School Nurse Shortage May Imperil Some Children, RWJF Scholars Warn

In the fall of 2000, Mary Newell left her job as a nurse educator so she could care for her son, Cameron, who was entering kindergarten at the time. Cameron had been born prematurely—weighing just over one pound at birth—and suffered from chronic kidney problems during early childhood. At age 5, Cameron was ready to attend kindergarten, but the local elementary school did not have a school nurse who could change his catheters regularly.

So Newell, PhD, RN, NCSN, decided to take on the job herself. She took a one-year sabbatical to help Cameron through kindergarten with the full expectation of returning to her previous work when Cameron entered first grade. But that never happened. Within a month, Newell was hired to serve as the school’s staff nurse, a position that had gone unfilled for almost a year. A few months later, she was asked to oversee nursing care for the entire school district—a position she has held ever since.

Newell’s story has another happy ending. Cameron was able to attend school regularly and outgrew the need for catheterization within a few months. He graduated from high school last spring.

But many other children are not getting the care they need to survive, and thrive, in school, according to Newell, an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows (ENF) program (2006-2009) who sits on its National Advisory Committee.

Erin Maughan, PhD, MS, RN, director of research at the National Association of School Nurses (NASN) and an RWJF ENF (2013-2016), agrees. Nationally, the number of school nurses is “woefully inadequate,” she said.

Students in a quarter of the nation’s public schools do not have access to a school nurse, according to the NASN.  Fewer than half (45 percent) of all public schools have a school nurse all day, every day, and another 30 percent have a school nurse who works part-time in one or more schools. Wide disparities exist between and within states and school districts.

The situation is especially dire in rural America, said Tami Thomas, PhD, RN, FAANP, an RWJF Nurse Faculty Scholar who works in Georgia. Many rural counties lack even a single physician or nurse practitioner, so the school nurse—if there is one—becomes the “frontline expert” during the school year and sometimes during the summer too, she said. “In these rural communities, school nurses are viewed as the conduit of health care information.”

Demand for school nurses is growing.

Medical advances are allowing more premature babies and others with severe health conditions to survive into adulthood, but these children often require complex, continuous care at home and at school. There is a rising incidence of diseases with life-threatening implications such as diabetes, seizures, asthma, bleeding disorders, and severe allergies, according to a 2010 report on the future of nursing by the Institute of Medicine (IOM). And there is an increase in mental health disorders, such as substance abuse problems, eating disorders, anxiety, depression, and aggression. “What we saw 20 years ago in acute care hospitals is what we’re seeing now in the schools,” Newell said.

Growing poverty rates are also taking a toll, Newell added. She sees students with rotting teeth who can’t afford dental care; students who share asthma inhalers and insulin strips with relatives because their families cannot afford enough supplies for each individual member; and students who go to school sick because their parents can’t afford to take unpaid time away from work to care for them.

Under these circumstances, an inadequate supply of school nurses can be deadly. In September, Laporshia Massey, 12, died after suffering a severe asthma attack at a Philadelphia school on a day when no nurse was present. Massey’s father has said that an on-site school nurse could have saved his daughter’s life. “We’re worried that more tragedies like this will occur” if students don’t have access to a school nurse, Maughan said.

A Vital Role

School nurses serve nearly 50 million students nationwide in nearly 100,000 public schools, according to the IOM report. They are a subset of the nation’s public health nursing workforce; learn more about this workforce in a 2013 RWJF report.

School nurses play a vital role in improving the health of children and the public, experts say. In 2009, to cite one example, a school nurse alerted health authorities to the arrival of the H1N1 flu virus in New York City, helping to curb the spread of the disease.

Ensuring that all students have adequate access to a school nurse is a daunting challenge, however, especially in the wake of a severe recession that has led to cuts to education and public health budgets across the country.

School support services, including nurses, are often targeted when budgets are tight, Maughan said, and nurse positions are sometimes “under-filled” with licensed practical nurses or health aides. “Educators are worried about test scores. If they don’t have the experience to understand how school nurses help students stay healthy so they can learn, they see under-filling nursing positions as an easy way to cut the budget.”

Recruiting school nurses is a challenge for other reasons as well, Maughan and Newell said. School nurses tend to earn lower salaries than peers in other settings, and suffer from an image problem that deters some nurses from entering the field. “People think it’s just handing out Tylenol and ice packs,” Maughan said. “But it’s much more than that.”

The National Association of School Nurses is adopting a number of strategies to address the problem. They include a public relations campaign to educate the public about the critical role school nurses play in education and in public health; efforts to encourage more school nurses to continue their education so they better understand their role in collecting and using data to advocate for their positions and to provide high-quality and effective care; and work to help develop a common data set so all school nurses collect the same kind of data in the same way.

The association is also supporting data collection to demonstrate the effectiveness of school nurses to policy-makers, as well as efforts to lower the ratio of students to school nurses in certain states. It also backs a prevention and public health fund created by the Affordable Care Act.

The IOM report, meanwhile, highlights the important role played by public-private partnerships, in which school nurses coordinate care among providers outside the school setting, and by primary care clinics located on school campuses. There are about 2,000 school-based health centers nationwide, it says, including one launched by Newell in Washington state as part of her RWJF ENF project.

But prospects for ensuring that all students have access to a school nurse, let alone comprehensive health care, may be bleak, Thomas said. “Children may be only 25 percent of the population, but they are 100 percent of the future.” But because school children don’t vote and have very little political power, she fears it is unlikely that they will have more access to school nurses any time soon.