Since before the COVID-19 pandemic, the D.C. region has been dealing with a shortage in school nurses.
A shortage of D.C. school nurses has become so critical that about half of public and charter schools will not have a nurse on campus full-time this year.
While every school will still be covered by at least two nurses – one registered nurse (RN) and one licensed practitioner nurse (LPN) – those nurses will be shared among a cluster of four schools geographically close to one another. The nurses will be physically located at one school and will travel within their cluster. Schools that do not have a full-time nurse on site will be assigned a full-time health technician, who are trained to assist nurses but provide a limited range of services. (Technicians are required to have a First Aid Certification, AOM Certification, and Nursing Assistant, EMT, or Patient Care Technician Certification.)
That's under a new work model created by DC Health and its grantee Children's School Services (CSS), who say it's a necessary short-term solution to the nursing shortage. Children's National Hospital, which oversees CSS, says it's "confident" in the model, which is designed to ensure that there is at least a nurse or technician available on campus at all times.
In each cluster, nurses are assigned to schools that have more students with serious medical needs as determined by data from student health records. Technicians are assigned to the schools with lesser need. The hospital noted that if they need assistance and a nurse is not immediately available, technicians can use telemedicine devices now available in every school.
But school nurses and their union, the DC Nurses Association (DCNA), argue that the cluster model could put student health and safety at risk. They say that while schools are experiencing a shortage, sharing nurses across several schools is not a viable solution to that shortage and that DC Health and CSS have not done enough to recruit and retain nurses.
Deborah Thomas, an RN and a nurse consultant for DCNA, says the model goes against best practices. The National Association of School Nurses and the American Academy of Pediatrics recommend that school districts employ at least one full-time registered nurse in every school building. (Children's National Hospital alludes to the National Association's recommendation on its page).
"This is a recipe for disaster," Thomas says. "It's making me feel like D.C. children aren't valued."
She also says the model goes against D.C. law. Under the Public School Health Services Amendment Act of 2017, every public and charter school is required to have at least one full-time registered nurse for a minimum of 40 hours a week.
Despite the 2017 law, At-Large Councilmember Christina Henderson says having a full-time nurse at every school for at least 40 hours a week has never been a reality. The law is contingent on funding, which was not included in the city's budget.
The D.C. Council discussed the proposed cluster model with CSS and DC Health at a public hearing on June 22 and approved it.
In previous years, Henderson says schools dealt with the shortage by hiring travel nurses for some schools. But school leaders said that approach meant a lack of consistency in care, because the nurses were not available throughout the year for a given school.
The new model is an attempt to shift to a more stable staffing situation. Each cluster of schools is expected to have a fixed team of four people throughout the year. (Henderson says it's unclear at this time whether this model will be in place next year.)
"I actually do think this model will deliver quality care to our young people and provide a level of consistency that our schools have been asking for," Henderson says.
This is the first time, however, that all school nurses are managing multiple schools and may have to travel between schools, and that health technicians will be filling in for nurse vacancies. Nurses say that can be a hazard for them and for the students they serve.
On Aug. 15, nurses with DCNA began circulating a petition demanding an end to the model. The petition has gotten 536 signatures and counting as of Tuesday afternoon.
"This decision not only blunts our efforts to place a nurse in every school, but also puts student health at risk by replacing trained nurses with health technicians who are not adequately prepared for such responsibilities," the petition reads.
Thomas says that technicians should not be working alone, particularly in the case of an emergency. They are not licensed to offer all the services a nurse can, such as administering certain injectable medications or dealing with a possibly life-threatening seizure or asthma attack.
"I don't know what they're doing, putting unlicensed personnel in these situations with people's children," Thomas says. "They refused to take anything that the nurses said seriously about how it would affect their practice."
Myra Hines, an RN in D.C. schools, says nurses became aware of the new model toward the end of the last school year. Hines says CSS should have focused on longer-term solutions to the shortage, including recruiting earlier.
Even if a shortage of qualified nurses persisted, Hines says current staff should have had more say in a short-term, immediate solution. "They could have asked for our opinion," she says.
The Children's National Hospital told DCist/WAMU it did meet with shop stewards from DCNA to get feedback on the model. But they note their collective bargaining agreement with DCNA for RNs and LPNS "does not require that we receive approval" from the union.
"We recognize this is a change, and we've participated in months of community outreach with school leaders and parents to answer their questions and make sure they're aware of the training and experience that all staff members will have," the hospital wrote. "We're committed to making sure parents feel safe and that every child is taken care of while at school."
Hines argues that it is a cost-saving measure for CSS, and that instead of recruiting and retaining more RNs, CSS has been prioritizing hiring health technicians. The technicians, who need fewer qualifications, have lower wages.
"Are you putting money over the value of a child? That makes me angry," Hines says.
This year, Henderson says there are about 96 full-time nurses and 88 health technicians spread out across 184 schools. In the last school year, 102 out of 183 schools had a full-time nurse.
"We are trying as best we can to make sure that there are people who are properly trained in the building to do a lot of the care work," Henderson says.
School nurse shortages are not new to the D.C. region. There was a shortage in the District in 2019, and nurses in Montgomery County were covering about two to four schools at a time that year. In Prince George's County, 10% of schools did not have a full-time nurse in 2012, and shortages continued over the years.
"I know people think like, 'of course, every school has a nurse.' That is not the norm," Henderson says.
The COVID-19 pandemic further exacerbated the stresses of that job, driving out more nurses.
The hospital says that it will "continue to hire nurses in alignment with the staffing model and needs of the children of the District of Columbia." However, Hines and Thomas expressed concern that technicians are replacing nurses and that management is not hiring registered nurses at this time. Children's asserted to DCist/WAMU that there is not a hiring freeze.
Retaining school nurses has become especially challenging amid a nationwide shortage in nurses. RNs are in high demand and on average, make about $20,000 less in a school than they would a hospital.
"If your nurse is not satisfied, she's not going to stay," Hines says. She added that while CSS has hired new RNs in recent years, "it doesn't seem like they care to retain their nurses."
"That makes you feel real bad. You work with somebody who doesn't really value you," she says.
Hines, who is in her early 70s, makes less than $100,000 a year. A mother of five, she has been working as a nurse for about 50 years and as a school nurse for more than 20 years.
For most of those 20 years, Hines worked at the same elementary school in Ward 7. She says she has watched the students grow up. Some of them are the children of students she used to care for.
"I can retire, but I stayed in my school because I love my school," she says. "I love my family, my students there. We were more than just a school."
But Hines says she was forced out of that school under the new model. She says that change brings instability to her students and disrupts the continuity of care she brought them.
"It really affected me health wise," Hines says. "It's too stressful for me to continue. And I'm not the only one who feels like that."
In 2020, DC Health gave school nurses an ultimatum: join health care workers in fighting COVID-19, or risk getting laid off until school buildings reopened. Hines says that as an older nurse, she did not want to expose herself to the virus, and was temporarily laid off. She lost her health insurance during that time (before she was re-hired, she was able to get it through social security because of her age.)
For school nurses, Thomas says it feels like management is working against them.
"It's been an uphill battle. Every single thing you do with school health, you have to fight," Thomas says. "I think some of the nurses have just reached a point where: 'I'm done.'"
In the future, Thomas hopes the District moves toward setting up a nurse in every school and starting a campaign to recruit and spread awareness about the work nurses do.
"I was so hoping that our children were important enough," she says.
But now, Hines says it feels like "nobody's listening." Unless CSS takes a different approach to its recruitment efforts, Hines says, it's going to be difficult to retain the nurses that D.C. schools still have.
"A lot of my colleagues are going elsewhere. And I'm tired," she says. "I'm through."
This story originally appeared on DCist.com