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School Nurse Shortage Update

The majority of school districts in the U.S. fail to meet recommended nurse-to-student ratios despite growing number of children needing complex care.

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In talking with a group of colleagues, a school nurse admitted recently that she had gone into the field a decade or two earlier thinking it would be less stressful than working in a hospital.

Everyone laughed.

"We all laughed because that's just not the case," said Linda Davis-Alldritt, MA, BSN, RN, FNASN, FASHA, president of the National Association of School Nurses (NASN). "School nurses have to be able to react to whatever student walks in through the door with whatever health issues they come in with."

With increased access to the classroom and a rise in the numbers of children living with diabetes, allergies and other chronic conditions, school nurses are more responsible than ever for a wide range of daily care.

"What I always like to say is that whatever the acute care nurse sees in the hospital or clinic, when those children leave, the great majority are going to be back in school within the next couple of days," she said. "So if the child has a tracheotomy or a gastrostomy, the school nurse must know how to handle that."

That's not even mentioning the health screening, health promotion, student planning, paperwork and meetings with administrators and staff regularly provided by the school nurse who often is the only adult on campus with any healthcare expertise.

Continuing education is another must, as the school nurse works autonomously and must understand the protocol for handling everything from seizure disorders to adrenal cortex issues.

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Yet, across the country, communities continue to grapple with funding school nurses to care for student populations with diverse and growing needs.

"The economy has really presented a lot of challenges," said Davis-Alldritt. "In some states, the number of school nurses has increased. In other states, it's decreased. It's hard to say specifically whether or not the situation is getting worse."

Schools Without Nurses

In many schools, however, the situation is not what it should be.

A report in the Twin Falls Times-News revealed that the number of full-time school nurse positions in Idaho from the years 2000-2008 grew from 93 to 121, with the most recent data suggesting somewhere around 136 full- and part-time positions.

But despite the increase, the state rates among the worst on the NASN student-to-school nurse ratio list. With a ratio of 1,881-to-1, it ranks 41st and falls far short of the recommended one nurse to every 750 well students recommended by NASN and Healthy People 2010. The article mentioned two part-time nurses at one school district who juggle the responsibility for 13 schools.

Meanwhile, an article on Northeast Florida's www.firstcoastnews.com  questioned the absence of nurses in many schools there. In Jacksonville, nurses at the Duval County Public School system each rotate among eight or nine assigned schools. When a nurse is not on-site, children receive care from administrative staff who have been trained by school nurses.

The scenario isn't uncommon in the region. Florida ranks 48 out of 51 for its student-to-school nurse ratios; nearby Georgia, 46.

"It is going to take one wrongful death, God forbid, or negligence. A person who is not a nurse cannot make a decision about whether a child's lungs sound clear or whether it is an asthma attack," Peyton Bryan, RN, told firstcoastnews.com.

The school nurse at Risley Middle School, Brunswick, GA, Bryan serves in a school district that has made it a priority to have a school nurse on-site full time.

Is Funding to Blame?

"The school nurse is absolutely essential in every single school in every single state in the country," said Judy Hightower, PhD, MEd, RN, dean of academic operations at Chamberlain College of Nursing's Phoenix campus and former school nurse.

"We are having kids with more and more complex problems, and there needs to be somebody in the school who can handle those kinds of things."

When questioned about a lack of school nurses, most districts blame lack of funding, which differs from state to state and could explain ratios that range drastically from first-place Vermont's 1-to-396 to worst-case Michigan's 1-to-4,411.

"Our schools are not a priority all of the time, so school funding is not always there," said Hightower. "It's a trickledown effect. If it's not there for teachers or programs, it's not going to be there for school nurses."

When county commissioners in Mecklenburg County, NC, met recently to set priorities for the 2014 fiscal year budget, local parents convinced them to bump up school nurses to their highest priority grouping, The Charlotte Observer reported Feb. 1.

The advocacy group Parents Advocating for School Health was founded by a woman who has a 5-year-old daughter with food allergies. Although administrators warned that additional funding might not be available, she told the newspaper she was pleased with the heightened priority school nurses garnered.

'School Nurse' Differentiations

In a September 2011 poll of about 1,000 school nurses conducted by NASN, 70% responded that their school districts had not reduced the number of RNs.

Meanwhile, 11% said the district had reduced the number of RNs on staff and had not replaced them with anyone.

Another 7% indicated the district had actually increased its RN staff, while 7% more said the district had reduced its RN staff and replaced them with LPNs.

Like funding, who, if anyone, fills a school's health office differs among states as well.

In Arizona, school districts are free to determine whether their school nurses will be BSN-prepared RNs, RNs, LPNs or health aides, Hightower said. The state ranks 34th in its student-to-nurse ratio.

"Who you have in those schools varies on a district-to-district basis, depending on how much money the district has to spend on that program," said Hightower, a former school board director.

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In Illinois, the state board of education is set to require that, beginning July 1, all recommendations for students with special-education needs come only from RNs with school nurse certification, The Register-Mail reported.

Districts who currently employ RNs without the certification told the newspaper that finding and funding certified school nurses will be difficult in a state with just a few certification programs and a projected $400 million reduction for education in the governor's next budget.

In California, all school nurses are required to have school nursing certification, said Davis-Alldritt, who lives in Sacramento. Since the credential requires 28-32 credits in an accredited university-based program, many school nurses go on to complete a few classes more and earn an MSN.

Yet the school nurse-to-student ratio in the Golden State is about 1-to-2,100, or 45th on the NASN ranking.

"The reality is, I was talking the other day to a school nurse in California who told me she is the only RN for a district of about 18,000 students. Her district employs health clerks to help her," said Davis-Alldritt.

"So she is it. She is responsible for doing all of the individualized healthcare plans for students with special needs, she is responsible for doing all of the assessments on those kids for individual education plans plus making sure all of the other students in the district are adequately cared for."

California requires no specific training or background for health clerks. That decision, said Davis-Alldritt, is up to each district.

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School nurses can play a lead role in preparing for emergencies on campus and in the community.

A Brighter Future

Despite high student-to-nurse ratios, dwindling budgets and the ongoing struggle to fund full-time nurses in many schools, Davis-Alldritt is hopeful things will get better.

The reason why is simple: She understands the value full-time nurses provide students, staff and the greater community.

"We know that healthy children learn better. And we know that school nurses make an impact in keeping kids healthy, in school and ready to learn. So I believe very strongly that there is a positive outlook for school nurses," she said.

"There needs to be - and will be - a change in the number of nurses in our school. We can't afford to do anything less as a society."

Jolynn Tumolo is a freelance writer.


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I strongly feel that there is NOT a nursing shortage in the schools or in the hospitals.
Recently a local hospital layed off 58+ nurses with experience.
Why? To replace with new nurses just graduating. This was a budget decision.
There are many nurses who want to work in a school setting. Schools are hiring lay people for the health room. Again, a financial decision.
Patient care is suffering greatly. Best defense: Bring an advocate with you when receiving any medical care.


Deborah Simmons,  RN Lead,  OCPSApril 19, 2013
Orlando, FL



I was a school nurse who went back to school and got the required credentialing along with my FNP. When I returned to my district with the goal of doing more for my students I worked one year then was laid off due to budget cuts. Rationale was that I was the last hired in spite of my past work history as a school nurse and being credentialed while other school nurses were working on theirs. It was very upsetting to have that happen when my goal was better care for the many students/staff under my care.

sandra peeke,  FNP,  clinicMarch 26, 2013
Cobb, CA



The only one who understands the scope and standards of the specialty of school nursing is someone who has been educated in that pediatric specialty. One who teaches to all the value of her/his knowledge of nursing interventions produces ethical and beneficial effects. Some fail to recognize the link between this specialty and quality pediatric nursing assessments and its outcomes. We are obligated to teach all with whom we communicate the value of this practice setting.

Jeanne Kiefner RN FNASN,  Educator,  Rowan UniversityMarch 21, 2013
Cherry Hill, NJ



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