– It’s only 10:30 a.m. when Jolie Holland pulls up to the fourth school she’ll visit for the day.

She’s already driven more than 20 miles across Wright and McLeod counties, stopping to care for some of the 1,750 students for whom she is the lone school nurse.

In one elementary school, there’s a diabetic preschooler in need of insulin. In another, there are teachers to be coached on an emergency plan for a young girl with cerebral palsy, who is nonverbal and uses a wheelchair. At her fourth stop, there’s a student who needs to be fed through a tube. On Holland’s smartphone, there’s an endless series of requests: a student missing the EpiPen he needs for severe allergic reactions, another suffering from serious breathing problems who must be kept out of gym class, parents whose insurance companies won’t cover the medications their children need to take to school.

“I don’t think people realize that we go from Band-Aids to tube feedings to handling third-party billing,” said Holland, who has served in the Howard Lake-Waverly-Winsted School District for 15 years. “It’s like there’s 1,000 marbles on the floor of all different colors and sizes, all going to different locations, and I have to keep track of where they’re all going.”

While Holland’s territory may be larger than that of some Minnesota school nurses — she cares for students in 11 different buildings in a half-dozen towns — the soaring demands of her job are far from unusual. Across the state, school nurses are finding themselves managing the care of more students with complex needs: diabetes, life-threatening allergies, seizures, mental health crises.

Districts with no nurses

Jolie Holland, the school nurse in Howard Lake-Waverly-Winsted Public Schools, covers 11 district schools.

In many cases, the nurses are stretched so thin that some of those complicated responsibilities are handed off to staff members with little or no medical training. Meanwhile, preliminary research from the Minnesota Department of Health, which is surveying school districts about their health care staffing, found that more than a quarter of Minnesota school districts have no nurses at all.

“A lot of parents are under the impression that all over Minnesota there are just nurses in every school,” Holland said, “and that ain’t necessarily so.”

Both the National Association of School Nurses and the American Academy of Pediatrics recommend students have direct access to a school nurse — ideally, one in each school building.

In Minnesota, state law mandates that districts with at least 1,000 students have one licensed school nurse: a registered nurse who is licensed both through the state Department of Health and by the Minnesota Professional Educator Licensing and Standards Board.

There are no other staffing requirements, which means a district with 900 students can go without a nurse, and one with 30,000 students could rely on just one nurse. Some districts hire a single licensed school nurse to supervise a team of other nurses and staff with varying credentials. Those range from registered nurses — who have four-year degrees, can assess patients and administer medicine and complex treatment plans — to licensed practical nurses, who can handle more basic duties, to medical assistants, who are often trained in first aid and CPR but have no formal medical education.

Erika Yoney, state school consultant for the Department of Health, said it’s hard to tell who’s handling all the bloody noses, asthma attacks and medical emergencies in many schools. That’s because the state collects little data on school nursing. Yoney, who is leading the state’s survey, has received responses from about 60% of the state’s school districts. Of those, more than half lack a licensed school nurse, and 28% have no medical staff at all. In those cases, schools depend on whoever is around for students’ medical needs.

“Generally speaking, what we hear is that somebody has taken maybe a first aid class, and oftentimes it’s maybe the administrative assistant in the office,” she said.

Yoney hopes the data will help health officials to better understand the needs of schools and nurses. For now, schools are only required to track data about immunizations and communicable diseases. There is no statewide collection of data on the prevalence of diabetes or asthma in schools, how often nurses deal with students’ mental health concerns, or how frequently they call for an ambulance.

That’s not the case in all states. North Carolina, for example, publishes an annual report detailing nurses’ training and backgrounds and the number of students with chronic conditions. The state tracks how many students are seeing school nurses about drug abuse, depression and suicidal thoughts.

Ann Nichols, North Carolina’s state school health nurse consultant, said the ratio of nurses to students has improved since the state began gathering data, and it has remained steady even as state and school budgets have contracted. She said that’s because policymakers have up-to-date information at hand — which makes it harder to slice budgets.

Without that information, Minnesota lawmakers and school boards have to rely on the individual experiences of school nurses.

Role expands with the times

Deb Mehr, health services consultant for the Rosemount-Apple Valley-Eagan School District — and president of the School Nurse Organization of Minnesota — started her career as a school nurse 17 years ago. She’s seen a growing number of students with serious and complex medical conditions, something she links to health care advances that have helped children survive who wouldn’t have made it a couple decades ago. Many come to school with equipment you’d usually see in a hospital: breathing tubes, feeding tubes, ventilators.

At Minneapolis’ Northeast Middle School, nurse Nathan Grumdahl has a desk packed with action plans for students with chronic conditions like diabetes and asthma. He also sees a large number of students facing major challenges outside of school, like poverty and homelessness, and families who struggle to pay for lifesaving prescriptions. Grumdahl got a crash course in the complicated world of school nursing on his first day, when a student suffered a serious head laceration.

“I was applying pressure and calling 911,” he said, “and this was the first 15 minutes on the job.”

School nurses are often able to help diagnose serious problems, quickly call for more help and teach students the skills they need to stay healthy and manage their illnesses and injuries. But Mehr said there are also times when things don’t turn out well, like a recent case in Lakeville, where a middle school student suffered a permanent brain injury after an asthma attack. The student’s parents are suing the school district and a school nurse, who they say failed to follow the student’s asthma control plan.

Jolie Holland talked with a junior with a heart condition. The teenager was dehydrated.

“We do our best to support students and families with the resources we have available, but sometimes our best isn’t enough and we don’t have the outcomes we’re looking for,” she said. “And that’s difficult and disheartening.”

Back in Howard Lake, Holland remains hopeful that school nurses can lead the charge toward making students and their families healthier. In between the emergencies and her daily responsibilities, she’s busy writing presentations she’ll give to classrooms about the importance of hand-washing and the facts of going through puberty. She coordinates vision and hearing screenings, is working on a program to educate students about eating disorders and makes home visits when she can’t reach parents. She’s proud to be a second-generation school nurse; sometimes, she throws on a nurse-themed cardigan sweater her mother wore on the job.

But Holland also finds it hard to fully escape work demands. Asked what happens if she misses a day, Holland grimaces.

“I try not to get sick,” she said.