PIERCE COUNTY, Wash. — When school nurse Heather Guthrie told one of her students at Baker Middle School in Tacoma that she was being transferred to work at different schools, the girl was visibly upset.
So was Guthrie, who'd developed a trust with the students she'd see multiple times a day for various health needs.
"I said, ‘Sweetie, I wish you the best of luck. You're an awesome girl,'" said Guthrie, a six-year employee with Tacoma Public Schools.
Starting in September, Guthrie will leave Baker and split her time working at Lister, Stanley and Jefferson elementary schools.
Splitting her five-day work week means some schools will only have a registered nurse on site one day a week. When RNs aren't on site, assistant nurses or office staff — who are not required to have medical certifications — care for students.
Guthrie's schedule is one example of the changes coming to Tacoma Public Schools' health services this year after a $30 million budget deficit caused district officials to make cuts and transfers across the district.
"I think families think that there's a nurse at their school every day," Guthrie said. "I've run into families that are surprised when they find there is no nurse at their school. I think that's something that they need to know."
Another change is a reduction in the number of regional schools providing full-time nursing care, causing some students with life-threatening illnesses to change schools to find the care they need.
Tacoma Public Schools spokesman Dan Voelpel said district officials have had to make tough decisions to manage a budget "many millions less than it was before" and have made cuts to departments district-wide.
"We're meeting our legal obligations to provide access to the care and support our families' need," Voelpel said.
The changes make Tacoma nurses nervous, especially in light of future budget cuts in the 2019-20 school year.
"I don't feel that (administration) truly understands how important it is for nurses to be in the schools," Guthrie said. "I feel like we're being chipped away at."
Alex Stillman, a nurse with Tacoma Public Schools for eight years, decided to leave her job at the end of the school year to work at MultiCare due to what she sees as a safety risk to students.
She referred to a case in the Bethel School District from 2008, where a fifth grader died from a severe allergic reaction. The girl's family sued the district for $15 million, arguing district personnel were "ill-prepared" by not using an Epipen prescribed to the student, The News Tribune's Kris Sherman reported in 2009.
"I can honestly say, and not for dramatic effect, that they're leading towards where a kid's going to be severely hurt or ultimately going to die, and I just can't be here to support that," Stillman told The News Tribune.
DISTRICT-WIDE JOB CUTS
Tacoma Public Schools will start the 2019-20 school year with 156 fewer positions than it had the year before.
In the health services department, that's about 7.7 fewer full-time equivalent (FTE) positions.
Since December, the district has cut:
▪ 1 FTE clinical coordinator (administrative position)
▪ 1 FTE health service secretary (central office support)
▪ 3.90625 FTE assistant nurse (LPN)
▪ 0.8 FTE school nurse health services (RN)
▪ 1.0 FTE school nurse HeadStart (RN)
There are 22 full-time RNs and 14 full-time LPNs employed by the district, not including health clerks. The state only funds five RNs for Tacoma, Voelpel said. Any beyond that are paid for through local levy funds.
"We know those have taken a hit in the new (state) funding formula," Voelpel said.
Only 24 of Tacoma's 57 school sites — 42 percent — have a nurse every day. That's 10 elementary schools, nine middle schools and five high schools. All high schools and middle schools receive full-time nursing care. For elementary schools, the district takes into consideration the location in the district and how many students are at need at the school for the basis of becoming a regional school.
The American Academy of Pediatrics recommends one full-time nurse per 750 healthy students. The state superintendent's office's recommended ratio is one nurse per 1,500 students. Tacoma's ratio varies, but Stillman estimates it's no less than 1,000 students per full-time nurse and for some, upwards of 2,000 students.
A cap isn't specified in the contract the Tacoma Education Association has with the district. That could change at the bargaining table this year, but it's an expensive proposition.
Based on the district's budget documents, if the average school nurse makes $74,000 per year, the district would have to shell out roughly $600,000 in salaries alone to add enough nurses to meet the 1-to-1,000 ratio. That increases to $1.3 million for the 1-to-750 ratio, based on News Tribune calculations.
The district says it doesn't have the money to throw around, but TEA president Angel Morton said the union disagrees with the district's assessment of its budget, claiming there's enough money to make some moves.
"We're very interested in getting caseload language for nurses," TEA president Angel Morton said. "The nurses have been very vocal in their concerns."
By contrast, Seattle Public Schools and Seattle Education Association contracted a one to 1,000 nurse-to-student ratio.
Starting the 2019-20 school year, Tacoma Public Schools is eliminating two (Lowell and Geiger) of its 10 regional elementary schools due to budget restrictions. Regional schools provide full-time licensed care for students with specific medical conditions.
The fallout means students could have to change schools or search for a caretaker — something families in Tacoma have already experienced.
'INFURIATING' AND 'SCARY'
When their 10-year-old son Max was diagnosed with Type 1 diabetes last December, Beth and Steve Ruffner knew they would have to learn how to navigate a new world of scheduled insulin shots.
It wasn't until they notified the district of Max's condition that the Tacoma residents ran into an unexpected problem — there's no full-time nursing care at Washington Elementary, where Max attended for more than three years.
State law requires districts to develop a nursing care plan for students with life-threatening conditions, such as diabetes or epilepsy.
The Ruffners were told by the district that they had a number of options: Come to Max's school several times a day to administer his insulin, find someone else who could or transfer to a different regional school.
None of them were really options for working parents.
"We couldn't do it ourselves — that would require us going to school three to five times a day," Beth told The News Tribune. "That would be a big burden."
Voelpel told The News Tribune that it's uncommon for parents to provide at-school care for their kids; only one family chose to last year. Finding someone else to do it — called a Parent Designation Adult (PDA) — is also uncommon. The district might have one this upcoming school year, Voelpel said.
The Ruffners also didn't want to move Max to a regional school, away from his friends.
"He wants to stay at Washington," Beth Ruffner said. "He likes it there."
The Ruffners decided to fight for care at Max's home school and said the district agreed to provide it through the 2018-19 school year. No such service will be provided this upcoming school year.
Now, Max is leaving the district and enrolling in the Peninsula School District, at the same school where his mother works so she can help him.
Beth Ruffner said she doesn't want any other family to go through what hers did.
"My kid had to change schools just because he was diagnosed with diabetes," Beth Ruffner said. "It was infuriating and it was scary."
School nurses say they love their jobs and the kids they work with, but they stress the need for more health support staff as they see an increase in the number of students needing daily care.
Carol Bryant, a registered nurse with TPS, has been working at Stadium High School since 2004 and said she's noticed more students with more challenging medical issues come into her office.
"I find that most of the kids that come in are very legitimate — it's not that they're trying to get out of class," Bryant said. "It's usually something serious is going on, and it's scary to think I might miss something."
According to data supplied by Stillman, 625 students at TPS have life-threatening allergies, 22 students have feeding tubes, 81 students have insulin-dependent diabetes and 93 students have life-threatening seizure disorder.
Spokeswoman Katy Payne said the state superintendent's office has updated guidance that will be released soon to help schools determine when a student requires full-time nursing during the school day. The last guidance was developed in 2000.
Voelpel said the district is working on an analysis of 15 other district nursing service models in the area, including Puyallup, Seattle and Peninsula, for potential changes to its own.
Nurses hope changes are made sooner rather than later.
"You build a rapport with your students, you build a rapport with the families — they learn to trust you," Tacoma school nurse Annette Bunker said. "They know that they can send their child to school every day knowing their child is going to be safe.
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