During the past two school years, teacher Julia Keyse had to enforce an unusual rule in her kindergarten and first-grade classroom: No interrupting while she pricked Caylee's finger to check her blood sugar and adjusted her insulin pump.
"They were so good. They would just sit and wait," Keyse said of her class at Etowah Elementary School in Henderson County, N.C.
It's a task Keyse never imagined when she became a teacher, but medical duties have become a part of the job for educators across the country as schools cut nursing staff or require nurses to work at multiple locations. The change comes at a time when more students are dealing with serious medical conditions, such as severe allergies, asthma and diabetes.
It's a change that's unsettling for teachers, school nurses and parents.
"We don't want to pretend to be doctors or nurses," Keyse said. "I would have gone to school for that."
Federal guidelines recommend that schools employ one nurse for every 750 students, but the national average is one nurse for every 1,151 students, according to Amy Garcia, executive director of the National Association of School Nurses. A quarter of schools in the nation have no school nurse.
North Dakota falls into the category of one nurse for every 3,000 or more students.
Although there is no historical data regarding the number of school nurses nationwide, members of the profession say there are fewer nurses doing more work, while teachers and other school workers pick up the slack. The average nurse splits her time between 2.2 schools, according to the association.
"Teachers deserve a school nurse because their time should be spent teaching," Garcia said.
Meanwhile, the workload of school nurses has increased since 1975, when the federal government mandated that schools accommodate disabled students, clearing the way for children with feeding tubes, catheters and other serious medical conditions to attend school. Today, 16 percent of students have a condition that requires regular attention from the school nurse, Garcia said.
Many parents and school administers don't realize that nurses are handling life-threatening conditions as well as performing vision, health and diabetes screenings, said Barbara Duddy, president of the Tennessee Association of School Nurses in Memphis.
"They think the school nurse is nice little job where you take care of boo-boos," she said. "School nurses work very hard to make sure every child gets exactly what they need."
Garcia blamed shifting priorities, shrinking budgets and a misunderstanding of the school nurse's role for the loss of jobs.
The Southern Humboldt Unified School Board in Garberville, Calif., blamed a reduction in state funding when members voted in June to eliminate one nursing position and reduce the other position to 10 hours a week for the upcoming school year.
"The nurses provide great services for our students, but so do all the other positions that we've cut," said Susie Jennings, associate superintendent for the 800-student district.
Robin Correll, the remaining nurse, worries how she will oversee the district's seven schools. She was already struggling to perform annual health and vision screenings.
"It will be impossible to do all the work," she said. "It breaks my heart. Kids deserve better."
Correll, like many nurses around the country, has already trained teachers and secretaries to dispense medication, give shots of adrenaline and help children use inhalers. So far the district has stopped short of asking nonmedical personnel to administer insulin.
The thought of someone without a medical background managing Brandon Merrell's diabetes makes his mother, Amy Merrell, very uncomfortable. The Gilbert, Ariz., woman wants assurances that her 8-year-old son will be properly cared for while he's at Coronado Elementary School.
"There needs to be somebody in there that knows what they're doing," she said.
She and her husband, Doug, are among the parents speaking out about the issue. After they and other parents objected to a plan to cut the number of school nurses from nine to two, the Higley Unified School District decided in June to maintain five nursing jobs.
In Keyse's North Carolina district, Barb Molton told county commissioners that she worried her diabetic 13-year-old son, Brice, had access to a school nurse for only two mornings a week.
"It can be scary dropping your child off at school wondering if that will be the day they might have a medical emergency and wondering if that is the day you might be lucky to have a school nurse there," she said at the hearing.
The commissioners agreed to fund two additional nurses for the upcoming school year.
School nurses, who have spent the last decade defending their jobs, are happy to see parents take up the cause, said David Schildmeier, spokesman for the Massachusetts Nurses Association.
"That's how the change happens," he said. "That's how this issue gets solved."