In Mississippi, Lack of School Nurses a Threat to Health, Education

GREENWOOD, Miss. — On any given day, school nurse Samaria Stevenson is traveling between at least three schools in this rural Delta town.

She counts the carbohydrates in lunch for a student with diabetes at one elementary school every day, while providing medical care for students at two others. She teaches health classes and presents the district’s abstinence education curriculum to middle school students.

And all the while, she’s bracing for seasonal allergies, the flu and asthma outbreaks.

“I feel like there’s not enough time,” Stevenson said on a recent afternoon as she walked into Davis Elementary School. “There’s so much out there to do.”

The 2,900 students in Greenwood’s six schools are relatively lucky when it comes to health care access at school. The district employs two school nurses, which means students have a better chance of receiving professional care when it matters most, like when serious symptoms related to conditions like asthma appear.

“For asthmatics, time is important,” Stevenson said. “Timing is everything.”

The role of a school nurse like Stevenson is more critical than ever in a state with one of the highest rates of families without health insurance. More than 21 percent of families lack health insurance, more than a three percentage point increase from last year. Yet every day, more than 12,300 students across Mississippi attend school in a district with no nurse. Eleven school districts in the state did not have a school nurse during the 2013-14 school year, according to a report by the state’s Office of Healthy Schools.

Statewide, there is only one school nurse available per 1,138 students, even though The National Association of School Nurses recommends 1 nurse per 750 students in most schools, and one nurse per 125 students in a population with “complex health care needs,” like asthma and diabetes – both common in Mississippi

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Lack of access to a school nurse compounds rampant health issues for children in a state with the second highest child obesity rate in the nation, as well as one of the highest percentages of children who suffer from asthma and have oral health problems.

Only 17 percent of children in Mississippi receive a developmental screening by age 6, compared with the national average of 30 percent. Only about 60 percent of children receive preventative medical and dental care, compared with 68 percent nationwide.

Research shows that poor health related to obesity, asthma and diabetes can hurt school attendance rates and hinder academic achievement. Obese children, for example, are at higher risk of social, psychological and academic problems, including lower math scores, according to one study by researchers at the University of Missouri.

In recent years, the number of school nurses in the state has fluctuated. In 2008, 20 districts were without a school nurse. By 2010, that number dwindled to two districts. By 2011, though, the number of districts without nurses had skyrocketed to 14, which a state report attributes to the “economy and elimination of time limited grants.”

One reason is that many school districts decide they simply can’t afford to have a nurse, said Estelle Watts, the state’s school nurse consultant for the Mississippi Office of Healthy Schools.

Employing a school nurse often comes down to funding decisions by individual districts and how they budget the little money they have. Since 1997, the state has only fully funded schools twice, which means cash-strapped districts have had to cut teachers and skimp on supplies at a time when they are also expected to upgrade technology for new, online exams rolling out this spring.

“It is really dependent on the priorities that the district sets, because there’s no funding,” Watts said. There’s also no mandate in Mississippi that requires a district employ a school nurse, she added. “So that has to be a priority for the school district.”

Some of these districts, like Quitman County in the Delta, are among the most rural and impoverished parts of the state, where access to quality health care is already lacking or too expensive for most residents.

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More than 20 percent of adults in Mississippi can’t see a doctor due to cost, according to data from the National Center for Health Statistics. And even if residents can afford medical care, they often have few options. There are only about 175 medical doctors per 100,000 residents in the state, compared with the national average of 270 per 100,000, according to federal data.

In some of the most rural counties like Quitman, the number drops to 25 per 100,000 residents. The state’s life expectancy rate of 75 years is not only the lowest in the nation, it’s lower than 100 countries including Tunisia, Colombia, and Cuba.

In communities across Mississippi, school nurses can be the most immediate, and at times, the only access a child has to health care.

“Having nurses available to do health counseling is really important because children are more likely to just go to the school nurse and ask about health problems rather than waiting until they see their pediatrician,” said Therese Hanna, executive director at the Center for Mississippi Health Policy.

In recent years, the role of school nurses in the state has evolved in response to an uptick in students requiring assistance with diabetes, as well as an increased need for health education. “First aid needs, temperature checks, those are sometimes the only things that school nurses are associated with,” said Estelle Wells. “But we have students who have asthma…diabetes, seizures,” she added. “A lot of these activities that nurses do can help make sure that students are able to be in school.”

Related: The nutrition gap: A fight for quality food for Mississippi’s littlest learners

A 2013-14 report from the state’s Office of Healthy Schools found that Mississippi’s nurses mostly divide their time between direct interaction with students and teaching classes about topics like hygiene, tobacco prevention, and fitness.

­The role of school nurses has also received more national attention in recent years, especially after two students died from health-related issues at separate Philadelphia public schools that did not have a full-time school nurse. A 2013 survey from the National School Nurse Association found that only 48 percent of the nearly 7,000 school nurses who responded reported working in districts that meet or exceed the national recommendation of one nurse per 750 students.

Some legislation has sought to improve this ratio in schools. In 2013, Rep. Carolyn McCarthy (D-NY) proposed legislation in the House of Representatives that would provide grants for schools to improve the number of nurses in schools across the country. Similar legislation has been proposed in recent years in West Virginia and California.

In Mississippi, school nurses have long been funded by a variety of sources, including state funds, federal money, and tobacco settlement funds. Since 2007, when the state transferred oversight of school nurses from the Mississippi Department of Health to the state’s Office of Healthy Schools in the Department of Education, legislative efforts surrounding school nurses have largely focused on increasing the educational component of a school nurse’s job.

There has not been attention focused on increasing the number of school nurses and funding, or setting a state mandate for the number of nurses available per student. And the inconsistent funding stream has only contributed to unreliable access to school nurses.

Patsy Smith, principal of Enterprise Elementary in eastern Mississippi, estimates that the school has not had access to a regular, full-time nurse for 10 or 15 years. The last nurse the school had was a local mother, who received a small amount of federal funds to handle hearing, vision, and head lice screenings.

She also gave insulin shots to diabetic students and distributed prescription medication to kids with disabilities or asthma.

“It took a little off of us,” Smith said, adding that in the absence of a nurse, she and her small office staff now handle those tasks.

In Webster County School District, which serves about 1,900 students just southeast of Grenada, Superintendent Jack Treloar said the district has been without a nurse for about five years. Teachers now send their students to “sick rooms” where office staff will monitor the child until a parent can pick them up.

“Everybody in our district wears multiple hats,” Treloar said. “We have a whole range of children that we’re dealing with without that medical support,” he added. “If you had that personnel at your school, what a benefit it would be.”

The loss of a school nurse can have far reaching consequences on a district, according to a 2012 report by the Office of Healthy Schools. In the two years that followed the loss of a school nurse, six out of seven Mississippi districts experienced a drop in average daily attendance numbers, according to state data.

A 2009 report from the Center for Mississippi Health Policy found that the majority of students seeking help from a school nurse ultimately returned to class, meaning school nurses “are effective in enabling children to remain in school,” and ultimately ensuring that attendance numbers remain high and funding remains consistent.

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At Threadgill Elementary School in Greenwood, principal Lachada Robie said the biggest benefit of a school nurse is that students can immediately see a health care professional to determine the cause of any health-related symptoms. “We’re not just sending them home when they get sick,” Robie said. “She can reassure them that they’re ok.”

In the absence of school nurses, some nonprofits have stepped in to help. The Clarksdale-based Aaron E. Henry Community Health Services Center has two mobile health units that serve up to 20 schools in Clarksdale and several nearby counties. The center also runs two clinics in nearby schools, where students can see a nurse practitioner, who unlike a school nurse, can diagnose students and write prescriptions for medication.

“For some of the children, this is the only time they get to see a practitioner,” said Jessica Hunt, director of special projects for the Aaron E. Henry center. “For some of them, we’re the only care they receive at all.”

In Indianola, the non-profit Delta Health Alliance has initiated a home visitation program that is mostly meant to help parents, but also includes a health education component.

Karen Matthews, president and chief executive officer of the non-profit said that discussing pertinent health issues, like teen pregnancy and low birth weight babies with parents has been “very useful in improving health outcomes.”

In the Leflore County School District, the Greenwood Children’s Clinic has launched an initiative this year to provide extra medical care to students. This year, two physicians, a nurse practitioner, a dentist and an optometrist will visit students to update immunization, provide screenings, and offer wellness exams.

“We saw that many kids were coming in only because they were sick,” Treva Stigler, a nurse from the Greenwood Children’s Clinic told The Greenwood Commonwealth earlier this year. “They’re not coming in for their annual wellness exam, their preventive care.”

Experts say that that preventative care, and having the chance to receive screenings for things like eyesight, hearing, or Attention Deficit Hyperactivity Disorder (ADHD) can be critical to a child’s future success. “Most of these things aren’t catastrophic, most of them aren’t unfixable,” said Karen Matthews, from the Delta Health Alliance. “But if that particular thing — something as simple as a child needing glasses — if that goes on through the third grade, the child may not have learned to read well enough to pass the reading test, simply because they can’t see the board and nobody knows that.”

[Cross-posted at The Hechinger Report]