HOUSTON, Texas (KTRK) -- Brandy Bowlen says she's the guardian of her campus.
"Parents drop (students) off knowing that they're going to be taken care of by me, expecting that there's a school nurse, not knowing to even ask," said Bowlen, a registered school nurse at Klein Independent School District's Epps Island Elementary School.
When some students head back to class in person on Sept. 8 at Klein ISD, the district said every campus will have a nurse that will help monitor and identify COVID-19 cases and outbreaks.
But 13 Investigates reached out to 40 school districts and found dozens of Houston-area campuses without a nurse, who experts say are more likely to know students' individualized health risks. Others schools, we found, only have one nurse for thousands of students, more than double what national health experts recommend.
The Houston Independent School District is scheduled to begin all classes online Sept. 8, with students allowed to return to campus after a six-week transition period. Right now, in Harris County, nearly 14% of the county's 16,029 active COVID-19 cases are people under the age of 19.
Our investigation found at HISD, 7% of the schools, which served more than 11,000 students last year, didn't have a nurse on staff as of Aug. 21. Since then, the district said it's hired 43 additional nurses for a total of 282 nurses across its campuses but some of those nurses are part-time and there are still several nursing vacancies posted online.
In Texas, districts aren't required by law to have a nurse on staff at every campus. The Texas Education Agency does not track which campuses do not have a nurse on staff, despite requests from advocates to do so.
INTERACTIVE: Want to know if your child's school has a nurse? Search their campus online using the map below. On mobile device? Click here for a full screen experience.
Last year, Texas passed a law that requires districts to post information on whether or not each campus has a full-time nurse and for the first time this year, that information should be available for parents.
But passing the bill requiring that transparency took years, and the information still isn't collected on a statewide level.
Without it, the Texas School Nurses Organization and Texas Public Health Coalition said it's difficult to identify the communities most in need.
"School nurses across the state are volunteering to serve as the frontline providers (and contact tracers) to ensure that students across the state are able to return to school safely," the two organizations said in a July letter to TEA Commissioner Mike Morath. "Even school nurses who do not expressly volunteer for this program will inevitably be required to monitor the health of their students and report known instances of COVID-19 infection."
13 Investigates asked the TEA about the requests outlined in the letter, but the state agency has not responded to our numerous requests.
Yvonne Clark, Director of Health Services at Klein ISD, said people have talked more about the importance of school nurses this summer than ever before. At her district, which has at least one registered nurse on every campus and two on larger campuses, it's always been a priority.
"I always let our staff know we are extremely fortunate," Clark said. "I really feel for the rural school districts and the smaller school districts where maybe they do have a nurse, but that nurse covers two or three campuses and has to rotate either throughout the week to those campuses or throughout the day."
Nationwide, only 39.3% of schools employ a full-time nurse more than 35 hours a week, according to the National Association of School Nurses. Nearly 35% of schools have a part-time nurse working less than 35 hours a week. But 25% of schools nationwide have no nurse on staff.
Trudy Hilty, a registered nurse who has worked in public education in Houston for 25 years, said school nurses will now become the frontline workers deciding who can come into their buildings.
"Every person who comes in should have their temperature taken, have questions asked and be evaluated," Hilty said. "We have people who are asymptomatic, so they don't look like they're sick, but as the nurse who can ask those personal intimate questions that a front desk clerk may not feel comfortable asking, (I can say) 'come back in two hours, I'm going to check your temperature again.'"
At an HISD meeting on Aug. 13, Interim Superintendent Grenita Lathan said she expects every campus to have a school nurse this year, unless it's a shared property where one nurse will go between buildings.
But, as of Aug. 21, the last time the district provided an exact breakdown of each district, there were 20 campuses with vacancies, including Hartman Middle School, which had 1,260 students enrolled during the 2019-20 school year. Some of those vacancies, including Edison Middle School and Hobby Elementary School, have been posted online since May.
13 Investigates asked for an interview with HISD, but the district did not make someone available for a comment.
Although there may be fewer students on campus at the start of the year, Hilty encourages parents to ask their child's principal if there is a full-time registered nurse on campus five days a week.
If your child doesn't have a nurse on campus, Hilty said it's important for parents to contact their child's teacher and let them know of any health concerns that might arise, such as attention deficit disorder or anxiety attacks.
She also encourages parents to ask why and contact the school board or other community leaders to bring attention to the issue.
"Parents are the best advocates for their children, but parents have got to understand, you've got to start bringing this to the attention of people. Don't just let it slide," Hilty said.
'They're missing out'
The American Academy of Pediatrics' policy advocates for a minimum of one full-time nurse in every school. For larger campuses, the AAP supports a ratio of at least one nurse per 750 students in healthy populations, but gauging if that ratio is being followed is difficult due to complex health needs of students, according to the organization's latest policy on school nurses.
But for many campuses, Hilty said it's normal to have one nurse serving thousands of students due to lack of funding or resources.
Campuses who have only one nurse for thousands of students, or no nurse at all, mean some children will miss out on vision, hearing and scoliosis screenings or other preventative healthcare offered by school nurses.
"They're missing out on a nurse who can stop them at the door," Hilty said. "They're missing out on a nurse who can look at them as a medical professional and determine whether or not the child is well enough to stay in school or has the potential of infecting 3,500 students."
Statewide, during the 2019-20 school year, there were 5,922 school nurses serving 773 school districts with 3.8 million of the state's 5.4 million students, according to an analysis by 13 Investigates.
An additional 25% of Texas public schools had no school nurse on staff, per the TEA. However that doesn't take into account districts like Austin Independent School District, who contract those services out to Ascension Seton.
Bowlen said many parents just expect their child's school has a registered nurse.
Now, she said, it's especially important for parents to ask if there's a registered nurse on the child's campus all day, every day.
"If the answer is no, the question then becomes why not? And who is there? Who are you using," she said.
In addition to Texas not requiring nurses on every campus, Becca Harkleroad, advocacy chair for the Texas School Nurses Organization, said districts as a whole aren't required to employ a nurse, which makes it difficult to advocate for more.
"It's one thing for somebody to say, 'Oh, hey, we have 3,600 kids. We need more than one nurse,' but then, what if their district admin's response is, 'Well, (we) don't even have to have a nurse, so you're welcome that you have a job," she said.
Harkleroad said many communities are feeling overwhelmed with the number of positive COVID-19 cases that require contact tracing to determine who the individual interacted with.
Earlier this year, the Texas Department of State Health Services partnered with the Texas School Nurses Organization so nurses could volunteer with the state's contact tracing efforts.
Their hope is that when the school year starts, school nurses will be able to help local public health authorities, but those that serve thousands of students may feel like they're being set up to fail, according to Harkleroad.
"It's not possible," she said. "Having one nurse for 4,000 kids is better than having zero nurses for 4,000 kids. But at that point, your one nurse for those 4,000 kids is going to be doing more 'putting out fires,' I would say, not even so much triaged case management."
The Texas DSHS is also partnering with the TEA to track COVID-19 cases in public schools.
"Data on the number of cases in schools is of paramount interest to parents, students, teachers, staff, public health experts, policymakers and the larger community," the agencies said in a joint statement on Aug. 20.
The state is asking districts to report all cases since the start of the school year, if they occurred prior to when the case submission form was released on Friday. Already, some Texas school districts have launched their own dashboards indicating how many students have COVID-19. In Garland, a Dallas-area district of 55,000 students, there are six staff members and five students with COVID-19.
Question to ask your child's school
Bowlen said it's sometimes difficult for parents to know the qualifications of the nurse on their child's campus unless they ask.
13 Investigates found that while some campuses have registered nurses, who can dispense medication and document medical history and symptoms of patients, others have licensed vocational nurses, who can provide less or more basic services.
And a few campuses only have a clinic assistant - who does not have a nursing license - as their designated school nurse.
"If you call any given campus in Texas on any given day, you could get, 'There is a school nurse,' but what is their definition of a school nurse? Are we talking about a registered nurse? Are we talking about an LVN? Or are we talking about anyone who is the school nurse?" Bowlen said. "Until that is defined, the answer's going to be very difficult if the parent doesn't ask the right question."
Right now, during a pandemic, Bowlen said it's important for parents to know that the nurse serving their students is an expert in public health, nursing and education and to ask specifically if there's a nurse on campus and what their qualifications are.
Clark said school nurses provide a level of expertise that a clerk or secretary serving in that position wouldn't have.
Coughing or shortness of breath are symptoms of COVID-19, but a nurse would know to ask a student with asthma if it's their normal cough, if they've been taking their medication or using their inhaler.
"When you're a registered nurse, you develop an intuitive ability to read between the lines when it comes to health," Clark said. "If you are a campus and you don't have a registered nurse in your school, and you're depending upon a secretary or an unlicensed person to ask questions in regards to COVID or any other health problem. They don't have that ability, that training, that certification to look for those nuances between the lines, and sometimes between the lines is where the story lies and where the assistance is needed."
Clark said she's eager for students to return to school, and have that structure again. She knows students, parents and teachers will be nervous, but she said she'll be there to ease their concerns.
"Nobody knows 100% about this virus yet, so it's just being flexible and adaptable. And that's what nurses are used to doing," she said. "Nurses are used to being flexible and adaptable and as long as we have the tools in place, and we have the knowledge, we can then meet our community with what they need head on."
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