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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000365174.55331.e8
AJN Reports

School Nurses Are Needed More than Ever

Nelson, Roxanne BSN, RN

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At the same time, funding for them is dropping.

One day last April, Mary Pappas, RN, was surprised to see five or six seniors show up in her office shortly after classes had begun. All of them had sore throats, nausea, and fever—in short, flu-like symptoms. By 10 AM there were dozens of students in the hallway outside of her office. As the nurse responsible for overseeing the health of 2,700 students at St. Francis Preparatory School in Queens, New York, she quickly realized that something was amiss.

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Pappas's subsequent phone call to health officials heralded the first eight confirmed cases of the 2009 H1N1 pandemic influenza in New York City. Her quick and professional assessment of the situation facing her that April morning helped the public—and the news media—realize the important roles a school nurse plays, both for individual students and overall public health. Ironically, however, the news stories of Pappas and the H1N1 flu outbreak appeared alongside articles on proposed budget cuts that threaten to reduce or eliminate school nurse positions.

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Many parents and even school administrators don't realize how complex the role of school nurse can be. Kathleen Rose, MHA, RN, NCSN, president of the Florida Association of School Nurses, says, "The perception a person has about school nursing reflects that person's exposure. If you have a child without health problems, you think that the nurse is there to put on Band-Aids. But if you have a child with a problem, you realize the full complexity of the role."

Parents often assume a school nurse is available at all times to attend to their child and may be perplexed or get angry when they discover that the nurse is only at the school two mornings a week. Even though current guidelines from the National Association of School Nurses (NASN) recommend one nurse for every 750 students in the general population, the reality is that in many school districts around the country, a nurse may be responsible for several thousand students spread out among the district's schools. Delaware is the only state that has a legal mandate to provide a school nurse in every school.

In the United States, between 75% and 80% of public schools have a school nurse, although the amount of coverage varies considerably, according to a report, The Impact of the School Nurse Shortage, by Vicki Taliaferro, BSN, RN, NCSN, school health consultant and editor of School Nurse Digest ( Fewer than half of schools have a full-time nurse and about a quarter have no nurse at all. "We're always concerned about whether there will be enough nurses to meet the acuity needs of the students," says Amy Garcia, MSN, RN, executive director of the NASN. "The ratio of one nurse per 750 students is for healthy children. The ratio needs to be adjusted to the actual health needs of the population, which may be much more acute."

The shortage is not of nurses willing to work in schools but of funded positions, according to Garcia. "We're hearing widespread talk of elimination of nurse positions. In some parts of the country it's been dramatic." The following are just some examples.

* At the end of June the Los Angeles Unified School District board approved its budget for the next three years, which called for a total of almost $175 million in cuts. Although it's not set in stone, the budget for the 2011–12 fiscal year might require the laying off of half of the district's school nurses, along with elementary art and music teachers (for more, go to (School nurses there were already stretched outrageously thin by 2003, with a ratio of one nurse for every 2,532 students, according to the California State PTA.)

* The governor of Georgia, Sonny Perdue, proposed a spending plan for the 2009–10 fiscal year that would eliminate $30 million for school nurses, although as of this writing his proposed cut had been struck from the budget and the recommendation was that only 3% be taken from school nursing. At the same time, the ratio of nurses to students has been slowly widening in the state. Currently, it's one nurse per 1,598 students, up from one nurse for 1,287 students five years ago, according to the Georgia Association of School Nurses.

* The Palm Beach Post reported last June that the Health Care District of Palm Beach County, Florida, in an effort to contend with a $56 million budget deficit, had proposed a number of deep cuts, such as eliminating nurses in five elementary schools; in addition, school nurses would no longer be available before and after regular school hours. Funding for school nurses in Florida comes from a variety of sources, says Rose, depending on the county, and each county is its own school district. Therefore, some nurses may be funded through the school board, whereas others are supported by the Department of Health or even by hospitals. Palm Beach County has been the state's only school district to have a nurse in every public school and to be funded through a special health care taxing district. But tax revenues have declined at the same time the demand for health services has increased.

Other districts with strong coverage and support for school nurses are also feeling the pinch. The largest school district in El Paso, Texas, has a full-time nurse for each individual school, but the district recently eliminated seven Title 1 nurses, who performed hearing and vision screening tests in the schools, distributed vouchers for children to obtain glasses, and sought out community resources for the children. "Our district is growing, but seven nurse positions were cut," says Christina Maxwell, RN, an El Paso school nurse. "In other words, we have more children but fewer nurses. We have to now pick up their work."

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On October 1, 1902, Lina Rogers Struthers became the first school nurse in the country when she was assigned to four schools in lower Manhattan as an experiment to see whether school nurses could reduce absenteeism and improve children's health. After a month, the results were so promising that Struthers was awarded a school nurse appointment. Nurses were increasingly added to the roster, and by February 1903, Struthers was heading up a staff of 27 nurses. The "experiment" was clearly a success, as within one year of having school nurses, absenteeism was reduced by nearly 90%. (Read Struthers's own account at

More than a century later, health priorities have shifted for school nurses and in some ways have become more complex. According to the report by Taliaferro, 16% of students currently attending schools in the United States have a medical condition that requires management by a skilled professional, and that's not surprising. In 1975 a federal mandate that public schools make accommodations for disabled students brought a whole new set of challenges into the school system. Children with gastrostomy tubes, colostomies, and catheters—even children on ventilators—were now in the classroom. Many students have chronic diseases or behavioral or developmental issues, and given that children will continue to engage in risky behaviors such as substance abuse and sexual activity, there will always be a need for preventive health care and patient education.

In Florida alone, there are about 6,500 children with diabetes attending school, according to Rose. There are also increasing numbers of immunocompromised children returning to school after treatment for cancer. Rose says she also sees children with reproductive health issues, such as pregnancy and sexually transmitted diseases.

"Every single bit of my nursing education comes into use as a school nurse," says Rose. "I'm dealing with endocrinology, surgery, pediatrics, gynecology—the full gamut of health care."

Children attending El Paso schools have many of the same health care challenges, says Maxwell, including high rates of asthma and obesity. But unique to that setting is that it's a border town, with a large number of undocumented immigrants coming through. "The families don't have insurance, and for many of these children, the school nurse is the only health care provider they will ever see," Maxwell says. "The families also come to me with all sorts of health-related questions. My phone was ringing off the hook with questions about swine flu because they don't have a physician or anyone else to ask."

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Despite the economic turmoil and threats of budget cuts and job elimination, school nurses and their advocates are looking to reverse this downward trend—and in some cases, like Georgia's, they're succeeding.

In Florida's Miami-Dade County, residents recently passed a tax referendum to put more nurses into schools. "There are 72 nurses to cover 436 schools with a total of 350,000 students," said Rose. "Miami-Dade previously had the worst rate in the state, but things are gradually improving. This referendum is permanent."

On the federal level, HR 2730, the Student-to-School Nurse Ratio Improvement Act of 2009, was introduced by Representative Carolyn McCarthy (D-NY) on June 4 and currently has 18 cosponsors. If it passes, competitive demonstration grants would be provided to eligible states though the Centers for Disease Control and Prevention, in order to improve nurse–student ratios in schools.

Representative George Miller (D-CA), chairman of the House Committee on Education and Labor, has dropped a version of McCarthy's bill into HR 3200, America's Affordable Health Choices Act of 2009. "That ties the provision for school nurses to health care reform," says Garcia, "so we don't know where it will go as part of this measure."

She also believes that the services provided in school should be reimbursable by insurance companies. "Right now we're shifting a lot of care to the schools, but without allocating resources," she says. "In any other setting, the same care would be billable."

Roxanne Nelson, BSN, RN

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The School Health Leadership Program

An innovative approach to supporting the school nurse.

The School Health Leadership Program, sponsored by Johnson and Johnson, helps train school nurses to address the complex issues affecting their students. Started in 1988, it's the only initiative of its kind.

In addition to helping school nurses learn to manage their time, make appropriate decisions, and develop skills to address the unique issues confronting their students, the School Health Leadership Program also assists them in developing a stronger professional voice, says program director Gail Milgram, EdD, who's also director of the Education and Training Division of the Center of Alcohol Studies at Rutgers University, which hosts the School Health Leadership Program.

"A stipulation of participation is that the school principal has to participate in the program for two days," says Milgram. "For the program to succeed, it's essential that the administration fully understand the role of the school nurse and how important it is to have one."

Each school nurse can also apply for a "minigrant" to start a project or try out an idea that may have been spawned during participation in the program.

Christina Maxwell, an RN in El Paso, Texas, participated in this year's program and says that it helped her tremendously. "If all school nurses knew how good this program was, they'd all want to go," she says.

"We learned how to be agents of change. I came back to my school more motivated than ever," says Maxwell. "We learned how to look for grants and to network—and to reach out to people who want to be part of the school community."

Roxanne Nelson, BSN, RN

Cited By:

This article has been cited 1 time(s).

Journal of Pediatric Nursing-Nursing Care of Children & Families
Student Nurses as School Nurse Extenders
Rossman, CL; Dood, FV; Squires, DA
Journal of Pediatric Nursing-Nursing Care of Children & Families, 27(6): 734-741.
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© 2009 Lippincott Williams & Wilkins, Inc.


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