The “Other” School Shortage: Nursing Services

A lack of teachers in U.S. schools garners most of the headlines, but how could a decreasing number of school nurses be impacting this country’s students?

Recent news that striking teachers in the city of Los Angeles were demanding, among other things, more nurses to be staffed within their schools could be an encouraging sign for one of the country’s more problematic states when it comes to the national shortage of school nurses. According to many local and national reports, the Los Angeles Unified School District has ratified a new agreement with United Teachers Los Angeles, the main representative of certified, non-administrative staff in the school district, to bring to an end a weeklong standoff. The tentative agreement reportedly calls for reducing the city’s growing class sizes and more support for students in the form of librarians, counselors, and nurses. For a state ranked No. 12th in terms of largest student caseload per nurse at a ratio of 2,240:1, California may serve as a model for future states to emulate when it comes to acquiring appropriate resources to students.
As it stands, the shortage of nurses within America’s schools is a national concern. According to research published in 2018, 25.2% of schools in the United States did not employ a school nurse and 35.3% of schools employed nurses at only a part-time capacity (fewer than 35 hours).1 Although studies have concluded that school nursing, as a specialized practice that advances the well-being, academic success, and lifelong achievement and health of students, is uniquely positioned to meet student health needs while serving a pivotal role in bridging healthcare and education while improving absenteeism,2,3 a lack of available full-time nurses for this country’s students persists.

According to the National Association of School Nurses (NASN), an organization established to optimize student health and learning by advancing the practice of school nursing, school nursing services must be determined at levels sufficient to provide the range of healthcare necessary to meet the needs of school populations and that social determinants of health and student healthcare needs must be considered when implementing appropriate school nurse staffing and workloads.

When contacted by ADVANCE for comments related to the shortage and ongoing advocacy for the addition of school nurses nationwide, the following statements were prepared: “It is the position of the NASN that school nurses play an essential role in keeping children healthy, safe, and ready to learn. The school nurse is a member of a unique discipline of professional nursing and is often the sole healthcare provider in an academic setting. It is essential that all students have access to a full-time school nurse all day, every day. If there is a child who isn’t feeling fell, especially those students with a chronic illness, such as asthma, food allergies, diabetes, obesity, and epilepsy, a school nurse works with students to ensure they are successfully managing their chronic illness so they remain in their seat, learning. Also, most parents/guardians may assume their school has a school nurse. 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.”

The benefits of appropriate mental healthcare awareness and intervention services has been found to be especially important in the school setting, where many sources of pressure can lead to high levels of stress for students (and employees), according to the National Education Association (NEA), the nation’s largest professional employee organization, which reportedly includes more than 14,000 communities across the country. The NEA’s Healthy Futures campaign is an example of an advocacy initiative that promotes a greater emphasis on mental services to help ensure that students experience the highest quality of life possible. According to NEA officials, the school connection to educators and other school personnel is a key protective factor in the lives of children and for their families and other community members.

A recent national workforce study estimates that 18.1% of schools do not have any paid school nurses. Additionally, full-time school nurses may not spend all their time in one school. NASN recommendations, meanwhile, call for all schools to have a full-time nurse with a baccalaureate degree. According to the Centers for Disease Control and Prevention (CDC), only 33.7% of school districts indicate they have a policy requiring schools to have a full-time nurse and only 18.1% of districts require schools to have at least a part-time nurse. The CDC also reports that the percentage of school districts with a policy requiring a newly hired school nurse to be a registered nurse decreased by 16.6% over the last 16 years. According to a 2016 study, school nurses are funded solely through education dollars.3 In New York City, an average of 25 public school buildings each day do not have a nurse assigned, according to an article recently published by the Wall Street Journal.5

10 Highest Student–to-Nurse Ratios (by State4*):

  1. Idaho (2,368:1)
  2. Ohio (2,377:1)
  3. Florida (2,605:1)
  4. North Dakota (2,828:1)
  5. Illinois (2,893:1)
  6. Oklahoma (3,110:1)
  7. Montana (3,137:1)
  8. Oregon (3,142:1)
  9. Michigan (4,204:1)
  10. Utah (4,893:1)

*The state of Hawaii reports that no registered nurses are employed in schools.

10 Lowest Student–to-Nurse Ratios (by State4*):

  1. Rhode Island (632:1)
  2. Maine (602:1)
  3. Wyoming (595:1)
  4. Kansas (552:1)
  5. Alaska (530:1)
  6. Delaware (519:1)
  7. Connecticut (460:1)
  8. Massachusetts (419:1)
  9. New Hampshire (347:1)
  10. Vermont (275:1)

*The Overseas School Health Nurses’ Association, a professional organization that supports school nurses employed outside of the continental United States, reports a ratio of 445:1.

1. Willgerodt, MA, Brock DM, Maughan EM. Public school nursing practice in the United States. J of School Nurs. 2018 34(3):232-44.
2. National Association of School Nurses. The role of the 21st century school nurse (position statement). Silver Spring, MD. 2016.
3. Maughan ED. School nurses: an investment in student achievement. Phi Delta Kappan. 2018;99(7),8-14.
4. A national look at the school nurse shortage. NEA. 2019. Accessed online:
5. Brody L. Nursing shortage leaves some city schools uncovered. Wall Street Journal. 2018. Accessed online:

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