If Addressing Nursing Shortages, Don't Forget School Nurses

School health services for students have been referred to as a hidden healthcare system. This third school year of the COVID-19 pandemic sheds light on a system at a critical juncture. More than any time in my 30 years as a frontline state and national school nurse, the current work environment creates multiplied job responsibilities and moral distress.

The current school nurse shortage threatens the physical and mental health support of our nation's students, which is vital to learning. Our already overtaxed school health services system is at the brink during this pandemic.

Multiplied Responsibilities

Linda Mendonca, DNP, RN

In a typical year, back-to-school time is busy for school health services staff, complete with drafting new care plans, confirming students' routine vaccination status, and conducting screenings. This year, school nurses' already full workload is overburdened with contact tracing, COVID-19 symptom screening, and testing. School nurses make contact tracing calls on weeknights and weekends. Carefully planned back-to-school routines are disrupted when students or staff test positive for COVID and isolation or quarantine procedures are implemented. Screening and testing routines supplant routine priorities.

It's important to note that during a pandemic, routine healthcare needs don't stop. Today's students are more likely to face medically complex conditions and chronic health illnesses, including asthma, diabetes, food allergies, obesity, mental health, and behavioral issues. School nurses have knowledge, assessment skills and judgment needed to help manage these conditions. School nurses are critical in identifying and referring students for a host of behavioral health concerns, leveling the field regarding health inequities, promoting healthy behaviors, and serving as an early warning system for children and families in crisis or otherwise at risk of abuse and neglect.

When workloads related to COVID-19 occupy most of the workday, school nurses have limited time to manage individual students with chronic health conditions, address behavioral or mental health concerns, or provide population-wide student support to re-engage in school. School nurses are working two jobs this school year: pandemic-related response actions coupled with their full workload of typical population-based and student-specific school health services.

Increase in Moral Distress

School nurses are experts in communicable disease mitigation, preparedness, and response to school communities. Their expertise in collaborating with local and state health authorities, community-based healthcare providers, and community agencies enhances school and school district planning on responses to infectious disease outbreaks. School districts that include school nurses in planning benefit from holistic and public health perspectives. Excluding school nurse expertise from school plans and processes hampers responses to health and safety.

However, we at the National Association of School Nurses (NASN) know that some school districts aren't including school nurses and their critical expertise in their pandemic response planning process. In some states, guidance regarding evidence-based protocols has been subject to political influence. School nurses share with each other their moral distress of being verbally challenged by families when students must be quarantined or when COVID-19 public health mitigation strategies run counter to family beliefs. Nurses can become distressed if asked by school leaders to ignore evidence-based practice when implementing certain protocols and practices. Moral distress during this school year is leading some school nurses to resign.

In the global context, school nurses are just a small subset of the larger nursing community facing shortages this year. The COVID-19 pandemic exacerbated US nurse staffing shortages in hospitals, other healthcare settings, and schools.

Supporting Health Equity

Given the critical impact of school nursing on the public health infrastructure, the health and safety of our nation's school-age children, and already underresourced school health services, this decline in school nursing personnel illustrates a critical fracture in the infrastructure supporting health equity for today's students.

Prior to the pandemic, 25% of US schools did not have a school nurse; 35% of schools had part-time school nurses, according to a NASN workforce study published in 2018 in the Journal of School Nursing. Many school nurses support more than 1000 students and more than one school building — sometimes serving as the only nurse for an entire district. In rural areas, school nurses may travel for hours between buildings. Navigating the impact of COVID-19 in this school year challenges school systems and the structures that facilitate or hinder quality school health services.

Even in the most supportive environment, school nurses find it difficult to maintain their equilibrium. I recently spoke with a school nurse who described having a supportive school administrator, yet she doesn't know how much longer she can remain in her job working at the current pace. School nurses collaborate and coordinate to keep school communities healthy and safe. And yet, they find the ballooning of their job responsibilities during this pandemic highlights the lack of existing infrastructure needed to support student health services in child/youth serving systems.

Every student deserves a school with a full-time nurse, both to help navigate through the pandemic and support students' physical and mental health and their academic readiness. Currently, school districts experience staffing shortages that impede school functions, including school bus drivers, food services staff, educators, and school nurses. If districts cannot staff at the level required to support student learning, infrastructure changes must occur.

The American Rescue Plan (ARP) provides an opportunity to address systemic school health services in public schools. This infusion of federal funding should be invested in ways that will most effectively address the immediate and long-term impacts of the pandemic on students, while achieving the goals of safer classrooms and schools, improved student physical and mental health, and academic readiness and support.

We, the NASN, strongly believe that districts should seize this opportunity to invest in school nurses and other support staff who play critical roles in this effort. Coordination among federal health and education agencies to enable sustainable investment in student health, such as with ARP funds and Medicaid reimbursement for school health services, is paramount to providing state level guidance.

Investing in school nursing is not only good for students, but it has also proven to be an excellent investment for communities, by generating more than $2 for every $1 invested in a full-time, registered school nurse.

There are bright spots where this investment is occurring, like the high school that hired two school nurses and one aide to manage contact tracing as well as other school health services. Investing in local public health and local school infrastructures to enable quality school health services helps keep students healthy, safe, and ready to learn.

Linda Mendonca, DNP, RN, is the president of the National Association of School Nurses. She is a National Certified School Nurse and an advanced certified public health nurse. She has been a registered nurse for 40 years, practicing school nursing for 25 years, overseas and in five states as a military spouse. She is an assistant professor at Rhode Island College School of Nursing teaching community/public health nursing. She also consults as a state school nurse for the Rhode Island Department of Health.

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