It's 8:30 a.m. and students are starting to funnel into veteran nurse Jeanne Cozine's office at Line-weaver Elementary School.
"It's Monday. We're primary care," Cozine says.
Cozine, like school nurses across Tucson, still deals with common occurrences such as stomachaches and fevers. But increasingly, these professionals are dealing with much more complex issues, such as childhood diabetes, asthma, allergies and autism.
It's nurses who identify chronic illness and, after referring students and their parents to doctors, administer prescription drugs on a daily basis. In some cases, they're saving lives, not just sending sick kids home.
High levels of poverty at many schools in Tucson's core, a rise in chronic health problems among children and fewer families enrolled in regular insurance plans have created a dangerous trend, experts say: The school nurse now is viewed as a primary care provider.
Things aren't getting better, either, those experts say.
Nearly 55 percent of the more than 60,000 students in Tucson's largest district lack health coverage'"up about 20 percent from five years ago'"and the Tucson Unified School District also has a high number of immigrants, some here illegally. Even though many families qualify for the publicly funded Arizona Health Care Cost Containment System, nurses say that doesn't mean they always keep up with their children's health concerns.
So, sight and hearing screenings are a small piece of the pie as schools take on a more sophisticated role, delivering daily medications to students and even organizing dental cleanings. Next year, nurses in TUSD will stop regular height and weight screenings so they can focus on more serious ailments.
The job can be daunting for those like Cozine, who oversees three schools.
During the past five years, TUSD nurses have seen an 86 percent increase in cases of diabetes, up to 552 cases last year. That means they regularly administer insulin injections, take blood samples and closely monitor diets. Nurses might spend up to three hours a day dealing with one diabetic child.
"We have to take that child's lunch, look at it and work the carbohydrates through a formula," said Kathy Rucker, TUSD's executive director of student health services and early childhood programs. "Some principals are even having to do that."
Allergy cases are up 45 percent. This year alone, district nurses saved the lives of two children and one adult by administering antigen after they went into anaphylactic shock. And rising asthma cases mean nurses need to be prepared to use nebulizers'"breathing machines'"in emergencies.
For some families, a qualified school nurse is a major factor in deciding where to send their children to school.
It was after meeting Cozine at a school open house that Melissa Anderson decided to send her now 7-year-old daughter, Stella, to Roberts Elementary when she and her husband moved here from Louisiana a year and a half ago.
Stella, a first-grader, has congenital adrenal hyperplasia, which means her body can't properly respond to stress. The disease can be life-threatening.
"It's wonderful to me to have someone at the school who understands what she has," Melissa Anderson said.
What hasn't changed is that nurses don't take on the role of a doctor. If there is a problem, they tell the parent to take the student to a physician.
"Some do, some don't," Cozine says.
In the neighboring Sunnyside Unified School District, which has about 16,000 students, a pediatrician is on staff daily via partnerships with local clinics. Sunnyside has managed to give each school a nurse, whereas TUSD has nurses working multiple schools.
All this comes as the line between what is public education and what is health care has blurred, nurses say.
"The public expectation is changing," Rucker said. "It is expected as an entitlement that we provide that care."
Adding fuel to the fire is the fact that school nurses are hard to come by.
The benefits can be attractive: An eight-hour work day, summers off, annual raises, working with children. But TUSD's starting salary'"$31,000'"is about $11,000 less than nurses would make at a hospital.
And the education world operates differently from the private sector. Contracts for nurses are negotiated along with those for teachers. So there's no freedom to offer better wages to lure candidates. That makes recruiting young nurses difficult.
Mandating nurses would help, Rucker and others say, because it would require the state to provide funding. A statewide school-nurse focus group is currently drawing up legislation.
Some wonder if the role fits, though, especially as schools take on mounting duties not directly correlated with education'"such as serving breakfast, filling cavities, scheduling doctor visits, providing vouchers to families for free eyeglasses.
Darcy Olsen, president of the Goldwater Institute, a Phoenix-based research organization, says while nurses are an appropriate fixture in schools, mandating them would be wrong.
"Schools providing health care makes about as much sense as hospitals being responsible for student learning," she said. "Do we really want to go from having a nurse as a safety issue to having schools operate as a primary health-care provider?"
Olsen says schools are having enough trouble meeting the current mandates. "This is a bureaucratic answer," she said.
Still, some local nurses seem ready for their new roles.
"The reality is that that child lives with us for 6 1/2 hours a day," Rucker said. "The reality is, societal changes have created new problems. It has landed in our lap and we must deal with it."