Coronavirus. A Severe School Nurse Shortage. Uh Oh.

Several states have announced their plans to reopen public schools in the fall. This isn’t a surprise. The quickly cobbled together system of remote learning was never going to be able to replace, or even replicate, an in-classroom experience for many of America’s students, particularly younger children or those who don’t have consistent internet connections. But the decision to reopen raises many serious questions about the public health ramifications related to Covid-19. One of the biggest is: who will be in charge of monitoring students for Coronavirus? It’s of particular concern, because there’s a dire shortage of school nurses.

While much of the data on COVID-19 is incomplete, more than one study has suggested that while children are less likely to be infected by coronavirus than adults, reopening schools would give children three times as many opportunities to become infected. This could cause a massive surge in the virus, which in many states is rapidly climbing. So far, 2.4 million Americans are confirmed to have the disease and more than 120,000 have died.

Despite this evidence, states across the country have soldiered on with plans to reopen their doors in the fall. But schools aren’t hospitals. Should a kid get sick, an outbreak seems nearly inevitable, with the amount of people who carry the virus asymptomatically and the long incubation period of the illness. Since schools aren’t hospitals, the school nurse will be one of the sole medically trained guards against COVID-19. This isn’t radical. A nurse should do a nurse’s job. But there are very few full-time nurses in American schools.

The National Education Association (NEA) found that in 14 states across the country, there are far more than 2,000 students per single school nurse. This is despite the fact that the maximum recommended caseload for a school nurse is one nurse per 750 students. Most nurses serve well over their case-load.

“A school nurse is going to be key in the school,” says Linda Mendonca, president of the National Association of School Nurses (NASN) “They are the only health care provider in the school community.”

The dwindling numbers of nurses are alarming. Only 40 percent of all U.S. schools have a full-time nurse. Thirty-five have a part-time nurse. Twenty-five have no nurse at all.

So what accounts for the shortage? Well, hiring a school nurse traditionally comes from education budgets, not Medicaid or health insurance programs. This means that the ability to have a nurse depends on just how much money there is in the public education budget.

When the economy nosedived in 2007, school budgets were slashed, and with them, many school nurse positions were eliminated. Budgets have only been more and more hamstrung as the economy briefly recovered. Employment studies have suggested that the education-related job losses in 2020 so far are already greater than in all of the Great Recession — and school nurses have been over-represented in being laid off.

After the Great Recession, there was no significant effort to rehire nurses. This comes at a time when more nurses will walk out of school doors for good. The average school nurse is 55 years old, likely to retire within the next 10 years, and only 15 percent of school nurses are under the age of 40. The nurse shortage problem is one of both the immediate and the very near future. Nurses who work in schools make, on average, $15,000 less than nurses in hospitals, and unlike in hospitals, don’t have a path at career advancement.

Nina Fekaris, former president of the NASN, suggested that new school nurses also weren’t staying in their positions for long either. This was due to the fact that they felt they couldn’t do their jobs safely and feared losing their nursing licenses. When the old guard retires, who will take their place?

“That’s a high priority concern for the organization,” says Mendonca. “It’s really going to be key to ensuring that schools open safely. Nurses will take care of the maintenance of what’s happening on a day-to-day basis. Schools need the expertise and knowledge of a school nurse on board, as part of the team to make sure that everyone’s kept healthy and safe.”

That’s true. But in Utah, there are almost 5,000 students per school nurse. In Hawaii, there are none at all. On average, there is one school nurse per 4,000 students. This is all despite the fact that 25 percent of young children suffer from chronic illness — asthma, diabetes, and other ailments, all of which would make them particularly vulnerable to a pandemic and require regular care and attention from school nurses.

In any school, when a nurse isn’t available, teachers, who are not medically trained, have to pick up the slack. They administer medication and are responsible for seeing the signs of an allergic reaction or other potentially life threatening events. Adding this task to the thousands of American teachers who work in schools without a daily nurse puts undue stress on already burdened educators.

When teachers are forced to become medical caretakers, problems occur. There are dozens of stories of children dying preventable deaths because of a misunderstood asthma attack, a missed medication, or an allergic reaction.

One 7-year-old Philadelphia student died in 2014 after getting sick when no nurse was on duty. Critics blamed budget cuts that led the school to only be able to afford a school nurse on campus one day a week. A 13-year-old student died in California in 2013 after collapsing on the floor (no nurse was on duty that day) and going without CPR for 10 minutes. A 12-year-old student in 2013 died after having an asthma attack without a nurse on duty. She had told a teacher, who told her to “stay calm.” She died later that day.

These stories show the danger of not having a dedicated health care worker on campus. While an asthma attack, heart attack, blood sugar issue are immediate and lead to death without attention, a highly contagious pandemic presents similar worries. Teachers can’t be one of the few guards against the disease.

Nurses also manage more than physical health. They are also tasked with the mental health of children. Anxiety will be a huge problem as kids return back to school.

“School nurses are sentinels for student mental health needs,” says Mendonca. “Nurses have the skills to recognize what that underlying need [a student has when they are] exhibiting a physical complaint.” Despite that fact, three million kids are in school with police officers, but no nurses.

Living in poverty, and living with health issues, are compounding problems in the pandemic. In Oakland, for instance, school nurses work with 1,000 more students than the recommended caseload. Seventy-five percent of students live below the poverty line. Many of them are homeless. Poor kids are more likely to have asthma and diabetes. But the school nurses to help those kids don’t exist. Poverty and health problems come together, Covid takes advantage of it, and thus, there’s a massive problem in America’s most underfunded schools.

There have been efforts to rectify the school nursing shortage in America, and in particular, before children go back to schools in the fall. In 2017, Senator Jon Tester, a Democrat from Montana, introduced the NURSE Act, a bill that would make grants eligible to schools who receive Title I funding to hire more school nurses. While the bill was introduced, it never gained traction.

The NASN has been gearing up to prepare their nurses for the school year by arranging PPE, and working on conducting pandemic-related training and seminars over the summer, as well as directing individual states and school districts to follow CDC pandemic mitigation guidelines. It has started a petition to ask the government to hire 10,000 school nurses as soon as possible. There’s little reason to believe that nurses will be hired before September.

The NASN is working to give school nurses a chance at limiting spread of the pandemic, by providing guidelines, working with nurses, and local governments to figure out reasonable plans of how to operate. But they are, admittedly, working with a short hand. In the 60 percent of schools without a full-time nurse, teachers will be expected to pick up the slack. At the end of the day, that’s a losing proposition.

Teachers can’t be dedicated health care workers. They can’t wear masks all day. In schools without daily nurses, if a district decided to operate with daily temperature checks, who would take care of such a thing? What will students with asthma do if someone in the school gets sick? What will teachers do if they suspect someone does have COVID, or if they learn that someone has it and their classroom was potentially infected? Who’s in charge of making sure sick students go home and are quarantined? Where’s the chain of command?

Schools will, of course, come up with guidelines to answer these questions. They will try to make sense of the chaos and work their hardest to give teachers and kids a fighting chance. But such a proposition shows the limited moral imagination of budgetary experts and lawmakers. At the end of the day, parents will be sending kids into schools that are unequipped to deal with the pandemic. But what choice do they have?

Parents have to get back to work. The economic recovery of our country depends on schools being open. But safety is paramount. “Having school health services is a student and family equity issue,” says Mendonca. “School nurses are needed, especially now.”