There are so few nurses in North Carolina's public schools that a new state report says it could cost an additional $45 million to $79 million a year to help meet student health needs.
There's one school nurse for every 1,086 students, according to a state legislative staff report, meaning the majority of student medical needs have to be met by non-nurses. The report said it could cost $45 million a year to get to a ratio of one nurse for every 750 students and could cost $79 million annually to ensure every North Carolina public school has a nurse.
That money could come from the state or also from county governments, which provide 45 percent of the annual funding for school nurses. The amount needed to have a nurse available to every student could be closer to $65 million a year instead of $79 million based on the number of schools that are on the same campus that could share a person.
"We don't take a stand on how the cost should be divided," Sara Nienow, a principal program evaluator for the legislature's Program Evaluation Division., told a legislative committee on Monday. "That's simply what the cost is should entities choose to somehow work together to achieve a nurse at every school."
It's unclear how much and how soon legislators could boost state funding for school nurses. Rep. Nelson Dollar, a Republican from Cary and lead budget writer, said they'll also be balancing other requests for increased funding this year.
"We need to see what funding is available and if there are any recurring dollars," Dollar said after the meeting.
For now, a legislative committee is considering a proposal to revise the state's recommended student-to-nurse ratio and to place nurses in the schools that have the greatest needs.
State lawmakers had their legislative staffs analyze the need for school nurses. The state funds 48 percent of the $91.6 million annual cost for nurses.
The report presented Monday found that the duties of school nurses have increased over time even as the state hasn't met state and national targets for the number of nurses.
It's more complex being a nurse now, according to Nienow, because they're dealing with an increased number of student health issues. More prematurely born children are surviving infancy, which has led to an increase in the number of students with moderate to severe disabilities.
Schools also dealt with a 75 percent increase in student chronic health conditions such as asthma, diabetes and food allergies from 2002 to 2015.
Nienow said school nurse workloads are increasing as they deal with more families in poverty who lack transportation. More than 8,300 home visits were made by school nurses during the 2015-16 school year .
"Families without reliable transportation for instance may rely on the school nurse to determine if their child is ill, because they're unable to get to a doctor's office," Nienow said. "Communities with high rates of poverty or a lack of public health awareness may have student hygiene issues such as bed bugs, lice or a lack of toilet training."
In the face of these growing health needs, there were 1,318 nurses statewide serving 2,313 schools in the 2015-16 school year. The lack of nurses meant that 22 percent of them served three or more schools.
In 2004, the State Board of Education set a goal of having one nurse for every 750 students by 2014. In addition to falling short statewide of the goal, 69 of the 115 school districts also don't meet the ratio of one nurse for every 750 students, the report found.
In Wake County, the state's largest school system, the current ratio is one nurse for every 1,725 students. The ratio was one nurse for every 2,300 students in 2013, prompting the Wake County Board of Commissioners to hire more nurses.
There will be 102 nurses in 180 Wake County schools this fall.
"There are not enough nurses to go around for every school," said Donna Daughtry, Wake County's school nurse program coordinator.
The National Association of School Nurses recommends having a registered nurse at every school.
The lack of nurses, according to the report, means the state's education budget is helping subsidize health care costs when school personnel other than nurses perform health care services. Nienow said 60 percent of school medical services are not performed by nurses.
The report found that 76 percent of medication given to students is performed by non-nurses such as secretaries, teacher assistants, principals and assistant principals. Nienow said this cost the state's educational budget the equivalent of $15 million a year.
"This means that the equivalent of 331 education positions tended to the health needs of students instead of performing educational duties," she said.
The report has several recommendations:
- The State Board of Education should update the school nurse staffing standard.
- The state Department of Health and Human Services and the state Department of Public Instruction should plan to combine the two state-funded school nurse programs and implement a plan that provides nurses based on school needs.
- DHHS should examine the Medicaid rates for school nursing services.
- DHHS should request a Medicaid State Plan Amendment to authorize reimbursement for services on Individual Health Plans and 504 plans.