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Diagnosing the School Nurse Shortage
As schools across the country grapple with the myriad challenges of operating during the COVID-19 pandemic, school nurses and their role in stemming the spread of the novel coronavirus have found themselves in the spotlight. This scrutiny has also served to highlight a problem that long predated the pandemic: the school nurse shortage.
Historically, the school nurse shortage has received less attention than the teacher shortage, yet nurses are an integral part of any educational organization — especially given that 1 in 4 students have chronic illnesses such as asthma or diabetes. A shortage of school nurses means that schools may have to ask staff without medical training to dispense students’ medication, manage allergies and asthma, monitor blood glucose levels, and handle medical emergencies. And although educators are trained in CPR and first aid, there simply is no substitute for an experienced, trained medical professional in case of an emergency.
The pandemic has highlighted that direct care is just one piece of the support that school nurses provide. They consult with school and district leaders, educate students and their families on how to stay safe and healthy, provide training for staff, perform case management for students with serious health concerns — just to name a few of their other responsibilities.
In fact, studies suggest that schools with a full-time RN on staff see a host of benefits:
- Fewer student absences and thus increased funding
- More time spent in class because non-medical staff are more likely to send students home
- More accurate medical records
- Increased immunization rates
- Fewer student pregnancies
- Better health outcomes for students with asthma or diabetes
There’s no question that they play a crucial role, which is why the American Academy of Pediatrics and National Association of School Nurses (NASN) both recommend having at least one registered nurse (RN) in every school. Additionally, NASN recommends a ratio of one nurse for every 750 students in the general population and a ratio of 1:225 for student populations requiring daily professional nursing.
But are school districts meeting these standards, or are they falling short?
The Assessment: School Nurses by the Numbers
There are currently no federal laws regulating school nurse staffing, and the subject is not tracked on a national level by the Department of Education. But between government data and peer-reviewed studies, we do know that overall, schools are not meeting the recommendations outlined above.
According to the Bureau of Labor Statistics, only about 84,200 RNs are employed as school nurses: enough to staff just 64% of schools with a full-time nurse. However, many nurses are responsible for covering multiple schools, or they work part-time. As a result, only 40% of schools have a full-time registered nurse on staff. 35% have a part-time RN, and the remaining 25% do not employ one at all.
Schools Staffed by a Full-Time RN
As is often the case with topics in K-12, national statistics on school nursing don’t fully portray the many variables between different schools.
- Classification: 84% of traditional public schools employ full- or part-time nurses, compared to 52% of charter schools and 35% of private schools.
- Setting: Rural schools are more likely to lack nursing support than those located in cities, towns, or suburbs.
- Percent of K-12 students approved for free or reduced-price lunch: The higher this percentage, the less likely it is that a school will have nursing support.
- Geography: West Coast and Midwestern states have the most schools without nursing support. Schools in the South are more likely to have an LPN, rather than an RN, as the only nurse in a school.
The Provisional Diagnosis: Challenges in Recruitment and Retention
The fact that less than 50% of K-12 schools have a full-time school nurse is not ironclad proof of an overwhelming school nurse shortage — at least in terms that most people think of it. Some schools do have difficulty recruiting nurses and struggle to find qualified applicants. After all, there is a national nursing shortage, so school districts find themselves competing against healthcare facilities for the same pool of applicants. And while being a school nurse has definite benefits in terms of having holidays and weekends off, as well as regular breaks, there are some pitfalls.
Registered nurses working in schools make significantly less than their counterparts in other industries. According to data from the Bureau of Labor Statistics (BLS), school nurses earn a median annual wage of $58,530 versus $75,030 for their peers employed by hospitals. However, the BLS calculates annual wages by multiplying workers’ hourly rate by 2080 — the number of hours worked in a year by someone who works forty-hour weeks every week. As school nurses generally do not work year-round, and their peers in other industries often earn a great deal of overtime, this income gap is likely much wider in reality.
Compounding the problem, high turnover exacerbates any staffing shortage, and school nurses suffer from high rates of job dissatisfaction. School nurses also report high levels of stress and burnout, especially when responsible for extremely high caseloads — sometimes including thousands of students. Finally, the majority of school nurses cover more than one school, which can contribute to a sense of being stretched thin or guilt for not being present at a specific school when a student needs help.
The Differential Diagnosis: Lack of Funding
But until data show that job postings for school nurses are going unfilled, it may be that the bigger challenge is in funding school nurses, not finding them. Cost is the most-cited reason why a school does not have a school nurse on staff, followed by the school’s size. Arguably, school size is directly related to cost: when budgets are tight, it’s harder to justify hiring a full-time nurse for a school with 50 students than one with 500. And while there is an ethical argument that every student should have access to a qualified nurse to care for their health problems, there just might not be funding to hire a full-time nurse for every school. It’s a horrible reality that school and district leaders need to weigh the risk that a student might have a severe medical emergency against a budget.
Financial struggles are not a new challenge for education organizations, which have been consistently underfunded and asked to do more with less, over and over again. The majority of school nursing is funded by local education dollars — which no doubt contributes to inequity in access to school nursing — although there is also some support from state governments and departments of health.
Treating the School Nurse Shortage
Every school and district leader, every educator and every administrator, is doing their best to ensure that students’ well-being is addressed to the greatest extent possible. While it is best practice to have a full-time RN in every school and enough staff to ensure a manageable ratio of nurses to students, it’s also important to consider what can be done when hiring the recommended number of RNs is not yet feasible.
For example, schools may want to focus on decreasing nurse turnover. While a raise may not be in the cards, there are ways to increase job satisfaction. For example, it may help to implement more streamlined processes and systems that save school nurses time and free them from administrative work. They may also wish to take a greater role in health education. Offering them more opportunities for hands-on education has the added benefit of helping students and the community become healthier overall.
Another option for some schools is to evaluate different staffing models. For example, in states that do not require school nurses to be registered nurses, some schools have taken to hiring licensed practical nurses (LPNs). At this time, there are 27,530 licensed practical nurses (LPNs) employed as school nurses. As they have a more limited scope of expertise and less training than RNs, who complete an intense four years of nursing school, LPNs command lower wages. While a small number of schools do employ an LPN as the sole nurse, there is truly no substitute for the training and expertise of an RN. However, it is worth considering a staffing model where LPNs are responsible for lower skilled tasks, freeing up the RN to handle higher priority work. For large schools, this may be a more cost-effective route than hiring only registered nurses.
When it comes down to it, the only way to meet school nurse staffing standards on a national level is to solve the funding crisis. In recent years, some states have introduced legislation and grants to fund more school nurses, and hopefully these initiatives increase in scope and are passed in other states as well. Also, the Free Care Act is expanding Medicaid billing in schools to include nursing services beyond students with IEPs, which presents another revenue opportunity for schools.
Education leaders can (and should) get creative in stretching funds to provide the best health services possible for students, but the only real cure is long-term dedicated funding for supporting our school nurses.
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Employment Statistics [accessed December 2020].
National Center for Education Statistics. U.S. Department of Education. (April 2020). School Nurses in U.S. Public Schools.
Willgerodt, M. A., Brock, D. M., & Maughan, E. M. (2018). Public School Nursing Practice in the United States. The Journal of School Nursing, 34(3), 232-244.