BILL ANALYSIS
AB 2454
Page 1
Date of Hearing: April 21, 2010
ASSEMBLY COMMITTEE ON EDUCATION
Julia Brownley, Chair
AB 2454 (Torlakson) - As Amended: April 13, 2010
SUBJECT : Education: school nurses.
SUMMARY : Requires, commencing July 1, 2020, school districts
to employ one nurse for every 750 pupils enrolled in the
district; and, authorizes school districts to bill a pupil's
health insurer for the cost of health care services provided to
pupils. Specifically, this bill :
1)Authorizes the governing board of a school district to bill a
pupil's health insurer for the cost of health care services
provided to the pupil.
2)Requires the governing board of a school district to employ at
least one school nurse, registered nurse (RN), or licensed
vocational nurse (LVN) for every 750 pupils.
3)Specifies that a RN or LVN shall provide health care services
to pupils under the supervision of a school nurse; and,
specifies that a school nurse may not supervise more than a
combined total of five RNs and LVNs.
4)Authorizes a school district to contract with a county office
of education for services of a school nurse employed by the
county office of education.
5)Specifies that these requirements shall not apply to school
districts that are served by a school health center.
6)Specifies a RN is an individual licensed under Chapter 6 of
Division 2 of the Business and Professions Code; and,
specifies that a LVN is an individual that is licensed under
Chapter 6.5 of Division 2 of the Business and Professions
Code.
7)Makes findings and declarations regarding the fact that the
health needs of pupils are not currently being adequately met
due to the lack of qualified health professions employed by
school districts and that nurses are uniquely qualified to
attend to the primary care of pupils suffering from chronic
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and acute health conditions.
8)Declares Legislative intent to ensure that school districts
more adequately address and meet the health care needs of
pupils by requiring that school districts employ a sufficient
number of qualified nurses.
9)Specifies that no reimbursement is required by this act
pursuant to Section 6 of Article XIIIB of the California
Constitution because only costs that may be incurred by a
local agency or school district are the result of a program
for which legislative authority was requested by that local
agency or school district, within the meaning of Section 17556
of the Government Code and Section 6 of Article XIIIB of the
California.
EXISTING LAW :
1)Defines a school nurse as a RN currently licensed under the
Nursing Practices Act, and who has completed the additional
educational requirements for, and possesses a current
credential in, school nursing pursuant to Section 44877.
(Education code 49426)
2)Specifies the qualifications for a school nurse to be a valid
certificate of registration issued by the Board of Nurse
Examiners of the State of California or the California Board
of Nursing Education and Nurse Registration and a health and
development credential, a standard designated services
credential with a specialization in health, or a services
credential with a specialization in health. Specifies the
services credential with a specialization in health
authorizing service as a school nurse shall not authorize
teaching services unless the holder also completes the
requirements for a special class authorization in health in a
program that is approved by the commission. Specifies on and
after January 1, 1981, the qualifications for a nurse shall
also include proof satisfactory to the school district that
the nurse has acquired training in child abuse and neglect
detection. (Education code 44877)
3)Authorizes local education agencies to bill Medi-Cal for
health care services including nursing services. (Welfare and
Institutions code 14132.06 (a))
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FISCAL EFFECT : Unknown
COMMENTS : This bill requires, by July 1, 2020, school districts
to employ one nurse for every 750 students and authorizes school
districts to bill private insurance companies for the nursing
services provided to students during the school day. Further,
the bill requires credentialed school nurses (CSNs) to supervise
RNs and LVNs at a ratio of 1:5. Further this bill exempts
school districts with on-site health clinics from these nursing
ratios.
According to the author, studies over the past 15 years have
consistently document the connection between student health and
academic failure, with poor health affecting student's
attendance, grades and ability to learn in school. Chronic
diseases such as asthma, diabetes, obesity and tooth decay
affect about 20% to 30% of students in California, which lead to
more absenteeism and lower school performance. One way to
combat absenteeism due to chronic diseases is the return of the
school nurse.
School nurses help students monitor and manage their chronic
diseases. Management of chronic disease is necessary to improve
student's health and thereby improve a student's attendance and
performance at schools. According to Regional Asthma Management
Prevention (RAMP) students with asthma miss two and a half days
of school every year. These missed days are triggered by asthma
attacks that can often be managed by a combination of medication
and keeping students away from asthma triggers. This management
could be coordinated by a school nurse working with the student,
parents and teachers to ensure the triggers are not in the
classroom or at home.
Students without chronic diseases also benefit from school
nurses through visual and audio screenings and health
assessments for students with learning difficulties, emotional
and behavioral problems, as well as drug and alcohol abuse.
School nurses conduct these screenings and assessments but also
provide necessary follow-up for students and parents to ensure
students are getting the help they need. Students, parents,
schools and health insurance companies benefit from these
screening and assessments.
Nurse to Student Ratios : There has been a long standing
shortage of school nurses in California. Many of California
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students do not have regular access to a school nurse.
California's current nurse-to-student ratio is approximately
1:2,200. According to the California Basic Educational Data
System (CBEDS), about one-half of school districts do not have a
school nurse. In those areas, the county office of education
should provide a nurse but it is possible that no nursing
coverage exists for some school districts. The National
Association of School Nurses that recommends guidelines of 1:750
for students in general population; 1:225 in the student
population that may require daily professional school nursing
services or intervention; and, 1:125 in student population with
complex health care needs. The National Association of School
Nurses recommends that school districts should provide a
full-time professionally prepared RN all day, every day in each
building. Also recommended is additional school nurse staff to
accommodate other student health needs including, but not
limited to, special education evaluations, nursing services
included in IEPs, nursing services for students with 504 Plans,
and schools with large populations and large numbers of students
with mental or social concerns.
This bill requires school districts to hire enough CSNs to
supervise RNs and LVN's at a 1:5 ratio and requires districts to
employ either a CSN, RN or LVN at a 1:750 nurse to student
ratio. The chart below illustrates the number of preliminary
and clear nursing credentials issued by the CTC over the last
eight years. Based on the cyclical nature of school nurse
credential applications, it is unclear if enough CSNs will be
available to fulfill the school district demand in created by
this bill in 2020. It is also unclear whether the current
distribution of CSNs in districts across the state will allow
for an easy transition or if large numbers of CSN's will need to
be hired across the state.
On average, 247 School Nurse credentials were granted annually
between 2002 and 2009. As seen in the table below, however, the
number decreased 35% between 2002 and 2004 (272 to 176,
respectively) and then increased 83% between 2004 and 2008 to
322. Despite the increase over the past four years, the numbers
declined between 2008 and 2009 by 28%.
Number of Preliminary & Clear Credentials Issued for School
Nurses
-----------------------------------------------------------------------------------------------------------
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| | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 |
| | | | | | | | | |
|-----------+-----------+-----------+-----------+-----------+-----------+-----------+-----------+-----------|
|Totals | 272 | 222 | 176 | 220 | 247 | 284 | 322 |231 |
-----------------------------------------------------------------------------------------------------------
Source: Commission on Teacher Credentialing
Credentialed School Nursing Requirements . Under current law a
school nurse is required to have a Bachelor of Science (BS) in
nursing, be RN, and hold a school nurse credential. A
preliminary credential is issued for five years and an
individual qualifies for a clear credential after successfully
completely two years of service as a school nurse and by
completing a commission approved school nurse program.
According to the author, school nursing certificates require an
additional 15-30 units of education above a BS. New
requirements from the CTC make the school nursing credential
standards based, thereby allowing schools the ability to offer
the credential in a variety of units.
Registered Nurses & Licensed Vocational Nurses . According to
the Legislative Analyst's Office, all RNs in the state must have
a license issued by the California Board of Registered Nursing
(BRN). To obtain a license, students must complete a number of
steps, including graduating from an approved nursing program and
passing the national licensing examination. In California,
there are four types of prelicensure educational programs
available to persons seeking to become a RN. All four types are
generally full-time programs, and each combines classroom
instruction and "hands-on" training in a lab with clinical
placement in a hospital or other health facility. The first two
options are for students to enroll in either an associate degree
in nursing (ADN) program at a two-year college, or a four-year
bachelor's degree in nursing (BSN) program at a university. In
addition, individuals who are already LVNs may choose to enroll
in an accelerated nursing program at a two-year college.
Finally, students that already hold a bachelor's or higher
degree in a non-nursing field are eligible to apply for an
entry-level master's (ELM) program at a university.
LVNs are licensed by the California Board of Vocational Nursing
and Psychiatric Technicians (BVNPT). To obtain a license,
students must pass the licensure exam and either graduate from
an accredited Vocational Nursing Program or complete the
equivalent education and experience. LVN's skills are developed
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in medical-surgical, maternity and pediatric nursing. LVN's
practice under the direction of a physician or a RN and only
LVNs and RNs are allowed to use the title "nurse."
According to the LAO, there are more than 120 prelicensure
nursing programs in California that graduated more than 7,500
students in 2005-06. Additionally, the BRN estimates that there
are 375,000 active RNs in California today. According to the
BVNPT, there are currently 113,664 LVNs in California. Also,
there are 2,167 LVN students on track to graduate from
California accredited schools in June 2010.
While requiring school districts to hire nurses at a 1:750
nurse-to-student ratio may be a challenging hurdle for school
districts, authorizing districts to hire CSNs, RNs or LVNs to
fill this ratio will provide for a larger recruiting and
applicant pool, and in the end may alleviate the current
shortage of school nurses.
Insurance Coverage . This bill authorizes school districts to
bill private insurance companies for the nursing services
provided to students during the school day. Existing law
authorizes local education agencies to bill Medi-Cal for nursing
services and the author's intent is to expand the existing
authorization to private insurance companies. It is unclear how
long it will take for school districts to establish the ability
to bill private insurance companies. While billing insurance
companies for nursing services could be a steady source of
income to support nursing services at a school district, it is
unclear whether the income generated by insurance billing will
cover the full cost of employing nurses. According to the
author, Los Angeles Unified School District (LAUSD) has
successfully implemented a Medi-Cal billing system. LAUSD is
able to bill for direct-services and indirect administrative
services. While many school districts may be set up to bill
Medi-Cal, it will likely be an entirely new process to bill
directly to private insurance companies.
County Office Contracting . Recruiting CSNs is not only
difficult for urban districts, it is also difficult for rural
school districts. Not only are districts competing with
community employers that can often pay nurses higher salaries,
but they are also competing against the image that school
nursing can be a very challenging job in highly impoverished
areas. Some medium to small school districts have a difficult
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time recruiting a single school nurse because of this
competition. Ravenswood Unified School District, is one such
district that has trouble recruiting CSNs. Extremely rural
districts may not be able to recruit school nurses due to the
natural isolation of the district from a near by city. The bill
authorizes school districts in this difficult situation to
contract for CSNs through a county office of education.
Committee Amendments : The bill specifies that school districts
that are served by a school heath center shall be exempt from
the nurse to student ratio. To better align the bill to the
author's intent, staff recommends the bill be amended to
instead, exempt the number of pupils attending a school served
by a school health center from the school district's calculation
of the 1:750 ratio. Staff also recommends the bill be amended
to specify that schools with more than 750 pupils are not
required to employ more than one nurse. Additionally, it
appears that the wrong mandate language was inserted in this
bill, staff recommends this be corrected.
Related legislation : SB 1200 (Leno) from 2010, pending in the
Senate Health Committee, would add availability of school-based
health care to the timely access to care provisions for which
the department may adopt standards.
SB 1051 (Huff) from 2010, pending in the Senate Education
Committee, authorizes school districts to provide school
employees with voluntary emergency medical training to provide
emergency medical assistance to pupils with epilepsy suffering
from seizures.
AB 1802 (Hall) from 2010, pending in the Assembly Business and
Professions Committee, authorizes a parent of a pupil with
diabetes to designate a school employee to administer insulin to
the pupil under specified conditions.
Previous legislation : AB 426 (Hall) from 2009, which was
referred to the Assembly Education Committee, would have
required the Department of Education, in consultation with
specified entities, to recommend to the Legislature ways to
address specific health-related needs of pupils on school
campuses, including but not limited to, diabetes, asthma and
obesity-related diseases.
AB 1430 (Swanson) from 2009, which was held in the Assembly
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Business and Professions Committee, required any necessary
medication to be administered to a student by a licensed health
care professional operating within the scope of his or her
practice.
ACR 99 (Swanson), Resolution Chapter 93, Statutes of 2009, urged
school districts to take the necessary steps to increase school
nurse salaries.
REGISTERED SUPPORT / OPPOSITION :
Support
California Academy of Family Physicians
California Nurses Association
California School Nurses Organization
California Teachers Association
Opposition
Association of California School Administrators
Analysis Prepared by : Chelsea Kelley / ED. / (916) 319-2087