The purpose of this column is to examine the problem of a shortage of school nurses in public schools in the United States. Areas of focus include the role of school nurses in schools, the definition of ‘school nurse,’ the major reason for the school nurse shortage, the use of Unlicensed Assistive Personnel (UAP) to provide nursing services in schools, and recommendations for alleviating the shortage of school nurses.
Recent articles indicate that there is a critical shortage of school nurses in public school districts across the nation. Horovitz and McCoy (2005) reported "an analysis of 2004 census data by USA TODAY showed roughly 56,000 nurses worked full time at schools. That’s one for every 950 students, a ratio that fails to meet federal guidelines that call for one nurse for every 750 students" (p.1). According to Magnuson (2002), "the United States Department of Health and Human Services (USDHHS) recommends at least one nurse per 750 students in well populations (that ratio changes when students with disabilities are considered)." Similarly, the National Association of School Nurses (NASN) recommends a maximum of one school nurse to 750 regular education students (Green, 2006). A look at individual states may reveal an even grimmer picture. In California, for example, the school nurse to student ratio can be as high as one nurse to 5,000 students or more, as is the case with this author who has a work load of approximately 5,000 students.
The Role of Nurses in Public Schools
According to NASN (2006), the association adopted the following definition of school nursing in 1999:
School nursing is a specialized practice of professional nursing that advances the well being, academic success, and life-long achievement of students. To that end, school nurses facilitate positive student responses to normal development; promote health and safety; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy, and learning (para. 2).
The importance of school nurses in the nation’s public schools cannot be over-emphasized. School nurses play a vital and multi-faceted role in school settings. In low-income, public school districts, for example, school nurses are more often than not the initial health care personnel with whom students who are without health insurance yet require medical attention come into contact. The role of the school nurse has expanded tremendously over the years since the introduction of school nursing over a hundred years ago by Lillian Wald, a public health nurse and social reformer. The initial focus of school nursing was the prevention of communicable diseases and the treatment of ailments related to compulsory school life (Clark, 2003). School nursing has since evolved over time to include such services as case management, providing health education to students and staff, health promotion, first aid and emergency services, medication administration, advocacy, initiating emergency and individualized health plans for students with chronic medical conditions, and tracking immunizations. Other services include reporting cases of child abuse; providing assessment for and attending Individualized Education Plan (IEP) meetings for students with special educational needs; conducting and supervising state mandated screenings, such as vision, hearing and scoliosis screenings; referring students to appropriate agencies after screening; and providing families with information on available resources for procuring free or low-cost services.
The School Nurse
The definition of a school nurse varies from state to state. There is currently no national mandate directing requirements for entry-level, school nurses. Literature reveals that across the nation, school nurses come from different educational backgrounds ranging from associate to master’s degrees in nursing (Vought-O’Sullivan, Meehan, Havice, & Pruitt, 2006). A few school nurses even have doctoral degrees. In California, for example, the minimum requirement is that a school nurse must be a registered nurse who holds a bachelor’s degree in nursing or another field. This individual must possesses a health service or school nurse credential or be willing to obtain, upon employment, the credential from an educational institution approved to provide such services by the California Commission on Teacher Credentialing. Some states, however, do not require such stringent qualifications to practice as a school nurse. An example is the state of Florida.
According to Battin (n.d.):
There is not a minimum education requirement for school nurses. A nurse who provides school health services may be a licensed practical nurse (LPN), a registered nurse (RN) or advanced registered nurse practitioner (ARNP). Although certification is recommended as a professional standard, Florida school nurses are not required to hold certification in nursing or education. School nurses may seek certification through the National Board for certification of school nurses (para. 2-3).
Reason for Shortage of School Nurses
Although several factors contribute to the shortage of school nurses, the major reason for this shortage can be attributed to a lack of legislation mandating school nursing. There is currently no federal legislation mandating school nursing in the United States. A 2004 report by Pennsylvania Joint State Government Committee on laws regulating school nurses in Pennsylvania and other states reported that 33 states have provision for school nurses, 14 have established student per school nurse ratios, and only five states have set numeric ratios for school nurse to students (Taliaferro, 2005). The result is that most states either end up with no full time school nurses on school sites or they have very high nurse-to-student ratios. A report by the Centers for Disease Control and Prevention cited by Horovitz and McCoy indicated that "almost half of the schools nationally -47%- fall short of the federally recommended nurse-to-student ratio" (2005, para. 20).
The Use of Unlicensed Assistive Personnel in Schools
Certain national laws mandate that school districts provide services to students who require specialized services during school hours. An example is the Individuals with Disabilities Education Act of 1975 (re-authorized in 2004), which mandates a free, appropriate, public education for students with disabilities in a least restrictive environment. Others include Americans with Disabilities Act of 1990 as well as the Rehabilitation Act of 1973, section 504 (Vought-O’Sullivan et al., 2006). It is pertinent to point out that although the laws mentioned above require school districts to provide services to students with special needs, they do not mandate that such services be provided by school nurses. Public school districts in the nation therefore do not feel obliged to hire school nurses. Rather they resort to the use of Unlicensed Assistive Personnel (UAP) such as health assistants, school secretaries, and attendance technicians to provide nursing services.
The negative implications of using UAP as "nurses" in schools cannot be over-stated. In an attempt to cut costs, UAP who are already overwhelmed with assigned duties, are charged with the added responsibility of providing nursing services including first aid, medication administration, and care of students with chronic health conditions such as asthma, diabetes, and seizures. The use of UAP, as a result of shortage of nurses on school campuses across the nation, has resulted in life-threatening situations and even death in some instances. While commenting on the issue of UAP providing nursing services in schools, Udesky (2005) reported that the results of a 2000 survey by the University of Iowa revealed that "mistakes are more than three times as likely to occur when an unlicensed person and not a nurse is responsible" (para. 15).
Recommendations for Alleviating the School Nurse Shortage
As pointed out earlier, the major reason for the shortage of school nurses in public schools across the nation is the fact that school nursing is not mandated in schools. This results in school districts resorting to the use of UAP for nursing services. To alleviate the problem of the shortage of school nurses, it is therefore recommended that the federal government, in conjunction with the various state governments, enact legislation making it mandatory that school districts hire school nurses to provide nursing services to school children. Such legislation will help students to receive safe and quality care. Furthermore, the government should make funds available for the hiring and retention of school nurses as well as require school districts to comply with the recommended ratio of one school nurse for every 750 students.
In conclusion, nurses play a vital role in the education and overall development of the school-age child. The solution to this problem of a shortage of school nurses in the nation will require the collective efforts of the different levels of government, parents, teachers, school administrators, and special interest groups. Efforts to date by organizations such as NASN, local school nurses organizations, and Parent-Teacher Associations, which have already advocated for more nurses in our schools, are commendable.
Ozo M. Nwabuzor, MSN, RN
Email Address: Ozotom1@yahoo.com
Ozo M. Nwabuzor holds a Master of Science in Nursing from University of Phoenix. She is currently employed as a credentialed school nurse at Montebello Unified School District in Montebello, California. Her previous nursing experiences include pediatrics, home health nursing, and skilled nursing, and psychiatric nursing.
Green, C. (2006). School nurse activities in Utah. Retrieved August 21, 2006 from www.utsna.org/HTML/activities.html.
Horovitz, B., & McCoy, K. (2005, December 14). Nurse shortage puts school kids at risk. USA TODAY. Retrieved February 17, 2006 from www.caichildlaw.org/Misc/USA_Today.pdf.
Magnuson, P. (2002, November). Nursing necessity. Communicator, 27(3), 1. Retrieved August 17, 2006 from www.naesp.org/ContentLoad.do?contentId=1095.
National Association of School Nurses. (2006). About us. Retrieved February 17, 2006 from www.nasn.org/Default.aspx?tabid=57.
Udesky, L. (2005, September 29). No school nurses left behind. Salon.com. Retrieved February 17, 2006 from www.caichildlaw.org/Misc/No_school_nurses_left_behind.pdf.