It is the position of the National Association of School Nurses (NASN) that daily access to a registered professional school nurse (hereinafter referred to as a school nurse) can significantly improve students’ health, safety, and abilities to learn. To meet the health and safety needs of students, families, and school communities, school nurse workloads should be determined at least annually, using student and community specific health data.
School nurse-to-student ratios were first recommended in the 1970s, when laws were enacted to protect the rights for all students to attend public school, including those with significant health needs. Those laws included The Rehabilitation Act of 1973, Section 504 (2000) 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], (2004). Although evidence to support ratios was limited, some states and NASN recommended one school nurse to 750 students in the healthy student population; 1:225 for student populations requiring daily professional nursing services; 1:125 for student populations with complex healthcare needs; and 1:1 for individual students requiring daily, continuous professional nursing services (American Nurses Association [ANA]/NASN, 2011). While a ratio of one school nurse to 750 students has been widely recommended and was acknowledged in Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2014a) and by the American Academy of Pediatrics [AAP] (2008), a one-size-fits-all workload determination is inadequate to fill the increasingly complex health needs of students and school communities (AAP, 2008; ANA/NASN, 2011).
In addition to the laws that established rights for children with disabilities to attend school, medical advances have increased the number of students with special healthcare needs in schools. The Centers for Disease Control and Prevention (CDC) (2013) estimates that one in eight children are born prematurely, are more likely to have neurologic deficits and cognitive delays, and need lifetime health accommodations and/or require academic accommodations (Martin & Osterman, 2013; World Health Organization [WHO], 2012; Zirkel, Granthom, & Lovato, 2012). Students diagnosed and treated for cancer (American Cancer Society, 2012) or other life-threatening conditions such as congenital heart disease (American Heart Association 2014) return to schools sooner and often require special nursing care. Students who in the past would have been cared for in therapeutic settings now attend and must receive care in schools (Fauteux, 2010). Furthermore, the percentage of students who have chronic conditions such as asthma and diabetes, which require health care at school, has increased significantly (Van Cleave, Gortmaker, & Perrin, 2010; CDC, 2011a).
A growing body of evidence also indicates the impact social determinants have on health and the ability to address health concerns (CDC, 2014a). Where and how children live and play impacts their health. Shifting cultural, economic, political and environmental influences result in students and school communities with frequently changing health and social needs. These factors include economic instability, international strife, globalization, immigration, violence, and natural disasters (Weeks et al., 2013). The U.S. 2010 census revealed that the number of people who spoke a language at home other than English more than doubled between 1980 and 2010 (Ryan, 2013), and communication barriers challenge access to health care (Meyer, 2012). Global travel brings students in contact with infectious diseases such as H1N1 influenza, polio, Middle East Respiratory Syndrome (MERS), measles, and Ebola virus (CDC, 2010, 2012, 2014b, 2014c, 2014d). Increased mental health problems in students result from stress, disaster, and trauma (Chau, 2012; Harvard Educational Review, 2011; National Association of School Psychologists, 2012; WHO, 2012). Poverty continues to be a concern. Lower socioeconomic status is linked to poor health outcomes due to stressed environmental conditions, risky health behaviors, and limited access to health care (CDC, 2014a). Students and families affected by these challenges increasingly rely on access to school nurses for care.
School nurses serve as case managers, bringing providers, families, and schools together to support the health of our children and youth. School nurses facilitate children’s access to medical and dental “homes” and coordinate the care essential to addressing and improving their health (AAP, 2008; Association for Supervision and Curriculum Development (ACSD), 2014; Engelke, Swanson, & Guttu, 2014; Health Resources and Services Administration, n.d.). Schools are identified as primary locations to address student health issues, and the school nurse is often the healthcare provider that a student sees on a regular basis (Albanese, 2014; The Patient Protection and Affordable Care Act, 2010; Institute of Medicine [IOM], 2011, 2012). School nursing is a key component of the coordinated school health framework and is included in the Whole School, Whole Community, Whole Child model (ASCD, 2014; CDC, 2014e).
Appropriate school nurse staffing is related to better student attendance and academic success (Cooper, 2005; Moricca et al., 2013). When there is a school nurse present, a principal gains nearly an hour per day and teachers an extra 20 minutes a day to focus on education instead of student health issues (Baisch, Lundeen, & Murphy, 2011; Hill & Hollis, 2012). Baisch, Lundeen, & Murphy (2011) found that increased school nurse staffing resulted in improvements in immunization rates, vision correction, and identification of life-threatening conditions. Wang et al. (2014) determined that for every dollar spent for school nursing, $2.20 was saved in health care procedures and parent time away from work. Full-time school nurses in the schools studied by Wang et al. (2014) were attributed to preventing excess medical costs and to improved parent and teacher productivity.
Inadequate staffing can lead to adverse consequences (Kerfoot & Douglas, 2013). For example, the lack of access to a school nurse, who could have identified declining health status and provided or obtained necessary care, may have contributed to the 2014 deaths of two students in Philadelphia schools (Boyle, 2014; Superville & Blad, 2014). Insufficient staffing also leads to inconsistent care of students and to increased nurse turnover, which results in additional costs to school districts (American Association of Colleges of Nursing, 2014; Duffield et al., 2011; Hoi, Ismail, Ong, & Kang, 2010).
The determination of adequate nurse staffing is a complex decision-making process (ANA, 2014; Weston, Brewer, & Peterson, 2012). Individual state laws which regulate nursing practice to protect public health, safety and welfare must be followed. Student acuity status must be determined, as well as student care needs, including medications, health procedures, care coordination, case management, and staff training / supervision. In addition, a community health needs assessment will identify the social determinants that impact the health of students so that school nurses and administrators can plan to address those needs. Social determinants of community health and health disparities must be accounted for when determining school nurse staffing including how students and their families are affected by (CDC 2011b, 2014a; Fleming, 2011; Meyer, 2012; USDHHS, 2014b):
Health behaviors, health condition and disease prevalence, immunization levels;
Socioeconomic status, employment, education level;
Housing status, food security, transportation access;
Social and cultural supports and influences, discrimination;
Access to healthcare, health insurance, and social services;
Environmental stresses; and
Language and communication barriers.
NASN and the National Association of State School Nurse Consultants (NASSNC) (2012, 2014) assert that every student needs direct access to a school nurse so that all students have the opportunity to be healthy, safe, and ready to learn. In order to achieve adequate school nurse staffing, NASN recommends:
Using a multifactorial health assessment approach that includes not only acuity and care but also social determinants of health to determine effective school nurse workloads for safe care of students.
Developing evidence-based tools for evaluating factors that influence student health and safety and for developing staffing and workload models that support this evidence.
Conducting research to determine the best models for school nurse leadership in school health, such as RN only, RN-led school health teams, and RNs certified in the specialty practice of school nursing.
Increasing involvement of school nurses at national, state, and local levels in policy decisions that affect the health of students.
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. Social determinants of health and student health care needs must be considered when implementing appropriate school nurse staffing and workloads. Maintaining the health and safety of students is critical to the educational success and well-being of our nation’s children.
Related NASN Position Statements
Role of the School Nurse (2011)
School Nurse Role in Electronic School Health Records (2014)
Child Mortality in the School Setting (2012)
Albanese, E., (2014). School nurses serve many low-income students’ medical needs: Focus on safety, wellness & access to healthcare. http://www.schoolnewsnetwork.org/index.php/2014-15/school-nurses-bring-much-needed-medical-care-schools
American Academy of Pediatrics (AAP). (2008). The role of the school nurse. Pediatrics, 121(5), 1052 -1056. doi: 10.1542/peds.2008-0382
American Association of Colleges of Nursing. (2014). Nursing shortage. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage
American Cancer Society. (2012). Children diagnosed with cancer: Returning to school. Retrieved from http://www.cancer.org/treatment/childrenandcancer/whenyourchildhascancer/children-diagnosed-with-cancer-returning-to-school
American Heart Association. (2014). Impact on children. Retrieved from http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenitalHeartDefects/Impact-on-Children_UCM_307115_Article.jsp
American Nurses Association (ANA) & National Association of School Nurses (NASN). (2011). School nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursesbooks.org.
American Nurses Association (ANA). (2014). Connection between nurse staffing and patient outcomes can be made in all hospital clinical areas with expanded measures. Retrieved from http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2014-PR/Connection-between-Nurse-Staffing-and-Patient-Outcomes.pdf
Association for Supervision and Curriculum Development (ASCD). (2014). Whole school, whole community, whole child: A collaborative approach to learning and health. Retrieved from http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdf
Baisch, M.J., Lundeen, S.P., & Murphy, M.K. (2011). Evidence-based research on the value of school nurses in an urban school system. Journal of School Health, 81(2), 74-80. doi: 10.1111/j.1746-1561.2010.00563.x
Boyle, J. (2014, September 3). Suit: Lack of school nurse contributed to 12-year-old asthmatic girl’s death. Pennsylvania Record. Retrieved from http://pennrecord.com/news/14598-suit-lack-of-school-nurse-contributed-to-12-year-old-asthmatic-girls-death
Centers for Disease Control and Prevention (CDC). (2010). 2009 H1N1: Overview of a pandemic. Retrieved from http://www.cdc.gov/h1n1flu/yearinreview/yir5.htm
Centers for Disease Control and Prevention (CDC). (2011a). Asthma in the U.S.: Growing every year. CDC Vital Signs. Retrieved from: http://www.cdc.gov/VitalSigns/Asthma/index.html
Centers for Disease Control and Prevention (CDC). (2011b). Best practices for community health needs assessment and implementation strategy development: a review of scientific methods, current practices, and future potential. Retrieved from http://www.cdc.gov/policy/ohsc/chna/
Centers for Disease Control and Prevention (CDC). (2012). Global health: Polio. Retrieved from http://www.cdc.gov/polio/why/index.htm
Centers for Disease Control and Prevention (CDC). (2013). Reproductive health preterm birth. Retrieved from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm
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Centers for Disease Control and Prevention (CDC). (2014c). Measles cases and outbreaks. Retrieved from http://www.cdc.gov/measles/cases-outbreaks.html
Centers for Disease Control and Prevention (CDC). (2014d). CDC and Texas Health Department confirm first ebola case diagnosed in the U.S. Retrieved from http://www.cdc.gov/media/releases/2014/s930-ebola-confirmed-case.html
Centers for Disease Control and Prevention (CDC). (2014e). Whole school, whole community, whole child (WSCC): A collaborative approach to learning and health. Retrieved from http://www.cdc.gov/healthyyouth/wscc/index.htm
Chau, E. A. (2012). The role of the private and parochial school nurse during and after a disaster. NASN School Nurse, 27(3), 116-8. doi: 10.1177/1942602X12442089
Cooper, P. (2005). Life before tests: A district’s coordinated health approach for addressing children’s full range of needs. School Administrator, 62(9), 25-34. Retrieved from http://www.aasa.org/SchoolAdministratorArticle.aspx?id=7780
Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255. doi:10.1016/j.apnr.2009.12.004
Engelke, M., Swanson, M., & Guttu, M. (2014). Process and outcomes of school nurse case management for students with asthma. The Journal of School Nursing, 30(3), 196-205. doi: 10.1177/1059840513507084
Fauteux, N. (2010). Unlocking the potential of school nursing: Keeping children healthy in school and ready to learn. Charting Nursing’s Future, 14, 1-8. Retrieved from http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf64263
Fleming, R. (2011). Use of school nurse services among poor ethnic minority students in the urban Pacific Northwest. Public Health Nursing, 28(4), 308-316. doi: 10.1111/j.1525-1446.2010.00929.x
Harvard Educational Review. (2011). Symposium: Learning after disaster, voices from Haiti and New Orleans. Retrieved from http://hepg.org/her-home/issues/harvard-educational-review-volume-81-number-2/herarticle/voices-from-haiti-and-new-orleans_819
Health Resources and Services Administration (HRSA), Maternal and Child Health. (n.d.). Early Periodic Screening, Diagnosis and Treatment (EPSDT) overview. Retrieved from http://mchb.hrsa.gov/epsdt/overview.html#1
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
Hoi, S.Y., Ismail, N., Ong, L.C., & Kang, J. (2010). Determining nurse staffing needs: The workload intensity measurement system. Journal of Nursing Management, 18(1), 44-53. doi: 10.1111/j.1365-2834.2009.01045.x
Individuals with Disability Education Improvement Act (2004), 20 U.S.C. 1400 et seq.
Institute of Medicine (IOM). (2011). The future of nursing: leading change, advancing health. Washington, D.C.: National Academies Press. Retrieved from http://thefutureofnursing.org/sites/default/files/Future%20of%20Nursing%20Report_0.pdf
Institute of Medicine (IOM). (2012). Primary care and public health: Exploring integration to improve population health. Washington, DC: The National Academies Press. Retrieved from http://www.iom.edu/Reports/2012/Primary-Care-and-Public-Health.aspx
Kerfoot, K.M., & Douglas, K.S. (2013). The impact of research on staffing: An interview with Linda Aiken-Part 1. Nursing Economic$, 31(5), 216-220, 253. Retrieved from http://www.nursingeconomics.net/necfiles/news/SO_13_Kerfoot.pdf
Martin, J.A., & Osterman, M.J.K. (2013). Preterm births — United States, 2006 and 2010. Morbidity and Mortality Weekly Report (MMWR), 62(03), 136-138. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a22.htm?s_cid=su6203a22_e
Meyer, D. (2012). Lost in translation: Conference addresses ways to overcome language barriers in health care. Yale School of Public Health [online]. Retrieved from http://publichealth.yale.edu/news/archive/article.aspx?id=4411
Moricca, M.L., Grasska, M.A., BMarthaler, M., Morphew, T., Weismuller, P.C., & Galant, S.P. (2013). School asthma screening and case management: Attendance and learning outcomes. The Journal of School Nursing, 29(2), 104-12. doi: 10.1177/1059840512452668
National Association of School Psychologists. (2012). Managing strong emotional reactions to traumatic events: Tips for parents and teachers. Retrieved from http://www.nasponline.org/resources/crisis_safety/Managing_Strong_Emotional_Reactions_2012.pdf
National Association of State School Nurse Consultants (NASSNC) and National Association of School Nurses (NASN). (2012). Safe school nurse staffing for quality school health services in schools (Joint Consensus Statement). Retrieved from http://www.nasn.org/Portals/0/statements/consensus_safe_sn_staffing.pdf
National Association of State School Nurse Consultants (NASSNC) and National Association of School Nurses (NASN). (2014). School nursing services data: Standardized documentation, collection and utilization (Joint Resolution). Retrieved from http://www.schoolnurseconsultants.org/wp-content/uploads/2013/04/School-Nursing-Services-Data-Resolution-FINAL.pdf
Patient Protection and Affordable Care Act, 42 U.S.C. § 18001. (2010). Retrieved from http://www.healthcare.gov/law/full/index.html
Rehabilitation Act of 1973, 29 U.S.C. § 504.
Ryan, C. (2013). Language use in the United States: 2011: American community survey reports. Retrieved from http://www.census.gov/prod/2013pubs/acs-22.pdf
Superville, D., & Blad, E. (2014). Philadelphia tragedy highlights role of school nurses. Education Week, 33, 7. Retrieved from http://www.edweek.org/ew/articles/2014/06/04/33philly_ep.h33.html?qs=Philadelphia+tragedy+highlights+role+of+school+nurse
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Van Cleave, J.S., Gortmaker, L., Perrin, J.M. (2010). Dynamics of obesity and chronic health conditions among children and youth. Journal of the American Medical Association, 303 (7), 623-30. doi: 10.1001/jama.2010.104
Wang, L.Y., Vernon-Smiley, M., Gapinski, M., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of school nursing services. Journal of the American Medical Association-Pediatrics, 168(7), 642-648. doi: 10.1001/jamapediatrics.2013.5441.Retreived from http://archpedi.jamanetwork.com/article.aspx?articleID=187277
Weeks, S., Barron, B., Horne, M., Sams, G., Monnich, A., & Alverson, L. (2013). Responding to an active shooter and other threats of violence. Nursing, 43(11), 34-37. doi:10.1097/01.NURSE.0000435201.57905.38
Weston, M. J., Brewer, K. C. & Peterson, C. A. (2012). ANA principles: The framework for nurse staffing to positively impact outcomes. Nursing Economics, 5(30), 247-252. Retrieved from http://europepmc.org/abstract/MED/23198606
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Zirkel, P. A., Granthom, M. F., & Lovato, L. (2012). Section 504 and student health problems: The pivotal position of the school nurse. The Journal of School Nursing, 28(6), 423-432. doi: 10.1177/1059840512449358
Acknowledgement of Authors: (listed alphabetically):
Rosemary Dolatowski, MSN, RN
Patricia Endsley, MSN, RN, NCSN
Cynthia Hiltz, MS, RN, LSN, NCSN
Annette Johansen, MEd, RN, NCSN
Erin Maughan, PhD, MS, RN, APHN-BC
Lindsey Minchella, MSN, RN, NCSN, FNASN
Sharonlee Trefry, MSN, RN, NCSN
Adopted: January 2015
This document replaces the position statement Caseload Assignments (Adopted June 1982, revised June 1995, July 2004, June 2006, 2010).
Suggested citation: National Association of School Nurses. (2015). School nurse workload: Staffing for safe care (Position Statement). Silver Spring, MD: Author.