The School Nurse Shortage

To an outsider, the view of a school nurse's role can be a distorted one. But, the reality is much different.

Will universities start teaching a course for their teachers on how to be a nurse? Will teachers have to start studying pharmacology and basic anatomy? Perhaps they should if things keep going the way they are now in the American educational system.

On July 17, Kaiser issued a report about how the shortage of school nurses would put the role of nursing care of students on teachers, rather than solving the school nurse shortage. In fact, in some cases, nurses are training teachers to do such tasks as administering insulin injections.

Federal guidelines in the United States state that there should be one nurse for every 750 students in the schools. However, according to an article published in the Online Journal of Issues in Nursing, Legislative: Shortage of Nurses: The School Nursing Experience by Ozo M. Nwabuzor, MSN, RN, February 2007, the numbers vary considerably across the country and can be much higher: “In California, for example, the school nurse to student ratio can be as high as one nurse to 5,000 students or more.”

To an outsider, the view of a school nurse’s role can be a distorted one. They see a role that can be performed not only by teachers, but by unlicensed, untrained school personnel. But, the reality is much different. The days of the school nurse being responsible for sex education, calling parents to come get sick children, and patching up scratches from the playground are long gone. The school nurse now plays a much stronger role in the health and well-being of the students, especially in lower-income areas where the school nurse may be the students’ only contact with a healthcare professional.

The National Association of School Nurses (NASN) adopted this definition 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).

In today’s world, the school nurse deals every day with students with life-threatening allergies, chronic illnesses, sexually transmitted diseases, and pregnancies, among other issues. The importance goes even beyond these tasks, however. As the members of the NASN push for full-time school nurses though out the education system, they published a resolution in 2003 that stated: “research has shown that school districts with adequate nursing coverage have fewer absences, a decreased drop out rate, and higher test scores.”

Even the American Academy of Pediatrics (AAP) has recognized and advocated for the presence of school nurses. In a Policy Statement published in 2008 (Role of the School Nurse in Providing School Health Services (2008)), they stated, “The school nurse has a crucial role in the seamless provision of comprehensive health services to children and youth.” The statement goes on to say that school nurses provide more than on-the-spot care, but are in place to do screening and provide interventions for chronic illnesses, mental health issues, and abuse issues. The nurses see students who may face issues of homelessness, physical and sexual abuse, malnutrition, and violence.

Currently, there are no minimum requirements to perform the tasks of a school nurse — which could be part of the problem in administrations passing off nursing duties to those who are not qualified. The NASN would like to see such requirements and is advocating for this. In 2003, they published a position statement that said, “It is the position of the National Association of School Nurses that advanced practice registered nurses can provide unique and valuable services for students. In those communities where students do not receive consistent, appropriate medical care, advanced practice registered nurses offer a cost effective solution to this need. School districts that include both school nurses and advanced practice nurses on their staffs will be able to offer a broader range of health services. The anticipated outcome is more health needs of students being met, resulting in a positive impact on the health and educational performance of students.”

Some may argue that the dearth of school nurses is more due to the declining number of nurses in general. While this may play a small part in the problem, it’s highly unlikely that this is a major player. In fact, many nurses would quickly and willingly leave their hospital work to work in a school environment, given the opportunity.

So, is the solution to allow teachers to take on the role of school nurse? It’s highly unlikely that they even want to do nursing tasks. With the ever increasing workload on teachers and the unrealistic expectations that many of them face already, to ask them to take on yet another task, one that is beyond their knowledge and skill base, may be the tipping point for some.

Part of the reason for this could be the reluctance of yet another responsibility, but it also could lie in the very real fear of making an irreversible error. According to Nwabuzor, “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."” Sadly, having non-nurses play a nursing role has resulted in injury and, in some cases, death.

The issue is a complicated one because of the factors involved: cost, availability, and willingness to accept the vital role of the school nurse. But as society continues to change and rely on the interventions of front-line workers, such as school nurses, these issues must be addressed before more children slip through the cracks and more children die because they weren’t noticed — or they didn’t receive the assistance and treatment that they needed.