School nurses increasingly on pill duty

As the school nurse at Coppell Middle School North, Bette Felder is responsible for the health needs, from hearing checks to Band-Aids, of 900 students.

But as soon as the first lunch period ends, her focus turns to pills.

One by one, students file into her clinic, grab paper cups and take their medication from her hand. Then they dart back into the hall, pills swallowed, before Ms. Felder can reach for the next bottle. The process continues for more than two hours until 1 p.m. when – barring emergencies – the clinic goes quiet for the first time since morning.

“This is my typical day,” Ms. Felder said one recent morning, as she searched for one of the more than 100 bottles in her cabinet. “I’m in my seat for a minute, and that’s about it.”

On campuses from Coppell to Chicago, school nurses still tend to tummy aches, paper cuts and other ailments that have always drawn children to the school nurse. But in nearly every school in the nation, surveys indicate, pill duty is now a considerable part of a nurse’s day. And it’s a weighty responsibility.

With record numbers of prescriptions to dole out, nurses now have less time for traditional health services – which, health officials say, are more demanding than ever.

They also face higher stakes for errors.

“In many schools, the nurse is delivering care that used to be delivered only in 24-hour-care facilities,” said Judith Robinson, executive director of the National Association of School Nurses. “It can be really overwhelming. They rarely have time in the school day to do everything they need to do.”

Some states have responded to the school clinic crunch with additional funding, support and regulation for school health services. Vermont recently mandated that school districts have one nurse for every 500 students.

Challenge in Texas

But in Texas – where 30 percent of districts don’t have a registered nurse on staff – local officials must confront the challenge independently. The last state guidebook on school nursing was published in 1989.

The National Association of School Nurses recommends one registered nurse for every 750 students. The national average is one per 1,500 students.

With a nurse serving every 890 students, the Coppell school district is typical among North Texas districts: Although nurses aren’t completely overwhelmed, administrators say, they do feel the pressure of the medication surge.

“There’s definitely a lot more medication expected to be given during the school day,” said Paul Lupia, CISD director of student services, who oversees student health programs.

When Dr. Lupia and his staff of nurses and clinic aides gather at the administration building for their monthly roundtables, medication is one of the most frequently invoked topics. Dr. Lupia tries to stay abreast of developments in school health, he says, so he can keep his staff well informed.

Dr. Robinson of the National Association of School Nurses said many schools around the country, faced with budget crunches, have delegated the administration of medication to unqualified employees: clinic aides, health para-educators, even school secretaries and coaches.

Room for error

Although anyone – including doctors, pharmacists and nurses – can make mistakes, she says, the possibility is higher with uncertified or untrained employees.

“When you have nonprofessional people doing the work, you can end up with questionable results,” Dr. Robinson said. “If you have a very, very dedicated nurse aide who has been trained by a registered nurse, there isn’t much to worry about. But you get a very different kind of result with someone who was hired as a school secretary and didn’t expect to have to work the health room.”

Four miles from Bette Felder’s office at Coppell Middle School North, Jan Sorce runs the clinic at Cottonwood Creek Elementary, the district’s largest elementary school.

As one of the district’s four clinic aides – the rest of the clinics are staffed by registered nurses – she only has basic training in first aid and CPR.

Even so, she does everything nurses do, from teaching sexual development classes to passing out pills. And she does it well, said Cottonwood Creek’s principal, Andrea Penny.

Texas schools have been required to store and administer students’ prescription medication since the state Legislature established the rule in 1974. But until the 1990s, pill duty was a negligible responsibility for school health workers, officials say, because few students brought medications to school.

Ms. Felder can’t speak to the changes in the school nursing profession; she’s only done it since 1998. But she does know about the state of school nursing now, because she experiences it every day.

By 11:45 one morning last week, her sign-in sheet already had 25 names and complaints down the page: “throat,” “feeling cruddy,” “tired,” “feel bad,” “bleeding elbow.” And her medication log had myriad checkmarks beside dozens of pharmaceutical names: Adderall, Ritalin, Claritin.

“When I first started I had no idea it would be so demanding,” she said, in one of the few moments the clinic didn’t have a pack of kids waiting for her help. “I was hoping to be able to teach the kids about wellness and fitness, since I used to be a fitness instructor. But so far, there just hasn’t been any time.”