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Policy & AdvocacyPosition Papers and ReportsNASN Position Statements Full View    January 27, 2015
Caseload Assignments (Revised 2010)

See also Amy Garcia’s article in NASN School Nurse 24(5),198:  “Dear Lillian…Convincing My School District to Lower the Nurse to Student Ratio to 1:750”.  (2009, September)


Caseload Assignments


Position Statement

printable version

It is the position of the National Association of School Nurses (NASN) that schools should employ professionally prepared Registered Nurses, to conduct and supervise school health programs which address the variety of health problems experienced by school children.  NASN recommends a formula-based approach with minimum ratios of nurses-to-students depending on the needs of the student populations as follows:  1:750 for students in the general population, 1:225 in the student populations requiring daily professional school nursing services or interventions, 1:125 in student populations with complex health care needs, and 1:1 may be necessary for individual students who require daily and continuous professional nursing services.  Other factors that should be considered in the formula-based approach are number of students on free or reduced lunch, number of students with a medical home, and average number of emergency services per year.
The school nurse functions as a leader and the coordinator of the school health services team.  The American Academy of Pediatrics (AAP) emphasizes the crucial role school nurses have in the seamless provision of comprehensive health services to children and youth as well as in the development of a coordinated school health program.  The AAP acknowledges that the school nurse facilitates access to a medical home for each child and coordinates a school health program that meets the needs of the whole child and supports school achievement (American Academy of Pediatrics [AAP], 2008).  It continues to be the goal of NASN to provide children and youth with access to the primary school health care resource, the school nurse.

There are a wide variety of factors that have historically affected the school nurse to student ratios.  These include insufficient funding for school health services, local acceptance and understanding of the school nurse role. School districts across the nation use various models to deliver school health services.   To date, 45% of public schools have a school nurse all day, every day, with another 30% working part time in one or more schools (NASN, 2007).  Caseloads vary widely, between states and within states.  Throughout the nation, many school nurses provide health services to multiple school buildings, limiting the access that students have to a school nurse.  When there is no registered nurse on the school premises, the responsibility to administer the necessary medications and treatments, and appropriate monitoring of the children falls on the shoulders of administrators, educators, and staff that are ill-prepared to perform these tasks (ANA, 2007). 
Currently 98% (52 million) of the nation’s school children spend their day in schools (NCES, 2008).  Notably 16% of the 52 million students have chronic physical, emotional or other health problems.  Students today face increased social issues as well as the need for preventative services and interventions for acute and chronic health issues (AAP, 2008). Factors that impact the need for a more comprehensive delivery of health care services in schools include:

  • The IDEA/Individuals with Disabilities Education Act Federal law and the Section 504 provision of the Vocational Rehabilitation Act which mandate health-related services to children and adolescents in school (Section 504, 2005; IDEA, 2004).

  • An increase in the number of children with complex health problems. Overall, 15% to 18% of children and adolescents have a chronic health condition (Perrin, 2007).  From 2002 to 2008, the percentage of children in special education with health impairments, due to chronic or acute health problems, increased 60% (Bloom, 2009).  Within this group, the rate of children with autism has doubled since 2002 (Bloom, 2009).  A 40% increase in asthma has been seen in the past ten years (Levy, 2006), along with nearly 50% increase in the incidence of diabetes in the same time period (CDC, 2009).

  • The Centers for Disease Control and Prevention report that the percentage of children without health insurance was 8.9% in 2008 (CDC, 2009).  With over 1.3 million homeless children in our country, schools have become the only source of health care for many children and adolescents.

  • Language barriers face many families, including the children of immigrants.  Families that face barriers of communication have been found to be less likely than others to have a usual source of medical care (Flores, 2006).

  • Availability of affordable health care in the community may affect the need for school health services (RWJF, 2009).

  • Communicable and infectious diseases impact school attendance and require school nurse surveillance and reporting. “Infectious diseases account for millions of school days lost each year for Kindergarten through 12th grade public school students in the United States: 40% of children aged 5-17 years missed 3 or more school days in the past year because of illness or injury” (CDC, 2009).  School nurses have a positive impact on immunization rates with fewer parent requested exemptions (Salmon, 2005).

Every student in our schools, where instruction and learning are the primary goals, benefits from the assessment and treatment skills of a school nurse to keep him or her in the classroom and ready to learn.  Students at risk for educational failure may have social, emotional, or physical health concerns that must be addressed before optimal achievement can take place. 
School nurses use assessment and intervention skills to keep students in classrooms where education takes place.   One study’s results showed that school nurses attended to 64% of a given student population (grades 1 – 12) and returned 95% to class as opposed to the non-licensed staff that saw 36% and returned 82% to class (Pennington, 2008).  A similar separate study result showed that students were two times as likely to leave school early on days that the school nurse was not in the building (Wyman, 2005).
The National Association of School Nurses suggests measuring nurse staffing requirements using a caseload assignment formula.  In the example below, of an abbreviated caseload formula, the student population is 1000.   One medically fragile student requires mechanically supported breathing with a ventilator.  Three students require feedings through a gastrostomy tube inserted through their abdomen; five students have insulin dependent Type 1 diabetes; 50 students have serious asthma or allergies requiring monitoring and medication; three students require urinary catheterization; and nine have other complex needs. One hundred thirty students require medication during the school day. The remaining 797 students have state mandated health screenings (vision, hearing, BMI, etc.) and health promotion and periodic health care needs. (Garcia, 2009) 

Ratio  Number of Students  Divided by  Equals
1:1 1 1 1
1:125 72 125 .58
1:225 130 225 .58
1:750 797 750 1.06

Total Nursing Needs:


3.2 School Nurses

Ratio for this school population:

Nurses/Total Students



The utilization of this type of formula illustrates the importance of considering the individual medical needs of students in establishing appropriate school nursing coverage.  Therefore, the National Association of School Nurses strongly urges each state to mandate a maximum caseload, based on student acuity levels, with funding attached to the mandate.

American Academy of Pediatrics. (2008). Role of the school nurse in providing school health services. Retrieved from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;121/5/1052.pdf.

American Nurses Association. (2007). Assuring safe, high quality health care in pre-k through 12 educational settings.  (Monograph). Silver Spring, MD. American Nurses Association.

Bloom B., & Cohen R.A. (2009). Summary health statistics for U.S. children: National Health Interview Survey, 2007. National Center for Health Statistics, Vital Health Stat 10 (239)

Centers for Disease Control. (2009). Number (in millions) of civilian/non-institutionalized persons with diagnosed diabetes, United States, 1980–2007.  Retrieved from http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm

Centers for Disease Control. (2009). Summary health statistics for U. S. Children: National Interview Health Survey. Vital and Health Statistics 10 (249). Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_247.pdf 

Garcia, A (2009, September), Dear Lillian…Convincing my school district to lower the nurse to student ratio to 1:750.  NASN School Nurse 24(5),198.

Flores, G. (2006). Language barriers to health care in the United States, New England Journal of Medicine, 355:229-231

Levy, M., Heffner, B, Stewart, T., & Beeman, G. (2006). The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. Journal of School Health, 76, 320-324

National Association of School Nurses. (2007). School nursing in the United States:  A quantitative study. National Association of School Nurses. Silver Spring, MD

National Center for Educational Statistics (NCES). (2008). Digest of Education Statistics, 2007. Retrieved from http://nces.ed.gov/programs/digest/d07/

Perrin, J., Bloom, S., & Gortmaker, S. (2007). The increase of childhood chronic conditions in the United States. Journal of the American Medical Association, 297(24), 2755-2759

Salmon, D. A., Omer, S. B., Moulton, L. H.,  Stokley, S.,  deHart, M. P.,  Lett, S., Norman, B., Teret, S. & Halsey, N. A.  (2005). Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. American Journal of Public Health, 95: 436-440.

Pennington, N, & Delaney, E. (2008).  The number of students sent home by school nurses compared to unlicensed personnel.  Journal of School Nursing, 24, 290-297

Robert Wood Johnson Foundation. (2009). Unlocking the potential of school nursing: Keeping children healthy, in school, and ready to learn.  Retrieved from http://www.rwjf.org/files/research/cnf14.pdf

Wyman, L. L. (2005). Comparing the number of ill or injured students who are released early from school by school nursing and non-nursing personnel. Journal of School Nursing, 21, 350-355

Acknowledgement of Authors:        
Bonnie V. DuRant, BSN, MSA, RN
Linda J. Gibbons, MSN, IL/NCSN, RN
Cynthia Poole, BSN, RN
Mary Suessmann, BSN, MS, RN
Leah Wyckoff, BSN, MS, RN 

Adopted:  June 1982,
Revised:  June 1995, July 2004, June 2006, 2010

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