Facing shortages, Oakland school nurses concerned about meeting student health needs

The sun is just coming up over Pacifica and the cars on the road still have their headlights on. School nurse Danielle Schaefer is already awake and moving quickly through a familiar morning routine. Coffee with vanilla creamer to go. An expensive travel mug to keep the coffee warm for hours—she never finishes it before noon. Leftovers for lunch—even though she knows she isn’t likely to have time to eat it. An already-packed wheeled bag sits by the door, stuffed with vision and hearing testing equipment and medical books and files.

Schaefer has to leave the house by 7:00 this morning—7:15 if she’s pushing it, as she often does. Traffic means her commute to Oakland will take at least an hour. She will drive close to 100 miles before the day is over. She kisses her 6-year-old son Brayden good-bye, leaving him in the care of her parents, who are still upstairs sleeping. Now, in the quiet of her car, she can turn her attention to the more than 1,400 other children she worries about every day.

Schaefer works for the Oakland Unified School District (OUSD). She is one of just 21 registered nurses looking after the health needs of almost 37,000 students across district-run public schools.

There are supposed to be 31 nurses. That’s what the budget says. But months into the 2018-2019 school year, the district is still trying to fill the vacant positions. The total number of district nurses has been steadily declining, but this is the fewest they have had in at least ten years. The union-contracted caseload for school nurses in the OUSD is one nurse for every 1,350 students. Many nurses, including Schaefer, have a caseload that exceeds this ratio.

The situation has the nurses worried. Last year, in a letter addressed to the superintendent, board of education, and executive director of Community Schools Student Services, a dozen nurses warned the district of “a grave situation which endangers the safety of all students in Oakland public schools.” The nurses wrote that the problem isn’t just the number of kids they’re responsible for; it’s also the acuity of their health needs. “Nurses are on the front lines of helping students with mental health conditions, chronic food insecurity, housing insecurity, violence in the home or community, trauma, behavior issues, access to services, languages and cultural barriers, and poverty,” they wrote.

With so many kids and so few nurses, there are so many things that can go wrong, says Schaefer. Students with severe allergies need access to an EpiPen, an injection of epinephrine that can reverse the symptoms of anaphylaxis. Will someone at their school be trained to use an EpiPen? If a student has an asthma attack, will someone be able to find their medication? Will a student with diabetes go into shock if no one can find their supplies? “We can’t physically keep taking on this work. Because it’s not a matter of ‘if’—it’s a matter of ‘when’ something’s going to go wrong,” says Schaefer.

Administrators in the district office have heard the concerns of the nurses, and say they’re doing what they can to combat the nurse shortage. Barbara Parker, Health Services Coordinator for the OUSD, says the district is still holding onto the $500,000 allocated for nurses in the budget—an indication, she says, that “this district values nurses.” Parker says the district’s human resources department is recruiting as quickly as they can, and has just hired two new registered nurses. “Are we satisfied with that? No,” Parker says. “We want more nurses.”

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For nurses like Schaeffer, the staffing shortage means workdays serving students at multiple campuses. When Schaefer arrives at school, the sun is already up over Garfield Elementary in Oakland’s San Antonio neighborhood. She rolls her bag and carries a district-issued laptop and two oversized totes into her office. This is the only school where Schaefer has her own office. On Mondays, she’s scheduled to be at Fruitvale Elementary, where her working space isn’t much bigger than a closet. Tuesdays, she’s at Garfield. Wednesdays, she is at Garfield for the morning, then onto bi-weekly team meetings at another site. Thursday is her special education day when she travels between schools completing the medical assessments for Individualized Education Plans (IEPs), written plans for students with disabilities or special education needs. Fridays, she goes to Urban Promise Academy, where she works in a former teachers’ lounge, and people are constantly going in and out.

On this Tuesday, she sets her bags down by her desk and gets to work on a stack of papers. Her plan is to do vision and hearing tests—she’s responsible for the state-mandated tests for roughly 400 kids at Garfield. Before the nursing shortage, nurses would team up and do a whole school in two days. This year, she’s already been doing tests for a month, and still has four kindergarten classes and a special education class left to go. Those will likely require help from other nurses or Health Services staff.

As Schaefer looks through her packet of vision and hearing referrals, Barbara Holden walks into the office. She’s a 504 technician aide, whose job is to support students with disabilities while they are at school—and to support Schaefer. Section 504 is part of the Rehabilitation Act of 1973, a federal law that prohibits discrimination against a person because of a disability. Holden performs certain medical procedures, like catheterizations, and helps with gastrostomy tube (G-tube) feedings for students who have trouble eating and get liquid nutrition through a tube inserted into their stomachs.

As they update each other on what they’ll need to do today, Schaefer fills her partner in on what happened last week—she got pulled from her usual coverage to another school, where the nurse was absent, to help a diabetic student who needed insulin injections. Later that day at a different school, Schaefer was asked to assist with a G-tube feeding, which can take up to an hour. Being called in unexpectedly to cover for someone else is a common occurrence for Oakland school nurses. There are no substitute nurses, so they have to cover one another.

Caught up, Schaefer turns her attention back to the vision and hearing tests. Over the course of an hour, she rotates students from different classrooms into her office. They read letters on a chart as she points to them. They raise their hands if they hear a beep from an audiometer. Some students are nervous, hoping they won’t need glasses. Others forgot their glasses at home and Schaefer reminds them how important they are. She hopes to get enough referrals to bring a larger vision program to the school, which can provide some low-income students with glasses.

“That’s 50 kids who would have not had glasses or had those resources, and it impacts everything. Their academics—they wouldn’t be succeeding very well if they can’t see,” Schaefer says. “The small things you’re able to do make a big difference and go a long way.”

At 11:15, Schaefer packs up her things and drives across Oakland to McClymonds High School, as she does each morning. She does diabetes coverage for a student there, which entails checking the student’s blood sugar levels and giving him insulin, if needed. While procedures like catheterizations can be done by 504 technician aides or paraeducators, who provide classroom assistance to students with disabilities, a diabetes check must be done by a nurse. But McClymonds doesn’t have a nurse, so the job falls to Schaefer.

Oakland’s school nurses are broken into teams based on geographic areas, so they can cover as many schools as possible. McClymonds, which is located in West Oakland, should be part of Team 1 coverage. Schaefer’s actually on Team 2, covering the area just east of downtown and the Fruitvale and Maxwell Park neighborhoods. But she says all the other nurses on Team 1 are already overloaded with diabetes coverage. Schaeffer says she initially volunteered to cover McClymonds—for two days. But now, due to the shortage, she’s been tasked with doing it for the entire year.

McClymonds is one of the district’s 30 “red schools”—what the nurses call schools without a dedicated nurse. The students at those schools receive some services: nurses come to do IEPs, diabetes coverage, and vision and hearing tests. But they don’t have a dedicated nurse for medication checks and monthly monitoring for students with chronic health conditions.

According to information gathered by the nurses for their letter to the district, the number of nurses in the OUSD has been on a steady decline since at least 2011. That year, there were 41 nurses. By 2016, they were down to 32. Since then, there’s been a large drop-off—26 last school year and 21 at the start of this year. While the two new hires bring them up to 23, that still leaves the district with fewer nurses than at any time in recent memory.

Parker from Health Services says some reasons for the decline are outside the district’s control. Some of those departures were due to retirements or nurses deciding to work closer to where they live. Others were due to industry competition. “When they have an increase in hiring in the hospitals,” Parker says, “we seem to see the dip or the decrease of nurse applicants for school nursing positions.”

Part of the appeal of nursing jobs in hospitals is the salary. Nina Fekaris, the president of the National Association of School Nurses (NASN), says that nursing shortages like the OUSD’s often aren’t caused by a lack of nurses—it’s the lack of an “ability to pay.”

Fekaris says hospitals have a distinct advantage over school districts when it comes to pay—and that difference matters. “I think if you’re not able to attract school nurses, it’s because your salary is that much lower than what they can get competitively in a hospital,” Fekaris says. “Salary is number one.”

A nurse with a Bachelor’s degree and a Public Health Nurse Certificate earns a starting salary of about $47,000 as an OUSD school nurse. They also receive a benefits package worth about $13,000.

According to the Bureau of Labor statistics from 2017, the average annual salary for a registered nurse in the U.S. is $73,550. The Bay Area, though, offers the highest salaries for registered nurses in the country. In the Oakland-Hayward-Berkeley metropolitan area, the average annual salary is $116,660—nearly double an Oakland school nurse’s salary plus benefits package. According to the OUSD’s current salary schedule, the nurses get a pay raise with each year of work. After five years, the salary rises to just over $55,000. The highest possible salary an Oakland school nurse can make—after 25 years of service—is $83,723.

The salary challenges don’t affect just the OUSD—Parker points out that other East Bay school districts struggle to staff nurses. According to Kidsdata.org, a program of the Lucile Packard Foundation for Children’s Health, of the 14 districts in Alameda County with data in 2017, Oakland had the second best student-to-nurse ratio with 1,777 students per nurse. The best ratio listed—for a much smaller district—is Emery Unified in Emeryville, with 687 students per nurse. The highest ratio went to Dublin Unified School District, with 10,680 students per nurse.

While Oakland’s ratio is better than some surrounding districts’, it doesn’t even meet the outdated standards set by the NASN in the 1970s. Back then, as laws protecting the rights of children to attend school regardless of their health conditions were being passed, the NASN supported the concept of nurse-to-student ratios. Initially, it was 1:750 for healthy students, 1:225 for students in special education, and 1:125 for a student with complex health needs. Since a school nurse would typically serve students from all those groups, the recommended ratio was roughly 1:1,100—still lower than OUSD’s contracted 1:1,350 caseload.

The NASN’s position has since evolved; today, they have adopted the recommendation of the American Academy of Pediatrics that there should be one registered nurse in every school. Fekaris says that’s the ideal, but a one-size-fits-all model is not realistic. For example, rural schools may only have 50 children, so having a nurse just for that one building might not make sense. But schools in areas with what she calls “high poverty and high social determinants of health” will need more services because students and their families lack other ways to access healthcare.

According to Fekaris, in communities like Oakland, a school nurse is often the first health care provider that a student sees. “So, we consider that a particularly sacred relationship that the school nurse has the ability to build with children around health needs,” she says.

For nurses like Schaefer, though, it’s hard to build that “sacred relationship” when she’s already over her contractual caseload of 1:1,350. These numbers, she says, also don’t come close to reflecting the scope of an OUSD school nurse’s responsibility and the time certain tasks take. Students with IEPs or with severe needs aren’t factored into her caseload. Checking sugar levels in students with diabetes, a process that often means leaving one school for another, isn’t factored in. “I don’t have enough time in a day to be able to reach out to each student to make sure all of their needs—not only physical needs but mental, emotional needs—are met,” she says.

Schaefer says that when she was first hired, the psychologist at Garfield told her that one year in Oakland “is like five to ten years in any other district” because the students have such profound needs.  “It’s a difficult district to work in, that’s for sure,” Schaefer recalls the psychologist telling her.

Schaefer thinks the main cause of the nursing shortage isn’t retirements or people moving: It’s burnout. Last year, after seven nurses left, more than half of the remaining nurses wrote in their letter to the district administration: “Unofficially, we know that some of these nurses moved on because the working conditions are untenable.”

Schaefer feels that stress in her own life. She takes her work worries home with her. She finds herself lashing out at people outside of work or at home for no apparent reason. She’s started having nightmares—like the one about a student having a seizure with no one around to help because she didn’t train enough people on how to provide the appropriate care. “With the few nurses we have left, it’s too big of a weight for us to carry,” she says. “It’s affecting us a lot more than it should be.”

As she turns her car onto Myrtle Street, she sees an ambulance parked outside McClymonds. “See! This is what I worry about,” she says as she drives by and looks out the window for any familiar faces. Her immediate concern is for the student with diabetes she is about to see. “What if somebody found him passed out on the ground. Is somebody trained? Because I haven’t trained anybody,” Schaefer says.

She stops by the front office to inquire about the ambulance, but it turns out it’s for a house across the street—nothing to do with any students.

Before heading up to her makeshift office, she checks her phone to make sure the student is ready to meet. Lately, it had been challenging to coordinate with him. He doesn’t want to miss lunch with his friends, so Schaefer started arriving earlier. Then, he wasn’t always in class before lunch. A couple of times, Schaefer drove all the way to McClymonds but didn’t even see the student. An hour of her day, wasted.

Today, though, just as she’s opening the door to her office, the student appears in the hallway. As they go over his blood sugar levels, Schaefer asks him a flurry of questions: How have you been feeling? Have you been going to class? Have you been taking your medication regularly? How are things at home? Before the student heads off to lunch, Schaefer confirms that he’ll show up again tomorrow. He says that as long as she comes at the same time, he’ll be there.

On the car ride back to Garfield, Schaefer still has this student on her mind. Seeing the ambulance brought all her worries to the surface. She runs through the questions that rush into her head: What happens if he passes out and he doesn’t have his supplies? Is he only getting his insulin when he sees me? And what does that mean if he doesn’t see me?

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While Schaefer on Team 2 is handling parts of East Oakland—and her one student at McClymonds—Sarah Boyd is in North Oakland on Team 1. On a Wednesday morning, Boyd, a nurse at Oakland Technical High School, makes her way through the maze of doors that separate the hallways and rooms. She is tall and thin, with glasses and a soft voice. Of the more than 2,000 students at Tech, 500 have an IEP which qualifies them for special education. Boyd arrives in the special day class for students with moderate to severe handicaps. There are only two students in the classroom, but they are the ones she came to see.

Both teenage boys are in wheelchairs and need to be fed through G-tubes. A registered nurse from an outside agency, hired by the special education department, is slowly pouring a nutritional liquid into a tube that is directly inserted into one student’s stomach. A second aide, a paraeducator wearing beige latex gloves, sits next to the other boy and waits for his G-tube pump to finish giving him the nutrition he needs.

Boyd says a teacher for this type of classroom would typically know all the students’ health conditions. But this group of students hasn’t had a regular teacher since the start of the year. “I would have trained [the teacher] how to respond in the event of a seizure, vomiting or asthma attack. I would have a relationship with this person. They would know to call me. They would know how to respond until I get there. And that’s out the door. So I have to be here more,” says Boyd. “It’s my responsibility.”

Boyd works full-time at Tech. It is one of three high schools in the OUSD with a dedicated registered nurse because the student population is well over 1,000. Tech also has Amanda Epperson, a Licensed Vocational Nurse (LVN), on staff. LVNs are able to do much of the same work as registered nurses, but they are not able to work on IEPs, special education or hearing, and vision checks. Epperson has a small office, barely wider than her desk, where she takes care of first aid for everyone on the campus, including the more than 200 staff members. Today this includes a security guard who feels light-headed and wants her blood pressure checked and a teenage girl who rolled her ankle the previous night and wants to know what to do about the swelling.

When she started at Tech more than five years ago, Boyd said it became clear, very quickly, that a lot of students were coming to the school nurse for anxiety and panic attacks. At first, people treated these incidents as medical emergencies. Students would lie on the floor screaming, saying they couldn’t breathe, and staff—sometimes the student themselves—would think it was a heart attack. School staff was regularly calling ambulances.

But Boyd and Epperson realized that these weren’t truly heart or respiratory problems; something else was going on. “A school nurse’s job is to find patterns—about communicable diseases, food poisoning, stomach viruses. …Or, it could be, ‘God, there are a lot of panic attacks at school and we are calling 911 and no one knows how to handle it,’” says Boyd.

Boyd says Tech is a high-performing school and students feel pressure to get good grades. Epperson says some students go home with seven hours of homework a night. That’s what it’s like, they say, to be a high school student in 2018. The two nurses worked with the school administration and staff to create a mental health protocol to address anxiety-related health issues. They put together a phone tree that lists who to call and in what order, if there is a mental health emergency. They patched together a network of mental health providers. Staff and students attended classes on how to identify if someone is having a panic attack or what they can do if they feel one coming on. “Steep learning curve for me. I didn’t think I’d be dealing with mental health stuff,” says Boyd, who is also the nurses’ union rep for the Oakland Education Association, which also represents teachers, counselors and librarians.

Increasingly, school nurses are seeing and treating students with mental health issues, according to Fekaris. She says an NASN survey last month of school nurse leaders across the country identified mental health as the number one issue influencing the role of school nurses. “Children will come to the health office with these unspecified complaints—headaches or tummy aches or just don’t feel good—because those are generally the first signs of anxiety and depression and just really the inability to cope,” says Fekaris. The school nurse can provide one-on-one time with a caring adult and a quiet place to lie down. They’re often the first health care provider to uncover mental health issues.

School nursing is not just bandages and scraped knees anymore; it involves dealing with complex medical needs. According to the OUSD’s Health Services, the district currently has 51 students with diabetes who require insulin during the day. Another 208 students have a seizure condition, but only 10 require emergency medicine. There are 711 students who have severe allergies and require epinephrine, 26 students with sickle cell anemia, and 365 students who have asthma and require medication. That’s just the students with the five most common health conditions.

A 2011 study published in Pediatrics, the journal of the American Academy of Pediatrics, concluded that students with special health care needs are more at risk for low performance in school. School nurses can play an important role in identifying their needs to ensure a higher quality education. Healthy children learn better, says Sheri Coburn, president of the California School Nurses Organization. “If you have an earache or a toothache or have some issues going on in your family, it’s really difficult to concentrate on what you’re learning,” she says. “Once you meet a child’s safety and health needs, then they can really focus on learning.”

Boyd says doctors have also been shifting more responsibility for administering medication to school nurses rather than assigning it to family members. Boyd says that most once-a-day medications do not need to be taken during school hours—first thing in the morning or in the evening is usually sufficient. “When they write orders for the school to be responsible for giving the daily dose, number one, it puts a lot of responsibility on the school,” she says. “It also says something about what is happening at home: The family can’t manage this.”

Both of Tech’s nurses say the workload has caused them so much stress that they’ve considered quitting. Epperson says she likes her job and helping students, but she almost left the district last year because she was frustrated over having to leave her students at Tech and drive to two, sometimes three, other schools a day for diabetes coverage. She says it is ideal to stay at Tech, with Boyd, focused on one school and its students. Morale is low, she says: “I think if more nurses quit, that would also be a factor in my not coming back.”

Boyd cleared out her office last year and was ready to leave. But she says she really loves her job and couldn’t decide. So she’s staying put, for now. “It’s hard to talk about some of this stuff because it brings up a lot of emotions—toxic emotions like anger and frustration and stress,” she says.

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Seeing the ambulance outside McClymonds isn’t the first time this month Schaefer has had ambulances on her mind. She says a few weeks ago, an elementary school student was brought into her office after yard staff found him on the ground. He was having a bad asthma attack. Usually, if asthmatic students have their medication and inhaler at school, Schaefer can administer it. But this student didn’t have his inhaler. Schaefer called his mom, but she couldn’t bring the inhaler to school. So, Schaefer did some deep breathing with the student, calmed him down, and sent him back to class, only to have him return 30 minutes later—more panicked and having a harder time breathing.

She tried his mom again. It would take her 30 minutes to get to school. That was too long for Schaefer, so she called 911. “It’s scary for a kid. I mean, the poor guy, when he heard me say that I’m going to have to call the paramedics, just tears filled up in his eyes,” Schaefer says. “Of course it’s going to make it that much worse. Who wants to have all that attention, all these paramedics, fire department?”

And that’s at a school that has a nurse. Often, at the “red schools,” a nurse’s responsibilities fall to the other staff and to teachers. REACH Academy is a “red school” this year, and Jessica Funk, a third-grade teacher, has felt the absence of a nurse. She says that she has to figure out what to do when an asthmatic student comes in from recess breathing heavily. Unlike a nurse, she can’t administer an inhaler—she wouldn’t even know where the inhaler might be. All she can do is help the student calm down and take deep breaths. If that doesn’t work, she sends the student to the office, where school staff tries, more or less, the same techniques.

Last year, REACH Academy did have a nurse two days a week, but, even then, Funk felt the burden of providing health care to her students. She had one student who had a history of seizures. The student, a newcomer from Guatemala, was not yet fluent in English or Spanish, so it was very difficult to communicate. Funk says she only had a five-minute conversation with the school nurse about what to do if the student had a seizure, and it didn’t leave her feeling any more prepared. “That’s not training. That’s a conversation. And seizures are a very serious medical issue,” Funk says.

Training teachers on how to handle medical situations when a nurse is absent is a focus for the district, Parker says. They’ve implemented a new online dashboard this year, where teachers can check on the medical conditions of kids in their class and watch training videos on how to treat their students. Typically, Parker says, the school nurse would “present to the teachers an overview of the five common health conditions,” at the beginning of the year, so the dashboard is meant to serve as a stand-in at schools without nurses. But these schools won’t have access to a regular nurse until the district fills its vacancies.

Mary Claire Delgado, the manager of recruitment for the OUSD, says that the district is trying both old and new techniques to attract more nurses. They have been using Twitter and Facebook, along with posting the positions to job boards like EDJOIN, LinkedIn, Indeed, and Idealist, to spread the word about the open positions. But they’ve only been able to fill two since they started posting in June.

So Delgado says they’re expanding their approach. She recently went to a nursing program at the Fresno campus of California State University to do an informational session on being a school nurse in Oakland, and her team is testing long-term solutions like partnerships with universities like Sacramento State. She has also been working with the nurses to collect testimonials about the benefits of working for a school: hours line up well for nurses who have their own kids and they get time off during the holidays and summer. “The more we are able to craft and identify the positives and get the message out, that will increase the number of candidates for us,” Delgado says.

While Delgado is encouraged by the two recent hires, she’s not satisfied. “It’s not enough for me that we fill the vacancies,” she says. “My goal is for us to have a waitlist for all of our positions.”

***

When Schaefer returns to Garfield Elementary, where it’s an early dismissal day, she goes straight to her desk. With no students around, she’s able to catch up on emails and complete a few IEP reports. As the day winds down, she feels a familiar sense of relief: “It’s a nothing-went-wrong kind of feeling. Because there is so much going on, you think something is going to happen.”

Still, Schaefer says there are a lot of benefits being a school nurse and there are parts of her job she loves. With weekends off, she’s able to attend her son’s sporting events. And as a single mom, she appreciates that her schedule allows her to spend more time with him, and even occasionally pick him up from school. She loves her co-workers and knows she can turn to them for support. And she is passionate about the nature of the work. When patients leave the hospital, a nurse usually doesn’t see them again—it’s the end of the relationship. But with “school nursing, you’re helping students navigate their way and manage their health condition in their day-to-day life,” Schaefer says. “This is something that they’re going to have to figure out as they grow up. This is something that’s not just going to go away.”

But lately, when she leaves work, she often has to go home and study. Schaefer’s preliminary school nurse credential expires at the end of the school year, so she’s enrolled in a credentialing program at Sacramento State. It’s another heap of assignments on top of her workload. With so many vacancies and so many schools to cover she worries that the stress is becoming too much.  Even if she wants to keep working as a school nurse, she isn’t sure she can stay in Oakland. “I don’t know if it’s the best environment to remain in if it’s just going to keep going downhill,” she says.

Schaefer leaves Garfield Elementary promptly at 3:15. She never did get to eat her lunch. Her coffee remains unfinished and cold. She’s able to beat traffic and drive home while it’s still light out, picking up her son along the way. At home, she studies for her credential and manages to get in a workout on her exercise bike—it helps relieve some of her tension from the workday. Still, she says, she can’t help thinking about the next day, and whatever it may bring.