The message from the school nurses to the Philadelphia Board of Education was stark:

It’s been more than a month since the district’s physician left and hasn’t been replaced. There’s no policy handbook to guide them. Administrators with zero medical experience are handing out medications and altering student records.

“We are experts in our field,” veteran school nurse Anne Smith told the school board at its meeting Thursday night. “Our nursing practice is being interfered with by an administration that does not value our input, puts our nursing licenses at risk, and ultimately puts the health of the children we serve at risk.”

Smith was among a small contingent at the meeting who said they speak for many of the 200-plus nurses who care for nearly 200,000 students in the district’s traditional and charter schools. Their warning stunned some school board members.

“I’m incredibly concerned about this,” Maria McColgan, a board member and a physician, told the crowd. She said nurses “were hired to do a job, and their hands were tied behind their back and they were told they weren’t allowed to do that job.”

District officials disputed that the nurses speaking out reflected the views of the overall school nurse pool, and suggested they were simply uncomfortable with new ways of doing things.

“We don’t disregard professional credentials,” said Superintendent William R. Hite Jr.

Nurses have bristled at administrators’ directives for a few years, but said they were moved to speak out as issues have mounted. Among the questionable steps they cited was district officials’ decision to send students older than 14 on vaccination “field trips” to get immunizations without parents present.

Nurse practice law requires a physician to provide standing orders for school nurses to administer medications like ibuprofen and hydrocortisone to students, but Philadelphia currently operates without standing orders, the district acknowledges. The district’s physician left in early October, but nurses were not formally notified and so some continued to administer medication without the legally required orders.

District nurses had raised the issue to their supervisors before, but nothing changed, they said.

Karyn Lynch, chief of student support services and the administrator responsible for student medical services, said the district learned just this week that the district does in fact need such standing orders.

“With that, we have reached out to other physicians and we are moving to resolve this issue very, very quickly,” she said in an interview Friday.

Still, the revelations about how student health services are being managed led some board members to deliver a rare public dressing-down of the Hite administration.

“Credentials, professional expertise means something,” said board member Christopher McGinley, a former Philadelphia schools administrator and suburban superintendent. “And in all school districts that I know, we vet people by their professional expertise and we put people in charge of the work they were trained to do and the work that they have the credentials to do.”

McGinley said he was “quite upset and angry" that board members’ concerns had been ignored.

The nurses first spoke out earlier this year, when they expressed frustration over being barred from excluding unvaccinated students from attending school, as Pennsylvania law requires. Nurses had the authority to make decisions about when to exclude children for decades, but said they did so only rarely, and said excluded children were usually out only a few days.

» READ MORE: Read more: Should school nurses be allowed to exclude from school unvaccinated children?

District officials say they had prohibited nurses from excluding unvaccinated children in order to standardize procedures across the city and keep accurate vaccine records. Lynch then directed workers in the Office of Family and Community Engagement to help bring more children into compliance with state vaccination laws.

Emily Seiter, the school nurse at McClure Elementary School, said giving nonmedical professionals a role in the medical care for students has led to changing directives, a breach of student records, incorrect information being sent to families, and other mix-ups.

She and others said they are more concerned about a decision to organize vaccine “field trips” to city health centers for all unvaccinated children 14 and older, with parents signing permission slips for students to go on such trips but not being present for the administration of the shots.

At Lynch’s direction, the status of all unvaccinated city children 14 and older was changed from noncompliant to provisionally compliant. Children now have until April to get their vaccines; the district said it does not intend to send any child for immunizations without the permission slip.

Seiter and others say that parents should be present when children receive vaccines to receive information on the shots, possible risks, and side effects. And, they say, taking nurses out of the picture on vaccination compliance “doesn’t resolve that underlying issue that families aren’t getting the services they need.”

Many Philadelphia children are unvaccinated not because of parental objection, but “because they don’t have access to consistent health care. A lot of what we do as nurses is to figure out why that is and break down those barriers. We’re trying to get them comfortable with navigating the system,” Seiter said.

City health centers do allow minors as young as 14 to consent for vaccines, said James Garrow, a spokesperson for the Philadelphia Department of Public Health. The school nurses, however, said that students have already been turned away from health centers on the “field trips.”

Nurses also said the district encouraged them to distribute letters to the parents of unvaccinated students that would exempt them from vaccines based on religious, medical, or philosophical objections.

“I got 500 exemption letters,” said Patricia Melloy, another school nurse. “We have three children who are philosophically exempt in my school. Why would I push more?”

» READ MORE: Read more: District expands efforts to get students vaccinated

The percentage of unvaccinated students rose when nurses were stripped of the authority to exclude, they said. It has dropped this year with the renewed efforts, Lynch said. According to the most recently available numbers, 3,600 school-age children were unvaccinated. In April, there were 12,000.

“They’re just interested in their numbers looking good. They’re not looking out for the best interests of the students,” Susan Cook, another school nurse, said in an interview.

Lynch and Hite, in statements to the board and in an interview, disagreed with the nurses’ assertions. Lynch said medical professionals had been consulted on the decisions.

“There is a respect for the people engaged in providing health services to the children of the Philadelphia School District,” she said.