We interviewed 57 school nurses to learn what it's like to manage health in school. Here's what we learned...
She’s the district nurse at Springfield Unified, a district of 8,814 K-12 kids across 14 schools. Her real name is Anne Johnson, but to everyone at school she’s just Nurse Anne: every day, she goes above and beyond to ensure the health and safety of all her kids and staff. If you’ve been at a school in her district in the last 15 years, chances are you’ve been helped by Nurse Anne.
Nurse Anne’s story is one I heard over and over as I was meeting with school nurses from school districts all over California. The purpose of these interviews was to understand how health is managed in schools— and, more specifically, how diabetes is managed in schools.
I started this project hoping to apply my experiences from living with and building products for diabetes toward improving the way diabetes and other health issues are managed. I was diagnosed as an adult and as a result I could make my own decisions about how to live my life. Kids don’t have this luxury — they rely on their parents, family, and, when they go to school, school staff like Nurse Anne to keep them safe and healthy.
So I met with school nurses to understand a day in their life with managing diabetes — 57 school nurses to be exact. Together, they represent:
Here’s how the interviews break down:
School nurses care about what they do — a lot. They are extremely knowledgeable and experienced, and if there were a Nurse Anne in every school, this project could have been pretty boring. But there’s not. Not even close: in CA schools, there‘s ONE nurse to every 2,582 kids. The numbers for California schools are jaw-dropping:
Nationally, these numbers are a little better, but still not great:
74.8% districts employ a nurse (with only 39% full-time)
1,691 students per school nurse
(Source: National Association of School Nurses)
If kids were only dealing with bumps and bruises, stomach aches, and sore throats, these numbers might make sense. But they’re not. Kids today suffer from major-league health issues — issues like diabetes, asthma, and severe allergies that require dedicated care from trained staff.
So what do schools do? As I learned, they make do with what they’ve got: they train whoever is available. This usually means training unlicensed staff like office secretaries, teachers, or health aides.
For kids with diabetes, tight glucose management is essential to short- and long-term health. This translates to estimating food, delivering insulin for meals and high glucose, and eating carbs. Each of these takes time and requires significant decision-making skills to perform effectively.
Now imagine you’re a child with diabetes in school. You haven’t developed the physical or mental skills needed to manage a chronic condition, so you rely on Nurse Anne and trained school staff to make your diabetes decisions. Here’s what a morning might look like:
If this looks complicated, well, that’s because it is. Glucose is affected by everything — food, stress, hormones, exercise…add to it being a kid in a busy school day getting care from school staff, and well, things get quite a bit tricker.
Health isn’t a priority in schools unless it becomes an immediate issue.
I heard this over and over from nurses I spoke to.
We’re spread so thin — we do the best with what we have.
If we had another kid diagnosed with diabetes, I don’t know what we’d do.
You have to change your strategy so you can deal with it, but it becomes a problem when you have multiple schools, multiple students, and convoluted doctor’s notes. It’s not helping us, it’s making us have sleepless nights.
(Public) schools are legally responsible for providing sufficient accommodations to children with disabilities under Section 504 of the Rehabilitation Act of 1973. Chronic diseases like diabetes are covered under this statute, meaning that schools must take steps to remove barriers that would otherwise limit the child’s access to the general education curriculum.
How the school accommodates the child depends on the state, the school, and the family, and there is significant gray area in how care is delivered. I heard a number of considerations that factored into resourcing for diabetes 504 plans, including:
When it comes to resourcing, EVERY school, regardless of the above considerations, trains unlicensed staff to provide basic emergency care management, primarily for low glucose situations. These are the staff that are closest to the student throughout the school day and can be there to intervene if necessary.
Schools differ when it comes to the staff that deliver insulin. The most common scenario I found was a mix of licensed and unlicensed staff, where licensed staff are available for “scheduled checks” (e.g., times like lunch where insulin is given at the same time every day) and trained, unlicensed staff are available for the rest of the school day. Still, these models varied across districts, and I saw examples where only unlicensed health aides or only licensed health aides deliver insulin.
For schools, the process for providing care to a student with diabetes is quite involved. Here’s the general process the nurse/staff follows when handling diabetes at school:
To top it all off, nurses have a lot of other things they manage daily. This article would exceed the word limit if I had to write at length about the full responsibilities of a school nurse, so here’s an overly simplified version instead:
I’d love to make health a priority in schools, increase the number of licensed staff like Nurse Anne, or better yet, reverse the growing number of health issues kids face today. But these are huge challenges and we have to start somewhere.
So I’m starting with training and education:
Finally, thank you to all you school nurses and health aides who go above and beyond every day to ensure the health and safety of your kids. Our families and schools are lucky to have you.