School Nurse to Student Ratios 04.25.13

A generation ago, the school nurse (SN) cleaned and bandages the occasional scraped knee and sent kids home with stomach aches or fevers. Today’s SN now cares for students with complex medical conditions. Most SNs feel their jobs are changing because American life has changed. There is growing sense that a school is, in part, a health care provider.

State laws sometimes regulate the ratio of school nurse to student but more often” recommend” ratios. When the SN can’t meet all the demands they face, school districts may assign some of the SNs responsibilities to other school personnel. It then becomes the responsibility of the SN to train those people to perform the newly assigned duties, provided that the task is able to be delegated under the respective state’s Nurse Practice Act.

Do you agree with this solution to the increased demands on the SN? Why/why not?

Today, students have more complex medical problems in public schools, and school nurses are likely to become outnumbered in providing care. The National Association for School Nurses states that “The student-to school nurse ratio improvement act of 2011/2012 would provide demonstration grants through the U.S. Department of Education to eligible local educational agencies so that they may reduce the student-to-school nurse ratio” (2012). Reducing the student-to-school nurse ratio has been outlined in this act as a way of meeting students’ health care needs for efficiently in school. The National Association for School Nurses also explains that “ students today have increasingly complex needs for nursing care…School nurses help facilitate learning for all students, especially those with asthma, food allergies, obesity, vision and hearing difficulties, dental problems, mental and behavioral problems, and those who needs prescribed medicine for either acute or chronic conditions” (2012). The school nurse must provide care for all of these students, producing a very large student ratio to one school nurse. It is appropriate to delegate some tasks to trained school personnel as long as it follows the Nurse Practice Act. Delegation would allow the school nurse to handle more critically ill students in timely manner, allowing them more time in class rather than waiting in the nurse’s office for their turn. If staff is trained properly in managing some medical conditions appropriate for delegation, then delegation would help to solve the problem of the increased demands of the school nurse.

National Association of School Nurses. Student-to-School Nurse Ratio Improvement Act of 2011/2012. Retrieved from http://www.nasn.org/portals/0/legislation/NASN2012RatioBillAdvocacyfinal.pdf .

Honestly speaking, the ratio of a school nurse to students is quite outrageous throughout the country. Supposedly in MA, the ratio is as much as 1:700 which leaves the nurse wondering on how to cope and care for the students effectively. All this challenges have led to different changes in the way the nurse should care for the students, and therefore the nurse is driven to delegate care to other individuals as long as they are adhering to the Nurse Practice Act.The responsibilities of a school nurse range from delivering emergency care, administering vaccines, giving medications, performing assessments and making referrals, communicating with the parents, preparing for disaster and even identifying vision and hearing problems. This presents to be quite too much for one individual to deal with. I find it helpful to have wellness, guidance and counseling department in schools which somehow probably helps reduce the work load of the nurse in terms of advising and counseling the students. Therefore, l agree with the decision for the school nurse to assign responsibility to other school personnel per nurses practice act to help reduce the school nurses workload. However, a school nurse role remains a hard one to fill in by anyone without adequate clinical training, therefore delegation of a school nurse role is quite sensitive and also as mandated by the law, almost everyone is supposed to have some clinical background to help a school nurse.
http://www.nasn.org/Portals/0/about/making_the_connection.pdf

Am glad you talked about grants, l found out that most of the time the school nurses ends up spending their own money due to lack of funds to provide the students to what might be of immediate need. Some challenges l also found with the school nurses is that, if at any point a child has accident, they are sent to the nurses office, and of course the nurse doesn't have any extra clothes for the child to change in case they are wet, so the nurse ends up calling parents at home to come pick their child or else bring them a change of clothes. I feel like everyone at school looks up to the school nurse for even the smallest 'housekeeping' needs. All l want to say is, a school nurse remains a hero, and everyone in a given school including the teachers, secretaries, headmaster and the students should recognize a school nurse as a STAR.

CMUR makes a valid point about the high student ratio to only one nurse. She states it is 1 nurse to 700 students, leaving the nurse with an incredibly large amount of responsibility. As she mentions, school counsels could handle some of the medical problems that children may face, such as psychological, behavioral, or anxiety problems. Training selected staff members correctly to help deliver care would be acceptable if it follows the Nurse Practice Act, as CMUR also states. At my assigned school, the school nurse is also in charge of all the attendance in the school. She must receive phone calls on students who will be out and document this, receive and document the attendance from each classroom, and call parents who have not called their child out who are not in school. This is an added responsibility for the nurse that takes away from providing medical care to students, making her role even more challenging. Delegating some tasks would certainly help the school nurse operate more smoothly considering the high student ratio to only one nurse.

As nurses, we have learned about delegation since we have started school and many of us have experienced delegation in the work place. Delegation in the school setting is a bit of a different story. In regards to delegating tasks to teachers, I think it depends on what it is. At my clinical site, the school nurse was in charge of educating all of the staff to administer an epi-pen in case of emergency. After the education, the teachers had to fill out a post test. They brought the completed posttest to the school nurse so that she could correct it and then they demonstrated how to use the epi-pen using a trainer. This was an appropriate thing to delegate to other teachers especially since it could potentially save a life.
I think that the only appropriate way to delegate the responsibilities of a school nurse is having a good support staff such as a guidance counselor or a school therapist. These personnel have been specifically trained to councel and help students with their needs.
The article I found was really interesting and talked about expanding the role of the school nurse and extending it out into the community. The most interesting thing that I read was using the school nurse to help students with continuing health care- maybe because they are graduating and will no longer be under her care or because they have a new health issue that needs care outside of the care they receive in school. A few of the other ways of expanding the role of the school nurse are responsibilities that could be delegated- especially the ones concerning the mental and emotional health of students.
Glasper, A. (2012). Enhancing the role of the school nurse in contemporary society. British Journal Of Nursing, 21(10), 616-617.

Being responsible for attendance on top of taking care of the health care needs of students is a tremendous responsibility for the school nurse to take on, especially with such a high ratio. At my school, this task is divided between the main office and the school nurse. The main office makes a list of who is absent from school and then they send it to the nurse. The nurse then looks at the absentee record from the previous day to see who has been out of school for two or more consecutive days. If the student has been out three days or more, the nurse then calls the parent or guardian to check up on the student and make sure that the student is okay. This also helps her to keep track of the illnesses and viruses going around within the school.

It is a scary thought to think that sometimes there is only one school nurse and thousands of children in a school, and the nurse has to do it all by herself. This may have been acceptable years ago but now that there are so many children presenting to school with different medical issues the nurse is faced with more responsibility and knowledge. I think having a ratio for school nurse's to children is a must, and it is better to have 2 nurses rather than have the nurse educate other staff in the school how to care for a child when they don't have the medical educational background nurses do. At my school the nurse can see up to 70 children in a given day, and she is sometimes by herself. I would think that can be overwhelming especially if a group of students all came at once. In hospitals nurses are limited to how many patients they can care for at a time, regardless it may be that they are spending more time with these patients, but its not fair that this doesnt apply to the school nurses as well because the occurrence of different diagnoses now seen in schools. Many children today have diabetes and they all come at once before lunch to have their blood sugars checked and then the nurse has to help them all figure out what to bolus for them if they need insulin, and then children at the same time come in for their afternoon medications. There should be a nurses aid always there with the nurse as back up I think just incase something were to ever happen where the nurse couldb't do it all herself.

I agree with you that there may be certain things that the nurse can delegate to the other staff like learning to give epi pens incase of an emergency, but then there are other things that I think the nurse would need someone with a medical background to delegate to especially if the nurse sees a great number of student in a given day. In the school I am at the school nurse delegates mental health related advice to teachers like you stated which would be an appropriate delegation, and I think that's fine for the nurse to do.

I agree with allowing the school nurse to delegate certain tasks to other school personnel. “Delegation of nursing tasks in school settings is a necessity given the multitude of school nursing responsibilities, the increase of health needs among students in the 21st century, and the limited number of school nurses available to meet these needs” (Resha, 2010). After these past few weeks at the elementary school I realized a lot of the problems that kids go to the school nurse with should be dealt with elsewhere. For example, I do not think nursing skills are required to wash a cut and put on a bandaid nor do I find it necessary to go to the school nurse for a change of clothes when kids fall in puddles. As long as the personnel is trained to deal with things, and has good judgment it is okay for the school nurse to delegate out certain tasks. Part of our education is knowing when and what to delegate and it does not matter what environment the nurse is practicing in, whether it be a hospital or a school the nurse should have the ability to realize when certain tasks can be performed by others. According to the ANA and the National Council of State Boards of Nursing [NCSBN] (2006): “Delegation is a process that, used appropriately, can result in safe and effective nursing care. Delegation can free the registered nurse to attend to more complex patient care needs, develop the skills of nursing assistive personnel and promote cost containment for the healthcare organization.” I do think by freeing up the nurse to attend to more complex patient care needs, the school nurse will be able to better serve the school community and help those who truly need help.


Resha, C. (2010). Delegation in the School Setting: Is it a Safe Practice?. The Online Journal of Issues in Nursing. Vol 15, No 2. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No2May2010/Delegation-in-the-School-Setting.aspx

American Nurses Association and National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved on October 1, 2009 from https://www.ncsbn.org/Joint_statement.pdf.

Though the school nurse to student ratio of 1:700 seems incredibly high, that is for the healthy population. Many of these students rarely even visit the school nurse so it is not like caring for 700 patients at once. I agree that certain situations may arise when one individual cannot deal with everything in a timely manner and that is why delegation is necessary. I think you are right in mentioning that delegation is mandated by law because as nurses we do not want to put our license in jeopardy so if delegation is required in the school there should be laws allowing us to do so.

Clearly there is a disparity between the amount of students and the severity of cases compared with the number of school nurses. According to the National Education Association, "the average public school nurse cares for 1,151 students at 2.2 schools. About 25 percent of schools have no school nurse, partly because of funding. The average salary for a school nurse is $42,467" (Rosales, 2008). With these numbers, the positions aren't very attractive as the work load vastly outweighs the pay. More funding needs to be introduced into the public school system so that Nurses can be paid fairly for the work they perform, and so that they can be assigned an LPN to lessen the work load and efficiently care for all of the students. As it stands, it is physically impossible to care for even half of these students on a daily basis. Nurses can only hope that students don't end up in the office...

Rosales, J. (2008, November). Where have all the nurses gone? lack of health care professionals in schools affects students', teachers' performance. Retrieved from http://www.nea.org/grants/15303.htm

I would have to agree with CMC in that school nurses need support staff to help them throughout their day. By themselves, there is no way that school nurses can possibly care for all of the students under their watch. By training other staff in administration of epi-pens, and using guidance counselors to support students emotionally and mentally, this can lessen the load on the SN's shoulders.

This semester we are taking an entire class that deals with delegation and role of the Registered Nurse. Delegation is a major part of the nurse’s role, whether in the hospital setting or within the school. The idea of delegating appropriate tasks to others, in order to allow for the nurse to focus more on the medical aspects of care, is fine with me. I’ve been to several different schools while in the nursing program and have seen some complicated cases/students. I imagine the trend is going to increase and thus acuity of the student would grow like wise. The ability of the Nurse to delegate is growing more crucial.

I’m more than O.k. with this fact and know it’s an important piece to effective management. That said you do reach a tipping point when the burden of having to supervise so greatly itself begins to impede student care. At this point other options should be looked at such as hiring a second staff member, perhaps a LPN or secretary. I feel that states should not mandate the nursing to student ratio but instead should be up to the town itself. It’s the towns that are paying the largest amounts for their schools and this would also make for better accountability. Towns are also more than capable of producing policies and self-governance.

Another broader solution would be the accountability factor I had brought in to conversation. When the responsibility is kept at a more local basis, the people of the town can more easily affect change. These towns’ people can also affect change at the State level though as well. The majority of American’s do not follow politics regularly (Saad, 2009) but the ones that do know money is being wasted left and right as well as being used to line the pockets of many of our politicians. Change could be made to hold them more accountable for the supposed lack of funding and thus staffing levels of our schools.

Saad., L. (2009). More Americans plugged into political news. Gallop Politics. Retrieved from http://www.gallup.com/poll/123203/Americans-Plugged-Into-Political-News.aspx

I can certainly understand how the ratio you list of “1:700” may appear daunting, given its high numerical value. If we step back and analyze the acuity level of the target group, we find the ratio of 1:700 to be not so bad. To put things in better perspective, I’m from a town in the western part of Massachusetts. This town has Harrington Memorial Hospital, the only hospital for the area. In fact its website (see below) states it services South Central Mass and Northern Connecticut and boast having 40 primary care and specialty Physicians. This Hospital is about the size of Beverly Hospital. They are providing services to tens of thousands perhaps greater than 100,000, plus increased acuities. So with the proper auxiliary and support staff as well as delegated work, good care can be achieved.

http://www.harringtonhospital.org/about_us/about_us

School nurses have a very important job, they car for our children. When a school nurse is unable to fulfill his or her duties, a second medical professional should be delegated the extra tasks. “Advances in medical technology now enable many children with chronic health care problems to attend school” (Egelke, Guttu, Swanson, 2004). Due to the fact that children with chronic health problems attend school and the nurse is responsible for these children, I feel that a second school nurse or licensed practical burse should be brought in. I understand that budget is an issue when proposing the idea of bringing in another medical professional, yet a child getting injured should be enough incentive. I was able to see at clinical how busy the school nurse is, with teaching and setting up screenings. I can understand how these duties can become overwhelming and that the nurse would like to delegate some tasks to others. If the tasks delegated are not related to medical interventions or medications themselves, I feel that a non- medical professional could assist with these tasks. I think that there should be a clear standard of what the nurse can and cannot delegate and when a second medical personnel is necessary.
Guttu, M., Engelke, M., & Swanson, M. (2004). Does the school nurse-to-student ratio make a difference?.Journal Of School Health, 74(1), 6-9.

JAJ states that’s the school nurse does not have an appealing job. It is true that the school nurse has an enormous amount of work and potential patients in every given day. Funding does need to be made available to lessen the nurse to student ratio. The fact that some schools do not have a school nurse is petrifying. Children spend a large amount of time at school and they need to feel safe when they are there.

Important words for me...... 

i think this is one of the best option for children...