As the school year unfolds, COVID cases continue to impact schools across the country because the majority of our students are unvaccinated. While school nurses scramble every single day to keep up with the contact tracing requirements, we are being asked to add additional duties to our already overextended workforce. School nurses often work in isolation. Few of us have administrative support or better yet, work with another school nurse.
Staffing for safe care in the midst of a pandemic must include a team of school nurses. The complicated needs of our students and staff should be met with the workforce that can properly manage this national emergency. Please realize that most school nurses work alone, cover multiple buildings and are working as the de facto health department with no additional supports. Most of us have no team to lean on or to share the workload.
Testing is ramping up in schools, which is a plus for school safety, but where is the staffing to meet this moment in time? Districts are unrealistic if they believe that school nurses should continue to work long past their school day ends, through evenings and weekends to keep ahead of the cases that continue to come. Do not throw a stipend our way as a half-hearted “atta girl,” give us the supports we need to address the enormity of the task at hand. Meet the needs of our school communities and end the gaslighting that the “school nurse can handle it.”
The National Association of School Nurses published this position paper in 2020, just prior to the pandemic:
School Nurse Workload: Staffing for Safe Care
It is the position of the National Association of School Nurses (NASN) that access to a registered professional nurse (hereinafter referred to as a school nurse) all day, every day can improve students’ health, safety, and educational achievement. Student acuity and school community indicators should be assessed to determine appropriate staffing levels. Access to a school nurse may mean that more than one school nurse is necessary to meet the needs of the school population. School nurse workloads should be evaluated on at least an annual basis to meet the health and safety needs of school communities (Jameson et al., 2018).
BACKGROUND AND RATIONALE
Since 1902, school nurses have contributed to individual and population health, in ever-expanding ways (Rogers, 1903/2014). Laws implemented in the 1970s established the rights for all students, even those with significant health needs, to attend public school, and led to recommendations for school nurse-to-student ratios. These laws included the Rehabilitation Act of 1973, Section 504 (1973), and Public Law 94-142, the Education for all Handicapped Children Act (1975), reauthorized in 2004 as the Individuals with Disabilities Education Improvement Act (IDEIA). Changes in these laws increased the role and responsibilities of the school nurse.
Appropriate staffing is necessary in order to provide safe care and ensure quality outcomes, and is accomplished through understanding and considering the complexities of the role of the nurse and the care that is provided (American Nurses Association [ANA], 2020). Using ratio of nurse to student alone is not evidence-based or appropriate. Other factors that should be considered include:
- Safety, medical acuity, and health needs of a student;
- Characteristics and considerations of student or population including individual social needs as well as the infrastructure that creates inequities in social determinants of health;
- Characteristics and considerations of the school nurse and other interprofessional team members; and
- Context and culture of the school or school district that influences nursing services delivered (Jameson et al., 2018).
Evaluation of staffing plans, overall costs, effectiveness, and resources expended also influences staffing decisions. Safe and appropriate staffing has an impact on population and community health outcomes, enriching the patient experience of care, reducing health care costs, and enhancing the work life of the healthcare provider (American Association of Critical-Care Nurses [AACN], 2016; Bodenheimer & Sinsky, 2014). Consistent with the research in acute care settings (Aiken et al., 2017; Brooks Carthon et al., 2019; Kelly & Todd, 2017; AACN, 2016), multiple studies suggest that appropriate school nurse staffing has an impact on the health and academic outcomes of the students and the school community and contributes to reduced health care costs and a healthier population (Arimas-Macalino et al., 2019; Best et al., 2017; Daughtry & Engelke, 2017; Gormley, 2018; Hill & Hollis, 2012; Jacobsen et al., 2016; Nikpour & Hassmiller, 2017; Wang et al., 2014).
Little data exists on validated tools to determine school nurse staffing. Current best practice for staffing involves analyzing complex factors including number of students, social determinants, acuity levels, other responsibilities, barriers to care, current use of technology, and health care to adequately meet the health and safety needs of the children whose care is entrusted to schools (Jameson et al., 2018). Such a structure helps detail a 21st-century context for nurse staffing that recognizes the individual contribution and added value of each individual nurse as a provider of care (ANA, 2020). NASN recommends ongoing research to develop evidence-based health assessment and other tools that consider multiple factors for the development of staffing and workload models.
The school nurse provides the critical link to address gaps in healthcare by serving students and the school community as the health expert. School nurses can navigate and address socio-economic issues, physical health needs and health behavior factors; respond to student and community needs; and work as advocates and change agents.
NASN believes that school nursing services must be determined at levels sufficient to provide the range of health care necessary to meet the needs of school populations. NASN recommends continuing research developing evidence-based tools using a multifactorial health assessment approach for evaluating factors that influence student health and safety and developing staffing and workload models that support this evidence. All students need access to a school nurse every day. In addition to the number of students covered, staffing for school nursing coverage must include acuity, social needs of students, community/school infrastructure, and characteristics of nursing staff.
Aiken, L. H., Sloane, D., Griffiths, P., Rafferty, A. M., Bruyneel, L., McHugh, M., Maier, C.B., Moreno-Casbas, T., Ball, J.E., Ausserhofer, D., Sermeus, W. (2017). Nursing skill mix in European hospitals: Cross-sectional study of the association with mortality, patient ratings, and quality of care. British Medical Journal of Quality & Safety, 26(7), 559–568. https://doi.org/10.1136/bmjqs-2016-005567
American Association of Critical-Care Nurses. (2016). AACN standards for establishing and sustaining healthy work environments. A journey to excellence, Executive Summary (2nd. ed.). http://www.aacn.org/wd/hwe/docs/execsum2016.pdf
American Nurses Association. (2020). Principles for nurse staffing (3rd ed.). https://cdn2.hubspot.net/hubfs/4850206/PNS3E_ePDF.pdf
Arimas-Macalino, C., Weismuller, P. C., & McClanahan, R. (2019). Addressing illness-related chronic absences. NASN School Nurse, 34(6), 357–362. doi:10.1177/1942602X19852749
Best, N. C., Oppewal, S., & Travers, D. (2017). Exploring school nurse interventions and health and education outcomes: An integrative review. The Journal of School Nursing, 34(1), 14–27. doi:10.1177/1059840517745359
Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. doi:10.1370/afm.1713
Brooks Carthon, J. M., Hatfield, L., Plover, C., Dierkes, A., Davis, L., Hedgeland, T., Sanders, A. M., Visco, F., Holland, S., Ballinghoff, J., Del Guidice, M., & Aiken, L. H. (2019). Association of nurse engagement and nurse staffing on patient safety. Journal of Nursing Care Quality, 34(1), 40–46. doi: 10.1097/NCQ.0000000000000334.
Daughtry, D., & Engelke, M. K. (2017). Demonstrating the relationship between school nurse workload and student outcomes. The Journal of School Nursing, 34(3), 174–181. doi:10.1177/1059840517725790
Gormley J. M. (2019). School nurse advocacy for student health, safety, and school attendance: Impact of an educational activity. Journal of School Nursing, 35(6), 401–411. doi:10.1177/1059840518814294
Hill, N.J., & Hollis, M. (2012). Teacher time spent on student health issues and school nurse presence. The Journal of School Nursing, 28(3), 181-186. doi: 10.1177/1059840511429684
Individuals with Disability Education Improvement Act (2004), 20 U.S.C. 1400 et seq.
Jacobsen, K., Meeder, L., & Voskuil, V. R. (2016). Chronic student absenteeism: The critical role of school nurses. NASN School Nurse, 31(3), 178–185. doi:10.1177/1942602X16638855
Jameson, B. E., Engelke, M. K., Anderson, L. S., Endsley, P. & Maughan, E. D. (2018). Factors related to school nurse workload. The Journal of School Nursing, 34(3), 211-221. doi: 10.1177/1059840517718063
Kelly, L., & Todd, M. (2017). Compassion fatigue and the healthy work environment. AACN Advanced Critical Care, 28(4), 351-358. doi:10.4037/aacnacc2017283
Nikpour, J., & Hassmiller, S. (2017). A full-time nurse for every school: A call to action to make it happen. NASN School Nurse, 32(5), 290–293. doi:10.1177/1942602X17723920
Rehabilitation Act of 1973, 29 U.S.C. § 504.
Rogers L. L. (2014). A year’s work for the children in New York schools. The American Journal of Nursing, 114(9), 60–62. doi:10.1097/01.NAJ.0000453758.31388.80
Wang, L. Y., Vernon-Smiley, M., Gapinski, M. A., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of school nursing services. JAMA Pediatrics, 168(7), 642–648. doi:10.1001/jamapediatrics.2013.5441
Acknowledgment of Authors:
Wendy Rau, MSN, BA, RN
Beth Jameson, PhD, RN, CNL, CSN-NJ
Christine Amidon BSN, RN, NCSN
Janet Thornton, MSN-Ed, RN
Wendy Wilson, BSN, RN, NCSN
Erin Maughan, PhD, MS, RN, PHNA-BC, FNASN, FAAN
Laurie Combe, MN, RN, NCSN
Adopted: January 2015
Reviewed: January 2020
Revised: June 2020
Suggested citation: National Association of School Nurses. (2020). School Nurse Workload (Position Statement). Author.
“To optimize student health, safety and learning, it is the position of the National Association of School Nurses that a professional registered school nurse is present in every school all day, every day.”
All position statements from the National Association of School Nurses will automatically expire five years after publication unless they have been renewed, revised, or retired at or before that time.