School Nurses: Keeping School Children, Families, and Communities Healthy

Mayumi A. Willgerodt, PhD, MPH, RN, FAAN, FNASN; Catherine Yonkaitis, DNP, RN, NCSN, PHNA-BC


Am Nurs Journal. 2021;16(2) 

In This Article

Looking Forward: Challenges and Opportunities

School nursing faces many challenges, but these challenges also present opportunities to effect positive change.

Funding Challenge

Limited and varied funding remains one of the primary challenges to delivering comprehensive, evidence-based school nursing services. Although schools can bill for specific services through Medicaid and partially fund a small portion of nursing services, according to an NASN Workforce Study, most school nursing services (74.1%) are funded through local education dollars, with additional funding coming from states, health departments, and hospitals. Local education funding means that school nursing services must compete with teachers, support staff, and education-related expenses, such as textbooks and tablets. And because school nurses function within the education sector, health services frequently are managed by administrators who may not understand what's needed to effectively care for a diverse student population. With limited funds allocated to education, administrators look to make cuts "outside" of the classroom, which frequently results in reducing or eliminating school nurses and other professional support staff.

Opportunity. The need to ensure educational access by keeping children healthy and ready to learn presents policy makers and school districts with an opportunity to strategize on stable funding streams that support school nursing. For example, to provide a more reliable funding source for school nurses, some school districts have developed partnerships with health systems, including hospitals. In these partnerships, school districts contract out for school nursing services, which allows nurses to operate within a health infrastructure and ensures they have access to various resources (such as continuing education and mentorship) that otherwise might not be available to them. In addition, school and health system partnerships make health records more interoperable, which facilitates efficient care coordination.

Preparation and Allocation Challenges

The preparation and allocation of school nurses vary across the 50 states because of several factors, including state nurse practice acts, licensure and certification requirements, and local school district regulations. Although professional organizations recommend that school nurses be, at a minimum, baccalaureate-prepared, some states employ associate-prepared nurses or licensed practical nurses (LPNs). In addition, school nurse educational and certification requirements differ across states, which influences the type and level of care that can be provided. How school nurses are deployed and used frequently are pragmatic decisions—the limited number of school nurses relative to need impacts school district staffing decisions. As a result of these factors, schools may have RNs, LPNs, and/or health room aides who cover one to three schools of varying sizes.

Opportunity. Maughan states that caseloads among school nurses can range from 300 to 6,000 students per nurse. Generally, NASN recommends one nurse per 750 students, but more recent research by Jameson and colleagues indicates that a multi-faceted formula is needed to guide workload and staffing considerations. Comprehensive metrics to guide staffing could include the number of students on free or reduced lunch, number of children with medically complex needs, types of interventions needed, experience level of the school nurse, school academic performance, and number of and distance between school buildings. (See Every student counts.)

Workforce Challenge

An NASN Workforce Study reported that almost half of the school nurse workforce is over age 50 and only 5.4% are under age 30, indicating that the school nursing workforce is aging. Unfortunately, little attention is being paid to increasing the pipeline. Compounding this challenge is the fact that school nurse salaries aren't uniformly commensurate with nurses in other specialties.

Opportunity. These data point to the critical need to intensify efforts to recruit, retain, compensate, and diversify the school nursing workforce. Nurses who transition to the school nursing specialty have a range of work experiences, such as in emergency care, pediatrics, and mental health. The specialty provides an opportunity to make a difference not only through practice, but also in the areas of education, policy, and practice. (See Recruitment.)