When the young girl walked into the small clinic at Hoover Elementary in Tulsa, Laura Burgess listened to her list symptoms and asked questions along the way.

The student had fallen while running in gym class and hurt her elbow. Burgess and the school’s health assistant, Kathy Durbin, soon sent the girl off with a ziploc bag filled with ice.

Burgess is a registered nurse with Tulsa Public Schools who visits eight schools each week.

Sometimes students will come to Burgess with chapped lips or scraped knees. Other times there are more serious needs, such as help managing diabetes or other chronic conditions.

Burgess, who was wearing blue scrubs, is cheerful and easygoing. She said she wants her clinic to be a “judgment-free zone” for kids, a safe space they can come to without fear of being turned away. Other than tending to students who come into the clinic, she tries to be an advocate for them and ensure they get the health care they need at home, too.

“If a kid is in pain they can’t learn,” Burgess said. “For one, their quality of life isn’t very good.”

In Oklahoma, school nurses such as Burgess are limited and on the decline.

School nurses and agency employees told The Frontier while the number is shrinking, the amount of students who have acute and chronic health needs continues to grow.

School nurses are registered nurses or nurse practitioners who are certified the same as a teacher by the State Board of Education. In Oklahoma, the equivalent of about 272 full-time school nurses provide health care and education to hundreds of schools.

With 1,795 schools in the state, there’s about one full-time school nurse for every six institutions, according to a Frontier analysis of State Board of Education and Oklahoma State Department of Health data.

Some school districts have licensed practical nurses or certified nurse assistants, however, Oklahoma does not consider them to be school nurses. When those are included in the calculation, there’s about three nurses for every school.

Some districts share a nurse part time or get services through other avenues, such as contracting nurses through local health departments.

Still, the vast majority of Oklahoma’s schools do not have their own full-time nurses. Some districts don’t have a nurse at all.

Elizabeth Vaughan, president of the School Nurse Association of Oklahoma (SNAO) and a registered nurse at Tulsa Public Schools, said the state’s school nurses are stretched thin.

“Our state has lost many of these positions due to budgeting. … We also are having increasing numbers of students with acute and chronic health issues, medical equipment, multiple handicaps and special needs attending school,” Vaughan said.

“This alone should make nurses a high priority. Some districts have a traveling nurse, but they cannot be everywhere as quickly as needed.”

‘We work them to death’

Vinita Public Schools has four schools and one licensed practical nurse.

“At times, we’ve probably needed more than one,” said Vinita Public Schools Superintendent Kelly Grimmett.

“We work them to death, but for the most part, we make it work.”

Filling nursing positions can be difficult, Grimmett said.

“(Schools) pay less,” he said. “It’s (school nursing is) a good thing if you’re a mom and if you wanna be home with your kids in the summertime, but at the same time it can be bad if you want to support your family.”

Barbara Smith is a registered nurse who heads the state health department’s School Health Program. She said school nurses play several roles, including that of advocate, counselor and liaison.

“Depending on the school, our nurses will have some type of clinician-type duty, providing services, providing screenings, things like that,” Smith said. “Then advocating for students, school nurses deal with that on a routine basis.

“He or she would be advocating to make sure that they’re taking medications and make sure those children receive that medication in a timely manner.”

Burgess nurses also do outside referrals for students. For example, if a child comes into a clinic with emotional needs, the nurse might get him or her to a counselor.

‘Needs are getting greater’

Under Oklahoma law, when a school does not have a nurse, other school employees may step in to administer medication to students. Additionally, schools must have an assigned staff member to assist students with diabetes care.

Though these employees are not health care professionals, they are often trained by nurses or sometimes call health departments for help.

Smith said she often provides technical assistance remotely.

“I do receive calls from school districts where no nurse is employed but they have a situation with a school for a chronic health problem,” she said.

When it comes to the number of nurses employed, larger districts such as Tulsa Public Schools and Oklahoma City Public Schools are typically better off than their smaller, rural counterparts.

Most schools in Tulsa don’t have a full-time nurse, but have part-time nurses visit multiple schools throughout the district once each week for a few hours at a time. Many schools also have health assistants who work full time.

Oklahoma City’s schools are similar. The district has 32 nurses, most who visit several schools per week, said Dr. Terri Bell, executive director of student support services for the district.

“Those nurses have a caseload of about 1,300 (students) to one,” she said.

The nurse staffing level at a school often depends on the students’ needs, Bell said. The district has six licensed practical nurses who are assigned to special education programs that have kids with severe medical needs.

Bell, who has been with the district for 30 years, said although Oklahoma City’s schools have maintained nurse staffing levels, the need for nurses is growing.

“The health needs are getting greater,” Bell said. “We just have a higher rate with kids with diabetes. We have a higher number of kids that are considered obese, and with that I think we have health concerns.”

Oklahoma ranks among the highest in the U.S. for obesity and diabetes-related conditions, and studies show the number of residents with diabetes is growing.

Similar to most states, Oklahoma does not have a law that requires districts to have school nurses.

Some states have policies that recommend districts hire a certain number of nurses per student. A handful of states have laws that mandate nurses. For example, Minnesota law requires districts with more than 1,000 students employ at least one full-time nurse.

In 2016, about 25 percent of schools nationwide did not employ a school nurse, according to a National Association of School Nurses study. Less than 40 percent employed a full-time nurse.

“Although we (SNAO) feel strongly that there should be a nurse in every school or at least in every district, sadly the Legislature has never mandated this,” SNAO president Vaughan said.

With shrinking budgets, some schools and districts have left nursing positions unfilled.

Oklahoma’s schools, with some of the lowest salaries in the nation, have increasingly felt the strains of budget cuts. And enrollment numbers are growing — more than 694,000 students enrolled in schools in 2017.

“Once again, Oklahoma schools are educating more students than ever before with few new resources,” State Superintendent Joy Hofmeister said when the figure was announced last month.

“Funding has not kept pace with the steady rise in enrollment over the past decade, the growing diversity of Oklahoma’s student population or the decrease of trained educators entering the profession. We will continue to advocate for teacher pay raises and adequate funding levels to meet the needs of all Oklahoma schoolchildren.”

The difference in salary for nurses in a hospital or clinical setting as compared to a school contributes to the lower numbers of school nurses.

The median annual base salary for a school nurse in Oklahoma is about $37,000, according to state education department data. Meanwhile, the mean wage for a registered nurse not working in a school setting was $60,630 in 2016.

“There aren’t a lot of registered nurses that can afford the pay cuts to come to schools because registered nurses in schools are paid on a teacher’s salary,” Burgess said.

But Burgess, who worked in a hospital for 25 years, said there are perks to being a school nurse.

“One thing is that the kids are a lot of fun,” she said. “And people generally aren’t clenching their chests and falling over dead like they are in the hospitals. You’re not doing every other weekend, every other holiday on-call.

“I will say, if they keep cutting our education (budget) it will get to be a problem. … The state has cut so much that the districts are having a hard time everywhere. Teachers, the whole system.”

An earlier version of this story incorrectly attributed information to Savannah Owen. That has been corrected to be attributed to Laura Burgess.