At Risk for School Failure

Schools’ primary mission is the education of children. However, for over one million children in California with special health care needs (e.g., asthma, diabetes, food allergies), schools also must provide health services to ensure their safety and access to the curriculum. Students with special health care needs (SHCN) are at higher risk than their peers for missing school, repeating a grade, and dropping out. Yet in many cases, schools are not aware of students’ health conditions and do not monitor them as a group at risk for school failure.

To investigate the current state of health services for students with SHCN, we analyzed state education data, interviewed school education experts, and conducted a large-scale survey of certified school nurses who are members of the California School Nurses Association.

Schools are typically aware of a student’s health needs if the student has an Individualized Education Plan; but only about one third of students with SHCN qualify for special education. California’s Education Code (CA Educ § 49400) requires that “diligent care” be given to the health and physical development of students, but it does not provide a definition of what constitutes diligent care. The code also does not require schools to report health emergencies or adverse events to the state, or even to collect general health data on students.

So who is providing the required “diligent care” in schools? In 2013, 57% of California’s school districts, serving 1.2 million students, reported employing no school nurses. The statewide ratio of nurses to students is 1 nurse to 2,635 students, but this varies widely among districts, reaching as high as 1:13,635 (The National Association of School Nurses’ recommended ratio is 1:750). In the absence of nurses, a range of school personnel are being called on to provide health services, such as administering medication, treating life-threatening allergic reactions, performing gastrostomy tube feeding, injecting insulin, suctioning tracheotomies, and providing urinary catheterization. Often these personnel are not certified.

In the absence of more specific state regulations, decisions regarding school health services and personnel are left almost entirely to individual school districts. Districts make decisions about the availability of school health care services, and determine who is qualified to provide services, often without a health consultant.  

Given the financial difficulties faced by many of California’s school districts, the use of unlicensed school personnel is common. Such substitutions may be the only viable alternative to forgoing health services responsibilities altogether. However, it is likely that the health and safety of students is jeopardized when standards are not applied to assure adequate staffing and training to handle health problems, especially those that are chronic or emergent. A root cause for many of the shortcomings in school-based health services is the lack of authoritative guidance and dedicated school health services funding from the state Department of Education (CDE). This lack of investment in the provision of student health services does not align with multiple research studies demonstrating a clear link between health and school failure. Furthermore, schools are losing valuable average daily attendance (ADA) funding every day that students with SHCN are absent. 

What can be done to ensure that all students’ health needs are addressed during the school day and can succeed in school? As a start, California should require school districts to:

• Systematically identify and serve students with SHCN
• Track and report adverse health events and health emergencies to the California Department of Education and/or Department of Public Health (note: several states require districts to report 911 calls)
• Track attendance and educational outcomes of students with SHCN as they do other high risk groups
• Provide all school personnel delivering health services with standardized, mandatory training in firstu aid, CPR, and specific medical procedures for the services required by SHCN

The full study is in Dian L. Baker, Kathleen Hebbeler, Linda Davis-Alldritt, Lori S. Anderson, Heather Knauer, “School Health Services for Children With Special Health Care Needs in California,” The Journal of School Nursing, forthcoming. A fact sheet summarizing the study can also be found here.