In the majority of Iowa school districts, a scraped knee from a hard fall on the playground will be seen by a registered school nurse.

For the minority, like the tiny Andrew Community School District, a medical issue is seen by an outside professional.

Absent a school nurse, Andrew has a certified EMT on staff and the town's fire department across the street if an emergency arises.

With a state law passed in 2007 -- requiring every school district to have at least one registered nurse on staff -- Andrew will need to make a hire or risk losing its state accreditation.

The district is one of more than three dozen in the state facing that dilemma.

The law was passed with the goal of having one school nurse for every 750 students, according to Iowa Department of Education spokeswoman Elaine Watkins-Miller.

"There is an understood need for school districts to do more," Miller said. "It involves more than academics."

State Sen. Michael Connolly, D-Dubuque, helped spearhead the passage of the law.

For a district like Andrew, with 273 students, the required

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ratio means everything.

The school's two-year waiver period ends at the end of the year, and the state will not allow for any further waiver periods.

"It has good intentions, no question," said Andrew Community Schools Superintendent Kent Hammer. "Who wouldn't want a full-time nurse?

"It's also an unfunded mandate. There is no money with the law. Most schools in our situation make a choice of what goes and what stays."

Andrew had to make a choice before the 2003-04 school year. That academic year, the district lost 25 students and its insurance policy skyrocketed 78 percent.

A $214,000 budget cut was made, and the reductions included Andrew's school nurse.

"We just couldn't afford her," Hammer said. "It came down to a choice. Do you keep the nurse or fine arts? We wanted to keep our music program, our art program. For us, that had a higher priority than a nurse."

Andrew has two options to consider when a final decision is made in the spring.

One scenario includes a part-time sharing agreement with another school district.

Another option involves a search for a nurse in the community, one working for a doctor's office or hospital, who would be available on a part-time or on-call basis.

Bellevue Community Schools and Bellevue Marquette share a school nurse. Cindy Broders splits her time between the schools, spending most of her day at Bellevue but an hour in the early afternoon at Marquette.

"It's tremendous for us," said Marquette High School Principal Jim Squiers. "If we have an emergency, she is here within 10 to 15 minutes. We think it's a real advantage to have a shared program with Bellevue schools."

Bellevue Community Schools Superintendent Mike Healy noted that the law doesn't dictate how much time a nurse is on duty.

As for stretching Broders' time even more, Healy isn't aware of any requests from other nearby districts, including Andrew.

"They haven't approached us yet," Healy said.

Western Dubuque has five nurses serving its public buildings and parochial counterpart, Dyersville Beckman High School.

The district spreads its nurses over 20 buildings.

"I say we are thin (in nurses) with the number of buildings we have to serve," said WD Superintendent Jeff Corkery.

Dubuque Community Schools employs 18 full-time nurses and four part-time nurses. The district also covers Jones Hand-in-Hand program and works with Dubuque's Area Education Agency to provide services to preschool-age children.

"It's pretty complex," said health supervisor Patrice Lambert. "We take care of the health services for all schools in the city of Dubuque."

Superintendent John Burgart said the nurses also are "a key component" in the district's health and wellness program.

Some of the duties performed in the program include acute and chronic illness management along with safety and disaster planning.

"Our district has for a long time had a commitment for providing nursing services above and beyond the standards of the state law," Burgart said.

"We believe that the school nurse provides vital support for the students and their families."

-- TH staff writer Stacey Becker contributed to this story