In Session: The State of the School Nurse

• Despite recommendations that at least one school nurse be present in every school across the U.S., the shortfall that began years before the COVID-19 pandemic could soon be even more evident.
• Staffing concerns for school nurses date back to the early 2000s but saw temporary relief due to federal pandemic relief funds.
• Practitioners who work in the elementary and secondary education setting believe that their roles aren’t fully understood even within the industry itself.

At least one school nurse should be present in every school across the United States, but a shortfall that began years before the COVID-19 pandemic could soon be even more evident.

School nurse staffing concerns date back to the early 2000s and were temporarily addressed through one-time funds as part of the White House’s pandemic-relief efforts. However, a recent workforce study from the National Association of School Nurses (NASN) reveals that only 65.7% of schools have a full-time nurse on staff, despite recommendations that there be one full-time nurse for every 750 students.

Practitioners in the elementary and secondary education setting believe that even their own industry isn’t fully aware of the scope of their role, which ranges from public health awareness to treating students who have chronic conditions.

The Role of a School Nurse

Sheila Caldwell, a school nurse in New Jersey, told neaToday in June 2023 that compared to hospital nurses who see about 10 patients per day, a practitioner in a school setting could see between 200 and 5,000 students per day.

“This is not a cake job,” Caldwell said. “We are managing high needs of students every day, treating kids with asthma, diabetes, epilepsy, and other health conditions.”

In addition to treating children, school nurses are also proponents of public health initiatives and awareness, harkening back to the origins of the position. 

On top of the pandemic-focused responsibilities, they also ensure students receive the vaccinations required for enrollment and conduct vision and hearing screenings, according to a 2017 report in the Online Journal of Issues in Nursing (OJIN).

Care coordination — sending emails, writing reports, teaching, counseling, and managing chronic or acute conditions — takes up roughly half of a school RN’s time.

Specific requirements to become a school nurse vary by state, but some might require a School Nurse Certification, which can be obtained through the National Board for Certification of School Nurses and is valid for five years. 

School Nurses by the Numbers

Educational services rank among the top five work environments for registered nurses, according to the most recent data from the U.S. Bureau of Labor Statistics.

However, the NASN workforce study revealed a pay disparity between nurses in an education setting and RNs who work in other, more clinical settings. Only 34.2% of RNs who work in schools earn more than $60,000 annually, compared to nearly 70% of the overall RN workforce.

The school nurse workforce also trends older, losing practitioners to retirement.

NASN created the “Claim Your School” Campaign to help determine where “staffing gaps” exist throughout the country to refine its advocacy efforts. 

Federal Funding for School Nurses

The White House allocated $500 million for school-based health services as part of the 2021 American Rescue Plan (ARP), but Stateline.org reported at the time that the nationwide RN shortage and “unrelenting need for nurses in hospitals overrun with COVID-19 cases” meant most of those funds would be used to support school nurses, rather than bringing in new hires.

Janis Hogan, who has been a school nurse for more than two decades, told Stateline.org she hoped ARP funds would be used to hire a second nurse at her Maine school. Doing so would have meant a team could address COVID-19, “while still conducting annual vision and hearing screenings, flu shot drives and other services for students.”

“Instead, Maine’s public health agency plans to spend the new money on a telehealth contract and school-based health assistants with minimal health care training to fill in for school nurses while they’re busy juggling COVID-19 cases,” Emily Poland, president of the National Association of State School Nurse Consultants, told Stateline.org.

Other districts did use their Elementary and Secondary School Emergency Relief (ESSER) to hire nurses, according to a USA Today report, but “with access to those federal coffers closing, some school leaders are scrambling to find the money elsewhere to retain nurses.” ARP ESSER funding must be allocated by the end of September.

Kate King, an Ohio nurse and NASN president, said school districts that brought on nurses during the pandemic realized “how valuable” the practitioners are for the students.

“Unfortunately, when they hired nurses with ESSER funds, there was no thought of sustainability in those positions,” King told USA Today. 

Where Do We Go From Here?

Only 35 states and Washington, D.C., have policies related to the employment of school nurses, according to an August 2022 Child Trends report. 

But two legislative measures could alter the landscape of school nursing, and both have backing from NASN: 

• The Nurses for Under-Resourced Schools Everywhere (NURSE) Act would establish a Department of Education grant program to increase the number of school nurses in public elementary and secondary schools. To be eligible, at least 20% of the student population must qualify for free and reduced lunch programs. 

• The One School, One Nurse Act would require the DOE to establish a five-year competitive grant program for “recruiting, hiring, and retaining school nurses.” Grantees would also have resources to move part-time school nurse positions into full-time roles.

As of June 2024, both bills had been referred to the Subcommittee on Health. 

The Bottom Line

School nurses were in short supply well before the COVID-19 pandemic exacerbated the issue. Federal relief funds helped alleviate the pressure on nurses in educational settings, through both additional support and hiring of more nurses. However, allocation of the one-time funding must be set by Sept. 30, 2024. Legislative attempts to increase school nurse staffing outside of those funds are supported by the National Association of School Nurses and are making their way through Congress. 

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