The San Francisco Unified School District just agreed to raises, better health benefits, and more for its teachers — and for now, very few layoffs. But the district is still scrambling to cut spending, and non-union contract workers are a prime target.
That’s a big plus for the teachers union, which in negotiations demanded — and received — this pledge: “[The] district will make every effort to avoid hiring contracted employees.”
Public school nurses have something to say about that: be careful what you wish for. The district’s nurses warn that a similar shift of their ranks could lead to unintended consequences.
In fact, the shift has already begun. At the start of this school year, SFUSD reorganized the nursing staff and shook up their assignments. Tasks that don’t require a medical license are now the responsibility of central office employees and non-medical school staff. Nurses now must focus on more involved duties — helping kids with feeding tubes and catheters, for example.
One important task taken away from nurses is infectious disease prevention and control. This includes keeping kids up to date with vaccines — an increasingly fraught task with the nation’s growing vaccine skepticism.
All California students must be be up to date on vaccines to enroll in public school. School nurses don’t give shots, but it’s normally been their job to follow up with families when students are out of compliance. That follow-up work is now the responsibility of four central office employees, according to district spokesperson Katrina Kincade.
This “hurts our students, it hurts their families, and it hurts our entire community,” says Michelle Rait, a nurse at Visitacion Valley Elementary and Middle Schools.
Higher than average
To be clear, San Francisco is starting from a comparatively good place. Its public school students have much higher than average immunization rates. But there are signs of slippage. According to EdSource, SFUSD lost more than $315,000 for failures in vaccine compliance in 2023-24.
Only a few months into the SFUSD nurses shuffle, it’s too soon to know if more unvaccinated kids are falling through the cracks. Nurses worry that more students will miss school, either from illness or from truancy that leads to higher dropout rates. Daily attendance figures for the year should be released in June.
Their worry extends beyond vaccinations. More cases of once-rare diseases are cropping up, even in California. Archbishop Riordan High School, a private Catholic school in the city, recently suffered a tuberculosis outbreak. (A TB vaccine exists but isn’t recommended in the United States. A TB skin test is required for most school enrollment.)
When SFUSD announced the staffing changes a year ago, nurses warned the school board and Superintendent Maria Su about safety risks. They said the new assignments would curtail time to see students, a crucial step in catching early signs of contagious illnesses.
They say they never got a response. When asked about the warning, district spokesperson Kincade said via email that “SFUSD values the vital work our nurses do to support student health and well-being. This shift has strengthened collaboration and significantly improved coverage and responsiveness.”
‘Crazy hours’
Before this year, the district had a full-time or part-time nurse in three-quarters of its schools. Schools without an on-site nurse tapped into a central pool of eight on-call nurses, also SFUSD employees.
To fill gaps, SFUSD had also leaned on third-party contractor nurses. Kincade declines to say how many; school nurses who spoke with The Frisc estimate roughly 50 were hired during the 2024-25 school year.
These contractors often focused on helping kids with feeding tubes, colostomy bags, seizures, and other so-called specialized medical procedures. These tasks require licenses and aren’t easily delegated to non-medical staff.
SFUSD nurses say these contractors freed them up to focus more on community work, like helping families find doctors and get vaccines, which is no small feat. “Nurses have, for decades, spent crazy hours tracking families down,” says Julie Lisa, another district nurse. “Calling them over and over, helping them get clinic appointments, telling them where to go if they can’t get into their regular doctor in time.”
Andrea Haun estimates she spent a quarter of her time in prior years devoted to it; Haun is a nurse at Jefferson Elementary, Alice Fong Yu Alternative, and Independence High.
Splitting school time
Last June, the district projected $2 million in savings by cutting ties with agency nurses. “What they’re saving is such a minimal drop in the budget bucket,” said nurse Lisa, who covers Willie J. Brown Jr. Middle School and Thurgood Marshall High.
District spokesperson Kincade says the reorg has “significantly improved coverage” with a nurse now assigned to every school, even if some only see them a few hours a week. Most nurses split time between two or three schools with their new focus on specialized tasks.
For more everyday tasks like first aid and medication, principals designate volunteers from their school staff. Nurses can still tend to sick or injured kids, but only after those special medical tasks.
If a new student enrolls without vaccine clearance, staff must alert the central office. Nurses agree that chasing down families to vaccinate their kids doesn’t require a nursing degree. But they question if four central office workers are enough for all of roughly 49,000 SFUSD students. “There’s no way they could even begin to scratch the surface of a project like that,” says Rait.
Nurses say that all this delegation of duty sacrifices the personal touch that their school communities rely on, especially if they’re only present a few hours a week.
Often the families who are not compliant with immunization are struggling. You say, ‘You can’t come to school,’ and in some cases that’s just a green light to never come again.
SFUSD nurse julie lisa
This is critical for students and families who lack trust in the medical system. And beyond vaccines, disease prevention happens on many levels and often needs a medical professional’s attention.
One nurse who spoke with The Frisc cited cases of teen pregnancy, which comes with the risk of sexually transmitted infections. Another helped spot an early case of pertussis, or whooping cough, a highly contagious respiratory disease that can be dangerous if not caught quickly.
Immigrant histories
As of 2015, the California Department of Education has not let students opt out of vaccines based on personal beliefs. Students without complete vaccinations aren’t supposed to be allowed to start school.
But nurses say the policy has been at the discretion of principals, who find themselves between a public health rock and a funding hard place. “Many schools do not actually exclude students,” said Lisa. “Principals don’t want their enrollment down.”
That’s because absences impact state funding, which Su and other superintendents are lobbying to change in Sacramento. The nearly $316,000 that SFUSD lost in 2023-24 was from unvaccinated kids who didn’t come to school, according to the state audit that EdSource cited.
District spokesperson Kincade told The Frisc that SFUSD follows state guidelines, which say schools must exclude kids who aren’t in compliance after a ten-day grace period.
SFUSD must also grapple with immunizations for immigrant students. The district has more than 1,300 newcomer students — in the country five years or less and non-native English speakers.
A more recent state audit showed that some SFUSD schools behind on vaccinations also have higher immigrant populations. In Visitacion Valley, Rait says many of her immigrant students have little or no history of immunizations.
These kids can enroll with the promise that they catch up with the required shots. “It means tracking them monthly to make sure that they stay compliant, get to their appointments, and bring those papers back,” says Rait.
TB in the air
Tuberculosis screenings typically take place when a student gets shots. While there have been no reports of TB beyond the Riordan outbreak, the situation underscored SFUSD’s vulnerability.
Latent TB doesn’t cause symptoms and can’t spread to others, but it can become active at any time. Many Visitacion Valley students come from high-risk countries, Rait says, and many have had to take the antibiotic rifampin: “Unless you’re making sure they’re getting the correct kind of screenings, you might miss that.”
Tracking those cases is important. Even if it doesn’t become active, latent TB can cause long-term lung damage, which is preventable by “something as simple as getting a kid on rifampin,” says Rait.
The TB outbreak at Riordan revealed more than 200 latent cases, according to the Chronicle. SFUSD spokesperson Kincade says it’s city public health policy that “SFUSD must collect a confirmed TB risk assessment form from all new students.”
For some students, an order to stay out of school until they have their shots and tests means never coming back.
“Often the families who are not compliant with immunization are struggling,” said nurse Julie Lisa. “You say, ‘You can’t come to school,’ and in some cases that’s their green light to never come again, because they were already struggling to get here.”
