Childhood vaccinations are critical to protecting human health and to maintaining normal societal functioning. In recent years, the rate of childhood vaccinations has steadily declined, causing school closures and community outbreaks of preventable diseases in multiple states, including New York, Washington, and California. In 2019, before the COVID-19 pandemic, the Centers for Disease Control (CDC) reported the highest number of measles cases since the disease was declared eliminated from the U.S.in 2000, a result largely attributed to decreasing vaccination rates and disease importation. The effects of the COVID-19 pandemic have further exacerbated pediatric vaccine uptake. As gatekeepers of vaccine compliance required for school attendance, and health care providers who have near daily access to the nation’s children, school nurses can and should be leveraged to increase vaccination rates for the millions of children under their watch.
School nursing is a specialty of public health nursing that is often poorly understood, and as a result, is underutilized. Contributions to child and population health made by school nurses include early and sustained management of chronic diseases; increases in student attendance – particularly for students experiencing adversities – that contribute to reduced health and academic disparities; and the delivery of substantial economic returns to systems that invest in them. While school nurse roles are diverse today, their practice originated as a response to widespread student absenteeism due to communicable disease outbreaks in the early part of the 20th century. This original raison d’etre for the creation of this nursing practice remains strong today.
All 50 states require immunizations for school attendance, and most compliance verification falls to the school nurse. Pre-COVID-19, tracking student immunization status, and working to bring students into compliance with state laws in order to attend school was a tall order, particularly in the face of critical competing demands of conducting mandated screenings, providing daily management of chronic diseases, and fielding increasing numbers of students seeking support for mental health needs. School nurse caseloads are widely variable by state, but on a national scale average there are about 1500 students to one school nurse.
The health care system and safety net for children in the U.S. was overwhelmed before COVID-19, but now the system is experiencing compounded stress. Indeed, school nurses are reporting unprecedented levels of burnout and experiences of hostility. School nurses are accustomed to routinely interpreting and implementing public health guidelines and state and federal health mandates for educational staff, administrators, and students. COVID-19 has presented new challenges for public health nurses in the forms of enforcing masking, contact tracing, testing, providing education to students, parents, and school staff, and verifying COVID-19 vaccination status. These additional, new roles in addition to other COVID-19-related duties are placing unsupportable weight on an underfunded – and therefore fragile – system. This is occurring concurrently with a deficit in school nurses, due not only to burnout, but also to vast pay disparities between school nurses and nurses working in hospitals.
We now find ourselves in a situation where the school nurse – the national health care workforce focused on reducing inequities in health and educational outcomes and in life opportunities for students experiencing adversities – is itself at risk. To strengthen this critical infrastructure, the Interdisciplinary Research Group on Nursing Issues and the Child Health Services Research Interest Groups make the following joint recommendations:
- Federal and state funds should provide budgetary line items designated for the hiring of school nurses to decrease the nurse-to-student ratio. This can be accomplished through the budgetary and policy making process at the federal and state levels. These funds are particularly important in states with high Medicaid populations and low school nurse-to-student ratios.
- The Centers for Medicaid and Medicare Services should require states to reimburse school nurses for prevention and case management activities. This is recommended by the American Academy of Nursing and was put into law through the Every Student Succeeds Act.
- Provide attractive salary support to incentivize the pipeline of school nurses to ensure equality and continuity in health care and educational access for underserved students. Incentive payments can be issued by CMS and state Medicaid agencies to school districts for select school nursing services. These additional funds can be used to provide salary support for school nurses, particularly in underserved school districts.
- Utilize the state health system and education infrastructures to provide school nurse program oversight. States can provide a lead school nurse consultant whose role is to support an infrastructure of school nursing services that provides consistent quality assurance, technical assistance, education and training throughout the state.
- Intentional efforts to enhance the diversity and representation of the nursing workforce, especially among school nurses. To enhance diversity and representation of the nursing workforce, especially the school nurse, targeted efforts should begin during nursing student recruitment.
- Expansion of federal programs to forgive or repay student loans for school nurses. Through expansion of the Public Service Loan Forgiveness Program and the proposed Public Health Workforce Loan Repayment Act, nurses could be eligible for loan forgiveness, which will facilitate debt relief, which disproportionately affects nurses of color.
Since its inception, school nursing has evolved from quelling communicable disease outbreaks to improving student attendance and addressing current barriers to educational access such as chronic disease, mental health disorders, and effects of poverty and race on health and educational outcomes. The effects of the COVID-19 pandemic underscore the urgency to sustain and strengthen school nursing services.
The opinions expressed in this blog post are the author's own and do not necessarily reflect the view of AcademyHealth.
AcademyHealth Interest Groups facilitate interaction of individuals around specific topic areas relating to health services research and health policy. The Interdisciplinary Research Group on Nursing Issues (IRGNI) promotes and supports the development of health services research that focuses on nursing practice, workforce, and delivery of care. The Child Health Services Research Interest Group (CHSR) provides a forum for researchers, policymakers, practitioners, and trainees to interact around health services issues affecting children. Learn more about IRGNI here and CHSR here.