He's a brown-haired boy with big brown eyes. He's wearing a bright blue oversized sweatshirt. And he's got one giant problem: in gym class his legs bent a little too far in the opposite directions.

No sprained ankles or broken bones resulted. But a pair of pants split down the middle did. "How embarrassing," he mutters.

It's a classic school nurse moment, and Stacy Balmer, RN is prepared to handle it. Like many school nurses, she's got a closet full of replacement clothes for these types of accidents. But she's also working in an age where the responsibilities of her profession seem to just keep getting larger. As the nurse at the 654-student Judith Resnik Elementary School in Montgomery County, Maryland, she tracks 108 children with health conditions ranging from simple allergies to epilepsy. She also spends a couple of days each week at the 552-student Laytonsville Elementary a few miles away.

"A lot of what I have to do is coordinate services and help kids get on track. There's a lot of education and communication with parents going on," says Balmer. Meanwhile, kids continue to fall down, throw up, and run into things just like they always have.

"Every day is really different," she says. "Sometimes it's like a MASH unit—there's just kids everywhere. A lot of it's just little boo-boos, but then there's the recess gashes to the head, like we had last week."

A Changing Legal Climate
Evolving federal laws—particularly the Americans with Disabilities Act and the Individuals with Disabilities Education Act, or ADA and IDEA—have changed the landscape for school nursing. Parents of children with chronic illnesses now have clearer legal grounds for demanding that schools do what's necessary to help their children manage their illnesses while in school.

Bernadette Axelrod, whose daughter was diagnosed with Type 1 diabetes this year, has had her share of concerns about the lack of a school nurse to help treat her daughter at the private Seagull School of Kapolei in Hawaii.

The teachers at the school were willing to administer medication, but school administrators nixed that idea. That's probably a wise position: a University of Iowa study conducted in 2000 found medication errors in schools were far more likely to occur when someone other than a nurse was involved. According to the study, errors included giving an overdose or double dose (22.9 percent), giving medicines without authorization (20.6 percent ), giving the wrong medicine (20 percent) or unspecified mistakes (29.8 percent).

Axelrod and her husband didn't let the issue drop, nor did they move their child to another school. Instead, they educated themselves about the rules of the ADA and the laws protecting their child.

One law that proved especially useful was section 504 of the Rehabilitation Act and Anti-Discrimination Law. It says that no qualified individual with disabilities can be excluded from the participation in any program or activity receiving federal financial assistance. With help from the Hawaii Disabilities Rights Center, the Axelrods confirmed that the school received federal funding.

By the beginning of this school year, administrators at the Seagull School realized that the Axelrods had the law on their side. Six staff members were trained to assist their daughter with her blood glucose checks and her insulin injection, and learned how to administer glucogon—all duties that school nurses regularly perform.

"The reason, I think, for lack of understanding of ADA is that it is practically a full time job to understand any one of these mandates," says David Schoenbrod, a Professor at the New York Law School who monitors the effects of laws on public schools. "School officials must of course comply with many of them and run the schools at the same time."

Expectations Increase, Salaries Don't
When the practice of school nursing began over one hundred years ago, nurses tried to help keep kids healthy, but they weren't dealing with complexities like monitoring blood sugar levels, dealing with diagnosed psychiatric disorders, or developing individualized asthma management programs—all jobs that Balmer regularly performs.

According to the National Sample Survey of Registered Nurses, which is conducted every four years by the Department of Health and Human Services, almost 58,000 registered nurses were employed as school nurses as of March 2000, the most recent survey to date. This figure represents a 22 percent increase over the 47,600 school nurses reported in the 1996 survey.

Despite the increase, the American Federation of Teachers says the figure is nowhere near the number needed to provide proper care for the nation's 52 million students. The organization's position is that without substantial increases in nurses, the duties of administering complex medications and monitoring the children afterward will increasingly fall on the shoulders of school personnel—like teachers—who are ill-equipped to perform these tasks.

National data on how school nurse employment levels were affected by the widespread state budget problems of the past few years will be released in 2004.

"I became an RN at 19 and was a candy striper before that," says Balmer, who's now working in her third decade in the field. "When I was embarking on my career, economics weren't really on my mind, but I think young people today have to think along those lines—You would think, because of the shortage, that it would really be driving up our wages, but I don't think that's the case. The ceiling is kept pretty low.—

Boards of education, public health agencies and private contractors are the main employers of school nurses. According to a National Education Association member survey, health and student services education support professionals, which include school nurses, receive salaries generally far lower than private sector health professionals doing comparable work. Of all NEA members, these professionals tend to remain for the shortest number of years with one school district employer.

Mindy McCartin, who has a Master's degree in nursing and works at Gaithersburg High School in Maryland, has strong feelings on the negatives—and positives—of her situation. "Look, it's actually embarrassing what I get paid considering my education, but it's what we do," she says. "We like working with the kids—many of us have kids ourselves, so it's also of benefit to be able to work on the same schedule as they go to school."

Spread Thin
Laws that govern special education services have meant that more children with chronic health conditions are mainstreamed into regular classrooms. And nurses around the country are realizing that as their responsibilities increase, they need more staff and trained nurses to deliver the necessary services.

Ann Marie Duquette, a school nurse from Kern County, California serves hundreds of special education children with demanding needs. "I've been a school nurse for the past 23 years and I will tell you that I am being constantly challenged more and more."

Since Duquette serves 46 school districts, some of the kids she assists go to school two hours apart. She estimates that she drives about 1,000 miles per month to provide such care as tracheotomy suctioning and tube feedings. In California, the average ratio of school nurses to students is one to 1,418 according to the state's School Nurses Organization.

Specialists such as Duquette serve fewer children with more intensive needs, but they are often spread out among more schools. "It's like ER nursing, but out in the field," she says. "We need more nurses."

In Monroe County, New York, school officials are considering eliminating school nurses altogether to help cope with a serious budget shortfall, according to WROC TV News. There are approximately 40 certified school nurses for the district's 36,000 students.

Susan F. Wooley, Executive Director of the American School Health Association, says that there should be one school health nurse to no more than 750 students in the general school population to provide effective coverage. Both the National Association of School Nurses and the Centers for Disease Control and Prevention agree that schools should strive for that ratio.

A national survey in 2000 found that there are roughly 2,200 students to every nurse in the state of Oregon—three times the recommended number. But in Utah, there is one school nurse for every 6,330 students—the worst ratio in the nation.

A team of health experts recently completed a successful campaign to have the 1:750 ratio included within the objectives of Department of Health and Human Service's Healthy People 2010 initiative. This means that the federal government could play a crucial role in the push for more school nurses in the coming years.

In addition to increasing the overall number of school nurses, Bremer believes that more needs to be done to help nurses keep in touch with each other so they can work as a team to promote children's health. "It's the most important part of being a school nurse," she advises. "If you don't initiate that, then you're kind of sunk because nurses are used to working on a unit and we all have each other to collaborate with. If you don't reach out, you'll eventually feel like you're on an island...That won't work for kids."

Almost 12,000 school nurses are currently members of the National Association of School Nurses, a non-profit specialty organization founded in 1968. Many of them participate in an on-going electronic discussion list on the latest health issues—like the dramatically increasing prevalence of asthma—that are a regular part of being a nurse in the 21st century.

Rather than viewing the increased responsibilities as a hindrance, Bremer says that nurses entering the profession should see them as an exciting challenge. "It's a great field,— she concludes. —You can do a lot of different things, and you are never stuck.— Nurse Duquette agrees with that assessment, but she'd like to have a lot more help—and fast.

• The National Association of School Nurses
• The American School Health Association