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Jan. 20, 2021

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School nurses key to reopening schools, but new research shows equity gaps in Washington

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Just as a slew of Washington school districts are planning to bring more students back into buildings this year, a new study from University of Washington researchers suggests that many districts are short of school nurses, who will play a critical role in developing pandemic-related health and safety plans and will care for sick students.

Statewide, schools employed an estimated 978 full-time equivalent nurses in 2019-20, up from 625 two years ago, the researchers found. But Washington has more than 2,000 public schools, suggesting that many buildings still don’t employ a nurse full time.

The findings also suggest vast gaps, like in the health care system at large, in who has access to medical care at school.

Districts in rural corners of the state, and those with more low-income children, have fewer school nurses per student, the researchers found. Conversely, districts with more Black, Native Hawaiian, other Pacific Islander or multiracial students have more nurses per capita. This might be because students of color have a higher prevalence of certain chronic illnesses, according to some research, and districts choose to hire more nurses to meet this need.

School nurses and other school-based medical staff constitute what many researchers call a “hidden health care system.” Students don’t need appointments, insurance or transportation. The result: School nurses help ease racial and income-based disparities common in other health care settings by providing basic care to students who might not otherwise receive it.

In pandemic times, on top of their regular duties, these critical medical staff members are charged with screening or testing staff and students for COVID-19 symptoms, contact tracing when cases crop up and tending to students who fall ill at school.

“There’s going to be a lot more COVID-related stuff that schools are going to have to do, right? And who is going to do that?” said Mayumi Willgerodt, who was involved in the research and is associate professor of child, family and population health nursing at UW. School nurses “are trained to do the assessments and make those judgments that I’m not so sure others can do.”

The new research, which is unpublished and hasn’t been reviewed by peer researchers, is the most recent look at Washington’s school nurse workforce — the last review was in 1997 — and one of the first comprehensive reviews of the distribution of the health workforce in schools nationwide. Other states could use it as a blueprint for their own local studies, said Laurie Combe, president of the National Association of School Nurses.

“We can see that there are disparities in the way schools are staffed,” she said. “We know that many students don’t have access to a usual source of care and the school nurse can fill that gap.”

The researchers also found that in many rural places in Washington, the school nursing shortfall overlaps with areas that are poorly supplied with primary medical care for the community at large.

Serving students

In Moses Lake, a rural district where about 67% of students come from low-income families, eight nurses serve 15 schools; the researchers calculated that each full-time equivalent nurse there serves about 1,632 students. The district has held classes in person for many students since September, offering a window into the pivotal role school nurses play during the pandemic.

“Oh, my gosh — this school year looks totally different than any school year I have been a part of in the past,” said Liz Pray, a Moses Lake school nurse and president of the School Nurse Organization of Washington.

Any time the district learns of a coronavirus case, Pray and her colleagues team up to call families, staff and other contacts. At least 181 Moses Lake educators or students have become ill so far, including Superintendent Joshua Meek. At one point in the fall, Pray helped make the decision to shut down a school for two weeks because of an outbreak.

She hears from colleagues across the state who are responsible for other important tasks, such as taking student and staff temperatures at the door, following up with those who fail a screening and isolating folks who are symptomatic at school.

“I’ve taken food to a single mom with four kids at home who tested positive and had no family in town,” she said. “Yes, we’re stretched thin. You can ask any school nurse across the state and every single one of them will tell you we’re exhausted.”

According to the UW research, on average, each Washington school nurse serves 1,173 students. That ratio has declined from 1,605-to-1 in the 2000-01 school year. For comparison, the American Academy of Pediatrics recommends one nurse per school. In Washington, that would work out to a ratio of one full-time nurse per 482 students, the researchers say.

The researchers calculated nurse-to-student ratios using 20 years of data from the state Office of Superintendent of Public Instruction and the state Department of Health.

Distribution disparities

The role of the school nurses has expanded over the past 20 years, the researchers say. The percentage of children with chronic health conditions is rising, and state and federal laws have increasingly reinforced the role of schools in keeping children healthy.

Nurses play a particularly important role for students of color, who are, on average, less likely than their white peers to have health insurance or consistent access to medical care, according to previous studies. The new work suggests that school nurses are helping close that gap.

Seattle Public Schools, where about one-third of students are from low-income families and more than half are students of color, has 1 nurse for every 774 students, the researchers found.

Highline, where 71% come from low-income families and 80% are students of color, has one nurse for every 736 students. The ratio is 1,211-to-1 in Bellevue and 1,173-to-1 in Kent.

It’s possible that some districts hire more nurses because they serve a greater proportion of students with serious health needs, but the study didn’t look at this question. The researchers also didn’t analyze whether nurses are distributed evenly across schools in a given district.

“It’s a really good place to start, and gives us a broad snapshot,” Willgerodt said. “But we need to remember this is district-level data and there’s a lot of variability within schools and among the students themselves.”

In towns and rural communities, each full-time equivalent school nurse serves between 1,293 and 1,327 students — or about 250 more students than nurses who work in urban areas. Nurses in less populated regions may be more likely than those in urban districts to split their time at several schools, which may be located many miles from one another.

Districts are also likely to have fewer nurses if they serve more low-income students: for every 1% increase in students from low-income homes, the researchers found, the ratio of students to nurses rises by 1.1%.

These disparities illustrate shortcomings in the way Washington funds school nurses. The funding formula provides money for one full-time nurse for every 5,263 elementary students, 7,200 middle school students or 6,250 high school students; the Office of Superintendent of Public Instruction is asking lawmakers to reduce those ratios during the upcoming legislative session.

In most areas the ratios aren’t as drastic as what state money would fund: The researchers say they suspect that state or federal dollars cover a third of the costs of school nurses here, while local levy dollars or other funding streams make up the difference. But districts in lower-income communities don’t have the same fundraising power as wealthier areas, leaving them without the same resources to fill in gaps in state funding, said Trevor Gratz, who led the study and is a research associate at the UW’s Center for Education Data & Research.

“It’s encouraging to see students of color have at least some better measures to access, but then a little bit discouraging that there’s an overreliance on local dollars to fund school services that seems to be driving a compounding access gap,” he said.

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