KOJO NNAMDIWelcome back. Have you ever raised your hand in the middle of class and said, excuse me, may I go to the nurse? Maybe you were feeling sick. Maybe you wanted to talk to someone who was not your teacher, or maybe you went after an injury playing for a sports team. It may be easy to assume that every child in school has access to a nurse, but that's not always the case.

KOJO NNAMDIResearchers project serious shortages in trained nurses in the next decade. All this at a time when school nurses are increasingly asked to deal with a lot more than cuts and scrapes, many are on the frontlines dealing with serious childhood asthma, diabetes and mental health challenges, too. Joining me in studio is Dr. Travis Gayles. He's the health officer at the Montgomery County Department of Health and Human Services. Dr. Gayles, it's good to see you.

TRAVIS GAYLESGood morning.

NNAMDIDonna Mazyck is executive director of the National Association of School Nurses. She began her career as a school nurse. Donna Mazyck, thank you for joining us.

DONNA MAZYCKThank you.

NNAMDIAnd Adrienne Rogers is a school nurse manager in D.C. Public Schools. She has 25 years of experience as a school nurse, much of it in Ward 8, in the District of Columbia. Adrienne Rogers, thank you for joining us.

ADRIENNE ROGERSThank you for having me.

NNAMDITravis Gayles, the Montgomery County Council is taking up the possibility of supplying extra funding for adding school nurse positions. There's going to be a hearing on that subject early in the New Year. What's the current situation in the schools?

GAYLESSure. So, we have 208 schools in the county, and we have approximately 98 RNs. And so our nurse-to-student ratio is about one to 1,600 students. And it's important to know that, even though there's not a nurse in every school. Each nurse averages two to four schools that they cover. We do have school health room technicians who staff each of the different schools. So, there is someone present but, again, there isn't a nurse in all of the respective schools.

NNAMDINinety-eight nurses spread across 206 schools is a pretty eye-popping statistic. How do you make decisions about how to distribute that staff that you have throughout the school system?

GAYLESSo, each year, the staff sits down to address trends and utilization based upon population and volume. They also look at the level of acuity in terms of the level of complaints that have come in each school each year. And each summer they determine where the nurses are needed the most based upon those numbers.

NNAMDIHas there always been this big a gap between the number of nurses in the schools and the number of schools themselves, or has this problem deepened over time?

GAYLESIt's deepened over time. You know, the model that we have in place hasn't grown to the level of the increase in student population. For example, over the last three years, the student population has increased over 10,000 students. In addition to the increase in volume, the level of requirements that the nurses provide based upon the state regulations, as well as the acuity of the health conditions that the students face and are coming to school with, have increased, as well.

NNAMDIDonna Mazyck, how common are school nursing shortages across this region and nationally, or does Montgomery County stand alone?

MAZYCKMontgomery County does not stand alone. I want to take us up higher. There's actually concern about a shortage of nurses generally, and school nurses, specifically. And some of the challenges that we face are, by 2030, about a million nurses will exit, by retirement, the nursing workforce. We do see that nursing is an excellent role and an excellent career, and we see there will be growth in that. However, there's some challenges specific to school nursing that brings these shortages.

MAZYCKFor one, there's sometimes shortages in positions. That's not the case in Montgomery County. Montgomery County wants more school nurses, but finding school nurses, there are disparities of nursing staffing across the nation.

NNAMDIHas that always been the case? Have we always not had enough nurses? Or is this a problem that's been getting worse overtime?

MAZYCKI think there's a complexity to that. I think student needs are different. Twenty-first century student needs include students who have those chronic health conditions you mentioned at the top of the show, the diabetes, the asthma. And they also have those social determinants that impact their health and education: housing, needing food and parents needing jobs. Those issues have deepened over the years. And what students need to reduce barriers to learning is what we're talking about. We believe that school nurses are a student-equity issue.

NNAMDIIndeed. Jack Patterson tweets: school nurse shortage is a regional equity issue. D.C. schools are short nurses, even though the law gives every school 40 hours per week of publically-funded nurse coverage. Somerset has had no school nurse from the city since the summer, so KIPP D.C. has been paying for a private nurse. You say it's an equity issue. Do you see less advantaged schools or less advantaged school systems not getting the nursing care they need, as compared with others?

MAZYCKUnfortunately, that's a reality. The National Association o School Nurses did a school workforce study in 2016. And we don't see that, for example, Title One schools, where there are students we know who have more needs, that they aren't necessary prioritized for having school health services and a nurse who's leading the team.

NNAMDIAdrienne Rogers, you spent much of your nursing career in schools in Ward 8 of this city. Would you agree that having school nurses is an equity issue?

ROGERSYes, I do agree with that. I also will say that the needs and the health disparities are, you know, very common. And it takes a lot to make sure that our students are having the healthcare that they need, going to their health providers. We do a lot trying to make sure that we link every student with healthcare in the school, as well as outside of the school and in the community.

NNAMDIYou spent, as I said, much of your career in Ward 8. And there's a perception that school nurses are still mostly dealing with scrapes and stomach aches. What is the day-to-day work of a nurse today actually like?

ROGERSI definitely have to laugh at that one. (laugh) When I first started, it did seem like scrapes. But now we're dealing with some very complicated health situations. For instance, when I started out, you very seldom saw a student with diabetes. Asthma has always been an issue, but not like it is now. A lot of education needs to go forth concerning that. And mental health issues were far and few in between. But now, we're seeing quite a growth in diabetes, asthma and mental health issues.

NNAMDITravis Gayles, you've presented to the Montgomery County Council about the nursing shortage and what it means for healthcare for students. Let's go back to the basics. Why is having a school nurse important, in the first place?

GAYLESWell, school health nurses provide an opportunity to triage a lot of instances, as pointed out, whether you're talking about cuts and scrapes. But nowadays, being able to -- as we make -- which is a great thing. We make schools more inclusive of individuals and don't exclude kids because of their health conditions. It's important to have qualified, trained staff there to be able to help them manage those issues, so that they can focus on their education.

GAYLESAs pointed out, as well, and this is from a pediatrician's standpoint, kids don't often tell you what's wrong for things that are non-medically related. But what often happens is those psychosocial issues will manifest in a physical complaint. So, that bellyache or that headache that they present to the school health nurse with presents an opportunity to have a deeper conversation to be able to triage and understand if there's something deeper going on.

GAYLESAnd as was also pointed out, especially nowadays, with the increase in behavioral health concerns and mental health needs of our young people, they also present an opportunity to be able to ask those questions and figure out what's driving the student's somatic complaint, so that they can be linked to the resources that they need to have a healthy outcome.

NNAMDIHas the Montgomery County Council been receptive to your concerns?

GAYLESVery much so. And what's been great about it is that the two committees that have met to discuss this have included the Health and Human Services Committee, in partnership with the Education Subcommittee. And they have recognized that one of the larger issues related to this is the need from a public health perspective is to look at strategies that include addressing all of those social determinants of health that impact the student when they show up to the school. Because, ultimately, if we can help address those from a comprehensive, holistic manner, we hopefully will be able to keep them healthy, so that they can achieve their full academic success.

NNAMDIOn to the telephones, here's Joe, in Boyds. Joe, you're on the air. Go ahead, please.

JOEHI. Thanks for taking my call. The panel, I think, has a good grasp of the issues, and Dr. Gayles touched on many of them. One thing that the public needs to be aware of is that school nurses and the school health room techs are not funded by Montgomery County Public Schools. And while we see sometimes that Montgomery County Public Schools have a great deal of funding, that doesn't go to the healthcare. That doesn't go to the school nurses and the school health room techs.

JOEThe other point is that the acuity, as they touched on, has increased dramatically, as have the numbers. And nurses -- and I've been a nursing educator for over 30 years. And nurses will do the right thing and will soldier on and get it done. And that is then what leads to that while the job might get done, but then you've got school nurse burnout. And now it's turned moral injury, and that leads then to a great deal of nurses leaving. They have started, but then leaving .

JOEAnd we have to recognize that the pay that the county offers at one time wasn't too bad. The benefits were excellent. Now, the pay doesn't add up. It doesn't compare to what they can get in the private sector. And the benefits are not what they were. So...

NNAMDIDr. Gayles, how are school nurses in Montgomery paid if they're not paid out of the education budget?

GAYLESSure. And this there is by jurisdiction, but in Montgomery County, the school health nurses and the school health staff are a part of the Department of Health and Human Services within Public Health Services. So their funding comes from the public health budget.

NNAMDIIndeed, Donna Mazyck, you have referred to school nursing as quoting here, "a hidden healthcare system." What do you mean by that?

MAZYCKWell, what I mean is that students who have healthcare concerns don't leave them parked outside the school door. They come into the school with whatever it is that they're dealing with, be it mental health, be it chronic health conditions, acute conditions that occur, and any of those social determinants that impact them. And so there are school nurses there, as the caller said, who will do the right thing, make sure they're making connections and making referrals.

MAZYCKOne of the things that we really believe is that there has to be some parity around who funds school nursing. It's very much a local issue, as we've heard. And what we're doing from a national perspective is watching what's going on with states. There's several states that are now billing Medicaid, as appropriate, for health services in schools for general populations. And that may be a funding source that we had not thought of.

NNAMDIGlad you brought that up, because school nurses, as you said, are squarely in the middle of these two really big, complicated systems the health care system and the educational system. What did the implications of that position for their daily work, who they report to, even who pays them?

MAZYCKIt's very much an issue. Nurses work at that intersection of health and education. And they sometimes have regulations and statutes that may not match up. There's not always alignment. And, right now, looking to make sure that there's alignment in those two systems is important. And it's also helpful that those two systems are a part of school health services, because, as we've heard, what children live with and deal with really requires the village, if you will, of multiple agencies and sectors involved.

NNAMDIWell, you mentioned this already, some schools are experimenting with alternatives to solve the funding challenges they face, like trying to get Medicaid...

MAZYCKThat's correct.

NNAMDI...to reimburse the care given to eligible students. Where are those efforts taking place?

MAZYCKWe've seen that in Massachusetts. There's new work happening in Michigan and South Carolina. There's several states where that is an emerging option for funding.

NNAMDIGot to take a short break. When we come back, we'll continue this conversation on school nurse shortages. I'm Kojo Nnamdi.

NNAMDIWelcome back to our conversation about school nurse shortages. Donna Mazyck, there's more than just a funding challenge for the school nursing shortage. Some school systems are also having trouble finding and especially retaining talent. Why is that?

MAZYCKThere are reasons for that, one of them that the caller mentioned earlier, and that is school nurses get a very low salary compared to other nurses. And some school nurses feel like they just can't do that. They can't live on that salary. And so they look for other opportunities in other healthcare agencies.

NNAMDITravis Gayles, has it been difficult for you to hire qualified people for these nursing jobs in schools?

GAYLESSimilar to the challenges that have been talked about already, that it has been tough. And, as you know, we are looking at alternative ways and creative solutions to be able to attract a diverse workforce and increase opportunities to partner with education facilities, for example, to increase exposure for nurses who are being trained right now to the school system to help, you know, build that affinity for the work. That may be able to offset some of those concerns about compensation and level of benefits.

NNAMDIAdrienne Rogers, have you ever considered leaving school nursing behind for a different part of the field? What has kept you in school nursing?

ROGERSOkay. What has kept me in school nursing, 25 years' worth, (laugh) I have a passion for our children. When I got into nursing, I've always liked to take care of people. So, that was a running trend for me. But the thing that is outstanding for me the most is the preventive care that we provide in the school setting. For instance, a lot of times, we are the first line of defense for students that have upcoming undiagnosed health issues.

ROGERSWhen we look at our assessments and looking at the students and our intervention and get them into the proper healthcare, we find that, a lot of times, if we didn't catch it when we did, they outcome would be so much worse. So, for me, it's being able to keep kids from getting sick, keep them healthy so they can continue to learn, because a sick kid is not going to learn well in the school setting.

NNAMDIJoining us now by phone is Katrina Clark, president of the D.C. Nurses Association and a school nurse in D.C. Public Schools. Katrina Clark, thank you for joining us.

KATRINA CLARKThank you for having me.

NNAMDIYou're not only president of the D.C. Nurses Association, you're also a nurse yourself in a school in Ward 8. What kind of health trends are nurses in D.C. seeing and treating these days?

CLARKWell, in my area of Ward 8, asthma is number one, diabetes the second.

NNAMDIAnother factor that D.C. school nurses are concerned about, Katrina, is the closing of the United Medical Center, the hospital east of the river. What are you hearing from your members about that?

CLARKOh, we're in a constant fight every day. I just attended a meeting last evening at the Berry Farm Recreation Center. And we spoke on that issue of the closure of UMC and the building of a new hospital on the St. Elizabeth grounds. That would not include a trauma center or high-risk OB. And we know that patients east of the river, most of the traumas occur on this side. And we need a hospital that will take care of prenatal patients who are going through rough challenges during their pregnancy.

NNAMDIKatrina, what do you think policy...

CLARKWhile trying to keep their hospital.

NNAMDIKatrina, what do you think policymakers, oh, on the D.C. Council or elsewhere can do to better support the nurses working in schools?

CLARKWhat can they do?

NNAMDIYes.

CLARKWell, they can provide financial assistance, of course, for those who lack financial stability in this area.

NNAMDIOkay.

CLARKThey can also have alternative methods, such as have immunization vans come to the different schools for those parents who cannot take their patients -- or take their students, I'm sorry, to the hospital, to the neighborhood clinics. They can come out and visit the schools to see exactly what type of students that we're taking care of, and what illnesses or chronic illnesses we're trying to manage while the children are in school. Because, like the caller said, a sick child cannot learn. And we're focused on prevention. So our immunization goal is to have 100 percent of the students with compliance with immunization.

NNAMDIHere is Nick, in Winchester, Virginia. Nick, you're on the air. Go ahead, please.

NICKHi, Kojo. Thank you. My comment may be completely impractical, but has there been any examination of the possibility of filing petitions H1A for foreign nurses?

NNAMDITo bring trained nurses from outside of the country, has that been considered, Donna Mazyck?

GAYLESThat does happen currently in other settings. I think attracting nurses to school nursing is another part of the puzzle. School nursing is a profession where you can have that touch right with a child in that consistent healthcare presence. And we need to do a better job at showing that role for nurses.

NNAMDIOf course, school nurses are not working for part of the year. How does that affect recruitment and retainment? You can answer that, Dr. Gayles or Donna Mazyck.

MAZYCKWell, I think that's an interesting dilemma, although I believe that although they're working only nine months, sometimes for 10 months, sometimes there's other wok that school nurses do with migrant children during the summertime who come into regions with their families to do summer work. Retention and recruitment is a 12-month-a-year effort that's done.

ROGERSI would like to add that the majority of our workforce, we do work 12 months out of the year, so we are working during the summers. We cover the summer schools, different programs that are taking place in the schools. So, those same kids that come to school during the school year, they come to school during the summer, as well. (laugh)

NNAMDIOkay. The D.C. Public Charter School board says that 76 percent of all charter schools with an approved health suite have 40 hours of school nursing coverage. Donna Mazyck, do you know what's happening at the other 24 percent or so?

MAZYCKI don't have that, but Adrienne can speak to that.

NNAMDIAdrienne...

ROGERSI could speak to that. The health suite needs to meet a certain criteria. Sometimes, they're not large enough, or they don't have facilities that the nurse can wash their hands. They may not have dedicated bathrooms, so there are some reasons why some charter schools may not have a nurse, because the facilities does not warrant itself for healthcare in that particular area.

NNAMDIHere is Sohir, in Washington, D.C. Sohir, you're on the air. Go ahead, please.

SOHIRFirst, I'd like to thank you for your continued interest in community issues. And I want to salute your guests for presenting a holistic approach to the social determinants of health. And, as a retired academic -- retired medical anthropologist, specifically -- what they are saying are songs to my ear. I am calling also to bring attention to the institute -- the Rodham Institute at the George Washington University, which I think is an embodiment on the philosophy articulated by your guests.

NNAMDIOkay.

SOHIRSo, please do look up the work of the Rodham Institute. I know you have shortage of time, but please do that.

NNAMDIIndeed, we do have a shortage of time. I just have time for one more call, and that's Crystal in Washington, D.C. who's associated with Children School Services. Crystal, you only have about a minute. Go ahead, please.

CRYSTALHi. Thank you for having me, Kojo. And thank you again for this topic. I am -- school health is my passion. I work for Children School Services. I am the clinical coordinator, but I've been a nurse for 26 years and a school nurse for 12. And I wanted to really share. While compensation, when I came to school health, I did take a considerable pay cut, but the rewards that you get when you are interacting -- and I came from an ER at UMC, actually. But you get the rewards, the instant gratitude and the return on your investment. You get to see it.

CRYSTALIn the ER with a stabilized patient, they would either go home or they'd go to the floor. You never knew what happened with them. In a schoolhouse you've not only touched the lives of the students, but you've touched them for a lifetime. I have been in school health for 12 years, and I can tell you that this is the place where my profession and my passion have come in line. And it's an opportunity for people to really, really make a difference. So, I just wanted to call in and just thank you again for having this topic and just for keeping the school health...

NNAMDI(overlapping) The issue alive. We're almost out of time, Dr. Travis Gayles, but what would your ultimate staffing goals for nurses in Montgomery Public Schools look like?

GAYLESWell, the ideal situation, we'd have a nurse in every school. That would be the goal. You know, as we continue to work with policymakers, to do that we have offered different solutions and ideas. You know, taking a tiered approach, making sure that there's at least a nurse in every high school. Making sure that there is a nurse in the larger schools, regardless of the level of education, so any school that has greater than 850 students. So, we do have some prelim goals, but ultimately, having a nurse in every school is the ideal.

NNAMDIDr. Travis Gayles, thank you for joining us.

GAYLESThank you very much.

NNAMDIDonna Mazyck, thank you for joining us.

MAZYCKThank you.

NNAMDIAdrienne Rogers, thank you.

ROGERSThank you.

NNAMDIAnd Katrina Clark, thank you for joining us. This segment about school nurses was produced by Margaret Barthel, and our conversation about roadside zoos was produced by Lauren Markoe. We'll be taking a break tomorrow to bring you special coverage of the impeachment debate on Capitol Hill from NPR and WAMU. In the meantime, thank you for listening. I'm Kojo Nnamdi.