(OLA #: 020-02)

LEGISLATIVE ANALYST REPORT

To: Members of the Board of Supervisors

From: Adam Van de Water, Office of the Legislative Analyst

Date: January 13, 2003

RE: Nurses in Schools (File No. 021048)

Summary and Scope of Request

Supervisor Maxwell, through the Board, requested that the Office of the Legislative Analyst (OLA) research existing programs that employ school nurses at all school levels in the San Francisco Unified School District (SFUSD). The report should examine the scope of services provided, the number of children/youth served, and the cost and funding resources for such programs.

Executive Summary

California ranks last in the number of nurses per resident in the overall population and San Francisco Unified (SFUSD) ranks fourth of the five major California school districts for nurses per student.

Twenty-five district nurses serve all 19 public high schools, 17 middle schools and 77 elementary schools in SFUSD. These 25 nurses staff the seven Wellness Centers in the larger high schools, monitor the Nurse-of-the-Day hotline, coordinate the middle school Healthy School Teams, teach health education curricula, staff the School Health Center for uninsured students, and provide other health-related services as necessary. For each of these activities, this report describes the services provided, the funding supporting those services, and the number of students using them.

As state and federal funding sources for school health programs come to an end (the Department of Justice funding for School Resource Officers ended in March 2002, the Safe School/Healthy Student Initiative ended in 2002, the Governor has not proposed additional funding for the Gang Resources Intervention Program for the 2003/04 budget year, and the state must close an estimated $21-$35 billion budget shortfall), school districts will have to cut pupil services and/or seek additional funding sources for their varied programs. This report concludes with several areas for further research and suggests possible beginnings for meeting this shortfall.

Nurses in Schools

The School Health Program Department (SHPD) coordinates the majority of SFUSD health-related curricula and programs. Nearly 96 percent of SHPD's total budget of $19 million comes from outside sources including the San Francisco Departments of Children, Youth and Their Families (DCYF) and Public Health (DPH) and the state and federal governments. Responsibility for health promotion efforts in San Francisco's public schools is shared by SFUSD teachers and staff, federally funded School Resource Officers (San Francisco Police Department Officers), Community-Based Organizations and a staff of 80 health educators, school nurses, mental health practitioners, nurse practitioners, psychologists, peer resource coordinators, health workers, and support staff.

According to SHPD, there are currently 25 school nurses serving the 19 SFUSD high schools, 17 SFUSD middle schools, and 77 SFUSD elementary schools or one nurse for every 2,343 students in the school district¹. San Francisco's nurse-to-student ratio is marginally higher than the statewide average of one nurse for every 2,281 students and is 3.1 times the National Association of School Nurses recommended ratio of one nurse for every 750 enrolled students². Table 1 below compares school nurse ratios for the five largest California school districts.

Overall, the California School Nurses Organization reports that California ranks 50th in numbers of RNs per 100,000 people. A number of factors have been cited for why this is the case, including impacted nursing programs, statewide nursing shortages⁴, rapid population growth, rising budget deficits⁵, and state credentialing requirements.

The 25 registered nurses in SFUSD (8 in the high schools, 6 in the middle schools, and 11 in the elementary schools) earn an average individual salary of $55,000 plus benefits⁶ and, per state law⁷, all must hold a credential from the state Commission on Teacher Credentialing (see Appendix C for details). These 25 nurses staff the seven Wellness Centers in the larger high schools, monitor the Nurse-of-the-Day hotline, coordinate the middle school Healthy School Teams, teach health education curricula, staff the School Health Center, and provide other health-related services as necessary. Each of these services is described in more detail below.

Current Health Programs in San Francisco Public Schools

School health programs have evolved over the years to include everything from physical education, nutrition and disease prevention to teen pregnancy, violence prevention, substance abuse, psychological counseling, social services, and health education.

The following are brief descriptions of the primary health-related programs performed by nurses in San Francisco's public schools. A list of schools with specific programs can be found in Appendices A and B.

a. Balboa High School Teen Health Clinic

(Source of Funds = DPH)

Begun in 1986 in response to rising teen pregnancy rates in southeast San Francisco, the Balboa Teen Health Clinic has evolved into the most comprehensive health care program in San Francisco's public school system. With a budget of over $400,000 - primarily from the Department of Public Health⁸- the Balboa Clinic has twelve mental health, medical and administrative staff that provide an array of services ranging from counseling and health education to comprehensive medical treatment⁹. The Balboa Clinic offers clinical work and can act as the Primary Care Physician for students without additional medical coverage.

According to Director Michael Baxter, in fiscal year 2001/02 the Balboa Teen Health Clinic had 2,015 nurse and nurse practitioner visits, 2,809 mental health contacts, and 1,695 Health Education contacts¹⁰.

b. Seven High School Wellness Centers

(Source of Funds = DCYF and SHPD)

The seven Wellness Centers (see Appendix A for locations) were opened during the 2000/01 school year in response to a citywide student survey indicating the need for student access to mental health, substance abuse, and reproductive health services. Students voluntarily seek these services, and may receive referral to primary health care providers. Each Wellness Center has five staff: a Wellness Coordinator¹¹, a School Nurse, a Peer Resource Coordinator, a part-time Substance Abuse Counselor and a part-time Mental Health Counselor. Some sites also have a Community Health Outreach Worker. SHPD funds a minimum of 2 nursing days per week at each Wellness Center and each school may allocate additional Department of Children, Youth, and Their Families (DCYF) funding to support more nursing days. In fact, according to Stacey Blankenbaker at DCYF and SFUSD, most Wellness Centers have between three and five nursing days per week that, taken together, served 2,952 non-duplicated students and attended to 1,355 nurse visits last fiscal year.

$1.4 million of the $1.9 million total budget for all seven Wellness Centers comes from DCYF and SHPD contributes an additional $500,000¹². As federal funding through the Safe School/Healthy Student Initiative (SS/HSI) ended in FY01/02, DCYF expects to increase its funding to $1.6 million in FY03/04 in part to fund a third day of nursing at the Wellness Centers.

c. School Nurse Referral and Nurse-of-the-Day - All Schools

(Source of Funds = SHPD)

One nurse each day is assigned to staff the Nurse of the Day hotline between 8:00am and 4:00pm. Begun in 1991, last school year (2001/02) the Nurse-of-the-Day hotline handled 361 advice and referral calls from SFUSD schools. School nurses also make appointments to visit schools and provide follow-up and case management as necessitated by the referral.

d. Middle School Healthy School Teams - All 17 Middle Schools

(Source of Funds = SHPD)

Every SFUSD middle school has a Healthy School Team, which is comprised of a Coordinator (a Registered Nurse and/or Social Worker) and four district teachers: a Respect Coordinator, a Health Liaison, a Sexual Minority Youth Liaison, and a Physical Activities and Positive Alternatives Coordinator.

e. Health Education Curriculum - All Schools

(Source of Funds = SHPD)

Finally, SHPD works to integrate health education into SFUSD curricula on topics such as HIV, drug, and tobacco prevention and develops school management plans for flu vaccinations, indoor air quality, and asthma reduction.

f. School Health Center - All 77 Elementary Schools

(Source of Funds = SHPD)

Founded in 1992, the School Health Center provides comprehensive medical screening (such as physical and neuro exams) primarily for students participating in Medi-Cal, Healthy Kids and Healthy Families. Two part-time nurse practitioners see between 150 and 200 students per year during open hours from 9:00am to 2:00pm twice per week.

g. Other Elementary School Services - All 77 Elementary Schools

(Source of Funds = SHPD)

Finally, the eleven elementary school nurses and learning support consultants provide a variety of psychosocial work in elementary schools, including case management, health consultation, checking for head lice, working to reduce absenteeism, strategy modification, behavior modification, and other means of early identification of barriers to academic success.

Other Related Programs

There are also a number of related programs geared toward after school activities, violence prevention, and community involvement that do not typically involve school nurses but collectively support the health of the students. These include:

a. Beacon Centers

(Source of Funds = Local)

The San Francisco Beacon Initiative is a public/private partnership that establishes youth/family centers in SFUSD schools. The Beacon Initiative began in 1994 and is based on the widely heralded 1991 New York Beacons program¹³. The eight San Francisco Beacon centers (see Appendices A and B) strive to be community gathering places and are open year-round, after school, in the evenings, on weekends and in the summer.

b. 21^st Century Community Learning Centers (CLC)

(Source of Funds = State and Federal)

The 21^st Century CLC program was established and funded by Congress in 1998 to award grants to rural and inner-city schools to enable them to plan, implement or expand projects that benefit the educational, health, social services, cultural and recreational needs of the community. CLCs offer educational (such as tutoring and computer classes) and cultural (such as music, art, theatre, sports, and field trips) opportunities for students after school, during the summer and on weekends. CLC Centers are currently operational at Balboa High School, 16 middle schools (See Appendix B), 20 elementary schools, and 3 K-8 schools and have received $4,114,434 since the first funds were made available in 1998.

Per the federal "No Child Left Behind Act of 2001", this program is in the process of transitioning to a $42.5 million state grant formula program¹⁴ administered by the California Department of Education, entitled the "Before and After School Learning and Safe Neighborhoods Partnership Program." The grant program requires a 50% local match and priority is given to elementary, middle, and junior high schools where a minimum of 50% of the pupils are eligible for free or reduced-cost meals through the National School Lunch Program under the U.S. Department of Agriculture.¹⁵

c. After School Learning Program

(Source of Funds = State)

Authorized by SB1756 in 1998, the After School Learning Program provides academic and literacy support and safe, constructive alternatives for students in kindergarten through ninth grade. Operating from 3:00pm to 6:00pm, this program is offered in 16 of the 17 SFUSD middle schools and 52 SFUSD elementary schools. State funding formulas provide for $5 per student per day.

d. School Resource Officers (SROs)

(Source of Funds = Federal; Last funds authorized in March 2002)

School Resource Officers (SROs) are San Francisco Police Department (SFPD) Officers who "engage in community policing in and around primary and secondary schools."¹⁶ SFPD currently has 26 SROs in SFUSD middle and high schools (see Appendices A and B). First funded in April 1999 by the U.S. Department of Justice as part of then-President Clinton's Community Oriented Policing Services (COPS) program, funds were made available for three years. The last round of funding was completed in March 2002. However, due to incremental hiring procedures, federal funds may be available for SROs through 2005.

According to SFPD Sergeant Colleen Fatooh, in addition to their community policing functions, SROs teach substance abuse classes, coach sporting activities, tutor students, counsel teachers on de-escalation techniques, lead the Student Assistance Programs, Project Alert and Project Impact and refer over 150 students per year to health and social service professionals.

e. Gang Risk Intervention Program (GRIP)

(Source of Funds = State; 2003/04 Budget Act contains no funding)

Building on pilot successes in Los Angeles County from 1988 to 1994, the State Legislature passed AB2516¹⁷ in October of 1994 making funds available to county offices of education statewide to address an increase in gang related activity. GRIP activities include after school tutoring, recreation and summer opportunities, professional staff development, student workforce development, and other means of building leadership, parental involvement, and positive cultural identity and respect. GRIP currently operates in four San Francisco middle schools "identified as having students at high risk of becoming involved in gangs"¹⁸ (see Appendix B for a list of middle schools with GRIP programs).

The California Department of Education awarded $200,000 to San Francisco in fiscal year 2001/2002 and allocated an additional $3 million to support GRIP programs statewide for fiscal year 2002/2003.

Conclusion

State and federal funding cutbacks for school health programs raise interesting questions for the future of school health in San Francisco's public schools. A few areas for further research might include:

Are staff currently deployed efficiently and serving the greatest identified health needs? Are there any ways that the Board of Supervisors or the Superintendent of Schools could better facilitate the interaction between the school district and community-based organizations to better meet the needs of students?

Should these programs be continued at current funding levels and, if so, what source of funds could replace the state and federal monies? For instance, are there any remaining tobacco settlement funds (estimated at approximately $500 million through 2025) not already allocated to rebuilding Laguna Honda Hospital? Could funds from Proposition 49, the After School Education and Safety Program Act of 2002, be used to support school health programs once allocated in 2004/05? Could the state use lottery funds to support these programs?

Are there unexplored financing strategies - such as a citywide bond measure to support school health - that are worth bringing to the Citywide School Health Planning Committee to discuss at their next meeting in February 2003?

Is there state legislation - such as establishing recommended nurse to student ratios - which might help to address the problem?

Appendix A: Primary Health and Wellness Programs at SFUSD High Schools

SOURCE: California Department of Education, Educational Demographics Unit

and SFUSD School Health Programs Department

Appendix B: Primary Health and Wellness Programs at SFUSD Middle Schools

pt = part-time

In addition to the 18,387 students in SFUSD high schools and 12,179 in SFUSD middle schools, there are also 3,582 students in SFUSD K-8 schools and 26,878 students in the 77 SFUSD elementary schools.

All SFUSD high schools also have Health Promotion Committees, all SFUSD middle schools have Healthy School Teams and Middle School Coordinators, and all SFUSD middle and high schools have Positive Alternatives activities and a Health Education curriculum.

and SFUSD School Health Programs Department

Appendix C: California School Nurses Credential Requirements

A Brief History

Prior to 1945, no formal credential was required for school nursing services. Following World War II, school nurses were required to have a public health nurse certification, a Bachelor of Science in Nursing, and/or a baccalaureate degree and 36 semester units of specified undergraduate work.

The "Fisher Act", passed in 1961 and fully enforced in 1964, added the additional requirement that school nurses complete a school nursing internship program. According to the California Commission on Teacher Credentialing (CTC), this could include an internship program, "under the joint supervision of a higher education institution and a public health department or school district, or, specific coursework equal to approximately one year of post-graduate study to include a supervised school nurse field experience."

The "Ryan Act"¹⁹, passed in 1970 and implemented in 1974, further altered the credential requirements, renaming it the "Health Services Credential: School Nurse", eliminating the requirement for public health nurse certification, and allowing for the issuance of a `preliminary' credential for five years during which time further coursework was pursued²⁰.

Current Requirements for School Nurses

To qualify for the professional school nurse credential today ("Health Services Credential: School Nurse"), state law²¹ requires that applicants:

1. Have a baccalaureate or higher degree from a regionally-accredited college or university²²,

2. Hold a valid Registered Nurse (RN) license issued by the State of California, and

3. Complete a CTC-approved school nurse program ²³comprised of coursework equivalent to at least one year (a minimum of 24 semester units) of post-baccalaureate study and two years of school nurse practice. Applicants that meet only the first two requirements can apply for a five-year `preliminary' credential while they seek additional coursework and experience²⁴. (NOTE: This last requirement represents a higher level of education than that required for hospital, clinic, or public health Registered Nurse positions.)

In order to teach health classes in schools, these state laws require school nurses to complete the three requirements listed above as well as:

1. Pass the California Basic Education Skills Test (CBEST), and

2. Complete a professional preparation program for the Special Teaching Authorization and obtain the recommendation of the California college or university where the program was completed.

Authorized School Nurse Activities

Holders of the preliminary and professional clear School Nurse Services Credential shall be authorized to perform the following services:

Conduct immunization programs pursuant to California Education Code, Section 49403, of the California Code of Regulations

Assess and evaluate the health and developmental status of pupils

Interpret the health and developmental assessment to parents, teachers, administrators, and other professionals directly concerned with the pupil

Design and implement individual student health maintenance plans, incorporating plans directed by a physician

Refer the pupil and parent or guardian to appropriate community resources for necessary services

Maintain communication with parents and all involved community practitioners and agencies to promote needed treatment and secure reports of findings pertinent to educational planning

Interpret medical and nursing findings appropriate to the student's individualized education program and make recommendations to professional personnel directly involved

Consult with, conduct in-service training for, and serve as a resource person to teachers and administrators

Develop and implement the health education curriculum

Act as a participant in implementing a comprehensive health instruction curriculum for students

Counsel and assist pupils and parents in health-related and school adjustment services

Teach health-related subjects under the supervision of a classroom teacher²⁵