School nurses could play a key role in helping school campuses reopen and keeping students and staff safe during the COVID-19 pandemic, but many California schools don’t have one. In districts that have nurses, most divide their time between multiple schools.

The lack of nurses on campuses can be challenging for schools, which must meet a raft of strict health and safety requirements in order to reopen campuses, including screening staff and students for symptoms of COVID-19, testing and contact tracing, and determining if anyone needs to be removed from the school and quarantined.

“School nurses should be involved in all conversations about school reopening and student health,” said Pamela Kahn, president of the California School Nurses Organization. “But in many districts nurses aren’t even at the table.”

In the 2018-19 school year, the most recent data available, there were 2,566 school nurses in California, according to KidsData, an annual report from the nonprofit Lucile Packard Foundation. That’s about one nurse for every 2,400 students. In some small rural counties, like Alpine and Sierra, there are no school nurses.

That means it will likely be teachers, administrators, yard supervisors and other school staff who will have to decide if a sniffle or sore throat is a symptom of COVID-19 or just hay fever.

Nurses help keep students healthy

The lack of school nurses isn’t new. It’s been many years since every school had a nurse of its own to conduct on-campus health screenings, review immunization records, tend to students’ minor medical needs and perform other duties intended to keep students healthy. But that was before a pandemic required schools that are reopening to follow a list of health and safety protocols that go far beyond most educator’s job descriptions.

“School nurses are not easy to come by,” said Dave Gordon, superintendent of Sacramento County schools. Nurses and speech therapists are hard-to-fill positions because the private sector pays more, he said.

In California, the average salary for a nurse is $113,250, according to a May 2019 survey by the Bureau of Labor Statistics. Meanwhile, the average salary for a school nurse in L.A. Unified was less than $80,000 in 2019, according to the district. In Fresno Unified, a school nurse is currently paid between $56,000 and $91,000 for 185 days of work, according to the district.

School nurses often work fewer days than nurses working in hospitals and clinics, but they have to accept a lower annual salary and must take additional classes and pay more fees to get the job, which requires a School Nurse Services Credential.

A preliminary credential requires at least a bachelor’s degree, a registered nurse license, an application, fingerprints and requisite fees. To earn a full credential, a school nurse with a preliminary credential must first successfully work two years as a school nurse and complete a school nurse program at a college or university, which is usually about 22 units of coursework.

Kelly Pagan is the only nurse serving 3,846 students and 475 teachers and other staff in the Enterprise Elementary School District in Shasta County, which is open for in-person instruction five days a week. She started working at the district this school year.

Pagan is assisted by one licensed vocational nurse, as well as health clerks at each of the nine school sites who manage the day-to-day health needs of students, said Annie M. Payne, the district’s director of Special Education and Health. Licensed vocational nurses generally assist registered nurses, but aren’t qualified to be school nurses in California.

Enterprise Elementary School District has two school nurse positions, but officials there haven’t been able to find anyone to fill the second spot this school year even though they increased the salary and are offering a $10,000 signing bonus. The district also will pay for any training a nurse needs to earn a school nurse credential.

Pagan has trained the health assistants to administer first aid, give most medications and to monitor things like glucose levels in students who are diabetic. They are also being trained to help with contact tracing.

Enterprise Elementary School District school nurse Kelly Pagan gives a hearing test to a fourth grade student. (Photo courtesy of Enterprise Elementary School District)

When Pagan isn’t training staff, she is helping students and staff with their health needs, administering hearing and vision tests, as well as tests to determine if students have special needs that need to be met by the school district.

She tests staff for COVID-19, does contact tracing and notifies those who test positive that they must quarantine. She also has to ensure that state and county COVID-19 protocols are being followed by schools.

“It’s a one-man show this year,” Pagan said. “COVID in itself is more than a full-time job. So I’m covering three full-time positions to keep the doors open. The pressure is extreme.”

Parents also call Pagan to report coronavirus cases in their families and to ask her for medical information, as well as the rules around quarantining. Pagan says she is sometimes the only access to health care some students have in the community.

School nurse: ‘I’m definitely working 24/7’

“I’m definitely working 24/7,” said Pagan, a mother of four children. “I can’t think of a single weekend I haven’t been on the phone and email.”

Pagan worked as a part-time school nurse before coming to the district and had worked 15 years in neonatal intensive care. She said the job satisfaction of helping her community as a school nurse outweighs the smaller salary, but she understands why convincing nurses to work in schools is “a hard sell.”

“It’s really the greatest job on the planet,” Pagan said. “I would love to have people look into it, call me if they’re interested. Don’t write it off as a boring job. Every day is different. I can’t wait to get up every morning and go to work.”

California is one of 10 states that does not have an appointed school nurse consultant. The person in that position generally offers leadership to school nurses, develops and promotes quality standards for the nurses and serves as liaison between school health programs and state boards and legislators. The position would be important to helping schools reopen safely, said Sheri Coburn, past president of the California School Nurses Organization.

“In this pandemic, schools need to be hiring nurses, and we need someone at the state to lead the charge,” said Coburn, who also is the director of Comprehensive Health Programs at the San Joaquin County Office of Education.

As schools reopen, school nurses can expand their role by educating students, families and staff about vaccines, quarantines and other issues; evaluating students who are sick; working with local county public health departments on campus safety protocols; and serving as a general resource for health-related matters, Kahn said.

The Centers for Disease Control agrees, saying that when a school has a school nurse, the nurse should be the designated staff person to respond to COVID-19 concerns. There is no federal requirement that schools have nurses, although the National Association of School Nurses recommends that all students have direct access to a registered nurse.

Some districts don’t have a nurse on staff

Sierra County doesn’t have a school nurse, even though all four schools in its one district are open for in-person instruction five days a week. Sierra-Plumas Joint Unified School District officials have been advertising for a school nurse for more than a year. There has been some interest, but no takers, said James Berardi, who is the superintendent of both the Sierra County Office of Education and the Sierra-Plumas district.

The rural nature of the district, located two hours northeast of Sacramento between the Tahoe and Plumas national forests, may be one of the reasons it’s difficult to recruit school nurses. The few nurses among the county’s 3,200 residents are likely to be working at one of its medical clinics or at regional hospitals in neighboring counties, Berardi said.

The county’s school nurse also would have to spend hours traveling between the four schools in Loyalton and Downieville — over an hour apart — that serve the district’s 411 students.

Without a nurse, select school staff, including Berardi, have been trained to give COVID-19 tests whenever a student or member of the staff is symptomatic of the virus. The staff also does some contact tracing with the help of the county health department, Berardi said. Hearing, vision and other tests generally done by a school nurse are contracted out to other medical providers, he said.

Alpine County’s public health nurse doubles as a school nurse to the 70 elementary and middle school students in that county. The current public health nurse does not have a school nursing credential, although her predecessor did, said Matthew Strahl, county superintendent of schools.

Larger school districts in California also struggle to fill school nursing positions. Los Angeles Unified has 455 nurses to serve 650,000 students. It has hired 49 this school year and currently has 149 vacancies. The district has been working with external partners to increase recruitment and retention of school nurses, according to Shannon Haber, district spokeswoman.

Fresno Unified School District, with 73,000 students is in the unique position to have filled all its nursing positions. The district has 69 nurses, said Vanessa Ramirez, district spokeswoman.

There are a number of steps that school districts can take to attract and retain nurses, including paying the fees associated with a nursing credential and pairing new nurses with a mentor, said Michelle Larsen, the health and nutrition director for the Shasta County Office of Education. New nurses were paired with mentors when the county was able to fill nurse positions and had a nurse who had extra time to be a mentor, but currently there aren’t enough nurses to fill all the open positions in the county.

“School nurses are essential for schools, and needed to keep students in school, healthy and ready to learn,” Larsen said. “We have open positions and no applicants to fill them.”

* EdSource reporter Carolyn Jones contributed to this story.

* Story originally published by EdSource.