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it often does take a village 
The school nurse is often still out as kids' health problems like suicide, allergies soar
The health clinic at her son's Colorado high school is "the best thing ever," says Hannah Chupp.
"My teen can go there for advice and private help when he is too uncomfortable to discuss something with me," Chupp says of the clinic and its nurse practitioner. "I am fine with him seeking help from someone other than myself. It’s part of growing up."
The Chupps are among the luckiest.Their school in Cortez has a clinic that includes a nurse practitioner who can prescribe medication and perform exams, plus a school nurse. Chupp's son got his sports physical from the nurse practitioner, who started last year when the clinic opened. If he has a migraine, he can get crackers, ibuprofen and a place to rest from the school nurse, Chupp says.
As complex and often-chronic health conditions soar among children, worsened in some areas by the return of diseases largely eliminated by vaccines, full-time school nurses remain hard to find. About 40% of schools only budget for a part-time school nurse, and 25% have no nurse at all, the National Association of School Nurses says.
"School-based health clinics," which are typically run by local hospitals, are an increasingly attractive solution, growing by 20% between fall 2010 and fall 2013, according to the School-based Health Alliance. At that point, there were 2,315 of these clinics.
School nurses and parents who rely on them say the clinics – rare as they are among the 100,000 public schools in the U.S. – aren't enough. Along with the primary care services the clinics provide, more school nurses and mental health professionals are also needed, groups representing the health care providers say – especially with teen and even preteen suicides increasing.
The new school nurse: Allergies to suicide prevention to gender transition
Treating everything from severe allergies and concussions to suicidal thoughts and gender transition, the role of the school nurse has come a long way from the colds and cuts they've been long known to care for. Among their other jobs, nurses say they serve an important role to triage and refer students to other health providers.
"The intensity of needs of students is a change," says Donna Mazyck, executive director of NASN and a former school nurse. "There's an inverse relationship between the growing need and the funding."
Although schools increasingly offer mental health services, demand still outpaces supply. School nurses and psychologists or social workers collaborate.
The National Association of School Psychologists recommends having no more than 1,000 students per school psychologist, but it says most school districts don't meet that standard and estimates the ratio is 1,381 to 1 in the U.S.
"When school budgets get tight, health services are tending to be on the chopping block," says Laurie Combe, NASN's president and a longtime school nurse.
Against that backdrop, slightly more than half of students in public schools live in poverty, notes Mazyck. That increases the risk of household and neighborhood trauma, which can exacerbate conditions such as anxiety and asthma. School shootings and the security measures adopted in response also heighten students' anxiety.
"Our bodies’ response to trauma comes in many forms," says Combe.
Students at Richard Wright School for Journalism and Media Arts in Washington come from the lowest-income wards of the nation's capital and "have a lot of things going on mentally," says school nurse Belinda Millner. When teens come in with physical complaints, referrals to the school psychologist or social worker might be in order.
"We have to use our nursing judgment, as it could be something else they are having issues with," says Millner, who started in October. "We’re kind of like the gatekeeper with the children."
Millner's background as a paramedic and emergency room nurse didn't prepare her for everything at the school. For example, students who identify as transgender have come asking for advice, including on which bathroom to use.
"I'll say, 'Hey, I’m still learning these things, too. Please explain to me what your feelings are,' " says Millner. It's far different from the "bumps and scrapes" she dealt with when she was an elementary school nurse.
"It's something different every day with the children," she says.
"Sometimes they really want someone they can talk to about something that’s confidential."
Without a nurse, students with diabetes could wait for insulin
Suicide, stress and addiction may steal the headlines when it comes to teen health, but there are growing physical health problems as well. Combe, who managed health services for her school district in Houston, notes that as hospitals save premature infants at earlier ages, some of these children's health needs follow them through life – and school. Some, she says, have feeding tubes in their stomachs and "need health care provision within the walls of the school."
Americans' increasing obesity has ensnared the schoolyard set, too. Type 2 diabetes is becoming far more common among overweight children and teens, and Type 1 tends to afflict students beginning at about 14 years old. The school nurse shortage can complicate diabetes care.
And American children are having more severe allergic reactions, too.
Denie Gorbey-Creese, a Maryland school nurse who splits her time between two schools, has four diabetic students at one elementary school. She and her health assistants see them several times a day. The ones with insulin pens rather than pumps sometimes need to have the dosage for their insulin calculated based on the carbohydrates they ate for lunch.
Health assistants aren't legally allowed to calculate an insulin dose so Gorbey-Creese says if she's at the other school, they have to call her, tell her what the blood glucose level was, how many carbohydrates the student is eating and possibly even the child's activity level that day. Then the assistant can administer the insulin.
"If I'm busy with an emergency at my other school, I'm not available right away," Gorbey-Creese says. "So it might delay their care some."
Nurses and the clinics fill roles that can make the lives of parents, students and teachers easier. Nurse practitioners,found in some school clinics,can do everything a primary care doctor can do in about half of states. That saves children and parents time away from classrooms and jobs, which for hourly workers can mean lost wages.
Although the hospital-run clinics are often proposed as a solution for the school-nurse shortage, NASN recommends schools have a nurse even when there is a health clinic, a combination that Chupp agrees is important. Having both has made her son far more self-sufficient when it comes to his health, she says. Her college-age children, who didn't have access to health care in high school, "call me for advice all the time and are afraid to make their own doctor appointments," she says.
In Cincinnati, there are 26 school-based health centers, including three run by Cincinnati Children’s Hospital. Vaccination rates at schools with these clinics are far higher than at schools without them.
"We are meeting children and families where they are," says Lisa Crosby, the nurse practitioner in charge of the hospital's health centers. "You do become a part of the community."
Like Chupp, Crosby has seen how the clinics improve health literacy. Her former students will often tell her they're paying closer attention to their children's health because "I saw what you did for me."
"That's the best story ever," says Crosby.
The Cincinnati health department provides a school nurse for schools with the health clinics, but they were overwhelmed with vision and other screening tests for 500 students, Crosby says. The Children's Hospital clinics also see other children in the community and have about 500 other patients up to age 18.
In Washington, D.C., school nurses are now required under a law that was sponsored by former Mayor Vincent Gray, who is now chairman of the City Council's health committee.
At the Richard Wright charter school in D.C., founder and CEO Marco Clark says that when it came time to pay for a school nurse – which he had long wanted – "we just had to figure it out within the budget."
"I didn't want to rob Peter to pay Paul," he says. "But it’s money well spent."
Cosandra Wright, whose four children have all been patients at the South Avondale School clinic in Cincinnati, agrees. She says she doesn't think her oldest two children would have graduated if it wasn't for the clinic.
"It made it possible for them to learn and focus in school," says Wright. Of the staff, she says, "My children love them because they’ve always taken care of them."
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