North Carolina public schools average only one school nurse per 1,086 students, according to the results of the state’s most recent Annual School Health Services Report
The typical school nurse here serves two to three schools, but some cover as many as six, Ann Nichols, the school health nurse consultant with the North Carolina Division of Public Health, said when presenting these findings to the state Board of Education last month.
The National Association of School Nurses takes the position that “adequate support is critical for achieving high school graduation,” but the latest figures show that, nationwide, more than 30 percent of schools only have a part-time nurse.
In North Carolina, school funding has not been allocated to create more nursing positions; the 2017-18 Appropriations Bill from the state’s General Assembly states that “communities [must] maintain their current level of effort and funding for school nurses,” not increase it. According to writers of the North Carolina House budget, “it is hard to recruit and retain nurses” for any state position. Qualified nurses often find better-paying jobs in the private sector.
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“We really are overwhelmed,” Susan Hawks, lead nursing supervisor for the Guilford County Department of Health and Human Services, told a local news station last year.
School nurses do more than tend to lice, playground injuries, headaches, and medications; they are tasked with spotting and intervening in cases of abuse and bullying, providing support to students struggling in their home or personal lives, and keeping track of countless immunizations and allergies across grades and campuses. For some students, the school nurse is the only health professional they ever see. This one-on-one time makes a difference in the lives of vulnerable populations already isolated in Appalachia. And when it comes to sexual education in North Carolina, the lack of school nurses could have detrimental effects on some students’ reproductive health and decision-making.
In 2009, North Carolina passed the Healthy Youth Act, requiring schools to provide accurate instruction of reproductive health and safety alongside the state’s abstinence-only curriculum. The act is supposed to ensure that students in grades 7 through 9 receive age-appropriate sex education on STD and pregnancy prevention, as well as information on sexual assault and sexual abuse.
These topics are referred to as “essential standards,” but the state itself admits that no single curriculum can adequately address all of the content. As such, school systems individually make local decisions about what combination of tactics and materials to use to cover the topics required by law. The school nurse’s role in students’ sexual health varies by district, but “every school district directs staff in a manner that is consistent with local needs and policy,” said Kelly Haight, press assistant for the North Carolina Department of Health and Human Services.
School nurses have practical and legal limitations on how they can support sexual education and reproductive health, according to Elizabeth Finley of the nonprofit Sexual Health Initiatives For Teens (SHIFTNC). North Carolina law prohibits the distribution of contraceptives on school property, so nurses and school-based health centers cannot provide condoms, though nurses can help to teach parts of health courses in schools. It is the local district that provides information regarding contraception and STD prevention, Haight said.
“Where school nurses can be a real asset is as linking and referral agents to community clinics. So, for example, if they identify a student [who] needs contraceptive care—they ask for contraceptives, they identify a sexual health need, they present with a pregnancy scare—nurses can be a really effective connector to a healthcare provider in the community who can provide teen-friendly reproductive and sexual healthcare services,” Finley said.
Teen pregnancy continues to be a major problem in this region; North Carolina currently ranks 22nd nationally in births to teenaged mothers. Despite progress in recent years, significant disparities remain as teen birth persists at about one-third higher rates in rural areas than in urban centers nationwide.
Resources make a big difference, Finley said. “[A] county like Mecklenburg has lots of youth-serving organizations, more money for school nurses, more healthcare providers who are adept at both providing sexual health services and at marketing them.” In less wealthy areas, school nurses play a pivotal role by helping to educate students and refer them to community clinics.
In 2014, Charlotte-Mecklenburg schools, a district with a poverty rate of “between 55 and 60 percent,” reached a long-term goal of having one nurse in every school through a two-year effort by North Carolina Parents Advocating For School Health, a grassroots group formed specifically to work for school nurse funding.
“Young people don’t know where to go for care and they don’t feel welcome to ask because of stigma or privacy fears,” Finley said. “What works best is when communities are proactive about building linking and referral networks–so, trained adults who know how to talk to young people about how to actually get the healthcare they need–so that information gets to young people whether they seek it out or not.”
Appalachians see the school as a major hub of community activity. As Karen Eppley, an associate professor at the Pennsylvania State University College of Education, told The Atlantic, “rural citizens tend to be highly involved with their schools; the schools are often the social anchor of the community, and they provide services not available elsewhere, like sports, summer lunch programs, night classes, and food pantries. They also tend to be major employers.” In Appalachian schools, a disruption to health resources of any kind can cause ripples far beyond the school itself.
School nurses free up other staff and funding within the school, increase academic achievement, and help provide a stepping stone out of the circumstances which might keep students in local poverty. For many teenagers, interactions with school nurses are the first positive conversations they have about their bodies.
But in North Carolina, “[t]he school nurse-to-student ratio is well below the level that child health advocates recommend,” Finley said. “School nurses can be powerful … but when they’re stretched thin or splitting time between schools, that’s harder to do.”