A Nurse in Every School?

As a school nurse, Traci Jones, RN, PhD, NCSN, handed out ice packs and bandages, but she also helped students manage chronic health conditions ranging from diabetes and asthma to seizure disorders and life-threatening allergies.

“There can’t be an expectation that the teachers know how to identify healthcare issues,” said Jones, a school nurse administrator in Temple Hills, Maryland. “[There should be] a nurse in every school.”

School nurses oversee case management, assist with individualized education plans for students with disabilities; implement public health strategies for immunizations, natural disasters, and school violence; and connect families with community health resources.

Despite the essential role that school nurses play in ensuring the safety and well-being of schoolchildren, a growing number of districts do not have enough nurses to meet student needs. Data from the National Association of School Nurses (NASN) found that just 65% of schools had access to a registered nurse (RN), licensed practical nurse (LPN), or licensed vocational nurse.

Although 20 states, including Connecticut, Delaware, Massachusetts, and Minnesota, require K-12 schools to have a school nurse, students in other states often lack access to healthcare in school. Rural areas and districts in the Midwest and West employed the fewest number of school nurses, according to NASN.

The Nurses for Under-Resourced Schools Everywhere (NURSE) Act was recently reintroduced in an effort to increase healthcare access in education. The legislation aims to establish a federal grant program to help Title I schools where at least 20% of students are enrolled in free- or reduced-price breakfast and lunch programs to hire and retain school nurses.

“The NURSE Act recognizes the critical role of school nurses in providing students with access to quality healthcare so they can be healthy, safe, and ready to learn,” explained NASN president-elect Pat Endsley, PhD, RN, NCSN, FNASN.

More Than Bandages and Ice Packs

Injuries, illnesses, and disabilities lead to chronic school absences for almost 6% of school-aged children, and school nurses can help manage acute and chronic illnesses that are linked with poor attendance. In schools without a school nurse, 18% of students were sent home for illnesses or injuries compared with just 5% of students in schools with a school nurse.

School nurses don’t just affect absenteeism. Studies have found that students with access to school nurses experience better management of chronic conditions and improved academic outcomes, too.

“Sometimes we’re just that place where students can come for some reassurance…Sometimes they just need 5 minutes to come in and decompress before going back to class,” Endsley said. “We’re a safe place [and] our goal is getting that student back to class and getting the most out of their education.”

However, providing healthcare and safe spaces in schools comes at a cost. On average, the cost of having an LPN in a school nursing program was $115,707 per school year at a time when US schools are facing their biggest budget crunch in years.

Funding for school nurses comes from a patchwork of sources, including the federal Department of Education, Medicaid, state health departments, and grants. The patchwork approach leads to disparities in resources between states and even among school districts. Cuts to Medicaid and uncertainty about the future of the Board of Education could also affect the number of nurses in schools today.

The expiration of Elementary and Secondary School Emergency Relief funding allocated during the COVID-19 pandemic led to severe implications in school districts that included job cuts and loss of critical programming, including the loss of school nurses.

“Schools got COVID funds to hire a lot of school nurses, but…after those funds expired, not very many schools made those positions permanent,” said Endsley.

While previous recommendations from organizations like the American Academy of Pediatrics suggested a ratio of one school nurse for every 750 students, it’s considered an outdated standard, according to Endsley. Instead, she believes districts should conduct ongoing assessments to determine student needs and inform hiring decisions.

A school with 500 students but few chronic health conditions might need just one school nurse, while a less populated school with a higher proportion of students with ongoing medical needs might need two (or more) nurses, she explained. But there is more to addressing the school nurse shortage than coming up with student-to-nurse ratios.

Changing Perceptions

Hiring school nurses is challenging. Misconceptions about the role of school nurses and burnout are among the biggest reasons that 50% of RNs and LPNs leave school nursing in 3-6 months.

“Most people don’t know what school nurses do,” said Jones. “I’ve had people tell me, ‘You sit at the desk all day and hand out candy.’”

The perception that school nursing is all about “Band-Aids, ice, and lice” prevents school nurses from entering the profession — but the RNs who work in school settings appreciate some of the perks: There are no weekend, rotating, or overnight shifts, and many school nurses work 10 months of the year, leading to better work-life balance. There are challenges, too.

School nurses experience significant pay disparities. NASN data show that just 34% of school nurses make more than $60,000 per year compared with almost 70% of the total RN workforce. This often forces school nurses to pick up additional shifts in hospitals and clinics, Jones added.

The workforce also tends to be older — more than two-thirds of school nurses are over 40 — and retire sooner, leading to greater turnover.

The role is also best suited to mid-career nurses. Jones calls it “grassroots nursing.”

“You have blood pressure cuffs and a stethoscope, and your own knowledge, judgment and skill set,” she added. “You’re usually the only medical expert in the building, and you need a solid foundation.”

However, when RNs work in schools, sick and injured students aren’t the only ones who benefit. Schools with full-time nurses receive an average return on investment of $1.59 for every dollar invested as well as significant savings in teacher, secretary, principal, and parent productivity — and the community benefits, too.

“School nurses really are an integral part of the whole education system,” Endsley said. “We work in partnership with our school community, with our teachers, our administrators, but also with the community at large.”

Jodi Helmer is a freelance journalist who writes about health and wellness for Fortune, AARP, WebMD, Fitbit, and GE HealthCare.