,” Merz says. “That leaves a pit in my stomach. That’s where I get a big, terrible feeling of worry for my students.”

Lalich says when a child needs medical care on a day the school nurse isn’t around, it falls to school secretaries or the rare health assistant to provide care.

“I would say it would vary day to day what would happen with that student,” Lalich says.

For students with complex medical needs, the student-to-nurse ratios are much lower. But with so few qualified to assist them, there is little flex in the system.

“If a nurse is not available, then the student might not be able to attend school,” Lalich says, noting the impacts to the students and families, who might have difficulty staying home from work on such short notice. “It’s not like a teacher where you can call up a sub pool. These students require highly-trained nurses.”

Fekaris notes that children in general have rapidly higher rates of disease and disorders these days. During her 27-year career, she has seen a huge increase in the number of students with serious medical issues who are coming to school as part of the general population or being integrated from special education settings.

“All the sudden you have more and more kids that are being diagnosed with illnesses that can be severe and life-threatening at school,” Fekaris says, listing seizure disorders, severe allergies, and type 1 diabetes among the increasingly common and yet inherently unpredictable disorders that school nurses are expected to manage these days.

“We can’t expect a secretary to just be able to give a pill,” she says. “It’s a lot different than that now.”

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