The School Nurse Shortage
Aashna Shah (PPS ‘24)
There is a shortage of school nurses in the United States. The American Academy of Pediatrics recommends having at least one Registered Nurse in every school. However, the National Association of School Nurses (NASN) reports that only 40% of schools have a full-time nurse and 25% of schools don’t have a nurse at all.[i] Although some might read these statistics and think, can’t anyone give out ice packs and band aids?, children with complicated healthcare needs like type one diabetes require trained professionals in school.
Following my diagnosis with type one diabetes at age ten, my school nurse served as an integral support to my diabetes management. Less than forty-eight hours passed in between receiving my diagnosis and leaving the hospital. Simultaneously, the medical regimen involves a complicated “diabetes checklist,” including knowing how to use blood glucose meters, glucagon, syringes, and insulin pumps, being up to date on all prescriptions, knowing carb counts and insulin dosages for every meal, and constantly assessing personal symptoms.
Being so young at diagnosis, I relied on my school nurse to give me insulin shots, help me assess my symptoms, and emotionally support me during the most challenging life transition I’ve ever experienced. My story does not stand alone; studies have found that school nurse support positively influences diabetes management, school life, and school safety for children with type one diabetes.[ii]
While bodies ranging from state governments to diabetes centers recognize the need for school nurses, progress is severely limited. In North Carolina specifically, 46 of 115 local schools meet the proposed standard ratio of 1 school nurse to 750 students.[iii] In schools with nurses, most nurses care for between 300–6,000 students at once, limiting the quality of care they could reasonably provide for children, like my ten-year-old self, who desperately need it.[iv]
How do we fix it?
One-third of School-Based Health Centers are funded through school districts and the rest rely on private funding.[v] Community healthcare centers receive reimbursements from Medicaid, but school nurse programs have been historically excluded despite their significant influence on children’s health.[vi] Because of this, the NASN advocates for Medicaid reimbursements for school-based nursing services.[vii] Reimbursements through Medicaid give schools flexibility to hire school nurses or nurse practitioners with specialized expertise in health conditions like type one diabetes.
Medicaid reimbursements could also fund diabetes education training for school nurses. The CDC reports that children with more understanding and support in diabetes management are healthier than those who do not receive diabetes education.[viii] With proper training, school nurses could improve health outcomes by helping children one-on-one or creating groups for children with type one diabetes to receive social support.[ix] Various diabetes centers offer training courses for school nurses about diabetes education and diabetes technology usage.[x] While states currently differ in their school nurse licensing requirements, these courses should be mandatory and publicly funded because of their demonstrated benefits.
What if nobody wants the job?
Funding to hire and train school nurses does not address people not wanting to work as school nurses. Nationally, the average salary for a school nurse is $55,716, almost $20,000 less than nurses who work in hospitals.[xi] Nursing students have little financial incentive to work in a poorly funded school district over a large hospital. These districts are also likely to have more children in need of school nurse support, as children without health insurance might rely on a school nurse as their only healthcare resource.[xii]
State universities typically partner with government, non-profit, and private organizations to connect students to service opportunities in rural areas or small cities. Fellowship programs can operate similarly; programs like Venture for America connect graduating students to start-ups in small cities to promote economic growth there. University-sponsored programs or fellowships that connect nursing students to rural public schools should be developed. Attaching educational and career benefits to these opportunities could incentivize students to become school nurses.
Through ten years of having type one diabetes, I’ve learned how important external sources of support are. Following diagnosis, doctors simply hand kids medicine and expect them to do the work of an internal organ on their own. As a society, we cannot continue to transfer responsibility for the health and well-being of children from parents to doctors to individuals without providing a standardized method of support in the form of school nurses. My community deserves better, and after years of unsupportive policies ranging from high insulin prices to this school nurse shortage, we are owed better.
[i]School nurse shortage: How to fill the gap. (2019). Retrieved 18 April 2022, from https://www.myamericannurse.com/school-nurse-shortage-how-to-fill-the gap/#:~:text=The%20American%20Academy%20of%20Pediatrics,don%27t%20have%20any%20nurse
[ii]Stefanowicz, A., & Stefanowicz, J. (2018). The role of a school nurse in the care of a child with diabetes mellitus type 1 — the perspectives of patients and their parents: Literature review. Slovenian Journal Of Public Health, 57(3), 166–174. doi: 10.2478/sjph-2018–0021
[iii]Meeting Current Standards for School Nurses Statewide May Cost Up to $79 Million Annually. (2022). Retrieved 8 April 2022, from https://www.ncleg.net/PED/Reports/documents/SchoolNurses/School_Nurses_Exec_Summary.pdf
[iv]Healthy and Ready to Learn: School Nurses Improve Equity and Access. (2022). Retrieved 7 April 2022, from https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-22-2017/No3-Sep-2017/Healthy-and-Ready-to-Learn.html
[v]Reimbursement for School Nursing Services — National Association of School Nurses. (2022). Retrieved 18 April 2022, from https://www.nasn.org/nasn-resources/professional-practice-documents/position-statements/ps-reimbursement
[vii]Reimbursement for School Nursing Services — National Association of School Nurses . (2022). Retrieved 18 April 2022, from https://www.nasn.org/nasn-resources/professional-practice-documents/position-statements/ps-reimbursement
[viii]Living with Diabetes: Education and Support. (2022). Retrieved 19 April 2022, from https://www.cdc.gov/diabetes/managing/education.html#:~:text=People%20who%20have%20the%20knowledge,fewer%20emergency%20and%20hospital%20visits.
[ix]Lee, M. (2004). School Nurses’ Roles in Diabetes Education and Management for Students with Type 1 Diabetes in School Settings. Retrieved 18 April 2022, from https://digital.lib.washington.edu/researchworks/handle/1773/40826
[x]School Nurses Education Program. (2022). Retrieved 18 April 2022, from https://www.joslin.org/patient-care/pediatric-care/pediatric-educational-programs/school-nurses-education-program#:~:text=School%2Dage%20children%20spend%20nearly,that%20affect%20school%2Dage%20children.
[xi]What Is the Difference Between a School Nurse & an Acute Care Nurse?. (2022). Retrieved 18 April 2022, from https://work.chron.com/difference-between-school-nurse-acute-care-nurse-27021.html
[xiii]How to Become a School Nurse — Career Guide. (2022). Retrieved 19 April 2022, from https://nursinglicensemap.com/nursing-specialties/registered-nurse/school-nurse/
Aashna Shah(PPS ’24) is a Public Policy Undergraduate at Duke University’s Sanford School of Public Policy. This piece was submitted as an op-ed in the Spring ’22 PUBPOL 301 course. This content does not represent the official or unofficial views of the Sanford School, Polis, Duke University, or any entity or individual other than the author.