Thank you Dr. Burbach...

Couldn't have said it better....

I am extremely concerned about a proposal to replace registered nurses (RNs) with licensed practical nurses (LPNs) in USD 259 schools.  My views are formed from 14 years as a nurse educator, 11 years in public health, and another ten years as a previous coordinator of school health in your district.   These views are consistent with leading professional organizations in nursing and national standards for school nursing, which recommend that only bachelors prepared registered nurses be hired in school nurse positions. 

Your charge to reduce the budget is indeed a challenging one, one I don’t envy.  I ache every time I see another news item about cuts to education funding.   Regardless, the decisions you make must be well-informed and based on consideration of exposure to risk in several areas.    

·         Financial – My assumption is that replacing RNs with LPNs has been suggested for no reason other than financial savings to the district given lower cost.    However, until current revenue sources for nursing staff are thoroughly analyzed, a simple savings-by-lower-salaries represents only one variable in the financial equation.  The Medicaid reimbursement you currently realize for payment of nursing services for special needs and potentially regular education students is most likely not eligible for LPN services.  The loss of that income must be weighed against estimated gains by decreased wages. 

·         Legal – Kansas law specifically regulates the practice of RNs, LPNs, and unlicensed (non-nursing) personnel such as your teachers and school secretaries when delegated to perform nursing tasks.   KSA 65-1113(d)(2) sets qualifiers for LPNs related to their supervision by an RN, the type of care they may provide, and the required match between their educational preparation and expected activities.   Additionally, KAR 60-15-102, in prescribing how RNs may delegate nursing activities to others, expressly includes language about LPNs and their delegation authority.  It is a given that nursing activities will be delegated in schools; it not a given LPNs can do it.  The district does not need a major legal battle after you’ve placed legally unqualified people. 

·         Supervision – The law clearly states that LPNs must be supervised by RNs, so unless you plan to assign them as assistants in buildings with RNs, they are not likely to receive the supervision their license requires.   Closed clinical environments such as hospitals and doctors’ offices provide adequate supervision, not schools where they are the only health staff.  In my capacity as coordinator, I felt keenly our inadequacy in supervising school nurses.  They called their peers and me often for advice, but never knew the luxury of in-building supervision and mentoring, except for the principal.  Most principals generally know a good nurse when they see one, but they clearly are not qualified to judge their clinical decision-making and technical skills.  Even in the coordinator’s position, I supervised from afar by proxy measures of reporting, recording, and secondary evidence of judgment calls.  Responsibility for principal supervision and evaluation of LPNs only makes this phenomenon more worrisome, not to mention the expectations of principals after years of relying on bachelors prepared nurses.

·         Scope of practice—The role of an LPN in our health care system fills a legitimately well-trained need for technical nursing skills.  However, this is not consistent with the role of a bachelors prepared RN in a school setting.  The aforementioned Kansas regulatory language states that LPNs function “within the framework of supportive and restorative care.”  Language about the scope of registered nurse practice is lengthy and describes a much broader and substantial expectation of assessment and actions, including wording about diagnosis, treatment, counseling and health teaching, management and supervision.    Comparable differences exist in the practice of advanced register nurse practitioners, who function in an even more expanded role and may prescribe medications.   Environments and expectations should match qualifications and scope.  Just because nurse practitioners can diagnose and prescribe medications does not mean they should be doing major surgery.

Look at your current school nurse job description and ask yourselves whether this level of performance can be met by a licensed technician with one year training.  You currently have twelve board-approved policies under the responsibility of Health Services and school nurses.   Many of these are absolutely incompatible with the qualifications of an LPN.  Much of the practice of a school nurse is assessment, a skill LPNs simply aren’t schooled in.  The technical skills LPNs are trained for are also used by RNs, but only as a part of the larger health situation.  When faced with cuts to nursing services in San Diego, Linda Davis-Alldritt of the California Department of Education was recently quoted in a San Diego paper.   She stated, "I could teach you how to give an injection, but I couldn't teach you in a day how to assess that person to make sure they need that injection."   Our school nurses are constantly assessing your students and their needs for the next action. 

The evolution of the H1N1 flu pandemic and its spread across the US includes the powerful story of a school nurse who discovered a first-of-its-size outbreak of H1N1 in this country in a NYC high school.  To quickly discover and contain the massive numbers of sick students and staff, she expertly used skills of physical assessment, communicable disease investigation, epidemiology, and people and system management, all the while humbly claiming that she was “just doing her job.”  This is the job of a much higher qualified person than an LPN. 

·         Safety – Every day committed teachers, nurses, and non-certified support staff reach above and beyond their job descriptions, many time at the limits their professional capacity to serve students who need their help.  It is likely that good LPNs would do the same.  However, if they lack the training, expertise, or legal authority to care for the health care needs that arise, but attempt to respond anyway due to supervisor expectations and their own commitment to helping, they risk student health and safety, place the district in a legally precarious position, and put nursing licenses in jeopardy, both theirs and the RNs who supervise them.

·         Education – Education is your business; so, not surprisingly, it is valued.  School nurses reside on the same pay schedule as teachers, where increased education is rewarded, albeit insufficient to pay the tuition it costs.  Like teachers who are required to regularly take coursework to maintain certification, professional nurses are required to regularly take approved continuing education to maintain licensure.   Many of your nursing staff have earned masters degrees; the more senior nurses possess a school nurse certificate, obtained by post-bachelors coursework. 

After rigorous entrance requirements, minimal education of a bachelors nurse includes a broad base of liberal arts and sciences, including supportive coursework in natural sciences, social and behavioral sciences, nutrition, pharmacology, ethics, and possibly child growth & development.  Nursing curricula include pediatrics, community and public health, health promotion & teaching, leadership training, and significant preparation in assessment skills—all providing a perfect foundation for the needs of school health.   USD 259 hires predominately bachelors prepared nurses over the alternative 2 year ADNs.  Will you consider cutting back two-levels to licensed technicians? This hardly speaks to value placed on education by an educational institution. 

·         School support – The school nurse is a vital member of an educational team that includes principals, teachers, and professional staff such as psychologists, counselors, and social workers.   These individuals benefit from years in the school environment and education in education.  Members of the Child Study Team, for example, most of whom are masters prepared, function as the school nurse’s peers.  LPNs typically get one year of training with no requirements for college work.  How will they ever be perceived as peers, contributing equally to the important team work of problem solving, leadership, and school improvement?   

·         Student welfare and achievement – Your mission statement clearly emphasizes learning and student achievement, both of which are highly dependent on their social welfare, health, family support, and readiness to learn.  School days lost to many related factors, including illness, all contribute to less learning, lower scores, and lack of achievement.  While schools do not choose to become families’ major source of health care, unfortunately this is often the case, and the very children who are at most risk for under achievement are most dependent on school nurses to do everything in their power to keep them in school.  This can only be done by someone with qualifications for comprehensive assessment and care.  It has been shown that on days when a qualified school nurse is not in the building, more children are sent home for developing symptoms that otherwise might be assessed and managed by the nurse, allowing the student to stay.   It is also possible that EMS (and thus hospital emergency departments) may be over- or underutilized by non-professional staff, due to their lack of assessment skill.  This can be avoided with the use of qualified nursing staff. 

·          Responsibility to parents – In my position as coordinator, I regularly spoke with parents who were either new to Wichita or new to schooling of their young children.  Parents of children with chronic health conditions were pleased to know that USD 259 provided school health services, but were then bothered learn that not every school had a nurse, or not every day of the week.  What happens to the brittle diabetic on that day the nurse is not there?  What are parent options?  Do they get to choose a school that has a nurse every day?  Do those schools deserve to have more of the community’s chronically ill children?  If my child has severe asthma, do I know if my particular school has an LPN, or an RN who’s been trained in the assessment and care of asthma, a major condition seen by school nurses?  LPNs have no training in assessment of mental health conditions, which are increasing steadily in our school children.  Sadly, the current epidemic of obesity in children already exhibits itself in blood pressure and heart conditions in our youth.  These are conditions and children that deserve the attention of a highly qualified clinician such as your current bachelors prepared nurses.   The acuity level of many children is worsening.  That trend will not change any time soon.  Now is not the time to risk potentially serious outcomes. 

Cindy A. Burbach, RN, DrPH

Apples and oranges...

Ever have one of those conversations with someone and you realize, at the end of the conversation, each of you were talking about something entirely different?  Even though it sounded like the same thing? That's what it's like talking to people about the importance of having RNs in schools versus LPNs. 

If you've been following the Wichita Eagle article about RNs in schools, as well as letters to the editor, you are probably wondering what is the BIG DEAL?  You're probably saying, why is it necessary for RNs to be in school?  They are more educated, and cost the district more.  Why can't a caring person fill those shoes?  While frustrating to those who are licensed RNs, it does have some validity. 

I didn't become an RN until I was 34 years old.  I had always planned to be an RN, from the time I was about six years old.  But life got in the way.  So, when I was 32, I applied to nursing school, got accepted and went about my studies to get my associates (2 year) degree in nursing.  At the time, Newman University had just merged with St. Mary's of the Plains School of Nursing, which was a Bachelor's Degree (4 year program).  After graduation, I readily got a job in a hospital working in an area I had dreamed of.  I loved my job, loved taking care of my patients, and believed that I was just "as good" as those nurses with a BSN.  I dared to think that I would pit my technical skills against a BSN prepared RN anyday. After a few years, I had the opportunity to work at Newman in the nursing program, and while there I pursued my BSN.  The first nursing class was such an eye opener.  The realization that this degree was so much "more" than the technical degree I had received earlier, began to dawn on me. And the lights went on for me that this education really was the key to becoming not just a good nurse, but a great nurse.  I began to learn about life for "patients" outside the hospital setting.  The idea of community, continuum of care, intervening in the "whole" person, were concepts that I began to embrace and pursue.

So...apples and oranges.  LPNs are trained in the "technical" aspect of nursing.  Their education was designed to be a "helper" to RNs or doctors, in the busy hospital setting.  The ability to work automously is not a part of their education, or the expectation of their profession.  LPNs work very, very well with RNs in a hospital, or physicians in a doctor's office.  I've had the privledge of working with many very qualified LPNs in the hospital and homecare setting.  But, they worked in conjunction with me, my skills guiding their decision making, my knowledge guiding them in thier tasks.  Never by themselves.  And this is what "people" don't understand about RNs in schools. 

The first year I worked as a school RN, I was astounded at the "alone-ness" I felt.  I was used to having doctors telling me what to do and other RNs to lean on.  I quickly realized that this job would take all of my skills to perform and provide for children, families and staff.  I had to call on all the education, college and otherwise, that I had learned through the years.  My knowledge of hospital, physician and community services were called into play everyday.  I was the "go-to" person for families and staff when they had a medical question.  I utilized every assessment tool I had been taught by professors, other RNs and physicians.  And I did it outside of the health care system, with no physician to give me orders, no protocols to follow, no algorithms to adhere to, no RN by my side.  This is the real issue here.  The ability to work outside these "normal" situations.

LPNs have a very valid role in our world.  They are trained to work in close conjunction, with RNs and physicians, in nursing homes, medical offices and homecare.  But they are not qualified to work autonomously in a school setting without someone near them to help guide their interventions.  So, apples and oranges.  Just because they are both a fruit, they are not the same.

The RNs in Wichita schools are working hard everyday to educate the public.  It's a difficult task, but in the words of a phenomenal school RN, "It's only 50,000 kids."