"Before 2011 We Were Able to Get Our Jobs Done": Philly Nurses Explain the Impact of Budge

The Impact of Budget Cuts on Philadelphia School Children- City Council Testimony from Margaret Devine, CSN, Lincoln High School

My name is Margaret Devine, I am the Certified School Nurse at Abraham Lincoln High School. I currently serve on the Executive Board of the Philadelphia Federation of Teachers. I am a member of the School Nurse Practice Committee and the Committee of Professional Standards for the School District of Philadelphia. I am a member of PASNAP, the Pennsylvania Association of School Nurses and Practitioners and the National Association Of School Nurses.

I am here today to discuss the impact of the budget cuts to school nurse service in Philadelphia and the effects these cuts have had on our most precious resource, our children.

School Nurses in PA are licensed and are required to hold professional certification in accordance with the Public School Code which was enacted in 1949. Certified school nurses or CSN’s are responsible for addressing the physical, mental, emotional and social health needs of the children enrolled in public and parochial schools in Philadelphia, with a goal of having students present in class, healthy and ready and able to learn.

The CSN provides school-based services to all students not just students who are covered by health insurance companies. CSN’s perform mandated health screenings that are required under the Public School Code including growth and vision screening for kindergarten through 12th grade annually. Screening for hearing is done for grades K through 3, 6th and 9th grades and scoliosis screening is done on 6th and 7th grade students. The state mandate also requires school nurses to plan for and administer first aid services and to instruct personnel who are responsible for administering first aid in the absence of the school nurse.

In 1975 when US congress passed the Education for All Handicapped Children Act, the role of the Certified School Nurse became even more essential. I.D.E.A. guarantees all children with disabilities a free and appropriate education in the least restrictive environment. Today’s CSN’s duties include many nursing procedures beyond just administering oral medication, such as blood glucose monitoring and insulin administration, providing rectal valium, and medication administration via nasogastric or gastric tubes, tracheostomy suctioning and urinary catheterization to name a few. The nurse develops Individualized HealthCare Plans for each medically fragile student. The nurse collaborates with the faculty and staff to remove barriers for these students. This may include creating a 504 Service Agreement to provide accommodations for these students who are protected under the Office of Civil Rights or participation in the writing of the Individual Education Plan with the necessary medical and nursing components included.

School nurses maintain confidential health records for every student. These records include past medical and surgical history, any known allergies, and any medications the student is taking. Gathering the health information includes documentation of physical examinations which are required by law upon entering school, entering middle school, and entering high school. Monitoring and documentation of the immunizations each child has received is recorded and this information is also shared with the State Department of Health annually.

The State of PA requires school districts to hire a Certified School Nurse for every 1500 students. Please remember that this law was enacted prior to I.D.E.A. and the inclusion of individuals with disabilities in the least restrictive environment. The National Association of School Nurses recommends a ratio of one nurse for every 750 students. In Philadelphia, this ratio was maintained prior to the lay offs of 2011. At that time, Philadelphia was nationally recognized for the excellent compliance of required immunizations. Today our immunization compliance is much lower. If the nurse is not in the building when students are registered there is a much greater chance that the student is allowed to enter school without being properly immunized.

Our most fragile children are receiving inconsistent care from non medical staff who have been given basic instruction on how to keep them safe. Any principal is capable of walking into a classroom and teaching because of their educational background. The same cannot be said when they are expected to act as the nurse in the building because they do not have the same skill set. Yet since the budget cuts, they are expected to handle all emergencies and administer medications when the nurse is assigned to a different building. In the absence of the nurse, medications are sometimes mismanaged.

Students may be given asthma inhalers without a nursing assessment to determine if the medication is in fact indicated. The risk of medication errors increases, especially missed doses and far too often there is no documentation that the medication was given and who administered it. Students who are assessed by the CSN are often able to remain in school after receiving a dose of acetaminophen or ibuprofen but these same students are sent home in the absence of the school nurse. The most tragic example of what can occur when the nurse is not present is all too familiar to the CSN’s in Philadelphia. LaPortia Massey, who died as a result of an asthma attack, spent much of the day in the school office, where there was no nurse assigned that day. She was waiting for someone to recognize her distress and care for her. A nurse would have listened to her lungs with a stethoscope and immediately recognized the danger. Today, far too frequently students are sent home with minor illnesses and principals will err on the side of caution and call Fire Rescue to escort a child to the hospital for care that could have been handled by the school nurse. This places an unnecessary burden on the EMS system and parents are strapped with exorbitant bills for the service.

Another direct result of having these unfair budget cuts is fewer staff to monitor the lunchrooms, halls and recess yards leading to more injuries sustained by students who have less supervision. This causes an increase in the visits to the health room. Consequently, increased visits to the nurse result in less time to perform mandated screenings; difficulty in management of health records; difficulty monitoring immunization compliance and inadequate time to accomplish health-related teaching among other vital tasks.

Another population that is unduly burdened by the budget cuts are the diabetic students. The diagnosis of diabetes is devastating to families. The number of cases of this life threatening condition has risen dramatically and these students deserve the protection of a Certified School Nurse all day everyday while in school. The school district has opted to provide outside agency visiting nurses to come into the schools on a part-time basis and monitor the blood sugar of these fragile students, they count the carbohydrates the child has eaten and administer insulin accordingly. The risk of the agency nurses not showing up is very real and when they do come there is no consistency and as a result no relationship develops between the child and the nurse. As a result, subtle changes in the child’s affect or behavior that would be seen by the CSN are often missed. The practice also makes a very dangerous assumption that the diabetic student will have no variation in blood sugar levels when the nurse is not present. Another undesirable alternative being offered to families is to have their child transferred to a school farther from home where there is a nurse present everyday. This is unacceptable to families who have already devastated by the diagnosis along with all of the other life changing consequences this disease brings.

Working with community partners such as the Eagles Eye Vision Program and Oral Health Impact Project have seen reductions in the number of students served because when the school nurse is not present in the building they are unable to coordinate these services as effectively.

When the nurse is not in the building and they are unable to participate in IEP and 504 meetings for medically fragile students, the vital input regarding the student’s health history is often missing. Case management is challenging when a nurse is responsible for 1500 students on a daily basis and when these students are spread over multiple buildings it is next to impossible to provide safe care.

As certified education specialists, school nurses are also charged with developing health and wellness programs for their schools. This is virtually impossible to do with the current staffing ratios.

Our children need and deserve so much more. I respectfully ask this committee to heed the recommendation of the National Association of School Nurses to seek adequate funding to provide a certified school nurse at the ratio of 750 students to one school nurse.

City Council Testimony from Eileen Duffey, CSN, Palumbo High School and Stearne Elementary

Good afternoon,

My name is Eileen Duffey. I am a certified School Nurse at the Academy @ Palumbo and the Allen M Stearne School in Frankford. I have worked as a pediatric nurse for over thirty years, 21 in the school district of Philadelphia. My prior experience includes 15 years working at Children's Hospital of Philadelphia and the University of Pennsylvania.

I thank you for inviting me here today to discuss the impact of the budget cuts on essential services to our vulnerable student population.

In many regards the information school nurse Peg Devine and I provide today is not new.

We, among other nurses, have remained the consistent outspoken proponents for the rights of our students to a certified school nurse from the moment the nurse layoffs took effect in December of 2011.

We have done so in op-eds, letters to the editor, on the radio, at community meetings, in a photography exhibit, at weekly rallies for 6 consecutive months, and at countless School Reform Commission meetings. We brought national attention to Philadelphia school children's unmet needs when a child died as a result of an asthma attack that occurred in a school where no nurse was on duty.

We nurses have advocated for our students at risk to our jobs as speaking up has put us at odds with the school district administration. It can be reasonably stated that we have left no stone unturned in our persistence in advocating for our student's rights to essential school health services provided by certified school nurses.

I have been requested to speak on the impact of the reduced funding on the services my colleague described a few minutes ago. While much warranted handwringing has occurred regarding the times there is not a nurse in the school, I would like to make it clear that the doubling and sometimes tripling of our caseloads (up to 1,500 students to each nurse) has wreaked havoc on the quality of service each nurse provides on the days the nurse IS in the building, Each school nurse finds herself in a professional double bind situation in which doing one essential service results in not providing another essential service. Hence, mandated screenings may get done, while non-compliant immunization follow-up calls do not get done. Chapter 15 504 service plans may get done, while mandated physicals do not get documented.

Documentation of myriad visits to the health room simply cannot be comprehensive, leading to poor records and leaving the district open to medical liability.

Most school district nurses agree that it takes about three years for a qualified certified school nurse to reach her stride after leaving a clinical setting in which a medical model is used and entering a school setting in which she is the only medical professional in the building. Long before the draconian budget cuts we nurses commiserated about the responsibility we felt in adequately addressing the mandated professional duties enumerated by my colleague earlier today. We had professional meetings several times a year in which we shared best practices, honed our skills, and supported one another in our difficult but rewarding jobs serving Philadelphia's children. Our passion for this work is unmatched.

But, let me be abundantly clear here. Before 2011 we were able to get our job done.

Before 2011 our quality, Philadelphia's school health program was nationally recognized. In fact, prior to the 2011 budget cuts school nurses were rarely in the news precisely because adequate, well functioning school nurse services did not constitute a newsworthy topic.

In spite of our vigilance, perhaps because of our persistence the School district of Philadelphia administration has sidestepped the school district nurses on numerous occasions in their attempts to provide school health services on the cheap.

Bureaucrats who ARE NOT professional certified school nurses have on numerous occasions suggested simplistic, half-baked solutions to meeting what they perceive to be the health needs of Philadelphia's children. Time and again their "shoot from the hip" solutions ignore the Pennsylvania School Code and the complicated needs certified school nurses are ably prepared to meet.

I would add that medical professionals, however prestigious their pedigree, who do not hold the school nurse certification are NOT the appropriate persons to weigh in on issues of school health. As a case in point, no one here who suffered a brain tumor would seek the expertise of an orthopedic surgeon to perform a delicate brain surgery.

One of the solutions put forth by non-experts is to think an "innovative" idea is to engage in partnerships with area universities. This idea is not innovative at all. In fact, long before the word "partnership" became code for abdication of financial responsibility, school health services have been engaged in university partnerships to supplement health related services in our schools. No partnership can be effective when engaged without the direct cooperation of the school nurse. All partnerships require more, not less, work on the part of the school nurse. Current partnerships such as vision and dental are experiencing the jarring recognition of this fact as they seek to provide services in schools without a nurse on site.

If I can leave you with just one realization after hearing my remarks today, please disabuse yourselves of any thoughts that vital school services can be done by any one other than a certified school nurse and school nurse services should be reinstated to the 750 to one ratio during the next school budget.

Thank you for inviting me to speak to this assembly today.