Published Online: June 2, 2014
Published in Print: June 4, 2014, as Pupil's Death Renews Calls for School Nurses

Philadelphia Tragedy Highlights Role of School Nurses

Pallbearers dressed as superheroes carry the casket of 7-year-old Sebastian Gerena at his funeral last month in Philadelphia. The boy, who had a rare heart defect, died after collapsing at a South Philadelphia public school that had no full-time nurse on duty.
Pallbearers dressed as superheroes carry the casket of 7-year-old Sebastian Gerena at his funeral last month in Philadelphia. The boy, who had a rare heart defect, died after collapsing at a South Philadelphia public school that had no full-time nurse on duty.
—Alejandro A. Alvarez/The Philadelphia Daily News/AP

Tragedy resonates beyond Philadelphia

The death last month of a Philadelphia elementary student who fell ill at a school that did not have a full-time nurse on duty has reignited debate in the city and nationwide over the importance of school nurses and the reasons why they are among the first to go when money becomes scarce.

Sebastian Gerena's death has been attributed to a congenital heart defect, but that hasn't stopped some from wondering whether the outcome would have been different if a full-time nurse had been stationed at the school. The student's death came eight months after Laporshia Massey, 12, died after an asthma attack at a different Philadelphia public school that also did not have a full-time nurse.

The two deaths have led some parents and residents to call for an end to years of budget cuts that have reduced the number of nurses in the district from 289 in 2011 to 179 in the 2013-14 school year, according to the local union.

The 7-year-old passed out at Andrew Jackson Elementary School on May 21, and a retired nurse who had been volunteering in the school library at the time performed CPR on the boy. He was pronounced dead later that day at Children's Hospital of Philadelphia.

Superintendent William R. Hite drew a connection between the tragedy and the district's current financial predicament when he released a statement after the boy's death. The district's $2.49 billion operating budget for 2015 has a gaping $216 million deficit, and, without extra money, thousands of workers—including more nurses—could lose their jobs.

The incident, Mr. Hite said, "illustrates the serious needs and challenges that our students, teachers, staff, and principals face every day.

"During times of tragedy, our community should not have to question whether an extra staff member or program would have made a difference," he said.

Resources for Learning

Helen Gym, the co-founder of Parents United for Public Education, a local advocacy group made up of parents and residents. She says students are entitled to all the resources they need in order to learn, including a nurse in every school.

"There should be a basic level of guarantees when a school opens, and it should not be enrollment-based," Ms. Gym said. "It should be absolutely based on what we know students and young people need, period, and among them is clearly health care."

School nurses treat injuries, monitor students who need to take medication during the day, and help manage those with chronic illnesses, such as asthma and diabetes. They create classroom plans to accommodate students with special learning needs, conduct state-mandated screenings, such as for vision problems, and supervise children with behavioral health issues. And they are involved in schoolwide health initiatives and in crafting school health plans.

"It's not just the stomachaches and headaches anymore," said Cheryl Peiffer, the director of the Pennsylvania Association of School Nurses and Practitioners.

Economic Payoffs

The value of full-time, registered school nurses is not limited to the medical assistance they provide; there is also an economic benefit to society, according to a study published last month in the Journal of the American Medical Association.

Researchers studied 78 Massachusetts districts that participated in the state's Essential School Health Services Program during the 2009-10 school year to demonstrate the benefits of having a full-time registered nurse on staff. The program cost $79 million, but researchers estimated that it saved $20 million in medical-care costs; $28.1 million in parents' productivity loss; and $129.1 million in teachers' productivity loss, generating a net benefit of $98 million.

Despite their medical and economic value, nurses are often among the first to go when districts face budget constraints because not every state requires a nurse to be in every school building, according to experts in the field. The U.S. Department of Health and Human Services recommends a ratio of one full-time, registered school nurse to every 750 students. The National Association of School Nurses suggests a lower ratio for schools with high numbers of students with special health needs, chronic illnesses, or developmental disabilities.

But in a 2013 survey of nearly 7,000 school nurses by the National Association of School Nurses, only 48 percent of respondents said they worked in environments that met or exceeded the federal recommendation—an improvement over 2011, when 43 percent met or exceeded that standard.

In the 2013 survey, 21.7 percent of the responding nurses reported that they covered several buildings and thus trained unlicensed co-workers to perform daily routines. And 16.2 percent of respondents said school nurse jobs in their areas had been threatened by cuts. Nearly 6 percent of nurses surveyed said other nurses in their district had been cut.

In Pennsylvania, public school districts, which also provide nurses for private and parochial schools, cannot exceed a 1-to-1,500 nurse-to-student ratio, according to state law.

Professional Training

It's not that school administrators don't value what nurses bring to the table, the issue is one of limited funds versus educational priorities, and school nurses often are not seen as educational priorities, said Sue Buswell, the director of the Montana Association of School Nurses. In her state, which has no ratio set in law, there is one registered school nurse for every 1,985 students.

"They just don't recognize what the need is," said Ms. Buswell. "And the need is for a registered professional school nurse because a registered professional school nurse is the only person that has the education, the training, and the skill level to meet the needs of kids in the schools."

The American Academy of Pediatrics takes the position that school-based health services should be provided by registered nurses with special school-nurse training. And nurses said that more errors are likely to occur—particularly during the administration of medicine—when an unlicensed individual takes the helm. When a nurse is located in one school with a smaller group of students, he or she is better able to detect potential chronic issues, such as poorly treated asthma, or to be involved in preventive health plans, said Beth A. Mattey, the president-elect of the National Association of School Nurses.

As districts search for solutions, Ms. Mattey suggests partnerships between districts and community organizations and health-care providers. The school nurses' association has also advocated for Medicaid reimbursements to cover care provided by school nurses and staffing by local health departments.

Around the country, some districts are using nurses whose salaries are paid by local hospitals, which grant them access to medical records of chronically ill students. In Montana, county nurses help to ease the school nurse shortage, but they can only do a small part of what a full-time school nurse would do, said Ms. Buswell. Ms. Peiffer, from the Pennsylvania School Nurses Association, said that her group has been lobbying the state legislature to lower the nurse-to-student ratio, but that each time, the group has hit the same roadblock: money.

In Philadelphia, 90 of the district's 214 schools have full-time nurses. The rest are assigned nurses on a part-time basis. Andrew Jackson Elementary, where the young boy collapsed, has a school nurse scheduled every Thursday and every other Friday, said Fernando Gallard, the district's spokesman.

Political Issue

Eileen McCafferty DiFranco, a full-time nurse at Philadelphia's Roxborough High School, said that she thinks having a full-time registered nurse on staff would have helped during the two recent tragedies. Ms. DiFranco said in the incident last year, when the 12-year-old girl died, a nurse would have further investigated the child's complaint using a stethoscope to check for distress.

"I would bet my life that nurse would have called 911," Ms. DiFranco said.

The issue in Philadelphia is also political. After the most recent death, the local, state, and national presidents of the American Federation of Teachers, which represents the nurses, sent an open letter to Pennsylvania Gov. Tom Corbett decrying the reduction in nurses during his tenure and asking him to fix a system they said he had broken through his budget cuts.

Gov. Corbett, a Republican, shot back that the unions were politicizing the tragedy for their own "self-serving" agenda.

Without local funds, some districts and nurses are looking to Washington for financial assistance.

For years, U.S. Rep. Carolyn McCarthy, D-N.Y., who is a former nurse, has unsuccessfully pushed to create a grant program to help school districts lower the nurse-to-student ratio.

Related Blog

Last month, Sen. Jon Tester, D-Mont., filed a similar bill in the Senate that would allow schools to apply for federal funds to assist in hiring school nurses.

Ms. Buswell said she was encouraged by Mr. Tester's bill. She is hoping it will pass and that the grants will filter down to their districts, Ms. Buswell said.

"It's all about what the kids need," she added, "and how can they attend schools, be healthy, and learn. Health and education go together: If a child is not healthy, he can't learn."

Vol. 33, Issue 33, Page 7

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