School Nurse Shortage

As the role of the school nurse grows, funds wane for school healthcare

School nurses do more than take temperatures and call home when a child is sick. They manage the insulin regimens of students with diabetes, supply quick-response asthma care, combat allergic reactions and care for students with epilepsy.

Illnesses that require daily medical attention have increased in children, and thus so have special healthcare needs in the school setting. Emotional, behavioral and developmental conditions such as autism, depression and attention deficit disorders exist in at least 17% of the student population.1 Anaphylactic food allergy among children increased by 18% from 1997 to 2007.2 According to the Asthma and Allergy Foundation of America, 8.6% of children have asthma.3

“We have seen an increase in chronic conditions affecting our students,” said Beth Mattey, MSN, RN, NCSN, president of the National Association of School Nurses (NASN). She said that in addition to diabetes, asthma and other medical conditions, injury plays a factor in a child’s academic career. “We have much more information on concussions and the need for brain rest after an injury. Return to learning is an important component of healing after a concussion, and school nurses work with the family, the healthcare provider and the school staff to ensure that the child has the accommodations needed for recovery.”

So why, with growing rates of illness and injury, does there seem to be so few school nurses?

A Nursing Shortage
Depending on a school’s location and tax revenue, it may not receive the necessary budget for school healthcare needs. Institutions of learning, schools and school boards must first cover education costs, causing the school nurse position to be overlooked.

Nurses across the country are spread thin, managing more than six schools a day. Oregon, which has “one of the poorest student-nurse ratios in the nation,” according to Nina Fekaris, MS, BSN, RN, NCSN, chair of Oregon’s task force on school nursing and president elect of NASN, has 1 school nurse for every 4,667 students.4North Carolina has 1 nurse per 1,112 students.5The nationwide accepted ratio is 1 school nurse to every 750 students.

Elizabeth Clark, MSN, RN, NCSN, a nationally registered school nurse, said age factors into the declining number of school nurses. “Because school nursing is a wonderful, independent, challenging nursing career, many school nurses stay in their position until retirement, 20 to 30 years,” she said. “There are many school nurses over the age of 50 and eligible for retirement in the next 5 to 10 years.”

Clark, who is the Colorado representative to NASN, also said funding is a big contributor to the shortage of school nurses.

“The school nurse shortage is a result of schools and local education agencies not investing the funds for a school nurse and not having adequate reimbursement for school nursing services,” Mattey agreed. “The American Nurses Association has a saying: ‘Nurses are an investment in the future, not a cost center.’ I say the same about school nurses. School nurses are an investment in the future of our children, linking health and education. We are not a cost center.”

A school nurse is defined as a person who has at least a bachelor’s degree in nursing and who is a registered nurse. Yet not every school has a nurse: only 50% of schools employ a registered nurse for at least 30 hours per week, and 18% have no nurse at all.6

When looking at programs and facilities, parents should always find out who is meeting the health needs of their child while in school. “It may not be a professional school nurse, and parents need to find out why not,” Mattey said.

NASN commissioned a workforce to determine how many school nurses are employed in the US and hope to have that number in the near future. The data will be able to show how a school defines its healthcare officials.

This word cloud represents the roles and growing responsibilities of the school nurse. Credit: NASN, 2016
This word cloud represents the roles and growing responsibilities of the school nurse. Credit: NASN, 2016

Importance of School Nurses
School nurses are vital to the academic routine. A school nurse administers prescribed medications to students during the school day, screens for vision and hearing, and much more. “The school nurse is generally the only healthcare professional in a school and provides recognition and early intervention for acute and chronic health conditions,” said Mattey.

Sometimes, the school nurse is the only healthcare provider a student sees. “Poverty has been shown to be a barrier to accessing healthcare,” Mattey said. “We are seeing more children who are food insecure and parents working in hourly jobs, having difficulty making ends meet.”

Studies show that when a nurse is present at a school, immunization adherence increases, as well as student attendance.7 School nurses spot communicable and infectious diseases before they spread school-wide, reducing the rates of absenteeism and increasing public school funding, which factors in attendance.

School nurses work with students who have disabilities (contributing to 504 plans and individualized education plans), educate students about healthy eating, promote tobacco education, and help students with chronic diseases better understand their conditions.

The most important part of a school nurse’s job is care coordination, Mattey said. “The school nurse is working with everyone impacting a child’s life, from educators to providers and parents.”

“I have found school nursing more challenging and rewarding than my years in acute care in pediatric nursing and PICU,” said Clark.

What are the Solutions?
The state of Oregon is looking in to numerous outlets for alternative methods to fund school nursing services. Suggestions include a $5 vehicle registration fee, taxing soda, accessing electronic health records in school, bringing in community health workers and creating a center for school-based health services.

Guilford County in North Carolina, where the school nurse-to-student ratio is 1 to 2,219, is looking into hiring certified nursing assistants to be in schools when a school nurse cannot.

In Clark’s home state of Colorado, the revenue schools generate is returned, used for school health services. “In 2014-15, $5.9 million were used to support school nurse salaries, according to the Colorado Department of Education School Medicaid annual report,” she said.

SEE ALSO: 5 Health and Safety Hazards at School

Medicaid is another outlet for schools to gain funds. “Often the funding [from Medicaid] either goes into the state’s general fund or the school district’s general fund to be used for other priorities,” said Clark. “There is hope that more funding will be available in the future. Centers for Medicare and Medicaid Services released a letter stating that Free Care did not apply to schools, therefore opening the door for states to increase their school Medicaid revenue.”

California and New Jersey are among the states already pursing this option.

Additionally, allying with hospitals is another way for schools to fund their school nursing program. A nurse knows when a child needs to visit an emergency room or when a child can heal without a visit, whereas teachers and parents may not. The school nurse is the key contact between providers and parents.

“The school nurse has a broad role in the school setting and recognizes the whole child and the factors that influence health and learning,” Mattey said. “The problem is in schools that don’t have nurses at all. Who’s handling those children’s needs?”


  1. Kids Count Data Center. Children Who Have One or More Emotional, Behavioral, or Developmental Conditions.
  2. National Center for Health Statistics. Food allergy among US children: Trends in prevalence and hospitalizations.
  3. Asthma and Allergy Foundation of America. Asthma Facts and Figures.
  4. Oregon Health Authority. Task Force on School Nursing.
  5. North Carolina Public Health. About Us: School Nurses.
  6. The American Federation of Teachers. Building Strong Children: Why We Need Nurses in Schools.
  7. National Center for Biotechnology Information. School-based Health Centers in an Era of Health Care Reform: Building on History.