Sarah Buckley’s kindergartener has life-threatening food allergies. In previous years, she worked with school nurse at Amidon Bowen Elementary (401 I St. SW) to discuss medication and formulate a medication plan.
But as the 2023-34, school year began, there was no nurse in the health suite. Instead, Buckley met a few weeks later with a health technician to discuss her son’s critical health needs.
In December, she received a phone call from yet a different health care provider, saying the school did not have her son’s medical forms or EPIPEN, the medication that would stop a life-threatening allergic reaction. She rushed to the school.
“More than halfway through the school year, no one had processed the paperwork we had submitted [to the health technician],” she testified at one of several public hearings. “His EPIPEN and Benadryl were just sitting there with no direction and no orders about how and when to use it.”
“I’m frankly shocked that a child has not died at a Washington DC school at this point,” said Advisory Neighborhood Commissioner (ANC) Andrew Pawley (6D04) after Buckley spoke about the absence of school nurses at another meeting. “This needs an immediate solution. Kids are going to die.”
The new cluster model implemented last fall is supposed to address the two issues that officials say encumber school health services: limited staff and limited funds.
But parents say the gaps are still there. In 2022-23, a school nurse contracted to work in the schools may only have been available on certain days or parts of days. Under the cluster model, parents say that often the health suite is empty. Even when the office is staffed, they say, the care provider may not be a nurse or regular staff familiar with a student or their needs.
Not only that, there are signs the cluster model may be contributing to attrition. The DC Nursing Association (DCNA) says the added responsibility placed on nurses in the new system is driving them out of District schools and into other municipalities or parts of the health sector.
What is the Cluster Model?
The cluster model is intended to fill school health suites by maximizing nursing hours. It’s a contract between DC Health and the Children’s School Services (CSS) program at Children’s National Hospital to staff school health suites. In the cluster model, a team of up to five professionals, ideally two nurses and three medical technicians, would serve up to four schools in geographic proximity. The nurses would create medical plans, conduct specialized procedures, and supervise the technicians who would administer medications and provide data collection and basic first aid. “This model is intended to focus our limited resources where they are most needed to address the health inequities in DC,” said Elizabeth Davis, Government Affairs Liaison for Children’s National.
A 2017 law mandating a full-time nurse in every school was never funded nor implemented. But a 1987 law remains on the books requiring 20 hours of care from a nurse in each District school. “Whether it was 20 hours a week or whether it was 40 hours a week, the District of Columbia has never reached 100 percent of every school having full time nurse, RN or LPN coverage,” said Councilmember Christina Henderson (At-Large – D), Chair of the DC Council Committee on Health.
One problem in recruiting and maintaining staffing is nurses’ compensation has not been competitive. To address this, Children’s National said in hearings before council that they had raised school nursing pay scales this fall to match more closely that of neighboring Prince George County. This appears to have stabilized ongoing hires, they said.
The second issue is lack of budget. In the last budget $25 million was allocated to the school cluster program. The administration tried to claw $4.3 million back; only intervention from DC Council kept it in the program, said Henderson.
In 2017, the nursing program—then mandated to provide 20 hours to each school — cost $19 million. Henderson estimates that today a budget of $40 million would allow each school to have a dedicated nurse. But, she says “the council alone cannot fund a $15 million enhancement for school nurses. This has to come from the mayor.”
“There’s been a lot of advocacy [directed] towards the council,” Henderson noted. “I hope that once the mayor launches her budget conversations [in March] that she should be hearing from the public that this is also a priority for them.”
DC Health Director Bennett says that whatever the desire might be, District schools must deal with reality, and the cluster model, she told DC Council, is the most realistic way of addressing health needs with the limited resources.
High Demand for Nurses
The second of the limitations is available workforce. Nurses are in high demand not only in the DMV but nationwide. In the wake of the pandemic, many nurses stepped away from their jobs. One estimate suggests there are one million open nursing positions in the United States.
“Even if we had enough money, there is no way there are enough nurses in this region, but also more broadly across the country, to fill the gap that would be required to get to 40 hours of nursing in every school,” DC Health Director Dr. Ayanna Bennett told the DC Council Committee on Health.
The cluster model started 2023-24 school year 90 percent staffed. However, the DC Nursing Association (DCNA) says that 25 nurses have left the CSS school nursing program since August. At a Jan. 4 hearing before the DC Council’s Committee on Health, CSS said that had staffing had declined to 52 percent.
In an email to Hill Rag dated Feb. 1, DC Health said that number had bounced back, saying that 73 percent of health suites have 40 hours per week of in-peson coverage as of Feb. 5. “All health suites receive telephone coverage in the event of a staff absence,” DC Health said.
DCNA has come out against the cluster model, authoring a petition in August 2023 and a letter to DC Council in November 2023, saying the delegation of health tasks to unqualified professionals “violates the safety of our most vulnerable children.” DCNA Consultant Deborah Thomas said the District did not consult with the Board of Nursing, which operates under DC Health, before adopting the plan. DCNA also argues that the cluster model violates professional guidelines, the DC Nursing Practice Act and a 1987 law requiring that each school have a minimum of 20 hours service from an LPN or RN every week. “[Nurses] are scared they’re going to be held liable for a mistake made by someone else,” she said.
In a report from a school nurse dated Jan. 12, 2024 and quoted by DCNA, the unidentified nurse said it is impossible to oversee a full team, respond to emergencies at multiple schools or properly do case management for the number of students served in a cluster. “In most of the care plans I and other DCPS nurses do,” the DCNA quoted the nurse as saying, “we have never seen the student because there is not enough time to go to every school and assess the students. I am not at any one school long enough to follow up.”
Both DC Council and CSS disagree that DCNA was not consulted as the program was being designed. CSS says they met with the four nursing union shop stewards from each bargaining unit regularly in the development of the plan and that DC Health also held a number of conversations with school leadership prior to implementation.
Where Are the Techs?
But the cluster model depends not only on nurses, but on high numbers of available health technicians, a position much like an EMT. For 2023-24. CSS expected to hire 120 health technicians; as of Nov. 28. 2023 they had only filled 67 vacancies, a 44 percent vacancy rate. In an email to the Hill Rag, CSS said that they anticipated that more medical technician candidates would have the required clinical experience than proved available. “We will continue our hiring efforts and have enhanced our orientation process to address this,” CSS said.
CSS and Children’s National have argued that part of the problem was with a process that did not determine school and health suite needs prior to budgeting. Some health suites were added after funds were set, complicating staffing and budget allocation.
Children’s School Services CEO Dr. Andrea Boudreaux said that a health technician needs to feel support from District administration, schools and families, and “that they are not just a fix but actually valuable members of the community. That is where we are seeing some of the attrition,” she told the Committee on Health Jan. 4.
The nurse quoted in DCNA testimony said the techs feel they are taking on too much responsibility. “They thought they were working with the nurse, not replacing them,” the report said.
These unmet expectations have resulted in empty health suite and unmet medical needs. One parent said their own student was old enough to administer their own medication, an inhaler, by themselves but still had to be kept home from school because a trained staff member was not available to get the medication from the nurses’ office; others reported parents coming to the school to administer medications themselves.
The cluster model might also be straining the District’s already strained emergency system. A representative from Firefighter Local 36 said he had anecdotal evidence of increased trips to District schools since the system was implemented, trips that he said seemed to have increased since the fall. When a parent cannot be contacted, he said, the student has to be brought to the emergency room and conveyed into the custody of a medical team there, taking one more Emergency Medical Services (EMS) team off the street.
Both DC Health and CSS say that like much of the medical system, school nursing in the District is in a post-pandemic moment. Dr. Bennett said that changes do need to be made, but not as an abandonment of the plan, rather, she said, “to get to some future, more stable model.”
Both DC Health and CSS say the cluster model shouldn’t be judged as they scramble to get to full staffing. “I want to clarify that we were in a fully staffed environment, and then we were in triage, which not necessarily the way the program is going to operate,” Bennett told a Jan. 4 roundtable on the program. Prioritizing the allocation of health care professionals is needed until more staff are hired, she said. “That is a triage response.”
Bennett cautioned that a step away from the model will leave children without care. “We have got to give ourselves the chance to get there before we take judgment,” she told the Committee on Health. “Because the reality is we will be way below 40 percent of full-time coverage in every school if we return to a nurse model.”
Others, however, are not confident, saying the sense of urgency has been lost. One parent told ANC 6D how her son went untreated for a head injury. “If the schools don’t have adequate nursing coverage for the days and the times students are in school, DCPS is just waiting for a child to die on their watch.”
DC Council will hold a Performance Oversight Hearing for the Committee on Health starting at 9:30 a.m. Thursday, Feb. 15.
This story first appeared in our February print issue. It has since been updated with data from DC Health.