HOUSTON, Texas (KTRK) -- As students head back to school this year, tens of thousands of children will be at campuses without a school nurse.
For the second year in a row, 13 Investigates surveyed 40 districts across the Houston area and tracked down nearly a dozen districts that don't have nurses on all of their campuses.
Our investigation found 46 Houston-area campuses without a school nurse with nearly 38,000 students combined.
School nurses said their role this year is especially important because they are trained to know each individual child's health needs and will be able to better tell the difference between a contagious student and one who may just be experiencing an ongoing health issue.
"I'm super concerned for schools that don't have school nurses," said Brandy Bowlen, a registered nurse at Klein Independent School District, which has a nurse on every campus. "People don't understand all of the work that happens in the background."
At Houston ISD, there are 20 campuses without a nurse, including some high schools that each have thousands of students.
"Prior to the pandemic, a lot of the tasks that were on the campuses could be delegated to an unlicensed personnel," said Jackie Birmingham, director of health and medical services at HISD. "Now with the pandemic, I think it has been very eye opening to what all the nurses bring to the campus as far as support, guidance, being flexible, being able to bridge that gap between healthcare and education."
Statewide, there's no mandate requiring districts to have a nurse on every campus. At HISD, it's up to principals to decide. Birmingham said all of the principals want one, but filling the 20 vacancies has been difficult.
"There has always been a nursing shortage and the last year and a half with health care personnel, some people are electing not to return to the profession, so you're dealing with all of these different circumstances," she said. "You have to want to choose this specialty, first off, to work with children."
INTERACTIVE: 13 Investigates surveyed 40 area districts across the Houston area to see if they have a school nurse. Want to know if your child's school has a nurse? Search for your campus on the map below.
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At Waller ISD, half of its eight campuses do not have a full-time nurse, but the district says those four campuses do share two licensed vocational nurses that rotate between them.
Nine percent of campuses at Alief, Aldine and Bryan independent school districts do not have a nurse.
Bryan ISD says the district does have two registered nurses as part of its COVID-19 response team that float between districts.
Alief ISD also has eight itinerant, or floating, nurses and 10 floating licensed vocational nurses to assist the campuses without a full-time nurse.
Aldine ISD is looking to hire six additional nurses this school year at the campuses that don't currently have one.
"As Aldine ISD knows the importance of school nurses and values their support as it relates to the health of our students, there are partnerships in place with healthcare and other professional agencies that have provided contract nurses to ensure our schools have the support they need," said Dr. Charlotte J. Davis, assistant superintendent of student support services at the district.
Becca Harkleroad, a school nurse in Central Texas, said she wasn't surprised this past legislative session when renewed efforts to mandate a nurse on every campus didn't get a hearing.
"We went into the session with very high hopes and then Texas froze and ERCOT melted down and that kind of sucked up all the air in the room for so long. ... It's concerning to me for the sake of our students and for the sake of our schools," said Harkleroad, advocacy chair for the Texas School Nurses Organization. "Our school nurses are a valuable resource no matter what ... you would think this year would be the year that it would go through, and it didn't go anywhere, which was disappointing."
Already this school year, there's been nearly 3,000 COVID-19 cases reported at campuses in the Houston area, and the largest district, HISD, hasn't even started classes yet.
Gov. Greg Abbott is not mandating that masks be worn and social distancing be enforced in the classroom this school year. Schools also won't be required to shut down certain campuses if there's an outbreak and there's limited virtual schooling options, even for students who test positive for COVID-19. Some local school districts are defying the order and requiring students to wear masks.
"It's a little astonishing that we're in our third school year that's been impacted by COVID and every single year it's been a different picture," Harkleroad said. "Now we're going back to school one more time except this time we don't have every mitigating measure. We can't use some of the ones that we know have worked the best, our most effective strategies to keep people safe in the schools have been taken away by political leaders, not public health."
'Guardian' of the campus
At Klein ISD, Bowlen said as a school nurse, she's the "guardian" of the campus. She gets to know all of the hundreds of students on her campus and their individual health needs.
"They become mine. They're my community and if I don't come in as my best professional registered nurse self, they lose," Bowlen said. "That's not something I take lightly. It's huge and so it's pride. It's taking pride in the community where you are and knowing your responsibilities."
Yvonne Clark, Director of Health Services at Klein ISD, said the district has been tracking COVID-19 data since the pandemic began and is aware every time a new wave of cases impacts the community and county.
Despite the latest wave of the delta variant, Clark said the district continues to make every effort to minimize the impact on students and their ability to go to school and learn every day.
"COVID-19 has highlighted the role of the school nurse, and it's highlighted the role of public health," she said. "They need a health professional who can look at the whole child because it's not just COVID-19 that's going to keep a child out of school."
School nurses educate students about hand hygiene, respiratory etiquette and encourage them to speak up if they feel sick. They also provide disease surveillance, even before COVID-19, to identify outbreaks of other communicable diseases and notify parents if they should look out for symptoms with their own child.
"School health is one of these specialized practices that often go under the radar that people don't recognize the constant public health challenges that school nurses are facing," Clark said. "This is not the first time school nurses have dealt with severe communicable illnesses, for example, the H1N1 breakout."
'Schools can't compete' when it comes to pay
Texas School Nurse Organization President Karen Schwind said some districts have full-time registered nurses, but she's worried about the districts that have part-time nurses who rotate between campuses or no nurses at all.
Campuses without a nurse typically have more absences, she said.
"Many feel that the funding should go toward the educator, not realizing that if you have a nurse that can help mitigate some of these medical issues and concerns, that the students will be more likely to attend school and the students in their seats learning is ultimately going to support the funding," she said.
One reason attendances increase on campuses without a nurse is because an administrator may have a list of COVID-19 symptoms and send home any child who comes into the office with one of them. But as a nurse, Harkleroad said she knows the child's health history and is able to better assess each student.
"It's not just a symptom on the list. The nurse can address that. Last year we had a lot of headaches that came in but with kids wearing masks all day every day, they weren't drinking as much water as they usually do," she said.
Nurses were able to recognize that a child coming into their office with a mild headache in the middle of the day, and no other symptoms, might just be dehydrated - not sick.
"The nurse could treat it, give the kid a glass of water and have them hang out for a little bit and their headache goes away and they get to go back to class," she said. "They can do that for a number of things, not just headaches but you know, a mild upset stomach. You can talk to them ... maybe this kid is having anxiety and not having an upset stomach because they're coming down with COVID."
One thing that's made it difficult for districts to staff each campus with a nurse or nurse substitute is pay, Harkleroad said.
"We pay our substitute nurses, credentialed healthcare professionals, between $100 and $140 a day. Right now they can make that per hour in the hospital," she said. "Schools can't compete with that."
At Houston ISD, Birmingham said wraparound specialists will assist the campuses that do not have a nurse. She hopes every single one will have a nurse on the first day of school and that it becomes mandatory moving forward.
"I am new to this position (and) we have a new superintendent so I'm hoping a lot of the past issues and concerns can be readdressed and brought back to the forefront," she said.
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