When confronted with this “age-old story,” as King calls it, she starts asking questions. Do you not like the class? Is something else going on? She checks their grades. And once she identifies the core issues, she provides the student with wraparound services, engaging school counselors, social workers, teachers and parents.

The main goal? To get students the support they need to return to class as quickly as possible. She calls school nurses “the sentinels,” arguing it’s their role to identify when there’s an issue and then pull together as many people as they can to support that child.

Her current school, World Language Middle School, a bilingual language immersion school in Columbus, Ohio, electronically tracks when students go to the nurse’s office so they can quickly identify these patterns.  

“My primary focus — and a school nurse’s primary focus — is that children are in school,” she said. “Many people think our primary focus is to send children home, but actually our focus is to keep kids in school.”

King’s experiences mirror the results of a of 21 nurses out of the University of Missouri Sinclair School of Nursing. Researcher Knoo Lee, himself a registered nurse, found that students who have many partial-day absences often seek out school nurses as a source of comfort and support. This puts school nurses in a unique position to intervene before their absences become chronic. 

“We discovered something that we haven’t seen before,” Lee told ����Ӱ��, “where school nurses are actually in a position where they are able to identify students who are going through the early symptoms of partial-day absences.” Knowing that partial-day absences often lead to full-day absences, “we believe from these results that school nurses have the potential to play a key role in terms of really helping out with chronic absenteeism.”

Despite this, school nurses are often left out of policy-making decisions and conversations, Lee found. They also need access to greater support and resources to respond to the challenges students face that impact chronic absenteeism, including mental health concerns, homelessness, lack of transportation and food insecurity. And in order for school nurses to be effective, the report recommends that districts work to make sure schools are staffed with an adequate number who are trained and certified and that they have the needed supplies.

Especially post-pandemic, chronic absenteeism, when students miss 10% or more of school days a year, has proved to be an intractable problem. In the 2020-21 school year, at least 14.7 million students nationwide were chronically absent — more than double the number pre-COVID, according to , a nonprofit that aims to reduce chronic absenteeism. Children living in poverty are two to three times more likely to be chronically absent. Students from communities of color as well as those with disabilities are also disproportionately affected. 

Historically, researchers looking at chronic absenteeism have largely ignored partial-day absences, according to Lee, even though they are more prevalent and can be a precursor to full-day absences. And both types impact academic outcomes. Lee’s study is the first to examine the effect school nurses can have on partial-day absenteeism, which is tracked differently from state-to-state and sometimes not at all.

The study is based on interviews with the nearly two dozen school nurses in six online focus groups between June and August 2020. Their years of experience varied and they worked in rural, urban and suburban schools across greater Minnesota. Nurses were also asked to complete a pre-interview survey. The study was conducted in collaboration with the Minnesota Youth Sex Trading Project, which is associated with the University of Minnesota School of Nursing and works to prevent the sexual exploitation of young people.

The research is the first to reveal that students who miss school partially are inclined to initiate their own visits to the school nurse’s office, according to Lee. These scenarios could involve a student trying to avoid a particular class; proactively stopping by the nurse’s office each morning to receive a meal they weren’t getting at home or needing to lie down after working late hours to help support their family. Once there, the nurses were able to intervene with these students and provide support. Since they didn’t have to seek out these “at-risk” students, identifying them was a relatively low lift with potentially big positive outcomes.

This demonstrates the importance of advocating for a more holistic understanding of the role of a school nurse, the study argues, particularly when it comes to offering mental and emotional support.

It becomes much more challenging for nurses to identify these absenteeism patterns if they’re not in the school building every day, according to King, who also serves as president of the more than 17,000-member National Association of School Nurses. On average, about two-thirds of public schools have access to a full-time school nurse, according to the association’s  In rural districts, this drops to 56% and in the West, it plummets to 16%. About 40% of school nurses rotate between at least two schools. 

Parents — especially those whose kids have chronic illnesses — feel more comfortable sending their kids to school when there’s a nurse in the building every day, according to King. This is particularly true when students lack access to medical care outside of the school building. “We’ve seen so many times, the school nurse is the only health care provider that students see,” King said.

 In addition to taking away that much-needed health care opportunity, when there is no school nurse for a student to see, they are more likely to be sent home: 18% of the time versus 5% of time, according to King.

While the number of schools that have full-time nurses has substantially increased since before the pandemic, King thinks that’s likely due to COVID relief funding. She worries a number of schools will once again lose access to a full-time nurse when that federal money runs out later this year.

Notably, the study took place during the first few months of the pandemic. Since then, chronic absenteeism has only gotten worse. While there have been lots of attempted interventions over the last few years, most school districts are still struggling to find the right mix, according to Lee, the researcher. 

His study, he hopes, will highlight that “school nurses can really take a huge role in this.”

That’s the nurse-to-student ratio for K-12 schools in Pennsylvania — one of a handful of states to staffing requirements in the law.

Karla Coffman, a nurse in the , is about 250 students away from reaching that threshold as the certified school nurse for the high school and one of the district’s elementary schools.

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With nearly across six buildings, York Suburban, about 40 minutes from Harrisburg, employs three certified nurses, three full-time health assistants, a floating health assistant, and another who provides care to one student within the district.

So far, meeting those responsibilities hasn’t been an issue, and a nurse having to travel from one facility to another hasn’t meant life or death in York Suburban. But student health needs have changed since the Pennsylvania General Assembly wrote staffing requirements into the nearly 60 years ago.

Though once appropriate for K-12 schools, the requirements are now “unrealistic,” Coffman said.

“You can not use those same standards in our world today,” Sherri Taylor, a nurse at , also in York County, told the Capital-Star. “The only care for a student that was diabetic was to keep that child home because we didn’t have finger sticks. We didn’t have insulin pumps. We didn’t have continuous glucose monitoring systems. A child with cancer didn’t come to school; a child with severe asthma wouldn’t have come to school.”

Now, kids with chronic health conditions can attend in-person instruction in a traditional school setting, and nurses are the first line of care, Taylor said.

“We see that kid every day,” she said, adding that school staff likely interact with kids more than primary care providers or specialists. “We know the norm. We know when something’s wrong or when something’s off.”

Data from the show that more than 40 percent of school-aged children in the United States have at least one chronic health condition — asthma, diabetes, epilepsy, obesity, and food allergies. Additionally, young people are experiencing the mental health effects tied to the COVID-19 pandemic after two years of mixed instruction and isolation.

Over the last two years, nurses — also dealing with the — took on the role of a health department, helping districts develop health and safety plans for COVID-19, monitoring case counts, contact tracing, and sometimes covering multiple buildings. When schools reopened for in-person learning, they maintained their standard job duties as students demonstrated increased need during the health crisis.

School employees have taken on additional roles for years, resulting in workplace burnout and limited resources. Cuts to health professionals are not new. Over the years, districts have opted to have one nurse cover multiple buildings.

from the National School Nurse Association show that 35 percent of schools in the United States employ part-time school nurses, and 39 percent reported having full-time school nurses. Across the country, 25 percent of schools did not have a school nurse.

In Pennsylvania, state lawmakers have introduced bills to update the staff-to-student ratio. The proposals, which have never passed the Republican-controlled Legislature, would adhere to recommendations from the , which calls for one nurse for 750 students. But with an ongoing staffing shortage, officials aren’t convinced that changing the ratio would help ease the burden on K-12 school staff. 

“No school district in Pennsylvania should be talking about layoffs or limiting health, mental health, and disability resources,” state Rep. Dan Miller, D-Allegheny, who has introduced legislation updating staff-to-student ratios, told the Capital-Star. “If anything, we should be expanding those opportunities. Limiting those is an injustice to what we know to be a problem, and what was a problem before the pandemic has arguably gotten worse.”

A fascination turned reality

Motivated by a desire to help others, Coffman — a former child and youth services caseworker — decided to become a nurse after being “fascinated” with the profession while visiting her mother in the hospital.

Eventually, a substitute position turned into a full-time nursing job in the district where she lived, and her kids attended school.

But assumptions she made about the field were quickly debunked when she went back to school for her certification.

“I always assumed that there was a nurse in every single building. And when I signed up to be a substitute, I thought that I would be competing with tons of nurses within my community for substituting time,” she said. “That was absolutely not the case.” 

Nearly 80 percent of Pennsylvania’s 500 K-12 school districts reported 1,997 full-time nurses during the 2016-17 academic year. Outlined in a , that’s an average ratio of one nurse for 809 students.

The Department of Health tracks school nurses and supplemental nurse staffing for public school districts, charter schools, cyber charter schools, and career and technology centers that seek reimbursement from the department. There is no existing mechanism to track school nursing staff at private schools, spokesperson Maggi Barton told the Capital-Star in an email.

Data representing 686 school entities statewide provided by the Health Department show 2,101 full-time certified school nurses, 610 registered nurses, and 590 licensed practical nurses. Roughly 315 out of the 500 public school districts in Pennsylvania have more than 1,500 students enrolled.

“What happens is that school nurse covers multiple buildings,” Pennsylvania State Education Association President Rich Askey said during a March interview. “And I’ve been there when I had a student have an asthma attack, and we’re all waiting for the school nurse to come from another building a few miles away.”

In , a sixth-grade girl at a school in Philadelphia without a certified nurse on duty went home because of an asthma attack. She later died on her way to the hospital.

PSEA efforts to adjust the nurse-to-student ratio in Pennsylvania, including from Miller to set requirements for counselors, psychologists, and social workers. Miller has also introduced to set standards for counseling services in K-12 schools.

Taylor, who serves nearly 1,500 students at Red Lion Area Senior High School, is the only certified nurse — out of five — with one building districtwide. The other nurses have two facilities on their caseload, she said. The district also employs ten health room nurses, either LPNs or RNs, with full-time or part-time schedules.

Add staff members to the count, and Taylor and the health room nurse could be responsible for up to 2,000 people each day — “basically the size of a small town,” she said.

Certified nurses and supplemental staff undergo training. So if a student or employee has a medical emergency, such as a bee sting, school health professionals can respond as needed, even in cases where a nurse is traveling from another building, Taylor said.

“In our district, we’re fortunate. But that’s not the case in every district in Pennsylvania or every building in every district,” she said.

Taylor said there could be days when she’s absent and without a substitute to cover, leaving the health room nurse alone in the building, with the junior high school certified nurse roughly a half-mile away if there’s a “serious emergency.”

“But at the same time, that’s a huge responsibility,” Taylor added.

More than treating scrapes and bruises

If Coffman misses a day of school, especially if she knows she’ll be absent ahead of time, she makes every effort to find a substitute because “we don’t want to see any of our buildings go without a nurse.”

A , developed by the Pennsylvania School Boards Association and the Pennsylvania Association of School Administrators, stated that nearly every school district reported staffing shortages, with 46.5 percent of districts reporting a nursing shortage.

Sarabeth Abalos, a substitute school nurse and director of the BSN Program and the in Mercer County, told the Capital-Star that she makes about $12 an hour working in the Sharpsville Area School District in Mercer County.

Sharpsville, which has roughly 1,000 students enrolled, uses , a Delaware County employment agency, to day-to-day staff.

“That has always been a hard sell for a registered nurse to go and work for $12 an hour,” Abalos said. “And you are assuming a tremendous amount of responsibility when you are the only medical professional in a building.”

If Abalos didn’t already have a full-time position at Thiel College and wanted to work as a substitute nurse every day, she could.

Abalos said nurses, specifically in smaller districts with one nurse per building, have difficulty balancing daily duties with mandated procedures, such as vision and hearing screenings.

“There are records to be kept, screenings to be done,” she said. “There’s so much paperwork that they have to maintain in addition to their actual nursing responsibilities, and I think there’s potential for so much good for society. But they simply don’t have the time to engage at that level.”

Before the pandemic, Taylor, joined by a school social worker and high school students, worked on a remediation program and campaign to combat vaping, targeting students at all levels. She also helps at a group home for teenage moms. Her typical daily job includes record-keeping, caring for students with chronic illnesses, and treating those in need with an education-based approach.

“Students will come in and say, ‘Oh, I have a headache.’ I’ll ask if they had anything to eat today. And they’ll say, ‘No, can I have ibuprofen?’ And I’ll tell them that it’s really not in your best interest to take ibuprofen because it can be upsetting to the stomach or an empty stomach,” Taylor said. “It’s those little snippets of what I’d call real-life education.”

Coffman recently obtained her CPR instructor certification, so she can train nurses and school staff members. She serves as the advisor for the , which was by a York Suburban graduate now attending York College. Coffman also oversees a local Hope Squad chapter, which works to address youth and teen suicide by empowering them when they experience social and emotional crises.

Taylor also incorporates lessons on resiliency into her daily interactions with students.

“The world is a different place for them,” she said. “And we’re at that point right now where they have to be taught how to bounce back, and that it’s OK to bounce back, and life is going to get better. It’s not always going to be down in the dumps.”

‘Cautiously optimistic’ about garnering bipartisan support

Outside of support from school administrators, colleagues, and loved ones, all three nurses said lawmakers should focus on legislation to increase funding for staffing recruitment and retention efforts, as well as adjusting the School Code to meet CDC recommendations.

Investing in school health services leads to fewer student absences, Coffman said. And with more staff and educational resources, districts will have more accurate medical records, increased immunization rates, fewer student pregnancies, and “just better health outcomes overall,” she added.

Miller, who has repeatedly introduced legislation to address school staffing ratios and health services, said he’s “cautiously optimistic” that colleagues from across the aisle will support his bills, currently before the House Education Committee. His hesitancy, however, stems from Democrats being in the minority party.

“We need people who echo those concerns on the floor of the House and in committees to find — if not my bills — find solutions to make learning more accessible and to support our teachers and other school professionals,” Miller said. “But when you give them ratios that are unworkable, you’re almost negating the value of having any of those support services in place at all.”

If Miller’s proposals survive the House and make it to the GOP-controlled Senate, they’ll likely face opposition from the majority.

Sen. Judy Ward, R-Blair, a former nurse, serves on the Senate Education and Health committees. In a statement to the Capital-Star, Ward said “now is not the time” to consider changing staffing ratio recommendations because they require funding and hiring people to fill newly required positions.

“Our health care workers are critical to serving the needs of others in our communities. But with the pain of a workforce crisis facing just about every employer right now, the introduction of mandated or increased mandated staffing requirements may not be best — certainly not attainable,” she said. “This is especially true for rural healthcare providers.”

Sen. Scott Martin, R-Lancaster, who chairs the Senate Education Committee, told the Capital-Star that school boards have a lot of power in Pennsylvania.

“There’s nothing in law that prevents them from hiring more nurses,” he said, adding that he hasn’t heard nurse-to-student staffing ratios raised as a concern among constituents. “There’s a lot of industries in Pennsylvania that are facing crucial shortages right now.”

Reflecting on the staffing crisis affecting industries statewide, Martin suggested that the could help address the crisis. He added that the could analyze how to allocate money to address shortages and ensure those entering the workforce are hired for a “good-paying job” immediately, thus addressing multiple issues through targeted investments.

Gov. Tom Wolf, who and leaves office in January 2023, proposed $1.55 billion in new education funding as part of his . Democrats have also called for increased allocations, so schools have the resources to recruit and retain staff and make decisions based on individual needs.

But when it comes to changing the nurse-to-student ratio, the administration said the staffing crisis “could result in additional staffing problems for schools,” Elizabeth Rementer, a spokesperson for Wolf, told the Capital-Star.

“Such a mandate also could force schools to direct resources to attaining the required ratio rather than to areas where the needs are more critical,” she said.

is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Pennsylvania Capital-Star maintains editorial independence. Contact Editor John Micek for questions: info@penncapital-star.com. Follow Pennsylvania Capital-Star on and .

It’s long been an underlying logic of pandemic safety for schools: In order to contain COVID transmission, identify which students and staff have been exposed to the virus and make sure they quarantine or test negative before coming back to class.

That wisdom appears to be changing, however, in the wake of the Omicron surge, which experts say may have now peaked in many U.S. communities, but continues to strain K-12 operations.

Three New England states — , and — have recently announced new guidance recommending a pivot away from individualized contact tracing in schools and toward strategies like symptom monitoring and home test kits for those worried that they may be sick.

“We are recommending that school health personnel increase their focus on identifying symptomatic individuals, rather than monitoring in-school close contacts,” Massachusetts Education Commissioner Jeffrey Riley, Massachusetts wrote in a Jan. 18 . 

“Individuals identified as close contacts in school are very unlikely to contract or spread COVID-19,” he continued. “Therefore, extensive contact tracing and associated Test and Stay procedures are not adding significant value as a mitigation strategy despite the demand they place on the time of school health staff and school staff at large.” 

New York announced in mid-January that it was , which was for the general population rather than K-12 specific. And individual school systems including ; ; and have also opted to ease away from the practice, often ramping up other mitigation strategies instead.

Contact tracing puts a “​​now-impossible workload” on school districts, Berkeley Unified School District Superintendent Brent Stephens wrote in a Jan. 15 . The school system is now offering , regardless of exposure, and is investing in highly protective KN95 masks for students and staff.

A pre-Omicron study of classroom transmission in California and Illinois published by the Centers for Disease Control and Prevention found that roughly just out of every 100 school-based close contacts of positive cases, on average, ultimately got sick themselves — casting into doubt, for , the added value of the labor intensive practice of cross-checking rosters to track in-school exposure.

Then came the Omicron variant, spurring record-breaking infection levels. In Yonkers, New York, a . In Providence, Rhode Island, some classrooms had than present in class. Last week, across the country, more than caught the virus, a pandemic record and over four times more than at any point during previous surges.

The ultra-rapid spread made it next to impossible for some districts to accurately track exposures, school leaders said.

“Omicron is spreading more quickly than contacts can be traced. Contact tracing for this variant is ineffective,” wrote Lou Goscinski, superintendent of Maine’s York School District, in a Jan. 13 explaining that the practice would be discontinued.

Indeed, the timeline from exposure to transmission is than with Delta or other strains of the virus, scientists say. For districts that are practicing universal masking, that means “contact tracing doesn’t do much as a preventative measure,” said Danny Benjamin, co-chair of the at Duke University, which examines COVID-19 spread in schools.

“By the time you figure out who was in the room, were they really close, were they vaccinated, the list goes on and on, it’s now a couple of days after exposure and that child is now infectious,” Benjamin told ����Ӱ��. “So [contact tracing] is not as helpful to contain the disease as we were seeing with the ancestral variant or the Delta variant.”

From a labor standpoint, too, Omicron made contact tracing less tenable, said Linda Mendonca, president of the National Association of School Nurses. Tracking exposure was already a heavy lift for school personnel, usually requiring nurses to scour seating charts from mealtimes, bus rides and classrooms every time a student would test positive. In many cases, that work continued into the weekends because schools needed to keep sick or potentially exposed students from showing up on Monday, she said. At some schools, nurses had to let the typical yearly screening of students’ eyesight and hearing go by the wayside because the contact tracing programs took up so much of their time.

Then after the winter holidays, skyrocketing caseloads pushed many schools’ case tracking programs past the breaking point.

“I heard many school nurses just saying, ‘This is not manageable. We can’t keep doing this at this … capacity,” Mendonca told ����Ӱ��.

Regardless, the longtime school nurse chose not to comment on whether now is the right time to ditch contact tracing altogether.

“We’re waiting to see what the CDC comes out with,” she said, emphasizing the continued importance of mitigation strategies like masking, ventilation and vaccination.

The last update to CDC guidance on contact tracing in schools came in mid-October, according to the agency’s , which says the practice remains an effective strategy for reducing COVID spread in schools when used alongside other layered mitigation strategies.

But Benjamin is willing to take a stronger stance. Even amid Omicron, COVID transmission in schools remains low when all students and staff are wearing masks, he said. His team has a forthcoming paper that answers a key question: How many close contacts in fully masked schools develop infections after being exposed to the highly infectious variant?

“If everyone’s wearing masks, it’s still under 5 percent, but it’s no longer in the 1 percent range,” he said, referring to the secondary transmission rate in school under the earlier strains.

Those numbers combined with Omicron’s speed of transmission and the logistical headaches of exposure tracking lead him to believe contact tracing may no longer be a necessary or useful measure for schools that are universally masking. But for schools that aren’t mandating face coverings, he takes a different tune.

“In the unmasked districts, you probably want to [continue contact tracing],” said the Duke University doctor, explaining that the practice can help determine whether specific individuals who were exposed should mask going forward so as not to infect others and test, tactics known as mask to stay and test to stay.

“It interrupts the chain between a bunch of us infecting each other,” said Benjamin.

As cases begin to subside in some, but not all, parts of the country, many schools are now scrapping mask rules. Virginia Gov. Glen Younkin’s to let parents opt out of school face-covering requirements took effect on Monday (although it is now facing ). And two Long Island districts to end their requirement that students wear face coverings in school when the New York state masking mandate expires on Feb. 1.

A New York state judge, meanwhile, ruled on Monday night that the and can’t be enforced, but that decision was quickly stayed by an appellate court judge Tuesday afternoon. For now, until the appellate court decides whether to uphold or overturn the lower court’s ruling. The back-and-forth created at least temporary confusion for school leaders Tuesday and fueled school mask opponents, with the hashtag #UNMASKOURCHILDREN trending on Twitter.

Meanwhile, students themselves are spooked. In early January, young people in New York City staged a walkout to protest what participants said were unsafe conditions in schools. Thousands of students joined the demonstration, calling for more COVID safety mitigation measures and a temporary pivot to remote learning.

In the following days, students in ; ; and have also staged walkouts making similar demands.

Samantha Farrow, an organizer of the New York City walkout and a high school junior in the city, said that her school did not notify her when her desk-mate in French class left halfway through the school day after testing positive. The high schooler only found out about the exposure, she said, because that student texted her directly.

“No one tells students anything and it feels like we’re getting left out of the loop,” Farrow told ����Ӱ�� in early January. “It’s not fair to us because we’re the ones being impacted by this.”

Faced with burnout, low wages and now COVID-19, scores of education workers — including not just teachers but also school bus drivers, special education paraprofessionals, cafeteria and afterschool workers, nurses, school safety agents and custodians — have left their posts.

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Districts have been forced to cancel classes, close cafeterias and feed students pizza, bring back remote classes, and hire per diem emergency workers. School officials have also increased salaries and other incentives to attract and retain staff.

����Ӱ�� has found school staffing shortages in all 50 states.

The U.S. Bureau of Labor Statistics’ most recent data show there were in July. The rate of workers leaving their job only — wholesale trades and education.

“I fear the worst is yet to come,” Highline public school superintendent Susan Enfield told ����Ӱ��. Her district outside of Seattle has had to send central office staff to fill teaching positions. Enfield believes the approaching cold and flu season and new vaccine requirements will exacerbate shortages in the coming months.

In one Idaho district, the staffing situation was so dire, schools were “due to excessive staff absences and the shortage of substitute teachers.”

When schools managed to open, staffing shortages created headaches for students: A lack of cafeteria workers meant children at S. Weir Mitchell Elementary in Philadelphia weren’t served breakfast or lunch one day in September.

Many students haven’t made it to school at all because of a shortage of bus drivers. In a National School Transportation Association , more than half of the school district officials polled described their bus driver shortage as “severe” or “desperate.”

In Minnesota’s St. Francis Area Schools superintendent Beth Giese got her bus driver’s license to help ease the shortage.

“​​A very wise mentor once told me, never ask an employee to do anything you wouldn’t do yourself. Guess who got her bus license!” Giese in a Facebook post.

To see how widespread and pervasive the school staffing shortages are, click on states below to see ways they’re experiencing — and tackling — the back-to-school hurdle.

If you are having trouble viewing the interactive, click here