School nurse shortage in NC persists during COVID-19, as educators shoulder more of the duties

It’s a rare day when Melissa Lassen doesn’t get a phone call or email from someone trying to recruit her away from school nursing.

“I don’t even know how they get my name,” said Lassen, lead school nurse at Chatham County Schools, laughing. The calls are from recruiters looking to fill varying nursing jobs across the health care industry.

Hospitals can pay more than Lassen’s school district can, and nurse burnout during the COVID-19 pandemic has stressed health care systems’ supply of an already high-demand professional.

North Carolina’s school nurse work force is growing steadily, but not fast enough to more adequately handle the COVID-19 pandemic on top of the duties they were already burdened with, school nurse advocates say.

Last year, when the pandemic began, the state’s traditional public schools employed about 1,400 nurses total, according to state data obtained through a WRAL News public records request. The North Carolina Department of Health and Human Services doesn’t have a tally for the number of school nurses working during this academic year and won’t until this summer.

Just more than half of North Carolina's school nurses work at more than one school. With more than 2,500 schools in North Carolina, that means most schools spend at least some time during a typical school day without a trained nurse available to respond to student health needs. That leaves teachers, administrators and other staff to respond to emergencies, test blood sugar or administer children’s medications. Nurses teach children how to handle their own medical needs, like checking their blood sugar if they’re diabetic.

Only a quarter of the nearly 200 charter schools have a school nurse. That’s an improvement over recent years, but those nurses now serve fewer students, according to DHHS. It’s not clear why. Whether from enrollment drops, reductions in school nurses or changes to where school nurses work — just fewer than 19,000 North Carolina charter school students had a full-time nurse at their school during the 2019-20 academic year. That’s down from about 20,600 four years prior, when less than one in five charter schools had a full-time school nurse.

National recommendations are either for one nurse for every 750 students or one nurse, employed full-time, at every school.

The shortage in North Carolina continues as more students return to daily in-person learning and schools try to curb outbreaks of the novel coronavirus.

School nurses are conducting any screening or testing that schools may require. Many schools have done away with screening but ramped up testing of symptomatic employees and students. School nurses may coordinate vaccination opportunities for employees or conduct contact tracing, which they’ll do any day of the week, even on Saturdays and Sundays when school is not in session. On top of health-related responsibilities, Lassen notes nurses are often also delivering food and paper schoolwork packets to families.

Before COVID-19, they were tending to children who had fallen ill, who had an accident or who needed regular medication or illness management. They’ve often been a trusted source at schools, seeing children in emotional crisis.

One in five North Carolina children receive medical care at school, said Traci Hewes, legislative chairperson for the School Nurse Association of North Carolina. Children may have diabetes, epilepsy or other issues requiring regular medical attention.

Research from the North Carolina Department of Health and Human Services shows the average classroom has two students on medication, two with asthma, one with an attention deficit disorder, one with a life-threatening allergy and one student with a less common health condition, such as cancer.

Lassen, in Chatham County, hasn’t gone anywhere. She already took a $15,000 salary cut, years ago, to work in schools, and she finds the work rewarding and hours more convenient.

Luckily, it’s been a couple of years since Lassen lost any of the eight nurses who work for her.

Lassen herself is still looking to hire for a school nurse position open next year. The districts surrounding her county in the fast-growing Triangle are still trying to hire school nurses for this year, for positions created last fall, she said.

Chatham County’s local salary supplement is probably better than most districts’, Lassen said.

“It has always come down to a money issue,” Lassen said. Federal pandemic stimulus money will increase the number of school nurses nationwide soon, she said, but those may go away when the money runs out.

To reach the recommended ratio of 750 students to one school nurse, North Carolina’s traditional public school districts would need to hire about 500 more school nurses — a 35% increase. To meet the goal of one nurse for every school, those districts would need to hire at least 1,100 more school nurses, about an 80% increase.

A study published in 2018, by the state General Assembly’s Program Evaluation Division, said the state would need to spend $79 million more per year to reach the ratio of 750 students to one school nurse.

During the 2019-20 school year, 61 of North Carolina’s 115 school districts met that ratio or better. Wake County Public School System, the state’s largest district, had a ratio of 1,693 students per school nurse. While one of the worst ratios statewide, it’s far better than the 2,517 students per school nurse a decade ago, during the 2010-11 school year.

The 2018 study showed only five North Carolina school districts had one nurse in every school.

Education advocates call for more funding for school nursing positions, contending that the nurses are sorely needed.

At the same time, filling those positions is challenging.

Part of the problem is at the higher education level, experts say.

For the 2019-20 academic year, colleges turned away 80,000 applicants from nursing programs, according to the American Association of Colleges of Nursing. That’s because of a lack of faculty and clinical opportunities for students, among other things.

The association contends nursing schools aren’t graduating enough students to meet the demand for nurses and cites research warning of an eventual shortfall of hundreds of thousands of nurses nationwide, hurting the fast-growing South and West regions the hardest. It notes efforts to address the problem by medical schools forming partnerships with health care entities to expand student opportunities and capacity and providing incentives to nurses to teach.

In North Carolina, lawmakers have targeted simply funding more school nurse positions.

Democrats filed a bill last month to use $102 million in recurring state funds to hire a nurse for every school.

After funding the positions, the state will find out whether pay or graduates are barriers to hiring and to what extent, said Sen. Wiley Nickel, D-Wake, a sponsor of the bill.

The bill hasn’t yet been discussed in committee.

It’s a no-go for Republican lawmakers. Party leadership, who favor tax cuts and increasing state reserves, tout the steady improvements in the students-to-nurse ratio statewide and contend Democratic spending is too unwieldy.

“Republican policies have resulted in methodical improvements in the nurse-to-student ratio for the past decade,” Sen. Brent Jackson, R-Sampson, said in a statement sent to WRAL News. “Reasonable people can and will disagree on the pace of that improvement, and I welcome that.”

Jackson is chairman of the Senate appropriations committee.

Democrats contend the state has the money; it just isn’t spending it.

“It really just comes down to how we spend our money,” Nickel said.

Sen. Sarah Crawford, D-Wake, said the issue is about more than the COVID-19 pandemic or even students’ physical well-being.

One of her daughters frequented the school nurse’s office, complaining of stomachaches. The nurse informed Crawford about her daughter’s visits, and suggested she suffered from anxiety. It turned out, her daughter simply wasn’t reacting well to her teacher’s recent absences.

“It didn’t end up being a medical issue,” she said. “It ended up being an emotional issue.”

The push for more school nurses aligns with Democrats’ larger goals to increase counseling, social work and psychologist staffing on campuses, Crawford said.

Nurses say pay is one of the biggest barriers to hiring in the profession.

School nurses can make from about $36,500 annually to about $62,700 annually in North Carolina, in base state pay, said Hewes said.

School nurses must earn national certification within three years of beginning work at a school. Upon certification, the nurse is eligible for the local certified salary supplement.

The National School Nurse Association notes that average pay nationally for a school nurse is about $64,000 to $67,000, based on studies done in 2013 and 2010.

Compared to Chatham County Schools, Lassen said, hospitals will pay a nurse 10% to 15% more.

A possible temporary solution to the need for more school nurses is using nurse extenders, according to the School Nurse Association of North Carolina Association.

That’s when a licensed practical nurse, certified nursing assistant or unlicensed assistive personnel provide direct care for students. Those extenders are supervised by the school nurse, who must be a registered nurse to do so. Because of the supervision requirement, the organization doesn’t believe it’s a practical permanent solution.

According to Lassen, schools can help retain nurses by making their jobs easier. She recommends using electronic record-keeping, instead of handwritten records, and other modern technology. Many school districts keep records by hand and not electronically.

Offering a steady position also helps, she said.

Chatham County Schools for months was unable to hire temporary or part-time nurses without benefits, Lassen said, so the district combined resources and was able to hire someone.

“I see a lot of school districts trying to hire contract nurses,” Lassen said. “I just think it’s really hard to hire nurses part-time or even contract-type nurses into positions, because it was actually when we listed two of our positions as permanent position is when people actually started taking an interest in the positions.”

Lassen said she’s fortunate Chatham County Schools saw a need for more school nurses. Leadership recognized the workload increase caused by COVID-19, and teachers and administrators who saw the workload explode and were impacted by it asked for it, she said.

“It’s hard to ask an administrator to do medical things when they don’t know how to do it,” she said.

For the first time, next year, Chatham County Schools will have two nurses working full-time in schools across the district. The district has never had a nurse assigned to full-time to a single school.

The district’s ratio of students to school nurses has dropped from more than 1,300 to 1 to about 1,000 to 1. The addition of two more nurses next year will drop it to just more than 800 to 1, if enrollment bounces back to what it was during the 2019-20 school year, of just under 9,000 students.

Statewide, the ratio has improved from about 1,200 to 1 during the 2010-11 school year to about 1,000 to 1 last year. The number of school nurses has risen from 1173.5 — a figure including full-time and part-time nurses — that year to 1,398.77 last year.