How Many Schools Don't Have Nurses?

In 2006, the National Association of School Nurses (NASN) commissioned the largest and, to my knowledge, most recent national survey on the availability of nursing services in U.S. public schools. It was administered to a sample of over 1,000 schools in all 50 states and D.C.

The primary purpose was to gather basic information on the health staff in these schools, as well as a few core characteristics, such as school size and student demographics.

I must confess that I was a little surprised by the results. Here is the distribution of schools by nursing availability, summarized very briefly (these proportions vary by school size, type and other characteristics):

  • 41 percent of schools had at least one full-time registered nurse (RN) on site. In two of every five schools, there was a full-time RN on site (in some cases, more than one). The rates varied enormously by state – from about five percent in Colorado to 100 percent in several northeastern states, including Connecticut, Delaware, Massachusetts, New Hampshire, and New Jersey (though one must use caution in interpreting the estimates for individual states, as the samples are smaller).
  • 34 percent of schools had a part-time RN – i.e., one who visited the school at least once a week. Some of these RNs were part-time and worked in one school only, whereas others were full-time but rotated between schools.
  • 7 percent of schools had a full- or part-time Licensed Practical Nurse (LPN) on site. LPNs are supposed to work under the direction of an RN or physician. In 7 percent of U.S. schools, there was an LPN but no RN – full- or part-time – on staff. However, in some cases, these LPNs reported to an RN at the district level.
  • 3 percent of schools had no RN or LPN, but rather a full- or part-time health support staff member – e.g., a health aide or tech. Some of these support personnel had access to a district-level RN, some did not.
  • And, finally, in about 15 percent of schools, there was no RN, LPN or support staff member on site, whether full- or part-time. Some of these schools received visits from RNs or LPNs less frequently than once a week. Some of them had relationships, formal or informal, with nearby clinics or hospitals. And, of course, some of them had nothing at all.
There are several ways to look at these results. One might ask, for example, how many children are sent home from school unnecessarily every day because there is no nurse on site, and whether that affects their academic performance (a point that is likely to be politically viable in today’s test-obsessed environment). Or, taking a different approach, one could wonder about cost effectiveness – it costs money to hire nurses, and school budgets always reflect difficult choices. Finally, one might zero in on the ever-present issue of underlying variation – i.e., whether the staffing patterns varied by school size and poverty (and they do). For example, many of the schools with less extensive nursing services were smaller schools.

These types of issues are important, and worth discussing, but to some extent I think they are beside the point. Children spend very large proportions of their waking hours in schools. Many of them take medication or have serious conditions, and virtually all of them get sick or hurt once in a while. In many districts, particularly poorer districts, school nurses serve as de facto primary care providers. And, of course, regardless of income or where one lives, serious emergencies sometimes arise and lives can be at stake.

It hardly seems extravagant to demand that all schools of any size should have a full-time RN on site (this is the law in a few states, such as Massachusetts). For smaller districts that serve just a few hundred students, it’s perhaps acceptable to have a nurse rotating from school to school, especially if those schools are not too distant from one another.

(Side note: NASN recommends a student-to-nurse ratio of no more than 750:1. The national average, at least according to this 2006 survey, was 1,151:1. Given recent cutbacks, it is possible that the situation is worse today.)

Of course, it is very easy for me to say this, even though I suspect the vast majority of people, whether or not they’re parents, would agree. As usual, those who live in affluent districts will demand to have a full-time RN on site at all times, and they will pay for it. In lower-income districts, there are budgetary constraints, particularly during recessions, and these issues don’t go away just because huge majorities believe something needs to be done.

At the same time, however, there is something seriously wrong with a wealthy, advanced nation such as the U.S. having such gaps in basic health services within institutions as vital as our public schools. There may be no easy solutions here, but sometimes it’s useful just to acknowledge that we have a problem.

- Matt Di Carlo

Issues Areas

You suggest that there's an opportunity to study the academic effects of having a full-time nurse.

I'd add that there's the opportunity to also examine the health effects, right?

An example. How many medication errors happen in schools where teachers or administrators monitor kids taking medication, versus those in schools with FT or PT nurses?

I'm not sure I'd expect a difference. There could be one, but the teachers and administrators I've seen do this seem to be conscientious, since that task is following directions, not making medical decisions.