School nurses keep students healthy, safe, and ready to learn.
It’s more than just boo-boos, Band- Aids, and medication administration, Robert Mehl, BSN ’84, RN, says about school nursing, the profession he’s worked in for more than 30 years.
School nurses play a critical role in keeping students safe, healthy, and ready to learn. Unlike many bedside nursing positions, school nurses spend years with their patients. Watching them grow from young children into adolescence and adulthood is part of what makes the job so rewarding, he says. “You really can make a difference in children’s lives and their education,” says Mehl, who was the first male nurse hired by Baltimore County Public Schools, in 1987.
The past couple of years have been exceptionally challenging for all health care workers, especially for school nurses. Their role has shifted from specialized health care provider and educator – teaching students, parents/guardians, and school staff how to manage chronic illnesses, for example – to full-time COVID-19 contact tracer, in many cases. But they’ve also been instrumental in bringing vaccination clinics to their students and families, a community health initiative that was in place before the COVID-19 pandemic but is even more essential now.
The urgent challenges that schools are facing, including staffing shortages and increased mental and behavioral health problems among students, existed before the pandemic, but COVID-19 has amplified these issues. School nurses have always provided evidence-based care within the educational system, but the comprehensive care and leadership they provide has not always been well understood.
“School nurses need to become experts in many, many aspects of pediatric primary care – things as diverse as blood lead screening standards, specific disorders of hearing and vision in young children and what to do, managing anaphylaxis and allergies in the school setting,” explains Elizabeth Elliott, MS ’02, BSN ’95, RN, CDCES, NCSN, a nurse manager for school health services in the Montgomery County Department of Health and Human Services. “They become experts in students with special needs across a wide range of various syndromes and conditions that may impact students in a general education setting.”
A WEARY WORKFORCE
The issues plaguing school nurses today are similar to those impacting all health care providers. The workforce is stretched thin, and the aspects of the work that attracted them to the position are overshadowed by the disruptions of COVID-19. For school nurses, that includes the demands of contact tracing and responding to ever-changing national and local guidance.
School nurses have always spent a large portion of their time managing the social-emotional needs of students, but the number of students in crisis has increased significantly. Educators see more violent conflicts among students, and teachers are breaking up more fights. They’re also finding that many children are unable to manage being in the classroom setting and around peers because of the time spent isolated at home during remote schooling. “I think what we’re all feeling now is we can’t do the job that we feel called to do because we’re managing a myriad of aspects related to COVID-19,” Elliott says.
School nurses are seeing setbacks among students with chronic conditions as well. “That’s what keeps me up at night,” Elliott says. “The student with diabetes whose chronic disease is not well controlled – I’m afraid that we’re going to miss it because we’re so focused on COVID-19. That has caused a lot of distress among staff.”
Health care workers across the country are burned out, and older nurses are retiring, a trend that has been forecasted by nursing organizations for the past decade. Whether schools with open nurse positions can continue to attract the specialized providers needed is a concern.
A significant pay disparity affects hiring efforts too. Registered nurses (RNs) working in hospitals and other acute care settings can earn tens of thousands of dollars more than school nurses, according to data from the Bureau of Labor Statistics. “Pay disparity is a chasm and a challenge for recruiting school nurses,” says Donna Mazyck, MS, RN, executive director of the National Association of School Nurses (NASN). “According to our data, 80% of school nurse salaries come from local education funding, not health care entities, and that’s a concern. That is not going to be on parity with hospitals.”
The number of school nurses per school district varies, but fewer than 40% of the nation’s public schools have a full-time RN on staff, according to a 2017 NASN survey. At least 25% of schools have no nurse, and 35% have only a part-time nurse, the survey found.
NASN advocates for a full-time, baccalaureate-prepared RN at every school. But many districts across the country utilize different practice models, including a cluster model of service delivery, where one RN is assigned to deliver health services at several schools. A health assistant or licensed practical nurse is on site to assist with some tasks, but the RN has to drive to multiple schools in one day to attend to students who might need medication, such as insulin injections.
For many American children, the school nurse is their sole health care provider. There are wide school nurse ratio disparities across the country, and the numbers vary state to state, within states and school districts, and between urban and rural schools. NASN has been working with national lawmakers for years to pass the Nurses for Under-Resourced Schools Everywhere (NURSE) Act, which would recognize the critical role of school nurses in providing students access to quality health care and provide federal funding through grants for school nurses. The NURSE Act would also ensure student access to a school nurse, especially in Title I schools where child health and social needs are greatest.
Students have more significant health care needs than ever before, Mazyck says. Today’s children face more medically complex conditions and chronic illnesses than previous generations. Since 2000, there’s been a 15% increase in students served under the Individuals with Disabilities Education Act, which include children diagnosed with autism and with hearing, speech, and vision impairments. Additionally, about two in five U.S. children have a chronic health condition such as asthma, diabetes, or epilepsy, according to the Centers for Disease Control and Prevention, and managing those conditions in the school setting requires a school nurse’s skills and expertise. The American Nurses Association has reported that when there is no RN at a school, the responsibility to administer the necessary medications and treatments and to appropriately monitor children’s health issues fall on the shoulders of administrators, educators, and other staff, who do not have the appropriate education and skills to perform these tasks.
NASN has been advocating for expanded funding sources to pay for school nursing services, and Medicaid is one opportunity for eligible students. Historically, Medicaid funding has primarily been used for students in special education. More states are considering expanding Medicaid reimbursement for school health services for students not in special education.
“That is a way to move from the education funds alone, because they’re already stretched thin, and have the health care entities and insurers provide funding for student health services,” Mazyck explains. “We believe that’s reasonable for the chronic disease management and disease prevention that enables students to learn. Adequate reimbursement for services will, I think, impact the long-term retention of school nurses.”
ADVANCING HEALTH EQUITY
School nurses are responsible for both individual student care and for promoting the health and well-being of the broader school community, NASN states, and serve as the eyes and ears for our nation’s children and families from a public health perspective.
The work they do includes preventing and managing infectious and chronic diseases through tracking student immunization requirements, promoting healthy behaviors such as hand washing and safe sex, helping families access health care resources, and assisting in developing individualized education plans.
This type of community-focused work appeals to many nurses, especially those of the Millennial generation, characterized by tending to prioritize job fulfillment over pay. Rachel White, BSN, RN, a student in the Community/Public Health Nursing master’s specialty, has worked as a substitute school nurse and a community health nurse. White says that while she really enjoyed her community health position, she felt she wasn’t making enough of a difference. The population she was serving “was already disabled, older, and had chronic diseases,” White explains. Her interest in health prevention led her to pursue a master’s degree at UMSON.
White’s time as a substitute school nurse was also illuminating, and she sees school nursing as a possible future for herself. “If there was a way to provide some sort of education to students or help reform policy in schools that would make things healthier, it would align with the prevention aspect that I want to get involved in,” she says.
Disease prevention work in schools involves tracking immunization requirements, but school nurses also organize vaccination clinics throughout the year, which now include the COVID-19 vaccine. After the Pfizer-BioNTech COVID-19 vaccine received U.S. Food and Drug Administration authorization for ages 5 - 11 last fall, the Montgomery County Department of Health and Human Services targeted ZIP codes where COVID-19 vaccine rates were less robust to hold immunization clinics at schools with identified need. The clinics were publicized to families through their students’ schools, which serve as a trusted source of information for many communities.
“What I very much enjoy is helping children manage their health conditions and keeping them healthy – they’re our future,” Elliott says.
Veteran school nurses love the connections they forge with students inside and out of the health suite. “I’ve always seen my role as not just being there to see sick children, but to really impact children’s status and their health behaviors so they’re more able to learn and receive more from the educational program they’re in,” Mehl says.
TOP 5 REASONS TO WORK AS A SCHOOL NURSE
Working as a school nurse is different from working in a hospital or clinic. “It’s far more of an independent role – you are the only and main source of health care services and information for everyone in the school,” Elliott says. “In a large high school, you may have 2,500 students and over 200 staff. Figuring out how to grow into that role can be challenging, exciting, and heartwarming all at the same time.”
2. PASSION PROJECTS
“School nurses can pick an initiative and run with it,” explains Kristy Gorman, MS ’10, BSN ’04, the school nurse at Essex Elementary School in Baltimore County. “My school participates in Food Allergy Awareness Week, National Poison Prevention Week, and the Children’s Mental Health Matters Campaign. I go to individual classrooms for teaching, make videos for the morning announcements, and have also created an online health suite for students, families, and staff to visit.”
3. THE SCHEDULE
For nurses with young children, having a work schedule that aligns with your child’s school day is ideal, and many school nurses note that’s what initially attracted them to the position. “I was looking for a job that fit in with raising a family,” Elliott notes. Although a school nurse earns less than a hospital nurse, saving on child care costs is a real bonus, Mehl says. “If your schedule mimics your child’s schedule, that’s a big savings,” he says. “It’s not money that you put in your hands, but it’s money that you don’t have to put out.”
The school nurse can set the tone for the school, especially during a pandemic. In his role as a health leader, Mehl sought to relieve some of the school staff’s stress by teaching them appropriate COVID-19 mitigation strategies. “I take calls from staff at all hours to be a resource for stress reduction and guidance,” he says.
School nurses are part of the treatment team for children with physical, mental, and/or learning challenges and their families and can assist with educating parents and teachers on the best approaches to help students thrive in the classroom. “I’m an attention deficit disorder (ADD) adult, and that’s an area I’ve always specialized in,” Mehl says. “If you can help teachers have a different approach with an ADD child, it can make a world of impact on the outcomes for that child – whether that child stays on grade level, whether that child has positive self-esteem. And whether the parents buy into treatment, because they see it as part of a greater picture.”
THIS ARTICLE FIRST APPEARED IN THE SPRING 2022 ISSUE OF NURSING FORUM MAGAZINE.