PolicyLab

Editor's Note: This post is part of this year’s “Back to School” series in which our experts and guest authors discuss the need to support the health and well-being of youth as they return to school. For more, follow our hashtag #PolicyLabGoesBacktoSchool on Twitter.

The pandemic upended education and forced teaching and other school services online. Yet when in-person schooling returned, a  shortage of staff and funds, as well as additional duties related to COVID-19 safety precautions, meant a continued strain on student health services and school nurses. Even before the pandemic, staffing shortages existed; only 40% of schools employed a full-time nurse and 25% of schools did not have a nurse in any capacity. 

I observed the impact of these challenges first-hand in my role at an elementary school where I implemented language development, literacy and social-emotional programming. The school, while committed to enhancing opportunities for students and their families, faced resource limitations and the associated challenges. Pre-COVID-19, a lack of staff and classroom resources occasionally interfered with program implementation. Upon resuming my role when schools returned to in-person instruction, I quickly saw that the school faced additional challenges. Specifically, I observed administrators diverting from their responsibilities to address students’ health needs. 

In one example I recall, a student’s bruised head—the result of a playground injury—highlighted the absence of a school nurse. While the nurse was unavailable, one of the school’s administrators came to the aid of the student. She did her best to serve the student, but she also voiced her frustrations: without a school nurse on hand, this was not the first time in the day when she had been responsible for a student’s medical needs. As a PolicyLab intern, I have been expanding my knowledge of policies that impact child health and these experiences led me to explore what supports exist within schools to improve child well-being, specifically related to health services. Below, I’ll share how school nurses play a pivotal role in supporting children's health, outline the barriers to maintaining the services they provide and explore policy opportunities to address these challenges. 

The Impact of COVID-19 & Existing Challenges on School Nurses

School nurses are a source of quick fixes, band-aids, ice packs, and occasionally a bed to comfort an aching head or stomach—but they also play an important role in improving health equity. Routine screenings allow school nurses to support healthy development and early detection of health concerns. With an understanding of student health needs, school nurses can develop care coordination plans, assist families in accessing health insurance and implement health education programming. Research shows that these services have a positive impact on improving student attendance and overall student outcomes. 

The evidence also highlights the vital role school nurses play in community health. For example, efforts like student immunization events also offer parents an opportunity to address other common health concerns and promote community health education with a health care provider. 

But the pandemic exacerbated school nurses’ already limited capacity as they have worked nonstop to limit and reduce COVID-19 outbreaks through testing and contact tracing. In May 2021, a National Association of School Nurses (NASN) survey found that the majority of nearly 1,000 K-12 school nurses sampled reported an “increase in work-related responsibilities (68%), hours (73%) or stress (61%) compared to pre-COVID-19 pandemic.”  

To ensure a school has the capacity to support the range of student and community health activities, NASN recommends schools conduct needs assessments to determine the appropriate number of nurses needed to serve the student body population. Both community and student health data should be utilized to predict school districts’ nursing needs and effective distribution of resources. However, some states use a nurse to student ratio to determine staffing levels. In Pennsylvania, the ratio is one nurse per every 1,500 students. With this ratio, a nurse may support multiple schools, creating situations where staff and administrators with limited medical training become responsible for students’ health needs when a nurse is offsite.  

While school nurse shortages existed before the pandemic, this deficit is deepening and will be further exacerbated by an anticipated shortage of registered nurses in several states. Last year, $500 million of American Rescue Plan funding was set aside to assist school-based health services, but it is not expected to fully meet schools’ needs. As a result, school leaders will need to look to alternative strategies to address problems associated with the school nurse shortage.

Exploring Strategies to Support School Nurses

A 2019 PolicyLab assessment and review of school health services offered by the School District of Philadelphia reinforced the important role school nurses play in student and community health, but also the many responsibilities—clinical and administrative—required of them. To help balance these responsibilities, the report presented three opportunities to help optimize staffing models for the School District of Philadelphia that could also apply to other districts across the country:

1. use district data to establish unique staffing needs for each school,
2. hire full-time nurse substitutes to fill in gaps, and
3. shift non-medical tasks to health assistants. 

Additionally, building partnerships with local pediatricians and health centers can further support school nurses in addressing student health needs. As specified in the Good Samaritan Act, training staff and administrators to administer emergency medications to address urgent health needs can help ensure emergencies can be managed in the absence of a school nurse. Finally, additional and sustained investments should also be considered at the federal and state levels to prioritize school-based health services for students. 

Student health and well-being depends on school nurses, but failure to address issues of capacity and staff shortages weakens a key pillar for improving child health. Identifying and implementing supports for school nurses can help ensure all children have access to the critical services they provide.

Aliyah Jones is a policy intern at PolicyLab and a recent graduate of Rutgers University, where she studied psychology and social work.