Public Hearing
before
 
 
ASSEMBLY EDUCATION COMMITTEE
 
 
ASSEMBLY BILL No. 421
 
 
(Requires public school health services to be provided by a certified school nurse)
 
 



 
 
LOCATION: Committee Room 16 

State House Annex 

Trenton, New Jersey

DATE: April 29, 1997 

10:00 a.m.

 
 
 

MEMBERS OF COMMITTEE PRESENT:

Assemblyman Carmine DeSopo

Assemblywoman Barbara Wright

Assemblyman Craig A. Stanley
 
 

ALSO PRESENT:

Assemblyman John V. Kelly

District 36

Kathleen Fazzari Christine Costigan Jason Teele

Office of Legislative Services Assembly Majority Assembly Democratic

Committee Aide Committee Aide Committee Aide
 

(Internet edition 1997)
 

ASSEMBLYWOMAN BARBARA WRIGHT (Acting Chair): Good morning, everyone. I'd like to call this public hearing on Assembly Bill No. 421 to order. I'm Assemblywoman Barbara Wright, a member of the Education Committee, and I am Chairing the hearing today.

We're pleased that we have Assemblyman Craig Stanley and Assemblyman Carmine DeSopo -- Assemblyman Kelly will join the panel -- and we do expect other members. But in the interest of schedules and some people who have very tight ones, we want to move ahead with the testimony.

The testimony will be on the record, contrary to many of the hearings that we hold. Since this is established as a public hearing, this is not a time when the Committee will take action on this bill. We are just getting input from interested parties. There will be a record of this hearing. You may be aware that there are not always records of our hearings. Our usual Committee meetings are not recorded, nor, other than actions, is the Assembly agenda.

I would just like to make-- No, I will make some comments after Assemblyman Kelly, since he is the prime sponsor. I am the cosponsor of A-421. We're using this bill as the focus of our discussion today, but we recognize that our real discussion in focused on school health services.

Assemblyman Kelly, will you proceed?

ASSEMBLYMAN KELLY: You probably know more about nursing than I do.

Can you hear me? (affirmative response)

You know more about nursing than I do, I know that. This is a good bill. It's been around -- this is the second time around, to my knowledge. It was before this Committee once before. I think anyone who reads English can read the bill, and it states very simply that registered nurses should work in schoolhouses. I see nothing wrong with the legislation. I know it's rather costly, but that's besides the point. We're concerned about the health of the children, and I believe a registered nurse is the best nurse to be working in the schools.

With that, I'll shut up and turn it over to you.

ASSEMBLYWOMAN WRIGHT: Thank you, Assemblyman Kelly. Would you please join us here at the hearing panel.

ASSEMBLYMAN KELLY: I want to hear them any how.

ASSEMBLYWOMAN WRIGHT: The first witness to testify today is Ellen Schechter from the Department of Education. She is the Assistant Commissioner of Academic Programs and Standards.

Thank you very much, Ellen.

A S S T. C O M M I S S I O N E R E L L E N S C H E C H T E R: Assemblywoman Wright, do I have to push any buttons here or anything? (referring to microphone)

ASSEMBLYWOMAN WRIGHT: Yes, you need a red-- Kathy will help us.

ASSISTANT COMMISSIONER SCHECHTER: Okay. It's okay? (affirmative response)

Good morning, Assemblywoman Wright, Assemblyman Kelly, and other members of the Committee. I am Ellen Schechter, Assistant Commissioner for the Department of Education's Division of Academic Programs and Standards. On behalf of Commissioner Leo Klagholz and the Department of Education, I am pleased to appear before you to address the issue of health services in New Jersey's schools.

I've been involved in public education for many years, having started my career as a teacher of the profoundly deaf. Through my varied experiences in the classroom and as an administrator, I recognize the critical nature of the role of the school nurse and the impact of school health services in general on the entire educational community.

It is within the purview of the Division which I administer, Academic Programs and Standards, to oversee the Office of Professional Development, which includes certification of individuals, including the school nurse. I also oversee the Office of Standards and Assessment, which is responsible for the development and implementation of New Jersey's core curriculum content standards. Therefore, it is most appropriate to the context of this hearing for my testimony to focus on four relevant issues.

First, the core curriculum content standards which will propel my discussion; next, certification as it relates to health professionals in schools; third, the changing role of the school nurse in the contemporary time and the increased and varied demands on the school nurse to provide comprehensive health services, as well as to teach; and finally, the fiscal pressures for school districts to pay for the needed services.

Let's begin, if we might, with the core curriculum content standards and, in particular, with the comprehensive health and physical education standards, one of the seven academic areas. I believe a copy of this particular set of the standards is on its way. I apologize for the misconnect, but it's coming.

The standards, including the ones dealing with comprehensive health and physical education, were developed over a two-year period with the involvement of hundreds of educators and other professionals, parents, business persons, and citizens. We feel confident that these standards represent a consensus of what all children should know and be able to perform when they graduate from high school. Moreover, they are specifically designed to allow local educators to develop the curriculum and strategy to meet these standards.

Following the development and dissemination of the standards, the next undertaking of the Department of Education has been to assist districts in developing or revising their curricula to meet the standards, and that is being done through the development of curriculum frameworks in each of the academic areas. These frameworks will bring to life the standards through actual examples of classroom lessons and strategies to assist teachers in the development of the curriculum that best meets the needs of students in each community.

Because education is such a top priority of the Whitman administration, Commissioner Klagholz has been working to accelerate the development of these curriculum frameworks, and by June of 1998, we expect to have completed all frameworks in all subjects for local district use.

Let's focus now, if we might, on the standards for comprehensive health and physical education. There are six major standards which well reflect the importance of health related education for all children:

First, all students will learn health promotion and disease prevention concepts and health-enhancing behaviors. Secondly, all students will learn health-enhancing personal, interpersonal, and life skills. Three, all students will learn the physical, mental, emotional, and social side effects of the use and abuse of alcohol, tobacco, and other drugs. Number four, all students will learn the biological, social, cultural, and psychological aspects of human sexuality and family life. Fifth, all students will learn and apply movement concepts and skills that foster participation in physical activities throughout life. Sixth, all students will learn and apply health-related fitness concepts.

As you will note, four of the six standards for comprehensive health and physical education focus on instruction regarding student health, further recognizing the importance of this topic. This leads us to the next issue, which is the drawing of an important distinction between the teaching of health concerns and the actual provision of health services, and that's where we get into the discussion of certification and the possible various roles in the future of the school nurse.

Currently, the school nurse must hold an educational services certificate with an endorsement as a school nurse, and this certificate is issued by the State Board of Examiners. Only a registered nurse is eligible for this endorsement. With respect to employment of the school nurse in schools, New Jersey State statutes require every Board of Education to appoint at least one certified school nurse.

The school nurse is certified under State Board of Education regulations, which were established many years ago. It is important to note these health, safety, and physical education regulations are under review as part of the comprehensive review of code initiative, and the issues related to school nurse certification will be addressed in due time.

This review of our health-related regulations is important, since we all recognize that society has changed and shifted to schools many more demands for student health services, as they relate to such problems as drug or alcohol, poverty, parental neglect, etc. There are also other potential demands for increased health services to our students such as those which may be necessitated by the mainstreaming of special education students.

For example, since it is clear that the role of the school nurse is continually evolving as the demand for school health services increases, the inevitable question arises: Can we expect the school nurse to carry the full teaching responsibilities and still perform the critical and varied health services so vital to students? In other words, can we realistically expect the school nurse of today and the future to be Wonder Woman or Wonder Man?

I would like to offer some ideas for consideration as we look ahead to working with you, the State's legislative policy makers, in addressing this evolving issue. In light of the background which I have given you, it seems appropriate that one of the next steps we can take is to look at possible reforms in certification which will give boards of education more flexibility to meet changing needs.

We may want to consider proposals to the State Board of Education which would, in effect, separate the teaching of health services from the providing of health services with certified teachers of comprehensive health and physical education performing the teaching function and the school nurse providing the comprehensive health services.

Alternatively, we may also want to consider recommending proposals to the State Board of Education which might include a tiered system of nurse certification with one nurse certified to teach and the other authorized to provide services to students. Another option could be to have an L.P.N. or other health professional to perform certain functions under the direct supervision of the school nurse.

The sharing of professional services is another possible option which was among the recommendations of the Commissioner's Consolidation of School Services Task Force Report. Partnerships with other neighboring schools could be developed to allow students to receive specialized instruction which may not be available at his or her own school. In addition to student instruction, we recognize that there will also be a need to update and train staff in health issues, and the expertise of the school nurse will likely be tapped to provide staff development which can be a shared arrangement.

We should be open to opportunities which might reduce costs by exploring additional relationships, both formal and informal, with other school districts and entities, while at the same time, expanding educational opportunities available to students and valuing the critical importance of the school nurse.

In closing, I would like to stress the Department of Education's commitment to the issues of children and their health. We offer our assistance in working with the sponsors of A-421 and the Committee on the legislation. As my testimony indicates, there are many related issues which will affect the role of the school nurse.

Rather than in statute limit the provision of health services by the school nurse to those defined in the bill, which are exceedingly broad, we would respectfully request that any changes be viewed in conjunction with the ongoing educational reforms which I have outlined.

On behalf of Commissioner Klagholz, I thank the Committee for the opportunity to address these important issues which clearly affected the well-being of all of our students.

Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you very much, Assistant Commissioner Schechter.

Does the Committee have any questions or comments? Assistant Commissioner Schechter will be remaining for just a short time and then she has another appointment, so this is the best time if we have any -- a discussion we want to have with the Commissioner's staff.

ASSEMBLYMAN KELLY: I have no questions.

ASSEMBLYWOMAN WRIGHT: We want to thank you. I know that you have been generous in your time in working with us, and we know that this issue has a lot of discussion before it and the core curriculum standards certainly add to it.

So we appreciate your commitment to the health of the children in the schools, and we'll look forward to working with you.

ASSISTANT COMMISSIONER SCHECHTER: Thank you, we will also.

ASSEMBLYWOMAN WRIGHT: As I mentioned before, this is a public hearing, therefore, there will be no action taken on this bill. The ideas that are being brought forward will be very helpful as Assemblyman Kelly and I continue to work on this bill.

Has Arlene Cusick returned to the room? (affirmative response) I'd like to ask that the panel from the School Nurses Association--

Arlene Cusick, the President and Judy Kiernan the President-elect of the New Jersey State School Nurses Association, please come forward.

While they are coming forward, if there is anyone in the room who has not notified the staff either by phone or with a form that they would like to testify, there is staff who will help you. We're going to put the form out on the table. I know that many of you have contacted the staff and you are on the list. If you have not notified the staff or filled out a form this morning and you would like to testify-- This is not an attendance form, it's strictly if you wish to testify on A-421 or speak on this issue.

May I ask that Arlene Cusick and Judy Kiernan proceed.

A R L E N E H. C U S I C K R.N.: Thank you, Assemblywoman Wright. We are also asking to join our panel our colleague from Rowan College who will talk on certification issues.

ASSEMBLYWOMAN WRIGHT: Could you introduce her?

MS. CUSICK: Dr. Sandra McHenry.

ASSEMBLYWOMAN WRIGHT: Thank you.

MS. CUSICK: Good morning. My name is Arlene Cusick, and I am the President of the New Jersey State School Nurses Association.

I have been a certified school nurse for 20 years and am employed at Belleville High School in Belleville, New Jersey. I hold a master's degree in health education and an additional 32 credits beyond, primarily in the field of counseling and health-related issues. I welcome this opportunity to share with you some of our grave concerns about the schoolchildren in New Jersey.

The certified school nurse is an integral part of the education setting and plays a pivotal role in providing comprehensive services to all students. While the primary goal of the school is to provide academic instruction, we are aware of the many extrinsic factors which may impact heavily on the success of our students. The New Jersey State School Nurses Association believes that all children must have access to quality school health programs. The health needs of our children have always been the first priority of the school nurse.

In the 1990s, school nursing has become much more complex, embracing two professional disciplines, nursing and education. While our major responsibilities in the past included immunizations, screenings, and administering first aid, today we are now called upon to expand our roles. Issues like substance abuse, communicable disease, physical and sexual abuse, eating disorders, chronic illness, homelessness, grief and depression, teen pregnancy, sexually transmitted diseases such as HIV and AIDS, and violence are a part of our everyday lives.

Nursing assessment and intervention have been invaluable in providing a continuity of care for the regular, as well as special needs students. As part of the health care team, the certified school nurse takes the lead in early detection and correction of health problems. Prevention starts with education and the certified school nurse is an educator, as well as a healer, whether we teach in a formal setting in the classroom or whether we teach in the health setting itself.

As you are probably aware, more children with special health care needs and chronic illnesses are entering our schools daily. We provide the health care services prescribed by physicians and develop, implement, and monitor health care plans for these students to enable them to come to school. On a daily basis, we must know what to do, when to do it, and how to do it. So you will find in our schools students with tracheostomy tubes, feeding tubes, wheelchairs, and many other conditions not seen in school before.

As the advocate for children, we care not only for their physical needs, but also use our knowledge to integrate them as gently as possible into the framework of the school day. Children in crisis are not new to us. What is new is the increasing numbers of these children who find their way to our offices. Within the school population, it is often the certified school nurse who becomes aware of problems that require intervention. Our professional preparation enables us to effectively evaluate not only the problem, but also to determine what course of action may follow.

A student comes into the nurse for a Band-Aid. The nurse chats as the girl washes her hand. As the nurse begins to apply the Band-Aid, she pushes up the sleeve of the girl's sweater. There are two slash marks on the arm. She asks to see the other arm. They are present there, as well. After speaking privately with the girl, the nurse makes the assessment that an intervention is necessary. Calling together the crisis team, of which the nurse is a member in the school, a referral is made. Why? Because the student is so very unhappy and a few days before she did, indeed, try to harm herself.

In another instance, a young student comes to the nurse and states, "I don't feel well." His posture and manner, as well as the vague complaint, alert the nurse that something is terribly wrong. Taking him aside and talking with him, she finds out that his beloved karate instructor committed suicide the day before. The student is heartbroken, desolate. He feels betrayed. This is his first experience with death, but what is even more overwhelming is that this karate instructor told these kids to never give up, always fight on, and now he has taken his own life. Again, the nurse makes a referral, and the student receives the assistance needed.

A 16-year-old student confided to the nurse that she was pregnant and was undecided about a course of action. The school nurse was able to refer her and her single parent to an appropriate outside agency to guide her decision making. Additionally, the nurse was able to help them plan so that that student would be able to return to school and continue her education.

Every day, school nurses throughout this State find themselves in similar situations. The first week of school this year -- which was three days because we started on a Wednesday -- I directed the collection of three urine samples for possible substance abuse, invoked the suicide policy for a brand-new student who came to the office and just wanted to talk, I assisted with the return of a student with multiple sclerosis, along with the my diabetics, Ritalin, back braces, wheelchairs, and other routine parts of my day.

How did I know what to do? The clinical knowledge and nursing process which are interwoven in my educational background provide the skills necessary. This is what sets me apart from the uncertified registered nurse. We are a valuable asset to each school district. We are the one to whom the child will often tell or show things that no one else knows. The child who comes frequently is just waiting for us to notice or is hoping for just the right moment to let out that terrible secret of abuse. We know that a healthy child is more apt to be a learning child, so we act as the liaison between the school, the health provider, and community resources.

So why then do we seek legislation to promote the hiring of only certified nurses in schools? For all the reasons stated, but primarily for children, for that's what we are about. As health professionals we know all too well about budget constraints, but the children we service know only that their needs have increased and since the school is the constant in their lives, where else would these needs be met?

I make this point because I believe it, but I also find it hard to reconcile that some local boards of education would like to dispense with the certified school nurse and hire uncertified, unqualified personnel to provide fewer health services to our schoolchildren. County superintendents are looking the other way as new job descriptions are written and registered nurses are being hired as health aides. Many of these nurse are working alone in a school and infringe on the statutes which govern our practice, diluting services to the children.

We do not believe that a nurse is a nurse. School nursing in New Jersey is being challenged by the economics of our times. The New Jersey State School Nurses Association believes that the children of this State deserve to be cared for by a professional nurse, who has chosen this speciality, who brings the ability to make an assessment based on skills and professional credentials. We are not looking for a ratio, nor are we looking for a nurse in every school. Simply, that based on statute and prior rulings from the Commissioner -- for example, in 1982 -- that only certified personnel, as with teachers, be hired for all public schools.

Thank you.

ASSEMBLYMAN KELLY: I have one question.

ASSEMBLYWOMAN WRIGHT: Yes, please go ahead, Assemblyman Kelly.

ASSEMBLYMAN KELLY: You said that new job descriptions are coming forward and they're hiring nurses as health aides?

MS. CUSICK: That's correct.

ASSEMBLYMAN KELLY: What's that mean?

MS. CUSICK: What that means is that the district writes up a job description that does not state all of the things that the certified nurse does, but goes right to the borderline. They hire this registered nurse as a health aide so they do not have to put her on teachers' salary scale, they may or may not give the same benefits, and they put her alone in a school to function by herself, and that is happening throughout this State.

ASSEMBLYMAN KELLY: Thank you.

ASSEMBLYWOMAN WRIGHT: I think we'll proceed, and then if you have other questions of the panel, after each has testified, we'll continue with the dialogue with the panel.

Judy Kiernan.

J U D I T H K I E R N A N, R.N.: Good morning, Assembly Education Committee members. I'm Judith Kiernan. I'm a veteran school nurse, President-elect of the New Jersey State School Nurses Association, and I'm working in Burlington County.

We have been hearing a great deal about New Jersey's progress toward the national education goals. By her own admission, Governor Christine Todd Whitman states that since taking office in 1994, education has been a top priority of her administration. Commissioner Leo Klagholz has proposed changes in the Comprehensive Plan. In that Plan, the primary mission of schools is defined as being to provide academic instruction; however, Commissioner Klagholz stipulates that enabling all students to attain high standards is a complex challenge. In addition, the Plan further states that students must be provided a safe environment conducive to learning. I must say that school nurses wholeheartedly agree with these two premises.

A certified school nurse is the one, who by virtue of her training and education, has specialized in these two areas. The certified school nurse is schooled in community health nursing, which enables her to provide and access services. She is a knowledgeable participant in cooperative health planning. Certified school nurses espouse accessing health to further the educational process. The learning disorders of childhood and adolescence, nursing roles with child abuse and neglect, the chronically dysfunctional family, substance abuse, violence, and the pharmacology of commonly used pediatric medicines reference just a few of the areas of knowledge and skill required for school nursing practice.

Let's take a look at national education goal number one: Ready to learn. The deprivations caused by poverty in the urban and rural districts require that children's general health needs be met. You can argue that ancillary health services are beyond the mission of academic achievement, but who is it that will focus on the special health needs of our children? Who will collaborate between local schools and community agencies to provide the needed health services? Make no mistake about this, it is the certified school nurse who is prepared to make the judgements, provide solutions, and develop individualized health plans for these students.

Let us highlight goal number two: Student achievement and citizenship. As you are well aware, rigorous core curriculum content standards have been adopted. Frameworks were developed to assist educators in aligning curriculum and implementing the standards. What you may not know, is that a certified school nurse was selected to serve not only on the Health and Physical Education Standards Committee, but also, was one of the seven members sittings on the Alcohol Tobacco and Other Drugs framework's writing team. Why? Because former Assistant Commissioner Reese believed that she had a strong commitment to the health and education of children.

The certified school nurse is educated in the social and behavioral sciences, health assessment techniques, school and community nursing, methods and materials of health teaching, and child development. I believe that this nurse is definitely the one who is able to skillfully weave the pattern of lifelong health into the educational system.

Certified school nurses are prepared to function in schools. That's it, plain and simple. Nursing is nursing, but the view is speciality practice. Nurses working in schools are in the trenches. While the funding and curriculum battles go on all around them, they are there to meet the needs of every student -- learning disabled, handicapped, physically fit, and honor student. We run the gamut. We specialize in it. Don't ask me to work in the cardiac care unit or the obstetrical department. I'm not prepared for it; I do not have a specialized knowledge in those areas. I can only function as a generalist there.

I think you know the point I'm trying to make today. Three simple words -- preparation, focus, and skill. Revisit New Jersey's progress toward the national education goals. Do you want to be one of the leaders in this endeavor? Heed the words of Suzanne Gordon (phonetic spelling) writing in the February issue of Atlantic Monthly: "It is only in watching nurses weave the tapestry of care that we grasp its integrity and its meaning for a society that too easily forgets the value of things that are beyond price."

Assembly Education Committee members, I give you this challenge: If you care about New Jersey schoolchildren, you will ensure that a certified school nurse is there. It's no longer a question of what you are buying and how much you are paying for, but whether you are getting your money's worth for the children.

Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you very much, Judith.

If there are no questions, we will hear from the third member of your panel, Dr. Sandra McHenry.

S A N D R A L. M c H E N R Y, D.N.Sc., R.N.: Good morning.

ASSEMBLYWOMAN WRIGHT: We have testimony in front of us? (affirmative response)

Thank you, Sandy.

DR. McHENRY: My name is Sandy McHenry, and I am the Coordinator of the School Nursing Program at Rowan University. As a certified school nurse, I have provided health care and education to students in an urban school district.

I speak in support of Assembly Bill No. 421. Although many aspects of the school nurse role are not delineated in the bill, it does, in concept, support the provision of health services by a certified school nurse. This is important for the health and safety of our children.

School nursing is an area of nursing specialization. As you know, certified school nurses have a baccalaureate degree, as well as courses in child development, health assessment, community nursing, multiglobal issues, foundations of education, school law, health education, and teaching methods. Thus, this professional has an additional, discrete body of knowledge which is vital for the implementation of school health services. Although school nurses are certified by the State of New Jersey, they may also receive professional certification in their speciality.

The practice of the school nurse is guided by the New Jersey Nurse Practice Act, the American Nurses' Association Standards of Clinical Nursing Practice, the ANA Code of Ethics, and the National Association of School Nurses' Standards of Nursing Practice. There are 10 standards of practice which define the school nurse role and accountability.

The first three standards define the nurse as the provider of client care through utilization of clinical knowledge and the nursing process, as well as the provision of specialized care for students with special health needs. The nurse contributes to the education of the student with special health needs by assessing the student, planning and providing appropriate nursing care, and evaluating the identified outcomes of care. This is an ever-expanding role as more medically fragile children are being served in the public school system.

There is a standard that addresses the issue of effective written, verbal, and nonverbal communication. This is vital for effective implementation of the program management aspect of practice, which includes the development, coordination, and evaluation of programs and activities concerned with client health; the development and implementation of policy and procedure concerned with client health; the acquisition and management of funds to implement student health activities and programs; and, finally, the supervision and evaluation of nonprofessional health personnel.

Collaboration with other school professionals, with parents, and other health care providers is also vital to meet the health, developmental, and educational needs of students. The school nurse's role as case manager for children with ongoing health care needs is continually evolving.

The school nurse also collaborates with members of the community in the delivery of health and social services and utilizes knowledge of community health systems and resources to function as a school-community liaison. Furthermore, the school nurse assist students, families, and the school community to achieve optimal levels of wellness through appropriately designed and delivered health education.

The school nurse contributes to nursing and school health through innovations in practice and participation in research or research-related activities. Finally, the school nurse identifies, delineates, and clarifies the nursing role; promotes quality of care; pursues continued professional enhancement; and demonstrates professional conduct.

I believe that it is important that the comprehensiveness of the school nurse role be delineated as adherence to these standards of practice is the responsibility of the school nurse. The scope of practice and accountability to the school nursing standards demands a professional nurse who has completed the course of study required for certification by the State of New Jersey. School nursing is a health care specialty that is vital to the maintenance of the well-being of our students.

In a time when the school nurse may be the only health professional that a child or family can access, it is wisdom that provides for the maintenance of the services of a certified school nurse for every New Jersey school.

ASSEMBLYWOMAN WRIGHT: Thank you very much.

Are there any questions of this panel at this time?

Yes. Arlene, would you like to make a further comment?

MS. CUSICK: Yes, I would, if you wouldn't mind.

I would like to remind you that in the United States there are approximately 23 states that require a certification of their school nurses before they can practice. New Jersey is considered one of the leading, one of the strongest, the best. Massachusetts, not more than three years ago, used our program to set up certification in that state. We were the model. And I think it's very important for us that we keep that forefront and that we don't go backwards.

We thank you very much for your attention today.

ASSEMBLYWOMAN WRIGHT: Are there any questions or comments from the Committee? (no response) I believe this panel will be here if we have further questions later on.

MS. CUSICK: Yes.

ASSEMBLYWOMAN WRIGHT: We're particularly interested to hear from you, Dr. McHenry, since you are educating the nurses who are receiving the certification. Is that correct?

DR. McHENRY: Yes, it is.

ASSEMBLYWOMAN WRIGHT: And your information about the national standards, as well, is very helpful to us, and we truly appreciate all of you. We know the imposition of having a hearing in the middle of the week on a school day, so we really are grateful for your professional expertise on this day and the kind of efforts you made to get here.

Thank you very much.

The next panel is Susan Cohen, Ellen Keane, and Pam Weiss, who are representatives of the New Jersey State Nurses Association.

Susan, are you going to start?

S U S A N E. C O H E N, R.N.: Yes.

ASSEMBLYWOMAN WRIGHT: I'd like to say that Susan is a school nurse in my district, and we're very proud of the work that she is doing.

MS. COHEN: Thank you.

Good morning. My name is Susan Cohen, and I'm a clinical nurse specialist of school-age/adolescent children and a New Jersey certified school nurse. Currently, I'm a school nurse in the South Brunswick Public Schools. During my 22-year nursing career, I have staff and management positions in hospitals, community health, private industry, State government, and, of course, school systems.

Although I believe much of the language of Assembly Bill No. 421 needs revision, the conceptual intent of school health services delivery by a certified school nurse is a minimum to be maintained in New Jersey if we are really serious about maintaining or improving the well-being of New Jersey's children.

In the early 1900s when school nurses were first employed in New York City, the effectiveness of school health services on the health and educational status of children was so clear that all legislators in all states were given explicit authority to act to improve children's health in schools. As we approach the year 2000, we need to -- it is clear that we need a renewed commitment by you, our legislators, acting on the fact that our children are worth the investment of at least one certified school nurse per district.

School health services encompasses student health services, health and physical education, counseling, food service, building safety and sanitation, communicable disease, faculty wellness, and parent-school-community health collaboration. The certified school nurse is the only building professional educated and qualified to assure the delivery and integration of these services in the educational setting. Certified school nurses are registered nurses, with a bachelor's college degree, and additional college course work in the disciplines of education, human growth and development, counseling, community health, school law, and health assessment.

It is important to note that a basic nursing education does not prepare a nurse to practice independently with the breadth and depth of knowledge demanded in the educational setting. Currently, the standard of all health care professionals requires specialization and standardization of credentials to assure the safety of the public. It is irresponsible to require less and think that public safety will not be affected adversely.

As you look across the United States, the states with the highest child health indicators have made a commitment to quality standards of child health professionals, the largest segment being school nurses. In 1994, in the United States, there were approximately 31,000 school nurses employed in school health.

The ratio of nurses-student enrollment ranged from one to four hundred and eighty-six in New Hampshire to one to ten thousand eight hundred and fourteen students in Tennessee. New Hampshire had the per capita -- the greatest number of school nurses available, as well as the most favorable child-health well-being index. By contrast, Tennessee had the fewest nurses per student and ranged in the least favorable decile on the Casey Foundation's comprehensive measure of child well-being.

New Jersey has about 594 public school districts, serving approximately 1.2 million public school students, and there are approximately 2000-plus certified school nurses available to those students. The current New Jersey administrative code requires a public school district to employ one certified school nurse per district. Almost all districts have seen the importance of having and do employ a certified school nurse in each building. It is obvious that this existing code requirement was never a practical or reasonable practice to safeguard our students, much less the basic health services components mentioned previously.

Current school budget cuts have prompted school administrators to look at areas, especially personnel, to make cuts. State-mandated minimums are driving many decisions, not what is best or needed for students. Districts are trying to cut costs by cutting existing certified school nursing personnel and replacing them with health aides, L.P.N.s, or other unqualified persons. Would we consider replacing certified teachers and administrators with considerably cheaper and unqualified personnel?

Inferiorly quality personnel should never be considered a reasonable replacement option for our children's education or welfare, especially when we are falling behind other world countries in the areas of educational preparation and health status indicators. A-421 will help assure this basic public safeguard remains in place for New Jersey's children and families.

As more children with special health needs and educational needs are mainstreamed into New Jersey public schools, there is an increasing number of students at risk for health and educational difficulties. Now, more than ever, we need to assure the public that each school has, at least, one certified school nurse to administer and coordinate those services.

Commissioner Klagholz's May 1996 Comprehensive Plan for Educational Improvement and Financing, cites elements the State has used to determine approximate efficient resource levels to deliver a proposed thorough public education. This Plan calls for a nurse in the elementary and middle schools with populations of 500 and 675 respectively, and two nurses for a high school of 900 students. It is assumed the nurse is to be certified, as are all other education personnel cited.

It should be noted maximally 10 percent of these populations are classified for special education. My current elementary school has 560 students in which 12 percent to 13 percent are classified. Furthermore, parents and families are increasingly looked to the certified school nurse for health care assistance and child development consultation as an adjunct to their pediatric or family physician, providing they have one.

For example, last year, 32 percent of my total illness visits were for conditions existing before the students ever came to school. This year, so far, 45 percent of my total illness visits are for conditions existing before they came to school. These changes in the nature of the school health office visit directly affects the quality and quantity of student and family services needed. It also greatly impacts on the educational performance and potential of students given their compromised health and well-being while they're in school.

Children under 16 years old make up the largest group of Americans without health insurance, and 56 percent of children without insurance live in households above the poverty income line. Another estimated 25 percent of children live under the poverty income line. Increasingly, the certified school nurse may be the only ongoing health professional available to our children and their families.

Our families are stretched and stressed which has a direct effect on our children's well-being and educational performance. Certified school nurses are a valuable resource and health care link to students and families. A-421 will assure certified school nurses' continued presence and availability. You do credit to New Jersey State and local legislative bodies to act on the wisdom of this legislative investment, A-421, for New Jersey's children and our future.

Thank you for having me today.

ASSEMBLYWOMAN WRIGHT: Thank you, Susan.

Shall we proceed?

E L L E N R. K E A N E, R.N.: Hello, my name is Ellen Keane, and I'm representing the New Jersey State Nurses Association in support of the Assembly bill A-421.

Currently, I am a certified school nurse employed by the Jersey City Public School District. I have 21-year career in nursing and have many years of experience in different areas of medicine, which has enhanced my ability as a school nurse. I am also an adjunct faculty member at Jersey City State College, where I teach in the School Nursing Certification Program. In addition, I am on the Executive Board of the Bergen County School Nurse Association.

The intent of the delivery of health services by a certified school nurse, as presented in A-421, is of utmost importance in illustrating the need for one certified school nurse in every school. My colleagues and I do agree, however, that some revision of language is necessary in this bill. By providing a certified school nurse -- is offering insurance that the children of New Jersey will be in a safe and healthy environment with an appropriately trained, professional certified school nurses--

Public schools began employing nurses over 100 years ago, and the role of the school nurse has evolved into a far more complex role than ever before. Since 1902, the role of the school nurse was identified to help maintain the physical and mental health of all children so that more children could attend school. The role of the school nurse over the last four decades has broadened to encompass the increasing health needs of school-age children today, and in meeting these needs, the district must recognize that the certified school nurse is the professional to deliver this care.

I work in a large inner city with approximately 32,000 students and 3000 employees. Not only does the certified school nurse deal with the children, we are dealing with the families, and we are dealing with the employees. The school nurse touches all of these people on some level. Not only are we working with the children, but the family. The realm of school nursing is in prevention, as opposed to hospital nursing that is curative in nature.

The children in the inner cities very often do not get appropriate medical care necessary for their well-being. Very often, by them touching a school nurse is where they get the appropriate referrals and the medical care that they do need. In many cases, it is in the schools where these conditions are discovered, uncovered, and referred for assistance. Many students would never have a medical encounter should it not be for the school nurse.

In the growing complexity of the nature and treatment of illnesses, it is the certified school nurse that must have the ability to manage the care of these students. Children with very complex needs are now being included in school.

Unfortunately, in today's society the children are exposed to many different aspects that were not in the past, such as drugs, alcohol, and tobacco at very young ages, teenage pregnancies, AIDS, STDs; not only are we caring for ill children clinically, but we are also teachers and health educators. School nurses are continually teaching preventative medicine, health, and safety.

So you ask: Why a certified school nurse? Quite dramatically and simply stated is that if you needed brain surgery for a brain tumor you would require a neurosurgeon, not an obstetrician; just as if it were a gerontology nurse in a long-term facility, you would not want that person to be taking care of a student in a school setting.

Among the many duties of the certified school nurse are the screenings, immunizations, communicable diseases, evaluations for the Child Study Teams, physicals, bloodborne pathogens, scoliosis screenings, in addition to working with the parents, staff and administration, and outside agencies for the children. We spend many long, hard hours in the city with DYFS, the Division of Youth and Family Services.

And, unfortunately, my own personal experience -- I have spent-- I can log in five hours at any given time a week with DYFS and the unfortunate circumstances of child abuse and sexual abuse.

Certified school nurses hold a minimum of a bachelor's degree, in addition to the certification courses. At this point, the State Department then awards the certification. Medicine is very highly specialized today and so is nursing. Nursing has subspecialties and school nursing is one to be recognized. We do not settle for teachers to be noncertified so why would we settle for nurses -- who may be responsible for our children's very lives -- not to be certified?

I would like to close with this statement by a certified school nurse, educator, and author, D. C. Tipple, who said, "The costs for education and health represent much more than a payment for services rendered. They represent an investment in the future. The dividends cannot be measured only in terms of dollars and cents. The production of healthier, happier, better human beings is much more than a commodity to be purchased." And how can we put a dollar value on human life?

Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you.

Are there any questions or comments?

ASSEMBLYMAN DeSOPO: Assemblywoman.

ASSEMBLYWOMAN WRIGHT: Yes, Assemblyman DeSopo.

ASSEMBLYMAN DeSOPO: Just a short one.

I think you both indicated that you would like to see some revisions in A-421. What might they be, some of the revisions?

MS. COHEN: Well, I think there needs to be a broadened scope of the school nursing role tied to school health services as a comprehensive service within the school system, and I think there needs to be some recognition of the fact that there are other professionals who are involved in the delivery of school health services. School nurses are one of them, but I believe the certified school nurse is the leading role and the professional best qualified to coordinate and integrate all of those various components within a school system.

ASSEMBLYMAN DeSOPO: Thank you.

ASSEMBLYWOMAN WRIGHT: Yes, Assemblyman Kelly.

ASSEMBLYMAN KELLY: Ms. Cohen, you stated that districts are trying to cut costs by cutting existing certified school nursing personnel and replacing them with health aides, L.P.N.s, or other unqualified persons.

MS. COHEN: Yes.

ASSEMBLYMAN KELLY: What is a health aide?

MS. COHEN: Well, a health aide, basically, is a job description. But as my colleague, Ms. Cusick, had mentioned before, many times, registered nurses are hired with the job description/title of health aide, brought in on a very low level -- much like a paraprofessional in the classroom -- and expected to fulfill many of the program responsibilities of a nurse. And they're really not qualified to do that.

ASSEMBLYMAN KELLY: L.P.N.s -- I'm ignorant as to what nurses are. I see a woman in a white uniform, she's a nurse (indiscernible). When I was in the hospital, I'm talking about.

What is an L.P.N., and what kind of education do they have as compared to registered nurses?

MS. KEANE: An L.P.N. is a one-year program that is strictly clinical in nature and theoretically lacking. They defer to R.N.s at all times. The R.N. is either a three-year program or a four-year diploma program. For school nurse certification, you must come from a four-year baccalaureate program. In addition, you go on for further certification, which can range anywhere from nine credits to-- I've seen up to twenty-one credits for the actual certification.

Theoretically, there is far more learning and professionalism as you go up the rungs of education. L.P.N.s function more on a clinical level.

ASSEMBLYWOMAN WRIGHT: Also, under the law, Assemblyman Kelly, the licensed practical nurse works only under the direction of a registered professional nurse.

ASSEMBLYMAN KELLY: I'm learning something.

And what do these other unqualified persons-- Who are they?

MS. COHEN: It could be someone who has a first aid certificate, is maybe CPR certified, you know, has a minimal type of -- acute first aid type of qualification that certainly is just extremely narrow in its focus.

ASSEMBLYMAN KELLY: And they use those people instead of certified registered nurses?

MS. COHEN: Yes.

MS. KEANE: Yes.

ASSEMBLYMAN KELLY: Oh, interesting. Okay.

ASSEMBLYWOMAN WRIGHT: I think what they--

ASSEMBLYMAN KELLY: Do you know which districts are doing it? (laughter)

MS. KEANE: We can certainly supply that for you.

MS. COHEN: We'll get that.

ASSEMBLYMAN KELLY: I'd be very interested in that. (laughter)

ASSEMBLYWOMAN WRIGHT: Thank you.

MS. KEANE: We can actually send that to you.

ASSEMBLYMAN KELLY: Just one more question. Just one more quick question.

ASSEMBLYWOMAN WRIGHT: Yes, go right-- We're happy to have you.

ASSEMBLYMAN KELLY: If I understand you correctly then-- Let's say there is a model. You have a school -- a comprehensive school -- let's say, a high school, of 1500 kids; you would not be opposed to having a fully certified registered nurse or two and, then, an additional registered nurse?

MS. COHEN: I would not be opposed to that. I think, basically, school health services need to be under the direction of a certified school nurse, but--

ASSEMBLYMAN KELLY: So your opposition simply is not to have a noncertified nurse alone without any direct supervision from a certified nurse?

MS. COHEN: Right.

ASSEMBLYWOMAN WRIGHT: I think we need to add for the record, for those of you who don't know, the advantage we have in having Assemblyman DeSopo, who is a Superintendent of the Special Services School District in Burlington County. So he is bringing a level-- I'm sure he must employ certified school nurses and knows a great deal about them.

ASSEMBLYMAN DeSOPO: Quite a few.

ASSEMBLYWOMAN WRIGHT: And has a highly complex population -- as you have many children with very diverse needs, I would imagine.

ASSEMBLYMAN DeSOPO: Pretty much so.

ASSEMBLYWOMAN WRIGHT: And we are so grateful that he was able to be here today to share this.

Are there any other questions or comments? (no response)

We want to thank you very much. I think that some of your research is very valuable to us, as you saw, Assemblyman Kelly drawn. You're in the field, and that's why we were so eager for you all to come in today, to give us the facts on what's going on out in the field where it's all taking place.

So I want to thank you both for coming.

MS. COHEN: Thank you.

ASSEMBLYWOMAN WRIGHT: The next person-- We're going to shift gears for a second. The next person who will testify is Nancy Pinkin, from Barlett Associates. I believe she is testifying for the New Jersey Academy of Pediatrics.

Right, Nancy? (affirmative response)

I would just add that we have staff with us -- we have three staff here in the State House Annex. Kathy Fazzari, who is the key education expert in the Office of Legislative Services. She is the nonpartisan staff. And our partisan staff, Christine Costigan, from the Majority -- the Republican Majority side -- and then the Democrat is Jason Teele.

Nancy, please proceed.

N A N C Y J. P I N K I N: Okay. Thank you for having this hearing today. I'm here, as you said, on behalf of the American Academy of Pediatrics.

The Academy is in full support of maintaining a requirement that each school district within the State deliver school health services through certified school nurses, who are registered nurses in the State of New Jersey. The school nurse is uniquely qualified by nursing experience, academic preparation, and professional skill. The school nurse's primary function should be to strengthen the educational process through improvement and protection of the health status of children in the schools.

Recent efforts to replace the certified school nurses with nurses who are not trained as school nurses are not in the children's best interest or in the best interests of the school districts. It will cause the loss of an individual who has a vested interest in the children. It will harm the continuity of health care for our schools.

The movement to reduce certified school nurses comes at a time when the need for specially trained nursing staff in the schools is the greatest. With the federally mandated requirements for the provision of services to all children, including those with special health needs and disabilities, it seems hard to imagine that they would be trying to reduce the specific -- the needs of the school nurse. (sic) The acuity level of the care provided by the school nurse has increased dramatically with the inclusion of children requiring tracheostomy care, catheterization, anaphylactic allergies, asthma -- the increasing incidence of asthma -- HIV, mental health issues, family support issues, and other special needs.

Two of the other issues that the pediatricians wanted me to bring up today were: One, the issue of -- which is hard to imagine in a school but -- do not resuscitate orders, where some of the children are terminally ill, and now going to school, and the schools do not want to honor their -- the parents' wishes. Previously, when these things come up in the hospital, they're dealt with within the legal parameters, but the schools have a hard time accepting that. I think it's really a shocking thing, to think that schools are now dealing with DNR. I just find it hard to imagine, but it is an issue that needs to be brought to the forefront.

The last thing that they wanted to bring up was the issue of updating the school health policies in dealing with public health issues. They feel that some of the schools have policies that are very backdated, and they need to be brought up to the current medical and public health practices.

Do you have any questions that you want to ask?

ASSEMBLYWOMAN WRIGHT: No, I just really appreciate you coming today.

I have to add that I know most of these people. Nancy Pinkin is a nurse, (laughter) so I'm very pleased that she could represent the pediatricians because I think that's been a great advantage to them. And they actually recently supported one of our bills for school health physicals by nurse-practitioners to be accepted as part of the school regulations.

So you must be doing wonders out there with the pediatricians, Nancy, so we really appreciate you coming today.

Yes, Assemblyman Kelly.

ASSEMBLYMAN KELLY: You stated in your statement, to date schools have difficulty accepting the rights of a child's family to make those difficult decisions with DNRs.

MS. PINKIN: Right. They said that there are cases -- and this is both on a State level and nationally -- where the parents have chosen to, for whatever reason, not to resuscitate the child if something should happen, but the schools don't want to honor that. So the school feels--

ASSEMBLYMAN KELLY: Who are they to intend what-- I mean, that just seems wrong to me. If the parents have made that decision--

ASSEMBLYWOMAN WRIGHT: It is wrong.

MS. PINKIN: Well, I think legally if it went to court, they would have to uphold the parents' issues, but I think-- I just don't think the schools have been prepared with something like that. You know, who expected to have to--

ASSEMBLYMAN KELLY: Because I was the sponsor of DNR for senior citizens in nursing homes, and they ship them to hospitals, and they ignore the DNR, which I thought was ridiculous and wrong.

ASSEMBLYWOMAN WRIGHT: This is more of the same.

ASSEMBLYMAN KELLY: And I'm going to look into this one, I'll tell you that.

MS. PINKIN: Well, it's unfortunate that-- As I said, I think there have been a number of bills over the past couple of years, whether it was dealing with the EpiPen or dealing with what to do with kids who are going to school trips who have-- The illnesses are just so much more complicated than they used to be, and so-- And when we talk about the issue of who's going to take care of all these kids, the fact that they're looking at reduced-- Because of the costs-- But to reduce the specialty skilled nurse in light of all these complications is just hard for me to imagine, and I think the pediatricians, as I said, are in full support of retaining the certified school nurse.

I appreciate you taking the time to hear our testimony.

ASSEMBLYWOMAN WRIGHT: Well, we appreciate that the pediatrician is a member of the team and is so important to school health, as well. So we're particularly happy that you are working so closely-- And I have met the Academy members at the New Jersey School Nurse functions. So we're grateful for you coming.

Are there any other questions or comments?

Assemblyman Stanley.

ASSEMBLYMAN STANLEY: Right. You have to turn your mike off, I think. (referring to microphone) Thank you.

I just wanted to say thank you for coming forward and testifying. So as not to be redundant, I just want to thank everyone here who has testified so far, because it's been very enlightening -- and everyone who will testify today. It's very important. A lot of people don't realize how important it is to take time out and come here to these hearings.

I want to just publicly thank and commend Assemblywoman Wright for having the hearing. It's a very important issue.

As you know, I represent Irvington and Newark, which are special needs districts. I also represent South Orange and Maplewood, which are not. But when we're talking about the health of our children, it's a critical issue, as is school funding. But I just want to say that I really appreciate you taking the time out, and we're getting some very valuable information here.

Thank you very much.

ASSEMBLYWOMAN WRIGHT: Thank you, Nancy.

The next person to testify is Fran Quinless, the Dean at the UMDNJ-School of Nursing.

While Fran is coming up, I just want to add to what Assemblyman Stanley was saying. I raised this issue on a League of Women Voters' discussion group recently, where they were talking about adolescent health. And I said that we were having this hearing, and there was-- I think it was Howard Verliner (phonetic spelling) who was the consultant at the meeting, and they jumped right in and said, "They removed the school nurses in the City of New York, and it's been a disaster." So we know what happens, and we know that the school nurses in the City of Newark, as well, play an important role and have very fragile kids. So actually it's an intro to Fran.

Please, proceed.

F R A N C E S W. Q U I N L E S S, Ph.D., R.N.: Hi. Good morning, and thank you for this opportunity, on behalf of the University of Medicine and Dentistry of New Jersey, to provide testimony regarding A-421, which would prevent school districts from utilizing or employing any person to provide health services, to assist in providing health services, or to provide support for health services except for the school nurse -- a registered nurse holding an educational services certificate with an endorsement as a school nurse issued by the State Board of Examiners.

Given that the intent of this act is to ensure that New Jersey schoolchildren receive high-quality health services by appropriately licensed and certified health care providers, I am requesting on behalf of the University, that nurse-practitioners/clinical nurse specialists certified by the New Jersey State Board of Nursing be included alongside certified school nurses as providers of school health services.

I have the following three specific points to justify my request to include certified nurse-practitioners and certified nurse clinical specialists as providers of school health services:

First, and critically important, New Jersey Public Law, in 1991 -- c. 377 -- approved on January 15, 1992, states as follows: This is an act providing for the certification of nurse-practitioners and clinical nurse specialists and providing them prescriptive powers under certain circumstances and revising parts of the statutory law. Regulations promulgated by the New Jersey State Board of Nursing in May 1994 enable certified nurse-practitioners and clinical nurse specialists to "manage common deviations from wellness and stabilized long-term illnesses by initiating laboratory and other diagnostic tests and prescribing or ordering medications and other devices." Therefore, certified nurse-practitioners and certified clinical nurse specialists enjoy a legal scope of practice enabling them to conduct histories and physical examinations, to differentiate among abnormalities if such are found, to manage illnesses, and to provide all of the generalist practice functions outlined in the section defining health services under A-421.

Second, in order to be certified as a nurse-practitioner or a clinical nurse specialist by the New Jersey Board of Nursing, candidates must first pass a national certification examination which mandates, as a basic component of practice, clinical competencies in conducting histories and physical exams and in delivering primary health care services.

Thus, the health services outlined in A-421 are the most basic functions of a nurse-practitioner or clinical nurse specialist. New Jersey currently recognizes certified NPs and certified clinical specialists as primary care providers, capable of obtaining managed-care Medicaid HMO contracts; thus, these nurse providers, along with their medical colleagues, compete as PCPs -- as we call them now -- or primary care providers, in the Medicaid managed-care marketplace. There is no reasonable argument to bar such advanced practice nurses from providing health services within New Jersey's school districts.

Third, citizens of New Jersey deserve access to advanced-practice nurse/primary care providers. This law was passed in 1992, and the regulations promulgated in 1994, for the sole purpose of increasing access to our citizens to qualified providers. Advanced-practice nurses can conduct histories and physicals, manage illness, and improve health outcomes to citizens of all ages in our State. They are educated to do so, certified to do so, and regulated by the Board of Nursing to ensure quality and safety. Our schoolchildren deserve access to these high-quality providers.

As a simple point of interest, please recall that this New Jersey Legislature endorsed certified nurse-practitioners and certified clinical nurse specialists as primary care providers through several actions in the recent past. These advanced-practice nurses are more than amply competent to provide the health services outlined in A-421. Additionally, they can provide primary care services such as management of acute and chronic illnesses and conduct of histories and physical examinations. Through their educational preparation, they are able to provide primary care, health education, disease prevention, and health advocacy programs.

On behalf of the University of Medicine and Dentistry of New Jersey, I urge you to amend this proposed legislation to include certified nurse-practitioners and certified nurse specialists to enable them to provide health services within the New Jersey school districts.

Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you.

Are there any questions?

Assemblyman Kelly.

ASSEMBLYMAN KELLY: What is their training? Two years, three years, one year, six months?

DR. QUINLESS: Nurse-practitioners and clinical nurse specialists have four years of undergraduate baccalaureate education, receive their license as registered professional nurses, then complete a master's science degree in nursing for two years on a full-time basis -- or longer if part-time -- subsequently, take a national certification examination, and have to put in X number of clinical hours in their specialty area in order to be certified.

ASSEMBLYMAN KELLY: Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you very much, Dr. Quinless.

DR. QUINLESS: Thank you.

ASSEMBLYWOMAN WRIGHT: The next witness is -- and please forgive me (indicating pronunciation) -- Ellen Heintjes.

E L L E N H E I N T J E S: (speaking from audience) Heintjes. (indicating pronunciation)

ASSEMBLYWOMAN WRIGHT: Heintjes. Would you, please--

I have Ellen listed as a citizen. I'm not sure if she has other credentials or other background, but we welcome her.

You might notice that some of the association -- governmental relations staff have signed up, but we thought we would present the issue first and then have some of the dialogue, as they would choose to, about some of the issues that remain that concern them.

Please proceed, Ellen.

MS. HEINTJES: Thank you.

Good morning to the Assembly Education Committee and concerned others.

I am presently a nurse in the West Orange Public Schools and the President-elect of the Essex County School Nurses Association. I have prepared for my position with a bachelor's degree in nursing, a master's degree in health education, and have been certified by the State Department of Education as a school nurse.

As a school nurse, I am uniquely qualified to promote and safeguard the health of the children of our schools. It has taken several years of involvement within the school and community to get to know clients, become a trusted member of their health care system, and attempt to work with them and design programs around their needs.

As a certified school nurse, you're in a unique position to improve and protect the health status of schoolchildren and provide continuity, consistency, comprehensiveness, and quality to their school health programs. Coordination of health services remains a top priority in our presently fragmented health care system. Effective school health care programs demand collaboration, cooperation, and group effort. They focus on all facets of health: mental, physical, emotional, and social.

By illustration: You may have recently read in the newspaper about a tragedy in West Orange. A little over a week ago, a young six-year-old student -- at dismissal time from his elementary school -- ran, between parked cars in front of the building, into the street and was hit while attempting to cross. His school nurse was there immediately to perform CPR and administer first aid. The ambulance was there within minutes, but hers was the familiar face. The school nurse was also there immediately to help the grieving parent who witnessed the tragedy. The nurse had the familiar, trusted face, again. The child died shortly after impact.

To the young students who witnessed in shock and horror, hers was the familiar, trusted face -- their nurse. On Friday, the following day, hers was the familiar face the students saw. As an integral member of the crisis team, her personal knowledge of the student body enabled the crisis team to meet the needs of the grieving students.

The certified school nurse was and is the core of the team providing continuity, coordination, and quality to the school health program. Others can provide many services, but it is the certified school nurse who can provide all the services most effectively.

Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you, Ellen.

Are there any questions? (no response)

Thank you for reminding us, again. We heard of that tragedy, and it, indeed, was a tragedy. We appreciate you sharing that again with us.

Next we have Lucille Brabston, the President of the Passaic County School Nurses Association. And after Lucille, we will have Dorothy Grisby and Maureen Leavey.

Please proceed, Lucille.

L O U I S E B R A B S T O N, R.N.: It's Louise.

ASSEMBLYWOMAN WRIGHT: Okay.

MS. BRABSTON: Brabston.

ASSEMBLYWOMAN WRIGHT: We do have your last name correct?

MS. BRABSTON: Yes.

ASSEMBLYWOMAN WRIGHT: Louise?

MS. BRABSTON: Yes.

ASSEMBLYWOMAN WRIGHT: Thank you.

MS. BRABSTON: I'm reading this as requested by Dr. Ruth Hutchison, a professor at Seton Hall University College of Nursing.

ASSEMBLYWOMAN WRIGHT: Thank you.

MS. BRABSTON: "Honorable members of the New Jersey Assembly Education Committee, thank you for the opportunity to present my views on A-421.

"I have been a certified school nurse since 1974, having served in both public and private schools. In addition to my school nurse certification by the New Jersey State Department of Education, I am certified as a school nurse-practitioner at the national level by the American Nurses Credentialing Center, and also certified as a clinical nurse specialist in advanced practice by the New Jersey Board of Nursing.

"I am a Fellow in the American School Health Association, as well as a Fellow in the National Academies of Practice. I have served on many State and national organization committees addressing the many complex issues facing school health in our society today. I served on the national committee which developed the professional Standards of School Nursing Practice, as well as the committee which initiated school nurse certification at the national level.

"My career has been dedicated to the highest professional standards of education for school nursing practice and teaching. It is with this background that I address the issue of school nurse certification.

"Since the inception of the first school nurse in New York City's public schools by Lillian Wald in 1902, certified school nurses have been valued for their significant contributions they have made to maintain the health of children and in the prevention of disease and injury. According to New Jersey law, a registered nurse license and baccalaureate degree is required by the New Jersey State Department of Education to be eligible for study leading to the school nurse certificate.

"The requisite school nurse course work, which is generally 30 credits beyond the baccalaureate degree, is specified and approved by the New Jersey State Department of Education. This specific additional course work, which includes both didactic and practicum experiences, is what differentiates the certified school nurse from the registered nurse with a bachelor of science in nursing.

"Because of the intricate and complex legal, ethical, health, and social forces affecting individuals and families, it is crucial that the school districts employ well-educated, well-qualified certified school nurses who have the ability to assess and manage problems and use preventive measures, as well.

"Nationally, the trend in school nursing education is moving quickly into a graduate or master's degree program, recognizing that increasing complexities of health care and technology require advanced education preparation for speciality practice. This national trend is already acknowledged in New Jersey by the New Jersey Board of Nursing's certification of nurses in advanced speciality practice areas, including the school nurse-practitioner.

"Therefore, it would seem that employment of any individual with less than certification as a school nurse is taking a backward step. Sacrificing certified school nurse positions in the name of economy is unwarranted and may well precipitate additional burdens and liabilities on communities.

"With the resurgence of infectious and communicable diseases and increasing numbers of children physically and educationally challenged, it is more important than ever before to recognize certified school nurses who are able to render safe, effective care to our children.

"I trust that your decision will be predicated solely on that which is in the best interest for the health of all schoolchildren.

"Respectfully, Ruth Hutchison, R.N., certified nurse specialist, Associate Professor of Seton Hall University."

ASSEMBLYWOMAN WRIGHT: Thank you very much for bringing that testimony. Do you have anything further? Louise, you are a school nurse?

MS. BRABSTON: I'm a certified school nurse. I work at Wayne Valley High School, Wayne, New Jersey.

ASSEMBLYWOMAN WRIGHT: Is there anything else you would like to add?

MS. BRABSTON: I don't think so. I think it's all be covered by my colleagues.

ASSEMBLYWOMAN WRIGHT: We really appreciate you coming.

Are there any questions? (no response)

Thank you so much, Louise.

Dorothy Grisby.

D O R O T H Y E. G R I S B Y R.N.: Good morning. My name is Dorothy Grisby. I am a certified school nurse employed by the State-operated district of Newark. I have a master's in health administration. I have certification in clinical nursing, and now I'm in education. I also serve on the negotiating team for nursing contracts for the Newark Public Schools.

In Newark, we have some 47,000 students in 91 schools, which makes us the largest school district in the State of New Jersey. This in and of itself sets us apart from districts in the suburbs. Because of the multicultural complexities that pervade a large urban setting such as Newark, there is always an acute need for highly credentialed certified school nurses.

Our students are from Central and South America, Puerto Rico, Cuba, Mexico, Haiti, Jamaica, Panama, Vietnam, Africa, China, Portugal, Spain, and many other countries. Our nurses are Chinese, German, Spanish speaking. They're from Switzerland, the many islands of the West Indies, Creole-speaking, Haitian, and French-speaking nurses. I'm called upon to read, speak, write, and understand Spanish on a daily basis, because of the district I'm in. There is also a need to understand and respect vast cultural differences.

For example, a child was presented in my office with a burn on his hand, and he was from a Central American country. His hand was covered with a green paste. I called his grandmother, who was a Central American Indian, and she had never had any professional medical care. She had applied toothpaste to the burn.

I asked him where were his parents. He informed me that his father was a rebel organizer against the junta in his country. He apparently knew that one day they would come for him, so he drilled his children to hide in a root cellar, underground, if they heard shooting in the night. And my student took his younger brothers and sisters and hid underground for a long period of time. There was food and water there, but he held those children there until he heard trucks, as his father had trained him. "If you hear trucks and women, then those are the missionaries. If you hear tanks and men, stay hidden underground." They were found by missionaries who helped them, the grandmother, and her son -- which was his uncle -- escape to the United States.

I was finally, after a period of time, able to get health care for the children and the grandmother, provided her with health education and services, and taught her modern medical care. She had refused to go to a hospital, but she did have faith in me, the school nurse, because I was there every day, and I did care for her child. We further assisted her in getting on Medicaid and finding follow-up medical facilities and community aid.

The child told me that he burned his hand in the first place because his uncle had lost his job, and with the loss of job, of course, he wasn't able to pay utilities. So he was taking a kerosene lamp and attempting to study by that lamp. When he found he wasn't able to do that, he found a nearby fast-food place, and he went there. He told me, "I ordered the biggest hamburger and the biggest order of french fries and the biggest milkshake so I could sit there and spend time and study."

Well, I had contacted my principal, who is very well connected within the city, and guess what? We found that uncle a job in nearby Elizabeth. Their utilities were turned on, and we literally saved that boy. Now, he is a teenager, doing well, and his parents still are not in this country. He is still living with the grandmother and his-- He has a little brother who he has never seen. The junta did not kill his father. I think he's gone underground. But he has a brother and sister who he has never seen and a mother who he hasn't seen since he was a child. And I maintain that an uncertified per diem agency nurse would never have been able to provide that type of health education and the follow-up that was needed.

As you can see, the duties of the certified school nurse in urban cities are greatly magnified over and above smaller districts. More often than not, we are the only health care providers our students receive. Typically, in my office, I see anywhere from 65 to 110 students on a daily basis.

Another example: A child was presented with lethargy, malaise, and loss of appetite. My physical assessment revealed that he had slight jaundice in one sclera of the eye. I notified his grandmother, and I called the clinical nurse-practitioner at UMD who had been treating the child. And as I had suspected, he was diagnosed with hepatitis. There were nine siblings in that family, along with parents and grandparents who all needed to be screened.

This was a horrendous task for me because, at some point, they changed their address and some of the children lived with the grandmother and some of the rest of the children went with the mother and father and, of course, as we deal with in Newark, there was no telephone. So through the clinical nurse-practitioner at UMD-- And she would call me and say, "Dorothy" -- and I'll say -- "Joe didn't come for his blood work today." Now, I had the task of utilizing cousins and other people to find out where he was, who he was living with, and, to spare you a long story, we finally got the job done. The children ranged from 11 years and under, and some of them were in other Newark schools, so then I had to network with those school nurses, and this job seemed to have gone on forever, but we were successful. He was the only one in the school who was diagnosed with hepatitis.

He also had the type of hepatitis which could be caused by intimate contact, and then we had to set about agencies to investigate that, also. But because there was a certified, full-time school nurse in the school on a daily basis, the complete follow-up was done. And we did prevent a widespread epidemic within the school and within the family.

I went about and I taught hand washing to the staff. I inserviced the teacher and the other children. I got my principal and the custodians to take special care of the bathroom. Again, I have to repeat, an uncertified school health aide would probably not have been able to provide the necessary health education or the follow-up that was needed. She probably also would not have recognized the symptoms in this child, because it was very vague, and I recall it was a Monday. You probably would have just thought, "Oh, it's a Monday. He was up late, and he's just tired." The full-time certified school nurse knows all students, and in this case, there were 900 to 1000 students in my school at the time and 122 employees. These follow-ups take many months, and they're still going on.

Newark has been identified by the Center for Disease Control as the third city in the United States for tubercular incidence. Therefore, the certified school nurse in Newark is especially prepared to screen, interpret, and health educate the community and staff in this area. We have ongoing education provided, and we ourselves give workshops and presentations often to the community.

Newark is also a large industrial center, and at a time I was assigned to the ironbound section -- which is East Newark -- there was a radon scare, and that was appearing in the soil. Some of you probably remember hearing that on the news. As a school nurse, I contacted my Professor of Dermatology at UMD, who, incidently, led the battle in the war on the environment and brought to the nightly news the war against hazardous waste and toxic dumping. In fact, that's probably one of the reasons why Newark leads the states in this area.

I went to him, and he taught me about the rash and other symptoms of radon poisoning. Now, this occurred in the 80s, but I still teach my fourth-grade students about the environment. I invited my same renowned mentor from UMD to come to my school where I am now and talk to students and review their science projects. They have written to President Clinton, and they have won science fairs based on their projects.

They visit my health office and I explain how and why we use red hazardous waste containers and why we weigh contaminated materials. I gave them projects to do at home with recycling and cleanup at home in hopes that health education given now to our youngsters will make them more responsible environmentalists than our generation was. The uncertified school nurses are not involved in these kinds of school teaching projects or health education on that level.

Drug abuse is also a major health concern in Newark, accompanied by HIV, AIDS, and related illnesses. In Newark, our specialized drug core team is intense, and we are reeducated approximately every two years.

Just as different doctors are not interchangeable, different nurses are not interchangeable. Your certified school nurse is a specialist in child care and health education services. In Newark, you must be certified or show proof that you are in a certification program. Some of our nurses are master's, doctorate's -- we're health educators, and we are teachers in various areas over and above the State minimum requirements. We also bring to the schools our vast expertise in such fields as intensive care, pediatrics, orthopedic, neurological, trauma, and other specialities. This is an added burden--

Now there is an added burden for the Newark school nurse because, you probably know, of the abrupt closing of United Hospitals Medical Center. I am aware that United was used statewide, but it was a major referral base for the Newark community because of its full range of services for children and adults.

Now we find ourselves performing more in-depth assessment and reaching out for other agencies who will treat those who do not have adequate medical coverage. An agency, per diem nurse might not have the rapport or community contacts to meet this added need to provide optimum health services for our many needed families.

A final point that is unique to Newark is the establishment of the school-based planning core team, which was brought to Newark by the State-operated district. These teams consist of an administrator, teachers, parents, and the certified school nurse. We meet after school, and we meet in the evenings developing educational improvement plans for the entire school, and this is over and above, of course, health care services. As the only health care practitioner on the core team and recognizing, of course, that the full-time certified nurse is the only member of the team who is aware of every student, every parent, and employee in the building--

In my school, I am an integral member of the team, and I was selected by my principal to be the cocoordinator for the parent workshops. I work closely with the PTA President to develop workshops. Now, some of these workshops will involve counseling on no health care insurance -- where do I go; and various other counseling on health care facilities that provide treatment; and which HMO will best serve their needs. Also, other topics I plan to bring such as prevention of communicable disease, asthma, diabetes, seizure disorders, lead poisoning, and topics that plague our at-risk children.

You will also be pleased to know that with our parents we are also giving them skills such as computer skills and language skills as a means to help them get off of welfare, that they can be productive citizens of the community.

In summary, I attempted to bring to the Committee issues that plague urban cities on a daily basis. I hope you have seen the dire need for full-time certified nurses in every district as opposed to the per diem uncertified nurse.

Keeping in mind that your children are in school five and a half to six hours daily, five days a week, I ask you: Which one would you entrust your child to? A nurse who is fully certified and provides continuity of care daily or an occasional R.N. who drops in to sit and wait for emergencies to happen?

Thank you for allowing me to speak.

ASSEMBLYWOMAN WRIGHT: Just one moment.

MS. GRISBY: Are there any questions?

ASSEMBLYWOMAN WRIGHT: Thank you very much, Dorothy. We really appreciate the time and effort, and also the great work that you too are doing in your district.

Are there any questions or comments from the Committee?

Assemblyman Stanley.

ASSEMBLYMAN STANLEY: Yes. I just better thank Dorothy personally since she is from one of my home districts.

MS. GRISBY: Yes, I'm one of his constituents.

ASSEMBLYWOMAN WRIGHT: You should be very proud.

ASSEMBLYMAN STANLEY: I'm very pleased with your testimony.

MS. GRISBY: Thank you.

ASSEMBLYWOMAN WRIGHT: Is there anyone else? (no response)

Thank you so much, Dorothy.

MS. GRISBY: Thank you for having me.

ASSEMBLYWOMAN WRIGHT: It was great to have such a blow by blow on the urban setting. We really appreciate that.

Next, we have Maureen Leavey, President of the Sussex County School Nurse Association.

M A U R E E N L E A V E Y, R.N.: Good morning. I'm Maureen Leavey. I am President of Sussex County's School Nurses Association. I am a school nurse in Stanhope, and I also am a member of the Executive Board of the State School Nurses.

Societal changes that have occurred over the last 10 to 20 years have dramatically impacted and changed the role of the certified school nurse. This has been especially true in the State's urban areas where the certified school nurse is often the only health care provider that these students have access to.

I would like to share with you the concerns of a colleague of mine, Elizabeth Bodnar, who is a Supervisor of Nurses for the Trenton School District, one of New Jersey's identified special needs districts.

"Budget cutbacks for the 1996-1997 school year resulted in reductions in district nursing staff. The State of New Jersey's core curriculum content standards that will impact New Jersey school budgets for the 1997-1998 school year was the rationale for the 50 percent reduction of support staff, i.e., school nurses, guidance counselors, librarians, Child Study Team members, and vice principals in the Trenton Public Schools.

"The medical department of the Trenton School District is in a constant of crisis management in the attempt to provide nursing services to a school population of almost 13,000 students."

ASSEMBLYWOMAN WRIGHT: Maureen, would you just wait one minute?

MS. LEAVEY: Yes.

ASSEMBLYWOMAN WRIGHT: We're confused up here, but I think I just got the message. You're offering the testimony of Elizabeth--

MS. LEAVEY: Bodnar, from Trenton.

ASSEMBLYWOMAN WRIGHT: Bodnar. Okay. And we have the Trenton Board of Education-- Since you're from Sussex -- we're always into geography -- we're having trouble connecting.

Does everyone have their-- (affirmative response)

Okay. Please proceed, Maureen.

MS. LEAVEY: "The medical department of the Trenton School District is in a constant state of crisis management in the attempt to provide nursing services to a school population of almost 13,000 students. There are 18 elementary schools, 4 middle schools, and 1 high school for a total of 23 in the district. Currently, 13 elementary schools have shared nurses. A shared nurse services the high school. Eighteen school nurses are assigned the job responsibilities which once were provided by a staff of twenty-six.

"The current staffing of school nurses does not provide for a safe environment for students and staff in this urban, special needs district. School nurses responsible for two schools are in their building only approximately 50 percent of the time.

"Some areas of concern affected by these cuts include: administration of medication; administration of first aid; loss of student instruction time; registration of students not properly immunized; registration of students without adequate health histories; a decline in recognition of communicable diseases; a decline in recognition of nuisance diseases; a decline in health screenings, reporting, and health problems recognition; decline in availability of emergency school nurse coverage; an increased use of 911 by nonnursing staff; loss of work time and increased frustration for parents and guardians; and diversion of school administrator's responsibilities and time.

"Medicating students according to availability of nursing services, not their medical needs, has distressed students, parents, staff, nurses, and school administrators. Additional ongoing concerns are providing services to our diabetic students and controlling a chronic lice problem.

"Healthy children are more receptive to learning. School nurses enhance and promote this mission by serving as the front-runners of the health care system. The full-time certified school nurse is the most consistent health care resource for many of these students throughout their school career. It is recognized that medical situations and problems have a way of arising at unscheduled times.

"The school nurses' presence is necessary to ensure the safety of the individuals in schools, and restoration of nursing positions would provide for the health needs of Trenton's students and staff and decrease the district's risk of litigation."

Thank you.

ASSEMBLYWOMAN WRIGHT: Would you like to add anything from your own experience in North Jersey?

MS. LEAVEY: Again, in North Jersey, transportation is a major concern. It's difficult for many of our students. Many of our students have only one car, their parents are working, and access to health care is difficult.

More and more, in my own experience, I find that I have become the gatekeeper for health care. Accidents and illnesses that have occurred over the weekend wait until Monday morning, until the school nurse can first assess it and then advise the parents on whether further medical care is needed. So we've become, in some instances, primary care providers, but we are an extra step now in the health care administration system. Parents rely on the school nurse's judgement when to get further medical attention.

ASSEMBLYWOMAN WRIGHT: I have the feeling they've been doing that since the year 1902. Because we know that the school nurse is often the first health care professional that sees a child, parents are -- not overtly, but just sometimes the parents don't pick up on-- You know, it's just another day and another illness and it really isn't that important and you need to get to school--

So thank you for sharing that.

Are there any other questions or comments? (no response)

Thank you particularly for bringing to our attention-- We are aware of-- Being here in Mercer County -- my district is partly in Mercer, although I don't represent Trenton -- we are aware of some of the difficulties in Trenton, and hopefully, they can continue to be addressed.

MS. LEAVEY: Thank you for the opportunity.

ASSEMBLYWOMAN WRIGHT: We're going to shift gears now. Again, I'd like to-- Is Chuck Whedon, from the Athletic Trainer's Society, in the room? (affirmative response)

Please come forward, Chuck.

J O S E P H C A M I L L O N E: My name is Joe Camillone, and I'm going to pinch-hit -- if you will, since we're coming from the athletic community -- for Chuck Whedon. He had to leave to get back to Rowan.

ASSEMBLYWOMAN WRIGHT: As long as we get the spelling of your name.

MR. CAMILLONE: Okay. I think I can do that.

ASSEMBLYWOMAN WRIGHT: If it's on there, that's good. (referring to testimony)

MR. CAMILLONE: No.

My name is Joe Camillone -- C-A-M-I-L-L-O-N-E -- and I am presently the Athletic Trainer at the College of New Jersey. I've been there for the last 24 years, and 4 years before that, I worked in the public school system.

ASSEMBLYWOMAN WRIGHT: Please proceed.

MR. CAMILLONE: Let me first say that athletic train-- We're representing the Athletic Trainer's Society of New Jersey.

Athletic trainers are recognized by the American Medical Association as an allied health profession. We are registered with the New Jersey Board of Medical Examiners to practice athletic training in the State of New Jersey.

Beyond that, since I've been an athletic trainer for almost 30 years and I don't think my mother has one iota of an idea of what I do, I might just say what an athletic trainer provides. We provide services in the prevention and treatment of athletic injuries. The prevention might include development of strength training programs, issues that deal with the environment and the prevention of heat illness, taping or bracing to prevent an injury from occurring. We also treat injuries, which would include the first aid of and the rehabilitation, including exercise -- therapeutic exercise -- and the use of therapeutic modalities under the direction of a physician.

Now, our concerns with A-421 are: Number one, it seems to be an oversimplification of the qualifications and the duties of the school nurse. The athletic trainers work closely with school nurses to assure optimal student health care and are aware that A-421 oversimplifies the duties and responsibilities of the school nurse in relation to their training and practice.

We believe, though, that it also infringes on our existing health practice because, according to the wording in this bill, it would eliminate us from doing some of the duties that we have under the Athletic Training Practice Act. And it also asks that the athletic trainer be supervised by the school nurse, and that's really not a practical thing because the athletic trainer, our day pretty much gets into full swing at the end of the academic day, which is normally the end of the day for the school nurse. So these two people would, in all likelihood, not be on-site at the same time anyway, so the nurse wouldn't be there to supervise the athletic trainer to begin with.

The same would go for supervising our medical records. Athletic trainers keep medical records for the athletic injuries that are incurred and physician referrals and physician notes, and are normally in two separate parts of the building -- at the high school.

So in summary, the athletic trainer and the school nurse work together as a team in the pursuit of optimum student health care. A-421 does not identify the existence of this working relationship, which is a disservice to the students in New Jersey school districts. We would ask that the bill be amended to allow registered athletic trainers to provide services within their Athletic Training Practice Act.

ASSEMBLYWOMAN WRIGHT: Thank you.

Are there any questions or comments?

ASSEMBLYMAN KELLY: Where does it say you can-- Where does it cut you out? The very first sentence, is that what you mean? "No school shall utilize or employ any person to provide health services."

MR. CAMILLONE: Yes.

ASSEMBLYMAN KELLY: That excludes you? Why? You're doing it now. What are we excluding?

MR. CAMILLONE: Well, that's why we're here, to make sure that we're not excluded, I guess.

ASSEMBLYMAN KELLY: Well, I don't think the bill intends to exclude you.

MR. CAMILLONE: Well, we've seen other bills that didn't intend to exclude us and end up excluding us. So we're trying to prevent that from happening.

ASSEMBLYWOMAN WRIGHT: Okay.

Assemblyman Kelly, Ms. Fazzari is pointing out that one example would be -- in the bill -- on Line 31, under health services, if the athletic trainer administered first aid, the question is: Would that be viewed as within the athletic trainers' scope of practice?

So we certainly will--

MR. CAMILLONE: And so would Line 26, letter F, the decision making when involving the exclusion or return of a pupil from school, class, or any school activity due to fitness for illness or injury. So that if somebody is injured at practice, it's going to be the athletic trainer who is going to decide whether this athlete is well enough to return to practice or even a game.

ASSEMBLYMAN KELLY: Are you assuming that the nurse would say no? I don't believe it. She'd accept your word.

MR. CAMILLONE: We're trying to prevent--

ASSEMBLYMAN KELLY: We have intelligent nurses, I think.

MR. CAMILLONE: --from being told that we can't do this because the only person who is allowed to do this at the school is the school nurse.

ASSEMBLYWOMAN WRIGHT: We certainly will take your testimony into consideration. There are also statutes, I'm sure Assemblyman Kelly agrees with me, that would not be overridden by such a bill. So we are aware of your practice and the legal authority you have for it, and we will continue to take that into consideration. We really appreciate you coming.

Let me ask you this question: Do you have any idea how many athletic trainers are employed by the public schools K through 12 in New Jersey?

MR. CAMILLONE: I would better be-- Rather than a number, I would give you -- about 70 percent of the public schools in the State of New Jersey employ athletic trainers. If that's-- I'm pretty sure I can give you that percentage rather than a number.

ASSEMBLYWOMAN WRIGHT: These are not combined with the coaching positions? They are employed as additional staff?

MR. CAMILLONE: Separate. Some schools employ athletic trainers who teach and also provide athletic training services after school. Some athletic trainers provide strictly athletic training services, and in some schools, contract out to clinics, and the clinic provides an athletic trainer in the afternoon to provide athletic training services.

ASSEMBLYWOMAN WRIGHT: But if we go back to the core curriculum standards -- and someone gave us a model school early on, I think it was Susan Cohen, and mentioned that-- In the Commissioner's proposal there was, for example, two school nurses in a high school of 900. Where would-- Does an athletic trainer fit under the thorough and efficient education, or are they in the extracurricular activity program? Is that a fair question?

MR. CAMILLONE: I would imagine it would be under the extracurricular activity program.

ASSEMBLYWOMAN WRIGHT: Okay. I think, fundamentally, we're speaking a lot about the delivery of school health services under the thorough and efficient education, when the child is required to be at the school and in a program that is authorized and offered under the mandate of the State Department of Education. But we certainly-- As nurses -- I can speak as a nurse today, I'm not a school nurse -- we have spent our careers discussing issues such as this, so we're very sensitive to them. And I hope you do understand that and realize that we do appreciate your coming today.

Interestingly enough, it might be appropriate that since you happen to be at the College of New Jersey, we do have testimony that we will be placing on the record -- just general testimony -- because they certify school nurses. It may be worthwhile, in addition to sharing with us, for you to discuss. Roseann Conway is the head of the school nurse program at the College of New Jersey, and you probably work with her. But she has provided some testimony for us, also, today.

MR. CAMILLONE: Thank you for that information.

ASSEMBLYMAN KELLY: I just want to ask you one question.

ASSEMBLYWOMAN WRIGHT: Yes.

MR. CAMILLONE: Sure.

ASSEMBLYWOMAN WRIGHT: Please proceed, Assemblyman Kelly.

ASSEMBLYMAN KELLY: "Three, the athletic trainer is well prepared as a health care professional, making supervision by a school nurse unnecessary." You mean, you don't want any nurse to look at anything you do?

MR. CAMILLONE: I don't think the athletic trainer needs to have the school nurse supervise them, that's all.

ASSEMBLYMAN KELLY: What is your-- I'm learning something. I'm not trying to give you a hard time. What does the training of an athletic trainer, as far as health-- What courses does he take? Similar? Does he take the same courses that nurses do?

MR. CAMILLONE: Some.

ASSEMBLYMAN KELLY: Some? How some? How many credits?

MR. CAMILLONE: Well, athletic trainers hold a bachelor's degree and are required to pass a certification test that's given by the National Athletic Trainers Association. That is the requirement for becoming registered in the State of New Jersey, to hold certification with the National Athletic Trainers Association. So they have a bachelor's degree, at minimum, and there are many ways that-- There are different ways that somebody could have attained the right to take the test. Most places now, people are graduating with a degree in athletic training, and most of the emphasis there is in athletics and assessment of injury -- of athletic injury -- and rehabilitation of and treatment of those injuries.

ASSEMBLYMAN KELLY: Okay. But you don't have any problems with nurses now, I don't think, do you?

MR. CAMILLONE: Oh, not at all. I would imagine that almost every athletic trainer I know has a normal working relationship with the nurses. We just wanted to make sure that next August someone tells the people who work in the high school that "Well, you can't work here anymore because you're not a certified school nurse"-- (sic) That's all.

ASSEMBLYWOMAN WRIGHT: The irony is--

ASSEMBLYMAN KELLY: I don't think this bill is going to do that.

MR. CAMILLONE: Okay.

ASSEMBLYWOMAN WRIGHT: --that's what they're telling the certified nurses, though.

MR. CAMILLONE: Thank you for the opportunity.

ASSEMBLYMAN KELLY: It's the other way around.

ASSEMBLYWOMAN WRIGHT: Thank you for coming.

I'd like to move to Judy Annette, who is also opposed to the bill or may want amendments, from the New Jersey Council of Educational Services Commissions. She is from Basking Ridge.

Then, we are getting down to the wire, folks. What I have are--

Has everyone signed up who wanted to?

Kathy, I have everybody? (affirmative response)

We just want to have some dialogue with the governmental relations people who are here from the associations to see where they are on this bill at this point or on the dialogue.

So would you proceed, Judy?

J U D Y A N N E T T E: Thank you for letting me speak this afternoon.

On behalf of the New Jersey Council of Educational Services Commissions, who provide nonpublic nursing services to the school districts, we oppose -- we wish to oppose A-421, which establishes that all health-related services in every school district be provided by a certified school nurse -- a nurse holding an educational services certificate. We oppose A-421 because we believe this decision should be at the choice of the school district and the need for that district.

Presently, each school district must employ at least one certified school nurse to provide medical services, as well as teach health in the classroom. School districts have been able to supplement the health instruction with physical education staff and do not need a certified school nurse for classroom instruction.

This bill broadens the scope of responsibilities of this position beyond the classroom instruction, mandating that only the certified school nurse can provide the health services, requiring that this certified nurse must be present at all times when such services are provided, even clerical assistance.

Should this bill become law, every district will be mandated to employ at least one additional certified school nurse, and in some cases, more than one will be required, increasing the number of certified school nurses significantly throughout the State at a time when school district budgets are stretched to the limit.

This bill also directly contradicts Senator Bennett's bill, S-1506, which permits self-administration of medication by the student or administration or by a designated person in a life-threatening instance, which was introduced in order to allow immediate care in a life-threatening situation. If this bill becomes law, the only person who could assist the student would be the school certified nurse, who would then have to be available on all school trips, school activities, and sports-related activities. Requiring the certified nurse at these events will be at a significant added expense to the school budgets.

While the New Jersey Council of Ed Services values the vital role of the school nurse, we believe that the best authority to determine the needs is the school district itself. While the certified school nurse may oversee the program, it is possible for registered nurses to provide the same services.

At a time when school district budgets are faced with many program and staff cuts, to increase the position of the certified school nurse and require additional certified school nurses will cause undue hardship on staff requirements in the schools. Alternative staffing arrangements can be made which will more than satisfy the medical needs of the students and enable students in life-threatening situations to be taken care of rather than waiting for a certified school nurse to be present.

The New Jersey Council of Educational Services Commissions supports the local school districts and asks you to oppose A-421, as it would burden the school districts unnecessarily with additional staff requirements and take away their ability to determine their own needs.

ASSEMBLYWOMAN WRIGHT: Thank you very much.

Could you just tell us your role with regard to the Council?

MS. ANNETTE: Yes. I'm the Government Relations Coordinator for them and identify their position on these issues before speaking.

ASSEMBLYWOMAN WRIGHT: Thank you very much.

Are there any comments or questions?

ASSEMBLYMAN KELLY: Well, I'm inquisitive. The last paragraph, "Alternative staffing arrangements can be made which will more than satisfy the medical needs of the students and enable students in life-threatening situations to be taken care of--" What would be those alternatives?

MS. ANNETTE: Well, I think a lot of schools are turning to registered nurses with one certified nurse. I think Senator Bennett's bill is addressing children who are asthmatic, who can self-medicate, who are not allowed to do so in the current environment.

ASSEMBLYMAN KELLY: Why would that-- I don't understand.

MS. ANNETTE: People who have CPR could help someone, but in this kind of environment, they're not allowed to unless the nurse is present.

ASSEMBLYMAN KELLY: Okay. Thank you.

ASSEMBLYWOMAN WRIGHT: I'm glad that you mentioned Senator Bennett, because I failed to-- I will put on the record Senator Bennett's letter. He could not be here, but he is the sponsor of this companion bill in the Senate. I'll just say, he applauds our efforts on behalf of certified school nurses and the children. He feels that he is very supportive of moving in this direction and says that "the certified school nurse is an essential partner in today's educational process." So I just want to clarify--

And I don't think there is a relationship between Senator Bennett's bill and self-administration of medication in that specific case. But we're grateful that you brought your points forward because if, in fact, you have misunderstood some parts of either this bill or what is going on in the services' piece, this will give us a chance to be able to share that information with you. So we really appreciate your coming today.

MS. ANNETTE: All right. Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you so much.

I'm going to start with Joe Hancock and ask Joe if he would like to make any comments -- from the New Jersey Association of School Administrators. Next, I'll ask David Nash, from the School Principals, and Steve McGettigan, then, we'll finish up with Wayne and Mary Wachter.

We thought we would be out by 12:00, but we're getting close.

J O S E P H H A N C O C K: You're getting it.

ASSEMBLYWOMAN WRIGHT: We didn't mean to hurry you, Joe. Please proceed.

MR. HANCOCK: That's quite all right.

Thank you for this opportunity. As I said, I'm Joseph Hancock, Director of Governmental Relations for the New Jersey Association of School Administrators.

I'd like to say that I'm grateful for this opportunity to share with you our concerns about A-421 because, although we oppose the bill as it stands -- in terms of its language -- it does provide an opportunity for us to examine the status and the future of health service programming in our schools.

It should be noted at the outset, that our position on 421 should not be construed as a criticism of school nurses. Their professional dedication and their contributions to students have been clearly documented in our experience. And it is not our intention to undermine their role in any way.

Our concerns with the bill do focus on those job descriptions and operations provisions which place sole authority for the delivery of all health services exclusively with the school nurse and further prohibit a Board of Education from hiring or utilizing any other person to provide or assist in providing such services.

While such provisions may seem to be protective of the school nurses' position, they are, in our judgement, organizationally unsound, and they're shortsighted for the following reasons:

In the first place, the bill omits any reference to the medical inspector's authority over health programs and personnel -- the person who's in charge, the medical director of the health services for the entire district. Taken literally -- in terms of the language -- restrictions in this bill would prevent this doctor from participating in health services, even measuring a pupil's height.

Secondly, the emergence of the athletic trainer, whose preparation and certification is overseen by the State Board of Medical Examiners, is not recognized in this bill. The specialists in athletic conditioning, performance are competent to perform many of the duties listed in Section 1 of A-421.

The inclusion of first aid as a service reserved for the school nurse raises questions about liability should someone other than the nurse come to a student's aid with untoward results. We believe and our attorneys believe that under such circumstances, the Board of Education would be liable, and it would be a tough case for us to try to win in any situation. This, in turn, raises questions about the role and function of rescue squads or other municipal emergency response teams.

In the fifth place, the nursing field itself is changing in that L.P.N.s are being upgraded in training, and the nurse-practitioner, as mentioned before, is becoming a more popular field. Should these developments be taken into consideration?

Number six, Section 2 is intriguing in its requirement that the nurse and the secretary seem to be in the same room when data is being processed. With all the technology available -- faxes, and so forth, and so on -- I fail to see the logic of this particular language.

We believe that the issue at hand goes beyond the creation of protective job descriptions. There is a real need to recognize that the health service field is expanding in terms of its specialization and in terms of technology. The challenge, it would seem to us, is one of organizing that talent that is available to provide the most effective, operationally efficient, and administratively responsible system that is possible.

The team concept is what we should be moving toward. The certified school nurse has an important role to play in that team concept, but we have available to us other areas of specialization that can deal with the emerging problems and the emerging developments that are in the health care field. We believe that A-421 opens the door for this kind of a project.

We thank the sponsors for providing this opportunity and believe sincerely that this hearing takes a major step toward that end.

Thank you, Madam Chair.

ASSEMBLYWOMAN WRIGHT: Thank you very much, Mr. Hancock.

Are there any questions?

ASSEMBLYMAN KELLY: Are you saying L.P.N.s could replace--

MR. HANCOCK: No.

ASSEMBLYMAN KELLY: No? That's all. I want to make sure you don't agree.

MR. HANCOCK: What I'm saying--

ASSEMBLYMAN KELLY: Okay, thank you.

MR. HANCOCK: What I'm saying is take a look at what's available and see how we can put it together.

ASSEMBLYMAN KELLY: Well, I don't think L.P.N.s are ever going to replace nurses.

MR. HANCOCK: Oh, no. I come from a family of nurses, my friend.

ASSEMBLYMAN KELLY: And I agree with section six of your comments. I agree that that's kind of ludicrous.

ASSEMBLYWOMAN WRIGHT: Thank you, Mr. Hancock.

MR. HANCOCK: You're welcome.

ASSEMBLYWOMAN WRIGHT: Thank you, David, for coming forward from the Principals and Supervisors Association.

D A V I D N A S H: Thank you for the opportunity to share the comments of the New Jersey Principals and Supervisors Association regarding A-421.

Let me begin by stressing how much our members recognize and appreciate the invaluable role that certified school nurses play in our public schools. Certainly, we know that certified school nurses are critical, important players in providing health care services to our students and being an important part of the educational community.

Our Association has not yet taken an official position on A-421 in support or against, but at this point, based on existing policy and position on related legislation, we would like to raise a number of issues that we think you should consider.

The first issue deals with life-threatening illnesses. Current law permits self-medication by pupils who are carefully trained by medical professionals and who are capable of doing so. From all accounts, the self-medication law has worked well and given districts more options for dealing with students with life-threatening illnesses.

We think it would be logical to extend this law, and that's why we're supporting S-373, a logical extension of the self-medication law, in that it allows designated school personnel to administer an EpiPen for a student. S-373 includes safeguards, such as requiring personnel to receive training by the school nurse, requiring parents to give written permission, and requiring a specific Board of Education policy. Our concern here is that A-421 in its current form would prevent the designation of personnel to administer an EpiPen. I would just like to note that S-373 has received strong bipartisan support and was unanimously voted out of the Senate.

Another concern that we have deals with participation in off-site events. Oftentimes, our members are faced with a situation where a student who has asthma or another life-threatening illness requiring immediate medication wishes to be involved in field trips, athletic events, or other off-site events. Currently, we have to choose between requiring parental supervision and attendance or refusing to allow the student to participate if the appropriate health care professionals will not be present.

Another concern that we have with A-421 deals with the lack of a nurse at each particular school. We're faced with a problem where school nursing services, as you know, are, at times, shared by several school buildings within a district. If the school nurse or a doctor are off-site and a child has a asthma attack or is dangerously allergic to bee stings, a real crisis could occur. The Department of Education estimated that in 1994-1995, it would have cost local school districts almost $11 million to hire the necessary nurses to have one for each school.

Unfortunately, this legislation fails to provide any specific dedicated funding to address this cost, and districts would be placed with a very difficult decision about eliminating other programs or raising local property taxes to address the need.

And there are-- A final issue: There are other qualified personnel who can provide some of the services that are included in this legislation. An example that was raised earlier was that a doctor, under the legislative guidelines that are laid out here, would be prevented from providing such services. An athletic trainer, a registered nurse--

Once again, if a certified nurse is not available for a particular event, a real crisis could occur even though qualified personnel are available to address the student's needs. And when you're faced with a life-threatening situation, you really need to have somebody available at that event at that time to provide the services.

Let me again reiterate our strong appreciation for the critical role played by school nurses in our schools. We do feel it would be a desirable goal to have a school nurse present at all times in each school and at all off-site events, but, unfortunately, this does not appear to be possible at the current time without additional dedicated State funding to meet that need.

We do look forward to working with the sponsors and the Committee to improve the availability of certified nurses in public schools and ensure the health needs of students are addressed in a safe and responsible manner.

ASSEMBLYWOMAN WRIGHT: Thank you very much, David. We appreciate your patience in listening to the testimony today, we really do.

MR. NASH: Thank you.

ASSEMBLYWOMAN WRIGHT: Steve McGettigan, with the New Jersey School Boards Association.

S T E V E N V. M c G E T T I G A N: Thank you, Assemblywoman, members of the Committee, and Assemblyman Kelly.

In the interest of time, I'll try not to reiterate the positions that have been made before me. We were going to bring up some of the same issues that the Principals and Supervisors did, in terms of the apparent conflict with the recently enacted self-medication statute, and, also, some of the same concerns we have about--

If only a registered nurse can provide these types of services, we have concerns about what happens in life-threatening situations where that nurse is not available on trips and whatever. It seemed like the only way to address that would be the hiring of more staff. We think it's not the most efficient use of staff.

Other points that we would like to make are: Now certified physical education teachers and health care personnel have received the proper training and are authorized by law to perform auditory or scoliosis testing, and we see that wouldn't be permitted under this bill.

In support of our position, let me just refer to one Administrative Law decision from 1981. It's Wyckoff Education Association v. Wyckoff Board of Education -- that's W-Y-C-K-O-F-F. In that case, an Administrative Law judge determined that the clerical school aide could render services -- what they referred to as routine first aid services. Specifically mentioned was taking pupils' temperatures, washing and applying Band-Aids to minor cuts.

We believe-- And that decision, by the way, was affirmed by the State Board of Education in 1982. We believe that that's a sound one which recognizes the inability of a nurse to be in all places at all times, and we think that time-constraint problem is compounded when you consider that public schools are required to provide health services to nonpublic schools, as well.

David Nash, from Principals and Supervisors, brought up the funding issue. Our view of this, actually, is that it might present a State mandate-State pay issue. I wouldn't want to sit up here and try to discount any of the tragedies or extraordinary circumstances that you've heard about today, and I understand the delicate position of trying to put a price tag on students' health care.

I wouldn't sit up here and do that; however, if the Committee is identifying a statewide health care need, perhaps, it's the sort of thing that should be addressed by a State-funding source. To my knowledge, it's not the sort of thing that was addressed by the Comprehensive Plan and the recently enacted school funding legislation, and perhaps, it needs to be in a broader scope.

Having said that, let me just say that we understand that you're looking at the issue much broader than just the provision of health services and a lot of other issues involved in terms of implementing the core curriculum standards. We certainly offer ourselves and our assistance in helping you come up with any response that you think is necessary to do that. We'd just rather that the response was not Assembly Bill No. 421.

Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you very much.

Does anyone have any questions? (no response)

One thing I would like from the School Boards is-- Sometimes I wonder if we really have the data, Steve, and you may have it. How many buildings are there in the 600 school districts in New Jersey? Do we know?

MR. McGETTIGAN: I'm not sure if that figure is available. I was calling out to some of our field service people in the past week just to try to get an idea of what goes on in the real world out there past Trenton.

ASSEMBLYWOMAN WRIGHT: Yes.

MR. McGETTIGAN: And you know that in certain districts -- might have one district with one principal who, in certain cases, is the one who has to put on a Band-Aid. I mean, I know that happens. You heard from various sizes of school districts today, including Newark.

So the total number of buildings, I'm not sure, but I will try to get it for you.

ASSEMBLYWOMAN WRIGHT: Well, for example-- Well, I was thinking in terms of-- I think someone testified earlier that there are approximately 2000 school nurses out there, and, also, that the core curriculum standards do address this, and that they're looking in their base standard as something that looks like one for 450 students in the lower level, and then they suggested two in the high schools of 900.

These are all very soft kinds of recommendations, but I think that what we're talking about -- not necessarily every line of this bill, but the direction we're speaking about -- has been addressed by the Commission and by the core curriculum standards. And I think that some of what we're doing is going to help us determine how to implement some of those initiatives.

I was thinking if you had 2000-- For example, David testified that it would be $10.8 million for every school -- every school building--

Is that what your point was, David Nash?

MR. NASH: (speaking from audience) That was the Department of Education's estimate of what the cost would be.

ASSEMBLYWOMAN WRIGHT: Okay. I see Mariann is still here. We're grateful that she is. Mariann Rhodes, who is the Governmental Relations person--

Maybe this is a question I can ask of the Department and, perhaps, not of you, Steve.

Are there data or is this something we're looking at in the future of-- The majority of-- Well, in my district, I think, at the moment, every school has a certified school nurse in it, to my knowledge. And I have a district that-- We all have 200,000 people. What I'm curious about is, right now, to learn a little bit more about the data, so perhaps Mariann Rhodes, in working with the Department of Education, we can get a better handle on that--

I guess, Steve, that isn't -- we won't ask you to--

M A R I A N N R H O D E S: (speaking from audience) We will be happy to get those to you.

MR. McGETTIGAN: You could ask us to try.

ASSEMBLYWOMAN WRIGHT: Okay. Well, just somebody-- I think we need to know the parameters, don't you?

MR. McGETTIGAN: Yes.

ASSEMBLYWOMAN WRIGHT: And have a better idea-- Because I suspect if there are 2000 school nurses out there, we're already spending $10 million, so I can't understand why somebody is suggesting that $10 million is a lot of money. I think it may be more than $10 million already. So we need to talk to the Department and find out what-- It's a different cost and it's hard to get at, but I'm interested in that.

And I'm thrilled if we're spending $10 million or $11 million and maybe it wouldn't take a lot more, and I think that we may be more fearful of setting a high standard than we recognize.

We do appreciate you raising the issues. There is no intent to interfere with the self-administration-- The other thing is, there is a great deal of recognition-- When we're talking about services provided, we're talking about the fact that people are employed to provide those services; that's what we're talking about.

And, as you know, any court, I would suspect-- I haven't read the Wyckoff case and examined the details, but I'm sure that the Wyckoff case does not authorize a clerical aide to treat bee stings without some kind of supervision, to use the word loosely. That would clearly be outside the legally authorized practice of -- or within the legally authorized practice of a nurse, a physician, or some other health care practitioner. So we need to look at the Wyckoff decision a little more carefully. I suspect that in Wyckoff, they, perhaps, had an aide working -- and in most of these schools, there are aides or clerical people working with nurses-- But frankly, the bottom line is, it's this nurse's license that really holds the responsibility for the administration of that care.

So I think that we've made a great deal of progress today in the dialogue, and you have just been so great. I want to thank you, Steve McGettigan, and also call up then--

I have two witnesses. Maybe Wayne Dibofsky of the NJEA and Mary Wachter of the State Nurses would like to come up together, and we'll wrap this up, assuming that there are no other people to testify.

So, Wayne, would you like to start? And then, Mary will do any further wrap up we need to do before we close.

W A Y N E D I B O F S K Y: Thank you, Madam Chair, thank you, members of the Committee. My name is Wayne Dibofsky of the New Jersey Education Association.

Madam Chair, I'd like to thank you and Assemblyman Kelly for sponsoring A-421 and Senator Bennett for the companion legislation. There is probably no one in this room who has worked longer on trying to move public nursing care in the Legislature than myself. I started with Assemblyman Deverin back in 1980.

ASSEMBLYWOMAN WRIGHT: You do go way back.

MR. DIBOFSKY: And the issue is still confronting us. I believe there are four major issues in public education today. You have begun, in earnest, the long look at public school funding, yet again. We have looked at and are beginning to move in the area of school facilities. Through your fine work on the Assembly Courtesy Bus Task Force (sic), we have begun to look at transportation, and now you are looking at health care.

Over 100 years and we still have not come up with a concrete solution to dealing with the most precious resource in our schools, the children we serve. You've heard very, very compelling testimony today from the certified school nurses and, I must say, from my colleagues in the Associations, some very misguided information in trying to make comparisons with legislation that does not fit the rule of thumb and the intent of A-421.

We were in the forefront as an organization, working hand in glove with members of the Legislature and the State School Nurses Association, supporting the very legislation that many people have come forth and said would have a profound negative impact if this bill was implemented -- and that is the self-medication legislation. We see them as parallels.

We also agree wholeheartedly with you, Madam Chairwoman, with the issue of culpability and liability. It is the certified school nurse who is liable and culpable for any actions taken by the health aides in their school. It is not the principal, it is not the superintendent, and it's certainly not the Board of Education, because the first line of defense is the offensive measure taken by the certified school nurse. They have become an integral part in the educational process.

And what has not been spoken about today is that in the last 10 years -- a 500 percent increase in the mandates of work promulgated on the certified school nurse. No one stood up during that time and said -- from the other organizations -- "We better put a cost containment on this, and we better expand our budgets to meet the needs that we believe are impounded in the new declaration of legislation coming forth."

Yet, we constantly hear that we like the school nurses but there are no dollars to pay for them. You can't have it both ways. You cannot provide the service, maintain the credibility, and the interests of the students, and, for many cases-- As we heard so passionately today, they, for many, many students, are the only medical attention that many students get. Be it from Ms. Grisby in Newark, dealing with 91 schools and all the profound effects of the children in the Newark school system, to the suburban areas throughout the State of New Jersey, for many, many students it is the certified school nurse.

The $10 million cost is if you calculate the current number of school nurses currently teaching and add the additional needs if we were to pass such legislation. It does not impact on the differential between the health aides already there and uncertified nurses who are currently there. The cost is really minimal to provide the quality of service.

We expand our education standards over and over again because in New Jersey, as Arlene Cusick said, we want to do the most or the best and be the most accountable. Yet there is always a price when we do that, and the certified school nurse is part of the solution; they are not part of the problem. The problem is that we want so much for our children in the State of New Jersey, with so many excellent standards, that we've all realized that the amount of money that we have cannot go on forever, unless we make tough choices.

Then, I would ask my colleagues in the Association and to the legislators present that if we want the best and the brightest for all our children and we set high standards, we should know they come with a price tag. And in this case, health care is as equally important to a child when they enter school as the core curriculum standards. Because I challenge you, if a student comes to school hungry and a student comes to school abused and a student comes to school from a dysfunctional family, it is the certified school nurse who is making the first point of reference and is opening up, as the gatekeeper, the educational quality for that child. We cannot take that onus away, and we have to do more not less.

Thank you for the opportunity to testify today. You have a formal position in front of you. And I look forward, as always, to working with you to craft legislation that it is in the best interests of the students of the State of New Jersey.

Thank you.

ASSEMBLYWOMAN WRIGHT: Thank you.

Would anyone like to--

Mary Wachter, from the New Jersey State Nurses Association.

M A R Y B. W A C H T E R, R.N.: Yes. Thank you for the opportunity to testify, Barbara. I wanted to thank you and Assemblyman Kelly for sponsoring this legislation on behalf of the New Jersey State Nurses Association, as well as the Committee for having this public hearing. We think it's extremely important, and the testimony that has been provided today has been absolutely wonderful. I realize that this legislation is actually a vehicle for having this type of forum to raise the consciousness of school health services and the need for certified school nurses to provide those.

From a professional nursing association standpoint, one of the points that really hasn't been brought up -- specifically has been that there is a delegatory clause that's part of the Nurse Practice Act under the Board of Nursing, which requires that any nursing task which requires substantial nursing knowledge that is delegated to someone who is not licensed is the responsibility of the registered professional nurse. And as a lot of different school districts, so on and so forth, are bringing unlicensed people and giving them responsibilities, those people are practicing under the registered nurse's license, and the legality of that is, as Wayne had echoed, is that really, truly that it's going to fall on the registered nurse, and that needs to be considered in all of this dialogue.

I think that the other issue is that -- and Wayne already addressed it, as well -- I believe the intent of your legislation was clearly not to exclude providers of any type of care that's already been recognized by the New Jersey Legislature -- so, hopefully, that won't be a hindrance to the movement of this bill -- also, the fact that it is certainly not to prevent the legislation that's already passed, which is self-administration of medication. So I wanted to reiterate that fact.

If anybody has any questions, I would certainly be willing to answer those. I'm a registered professional nurse myself. I don't practice in school nursing, but--

ASSEMBLYWOMAN WRIGHT: Assemblyman Kelly.

ASSEMBLYMAN KELLY: You said there were some districts hiring unlicensed people?

MS. WACHTER: Well, I mean, as I've heard from testimony earlier.

ASSEMBLYMAN KELLY: Who are they?

MS. WACHTER: And I don't know them, and--

ASSEMBLYMAN KELLY: Oh. Does anybody know them?

MS. WACHTER: I'm sure they do, but to divulge that information at a public hearing probably isn't the smartest thing.

ASSEMBLYMAN KELLY: Thank you.

ASSEMBLYWOMAN WRIGHT: I think that the testimony that's been set forth will help to raise consciousness, clarify the issue, and that's some of what we're trying to do in this process, and that's what the Legislature's role is all about. I think that this has just been very valuable, and I think that those of us--

And you have been a most patient and courteous group. We are just so impressed to have you all come to the State House to show you that the legislative process does work and that you have a role in it and that we are here representing you.

Before I close the public hearing, I do want to give to the staff two pieces of written testimony. One is by the College of New Jersey, from the School Nurse Program, Roseann Conway, who is the Director of that Program; and then, also, a letter for the record from Senator John Bennett, supporting this legislation.

I don't know if there is any other written testimony that should go. Oh, there is one other piece that Ms. Fazzari has, and this is from a mother from Jackson, New Jersey, whose child has diabetes, and she has written her testimony. She just -- "I shudder to think of the consequences of a school without a certified school nurse."

So I want you to know that the testimony today has been recorded. It will be made available. It takes, often, about eight weeks to get the testimony back. But we think that this written record will serve to guide us as we move through this process to continue to address the quality of school health services in our State and, in particular, those offered by certified school nurses.

I want to, before we close-- Once again, I have to apologize for not-- Michelle Kramer (phonetic spelling), who is from our staff, has really worked very closely with Christine Costigan and Kathy Fazzari in planning for this hearing. This just doesn't happen, believe me. And I really want to express my appreciation. Michelle Kramer has been on our staff for over a year now. She is a nurse-practitioner, and I think she brings some special expertise.

So thanks to Michelle and Christine and Kathy and all of the staff and legislators who have joined us today, I think, for a really excellent day. And thank you all for coming.
 

(HEARING CONCLUDED)