The band-aids that Sherril Bailey has been applying since becoming a school nurse six years ago continue to cover an ever-growing swath of medical issues that now includes exposure to COVID-19.

Bailey, a Registered Nurse, spent the first three years of her career at different schools in the Battle Creek Public Schools. She is now beginning her third year as the school nurse exclusively for students at Dudley Elementary and says the medical issues she’s addressing have become “a lot more serious.”

“Times change and things change,” Bailey says. “Even I wonder how did all of this come about?”

While students still come in seeking care for cuts and scrapes and the occasional headache, an increasing number also are looking to school nurses like Bailey to administer medications for chronic diseases, including asthma and diabetes, which are increasingly on the rise among students of all ages. 

School nurse Sherril Bailey says in In addition to physical issues she also deals with students who have mental health concerns.“We have a whole asthma case management and education program,” Bailey says. “I also work with kids with diabetes and those who have seizures. Food allergies are a huge issue as well. Life-threatening illnesses have risen over the years. I am always working with the kitchen staff and students and families to keep our kids safe.”

In addition to physical issues, Bailey also deals with students who have mental health concerns. When a student comes in, she assesses them.

“If this child is coming in to see me on a frequent basis, I get to talking to them and unraveling things in their life. We refer them,” to mental health experts, she says. “We don’t do the mental health part, but we assist in making the connection.”

Bailey is one of 10 school nurses across Calhoun County. They are county employees and school districts reimburse the county for their salaries. In response to the request of school officials, the county recently hired three additional full-time school nurses and expanded services offered by the county Health Department’s School Wellness Program.

At their Aug. 20 meeting, the Calhoun County Board of Commissioners took these steps as they attempt to make sure that chronic absenteeism is not one of the long-term impacts of the diseases students face. The Board of Commissioners also was responding to increased health care demands caused by COVID-19, says Lucy Blair, spokesperson for Calhoun County.

“Previously, the county’s Health Department had nurses in local schools to handle a lot of primary care functions for kids who don't have access to health care, but the schools have approached us and asked for additional nurses in the schools for COVID purposes,” Blair says. “Using infrastructure from a program that already exists, they are amping up this program with additional staff and big grants that were approved at the Aug. 20 meeting.”

The total cost of the School Wellness Program is $1,120,409.  The funding breakdown is:
• $528,163 from BCPS, Lakeview, and Harper Creek schools.
• $332,246 in county appropriations
• $150,000 grant from the W.K. Kellogg Foundation
• $150,000 three-year grant from the Binda Foundation
• $50,000 grant from the Miller Foundation

Megan Banning, Deputy Controller for the County, says the amount each school pays depends on the number of nurses they want and the services they want the nurses to provide.

BCPS, Harper Creek, and the Lakeview school districts are all participating in the county’s School Wellness Program. BCPS went from having 4.5 nurses to six. Lakeview increased its school nursing staff from two to three and added two part-time Program Technician positions to assist its nurses. Harper Creek will continue to have one nurse, says Brigette Reichenbaugh, the county’s Deputy Health, and Public Information Officer.

The move comes at a time when school districts across the country are examining the need to restore school nurses as COVID-19 continues to spread. Less than half the country's public schools employ full-time nurses and the number of school nurses has been in decline since the early 2000s. When you count full-time and part-time nurses there is the equivalent of 95,766 positions nationwide. 

Meanwhile, the CDC recommends schools have one nurse for every 750 students. The National Association of School Nurses says around 40% of school districts in the nation meet this recommendation. In the Midwest, 32.7% of schools have full-time nurses. 

These statistics are not surprising to Lakeview School Superintendent Blake Prewitt. He worked in four different school districts in Detroit and none of them had school nurses.

“(Lakeview) is the first school district I’ve worked in that had a school nurse. I was happy when I got here to see that we actually had nurses,” he says. “It’s rare to find nurses in schools in Michigan. Budgets have been slashed so much throughout the years that it’s not affordable to have a nurse. If you have to choose between spending $100,000 for a nurse or more math teachers, you’re going to go with the teachers.”

In his previous administrative roles, it was up to Prewitt to assess medical needs and decide when EMS needed to be called in. He says it was not uncommon for him to administer injections and suppositories. The administering of simple medications was done by the school secretaries. On occasion secretaries at Lakeview will administer simple medications because “the nurses can’t do everything,” he says.

Bailey says her responsibilities at Dudley Elementary include assessing and determining when a student needs to be sent home. “The days that nurses are in the building, the rate of kids going home is a lot less” because the assessment falls to a secretary who doesn’t have the ability or training to make medical judgments, Bailey says. 

“We train the staff and they do medication administration, so we know the staff knows how to handle an emergency. Without a nurse in the district, I’m not sure who would train the staff with how to use an Epi-Pens or what to do in an emergency.”

Monique Cheeks, Director of Student Services with BCPS, says, “We are thankful to CCPHD and the Calhoun Area Intermediate School District for the excellent training they provide each year for our building secretaries and other staff. This includes medication administration, COVID-19 guidance and even training our medical emergency response teams at each school. Thanks to the training provided, we feel even more confident having a team of trained building staff to support our students' health needs along with our school nurses.”

Prewitt says, “It definitely helps to have a nurse available, especially when medical issues come up that I as an educator can’t speak to, like when parents will say they can’t have their kid come to school because of X, Y, and Z.” 

Kimberly Carter, BCPS Superintendent, says that pre-COVID-19, having nurses in school was essential and helpful to improve attendance. Nurses enabled BCPS to get student health needs met in school that they might otherwise miss school for. This includes addressing minor ailments, assisting with the management of chronic conditions like Type 1 diabetes, and conducting basic physical exams and wellness checks.

“Now with COVID-19, having nurses at schools is even more essential so that we have qualified medical professionals at the ready to handle any possible situations that may occur if a student or staff member begins showing symptoms while at school,” Carter says. “Even just for peace of mind, when nurses are available, we can feel more confident that teachers or support staff members will not end up needing to handle something that really should be handled by a trained medical professional.”

Once in-person learning returns to local schools, Prewitt says the need for school nurses will be even more critical because of the potential spread of COVID-19.

With the majority of learning happening virtually, the number of students in actual classrooms is very small and parents are supposed to be screening their children for COVID before sending them to school, Bailey says. 

“We have a whole system of policies and guidelines set up. We have an isolation room and a plan in place,” Bailey says. “If we follow the plan, we should be OK. We will do our best and get through it.”

“We’re not going to ask a secretary or teacher to assess if a student has COVID-19,” Prewitt says. “The virus has highlighted the need to have medical professionals in schools. It’s just a matter of how schools can financially afford it.

“Our county does a nice job of providing for us.”

How many nurses? How many schools?

The number of positions allocated to each school district is based on a ranking that looks at the total number of minority students; children living at or below the poverty level; the progress of students learning the English language based on standardized tests; and chronic absenteeism rates in each of the schools that participate in the School Wellness Program.

The score also determines if a school system will be using a Consultative Model, Care Management model or a combination to the two. Reichenbaugh says the consultative model is the basic school nursing model used by Harper Creek. “Care management is a higher level that focuses on case management and care management for students with chronic diseases like asthma or diabetes,” she says. “The majority of BCPS elementary schools are in that high-need category.”

In the rankings, Dudley, LaMora Park, Valley View and Verona BCPS elementary schools each had the high scores, showing the greatest need for nurses. Harper Creek’s five elementary schools and Lakeview’s Middle and High schools had the lowest possible, and the Lakeview’s four elementary schools fell between the others. 

In addition to school nurses, Lakeview High School has a Health Center operated and funded by Grace Health that opened last year and is available to any student or parent within the school district. Prewitt says Grace Health provides a nurse, physician assistant, and mental health therapist.

“It’s very nice to have that available and to be able to very quickly let students and parents know that they can go there and be taken care of,” Prewitt says. “The goal is that it will become self-sufficient. Insurance is used for people who have it and we go through another reimbursement system for those who don’t.”

Prewitt says there’s no doubt that the medical issues schools are seeing with students are much more complex than those he was seeing 20 years ago.

“Last fall we had the Equine Encephalitis virus and now we have COVID. It’s a new game for medical issues in schools with asthma and diabetes,” he says. “Then we have quite a number of students on medication for Attention Deficit Hyperactive Disorder and allergies.”

These medical issues are part of the nurse allocation model that the county’s Health Department began using in 2017 as part of its School Wellness Program that began in 1999. The model is based on a similar one used in Wake County, N.C. 

“Their model showed that there are a lot of kids who don’t have primary care providers that have chronic diseases that are preventing them from going to school,” Reichenbaugh says.

Since implementing the current model of care, the BCPS district, which includes four Care Management Model participating schools, experienced a drop in chronic absenteeism rates to 34% for the 2018-2019 school year from 40% in the prior school year. Harper Creek and Lakeview, with schools participating in the Consultative Model, remained consistent, experiencing only a 1% increase from the 2017-2018 school year to the 2018-2019 school year. Harper Creek increased from 12% to 13% and Lakeview went from 18% to 19%.

Parental buy-in is key

Bailey says she decided to become a school nurse because she felt like she could make a difference with the students.

“I think if you teach them young, when they grow up it benefits them more,” Bailey says. “We know that a healthy student learns better. If we can keep them healthy, we can keep them in school and that helps them to have a chance at a better life later on.”

The availability of school nurses is an essential piece of creating a school district that offers wraparound support for the whole student, Carter says.

“A key piece of the BCPS vision is to see every child by name, need, and strength and in addition to social-emotional and academic needs, we know that our students may have health challenges as well,” Carter says. “Having trained and certified nurses in our schools helps students build trusting relationships where they can feel comfortable talking about their health concerns and provides peace of mind for our entire school community since we know they are here to help students manage chronic conditions and health emergencies.”

In general, about three-quarters of each day at her job, Bailey is focused on case management.

Reichenbaugh says case management in the schools is all about teaching the family and their students how to manage their care which includes teaching them how to use their inhalers and practicing good hand washing. Nurses also teach families how to administer necessary medications, make patient referrals to healthcare providers, and work with those providers.

The majority of parents are receptive and appreciate having a healthcare professional able to administer over-the-counter or prescription medications as this enables their child to stay at school. Parents don’t have to leave their jobs to bring in medications, Bailey says.

She says her services are even more crucial for families that don’t have a Primary Care Provider and she works with these families to get access to a PCP.

“Having a Primary Care Provider cuts down on unnecessary Emergency Room visits,” Bailey says.

“Parents of kids with asthma and other chronic diseases are worried about sending their kids to school because something bad could happen. Most kids don’t have a primary care provider,” Reichenbaugh says. “For school nurses, it’s more than band-aids and boo-boos.

“It’s really about educating and trying to link families and looking and trying to provide access of care through this program in order for kids and families to learn how to manage diseases to keep kids in school and learning.”