Running head: SCHOOL NURSING: THE CHALLENGES 1

School Nursing: the Challenges Faced and the Pivotal Role They Play in Students’ Mental

Health and Academic Success

Ashley Selby

Delaware Technical Community College

NUR420-6W1
SCHOOL NURSING: THE CHALLENGES 2

Introduction

School nurses play a critical role in a child’s life as they go through their school journey.

School nursing is a specialized practice of nursing specializing in promoting student health,

facilitating optimal development, providing first aide care, developing care plans, and ensuring

public health records and guidelines are up to date. They are considered valued contributors to

students’ health and safety while in school and are considered the first line of defense when it

comes to identifying and treating a student’s medical needs.

Despite the importance emphasized in literature about school nurses and the role they

play in a student’s academic development, school nurses are not supported by federal law in

regards to safe practice ratios and are not mandated to be present in schools. Because of this,

many schools within the United States (U.S.) do not have the availability of a school nurse on

campus. When there is no school nurse present on campus, students are more apt to develop

health problems and more likely to perform poorly in school as a result. It is critical that all

students have access to a school nurse during their educational journey as a healthy wellbeing

has a positive impact on educational development.

The Role of the School Nurse

The role of a school nurse is vital in the school setting and requires many different skills

and a plethora of knowledge. Considered to be part of the public health system, school nursing is

a specialized practice that operates in environments very different from an acute care setting. The

school nurse’s role requires multiple duties and functions that include medication administration,

immunization record keeping, health promotion, and responding to any medical crisis within the

school setting in an effort to keep students and staff healthy.

SCHOOL NURSING: THE CHALLENGES 3

Currently, ninety-eight percent of children in the U.S. attends school. Within that

population, health concerns such as chronic illness, communicable diseases, violence/bullying,

and mental illness continue to grow. It is the nurse’s duty to provide preventative care and

promote healthy living to ensure students are safe and healthy during their time in school and to

give social and psychological support when needed.

Challenges of School Nursing and the Effects on the Student Population

Despite published literature regarding school nurses and the critical role they play in

student health and well-being, it is not a federal requirement for school nurses to be employed

full-time in schools. Currently, there is no law in Texas requiring a nurse to be employed at

every school. According to a report by the Texas Center for Nursing Workforce Studies (2021),

the national average ratio of students to school nurse was 1,107 students per nurse for the 2019-

2020 school year. The report also stated that out of the 254 counties in Texas, 27 did not have a

school nurse employed at either a public or charter school (Texas Center for Nursing Workforce

Studies, 2021).

School nurses often face challenges in regards to role clarification, accountability, and

scope of practice (Savage, 2017). Because of their wide range of responsibilities nurses can often

feel overwhelmed when dealing with large student populations and their daily job obligations.

They are often expected to accept non-nurse responsibilities such as administrative work and

must find help and support in duties by training and delegating tasks to unlicensed assistive

personnel (UAP) (Savage, 2017). Even with the help and support of UAPs, nurses still find

challenges in fulfilling their roles. Challenges such as insufficient time, the burden of redundant

documentation requirements, and lack of parent support and communication are all barriers

school nurses face on a daily basis (Lineberry et al., 2018).

SCHOOL NURSING: THE CHALLENGES 4

Because of the immense amount of work school nurses face and the restrictions on their

scope of practice and autonomy, school nurses often find themselves dealing with ethical

dilemmas regarding their involvement in treating and caring for students. According to S. Rivas

(personal communication, May 29, 2022), in order to treat and care for students with chronic

diseases such as asthma and diabetes, an action plan must be created by each individual student’s

primary care physician (PCP) and must be approved and signed by their parents or legal

guardian(s). Nurses face many challenges with these action plans as it legally restricts the nurse

from taking action to treat these students if they do not have a care plan in place. According to S.

Rivas (personal communication, May 29, 2022), if a student had an insulin pen at school but

there was not a documented care plan and/or written permission from the parents, she was unable

to administer it even in emergent situations. While scenarios like this never occurred for S.

Rivas, literature has shown that one of the challenges school nurses face within their roles is

establishing and maintaining communication and collaboration with parents. A majority of the

school nurse’s time during the first few weeks of school is spent solely on trying to collaborate

with doctors and students’ parents about their care and the management of their health (M.

Watson, personal communication, July 10, 2022). When it is known that a student has a health

need but it is not being addressed appropriately, it is the school nurse’s responsibility to take on a

leadership role by creating awareness of the necessity of a treatment plan. The challenge and

frustrations that school nurses face in regards to this, is the inability to reach or speak with the

student’s caretaker to obtain permission or the parent not following through with the appropriate

signed documents. Stated by S. Rivas: “There were few times I wouldn’t get paperwork or

rescue meds and I’d just make sure it was in the student’s health history so teachers were aware
SCHOOL NURSING: THE CHALLENGES 5

of the condition and hope nothing would happened because then all you could do was call 911”

(personal communication, July 9,2022).

With the large amount of students and lack of nurses to care for them, those that are

employed with the school districts often find themselves stretched thin and unable to perform

their duties. In a personal interview with M. Watson, BSN, school nurse of 14 years for

Pflugerville Independent School District (ISD), it was discussed how the lack of school nurses

within the school district impacted her job duties and the students’ health (personal

communication, July 10, 2022). Since Watson was not able to be in multiple schools at the same

time, she was responsible for training UAPs to administer medications such as insulin and

epinephrine injection pens during emergent situations (personal communication, July 10, 2022).

One of the main job functions and ability of a nurse is delegation. Delegation is defined

as the assignment of activities or tasks related to patient care by the nurse to UAP while retaining

the accountability for the outcome (American Nurses Association, 2012). While the nurse has the

ability to assign tasks to personnel who are not licensed, the ultimate outcome is still the nurse’s

responsibility. This means that if a UAP assigned by the nurse gives a medication that he or she

was trained for but an error occurs, repercussions could fall back on the nurse. Stated by M.

Watson:

“We had a parent sue a school nurse in our district and file a complaint with the board of

nursing after a disabled student developed a pressure sore from not being turned enough.

The task was delegated by the nurse to the teaching assistant in the student’s classroom.

The wound started off as a small scratch which the school nurse charted on correctly and

dressed and treated appropriately but it grew bigger due to not enough frequent turning

by the teaching assistant. The board eventually dismissed all the charges, but the nurse
SCHOOL NURSING: THE CHALLENGES 6

still had to pay $10,000 in legal expenses during that whole ordeal which her insurance

through the district did not cover.” (Personal communication, July 10, 2022)

Due to the high number of students and lack of nurses to care for them, districts like Pflugerville

ISD are faced with having to share nurses between multiple campuses. This means that a school

nurse is not always present for students and the school nurse is obligated to delegate care to

UAPs. While UAPs help take the stress of a heavy workload off of school nurses, it becomes a

disadvantage to students. With school nurses unavailable in schools, students’ health is more

likely to suffer as their acute and chronic needs are not being evaluated and treated by a trained

medical professional.

School Nurses and their Prevention of School Violence

Along with the medical needs of students school nurses have a key role in preventing and

reducing violence in the school setting on several levels. As an advocate for well-being, school

nurses help create safe environments in schools by collaborating with staff, parents, healthcare

providers, and community members. According to King (2014), school nurses are considered

non-disciplinary, non-academic staff members that often stimulates trust and builds rapport with

their students. Due to the unique position school nurses are categorized as, students are more

than likely to confide in their school nurse compared to other school staff members that may

have an authoritative presence.

Because of their expertise in assessment, school nurses can identify behaviors that could

be seen as malicious, such as angry outbursts, or sleeping in class, as possible effects of violence.

Their training also allows them to identify physical symptoms that may be caused by violence

such as headaches, stomach aches, and injuries. Thus making school nurses valuable assets to

schools in the prevention of violence and a contributor to student safety.

SCHOOL NURSING: THE CHALLENGES 7

Mental Health

According to the National Institute of Mental Health (2020) 49.5% of adolescents have

some form of mental health disorder and 22% experience some type of associated severe

impairment. A key function of the school nurse stated by the National Association of School

Nurses (NASN) is being the initial access point to identify concerns, determine interventions,

and link families to school and/or community resources for those who have mental health

concerns. Unfortunately, in states like Texas where it is not required to have school nurses

available in every public school, students are often left without resources and support when

dealing with mental health. Many of the ailments school nurses see students for are actually

psychological in nature. Social factors such as poverty, violence, and stressors at home impact

both the physical and mental well‐being of students which in turn, affects the students’ ability to

learn.

While it is suggested that all school nurses have training in mental health and

psychological conditions, not all schools offer it. According to Bohnenkamp et al. (2019) it is

estimated that school nurses spend approximately 33% of their time addressing student mental

health. M. Watson stated: “There is supposed to be [training]. We did not get additional psych

training, most of that was left to a counselor if we even had one available on campus” (personal

communication, July 10, 2022).

Currently, there is no state law in Texas requiring schools to have counselors on staff at

all times. In the United States (U.S.) the average counselor to student ratio is 470:1, the

suggested ratio by the American School Councilor Association is 250:1 (Philips, 2018).

According to Philips (2018), over 1.7 million students go to school with police on duty but have

no access to counselors. Perpetrators and victims of bullying are often frequent visitors to the
SCHOOL NURSING: THE CHALLENGES 8

school nurse with somatic complaints (Lineberry et al. 2022). In schools where school

counselors and school nurses are limited for students, they are left with a potentially dangerous

dilemma. With no mental health support in schools, students are more likely to develop severe

mental health problems that will proceed them in adulthood. However, with each visit of a

student, school nurses are given the opportunity to identify and intervene on psychosocial

problems.

Lack of Mental Health and Clinical Support in Uvalde

While researching the mass shooting that took place on May 24th, 2022 at Robb

Elementary School in Uvlade, Texas and the support staff available before and during, it was

discovered that Robb Elementary School did not have a school nurse employed. Salvador

Ramos, the perpetrator involved the Uvalde shooting, had spent years struggling in school.

According to Davis (2022), school records indicated that Ramos had a speech impediment that

was identified in elementary school. The identification of where Ramos attended elementary

school was never found through research; however, according to Uvalde Consolidated School

District’s (CISD) website, there are multiple counselors within the district for a majority of their

schools. According to Davis (2022), Ramos had multiple early warning signs of developing

severe mental health issues and had learning disabilities. In interviews from friends who knew

him in middle school, Ramos was constantly exposed to violence from bullying in school and

had an unstable home life.

As previously stated, one of the key functions of school nurses is to provide health

screenings and mental health support to students. If Ramos had a speech impediment, why was it

never addressed? According to Bohnenkamp et al. (2019), one third of a student’s school time

will be spent with the school nurse for things such as health screenings and evaluations and for
SCHOOL NURSING: THE CHALLENGES 9

treatment of minor ailments such as headaches and small cuts and bruising. Given the statistics,

is more than likely that Ramos spent at least one or two occasions in the nurse’s office. A school

nurse is an essential member of a multidisciplinary education team that helps identify, evaluate

and monitor students who may be eligible for services through the Individuals with Disabilities

Education Improvement Act (IDEIA) (National Association of School Nurses, 2018). While it is

unclear if Ramos was evaluated and treated by school personnel for IDEIA or other programs,

Davis (2022) states that no interventions in regards to his speech impediment or increased

absentee in school was addressed in records found.

The motives and reasons behind the Robb Elementary School shooting in Uvalde may

never fully be understood or discovered, however, multiple reports have been made that Ramos

had clear underlying issues. It can be concluded that both his home life and school life did not

give him adequate resources and support that he needed.

Collaboration with School Nurses

During my research I spoke with three school nurses regarding their experiences as well

as the limitations and challenges they faced. Redundant documentation was considered very time

consuming (J. Ritter, personal communication, June 14, 2022) as well as the large amount of

students that need to be seen. Another concern was the lack of protection they felt regarding their

license and practice and the legal actions that could be taken against them (M. Watson, personal

communication, 2022). According to J. Ritter (personal communication, June 8, 2022), in the

county that her school district is in, a doctor’s order is needed to give over the counter

medications, while other counties have discretionary medications, like Tylenol and ibuprofen

that is allowed to be given without a specific doctors order.

SCHOOL NURSING: THE CHALLENGES 10

Each nurse agreed that more help would have been ideal to help with their job duties,

whether it be a secretary to help with administrative work or another part time nurse. All were in

agreeance that they felt the amount of students that they saw could be dangerous if there was

ever an emergency as they were the sole providers of the students’ health needs.

Reassessing School Nurse Staffing

Despite multiple sources and literature stating that school nurses are “critical” in a

student’s development, the reality is that they are not utilized to their full potential. In order to

ensure the most optimal situation for students and their health while in school, support staff such

as school nurses need to be available in every school at all times. School districts need to also

address safe staffing in regards to the amount of students each nurse is responsible for. In a

statement by the NASN (2022), access to a school nurse at all times while school is in session is

vital in improving students’ health, safety, and educational achievement. However, with no

federal law mandating school nurses in schools, access to school nurses is left up to individual

states and school districts. Since each school population is unique and demographics vary

depending on region, staffing guidelines should not be based on a set ratio of nurses to students,

but instead, be based on the overall student population and health acuity associated.

The evaluation and determination of how many school nurses employed at each school

should be based on the following:

 Total student body population.

 Medical acuity and health needs of all students.

 The average student census seen in the nurse’s office/clinic daily.

 Context and culture of the school that influences nursing services needed such as student

demographics, family support, and families’ economic status.

SCHOOL NURSING: THE CHALLENGES 11

In a previous statement that has since been revised, the NASN suggested a student to

nurse ratio of 750 to 1 for schools with a healthy population. While this number seems more

feasible than the current national average of 1,107 to 1, it can still be an overwhelming amount

of students to care for. While there is an approximate population of 460 at Bayview Elementary,

J. Ritter states that she can see 50 or more students in a day when she is working and is

considered one of the busiest school nurses in the Cecil County Public School District (personal

communication, June 18, 2022). Schools that service students in poor economic areas can see an

increase in health needs (Lineberry, et al. 2018). Because of unique needs in different residential

areas, school districts need to reevaluate their student demographics and needs at each campus.

Even though a healthy population means less chronic disease management for the school nurse,

it does not mean that he or she is not busy with students’ needs and health concerns.

A Collaborative Approach

Local and district school policy makers should be mindful of the range of duties carried

out by school nurses. When determining budgets and making regulatory changes, school nurses

should be present in a collaborative team to help develop safe regulations and standards for

schools. Since literature supports the importance of school nurses and their contribution to

students’ academic achievements, school attendance, and behavior, it only make sense that they

are included when discussing and implementing new school policies.

More Training and Support Staff

With a large percentage of school age children and adolescence dealing with mental

health issues, it is imperative that school nurses have thorough and proper training regarding the

subject. In Bohnenkamp et al.’s (2019) study, it was identified by school nurses that more

training related to the screening and assessment of mental health problems within the context of
SCHOOL NURSING: THE CHALLENGES 12

somatic health presentations would be beneficial in efforts to effectively treat and help students

with mental health needs. If school nurses as well as school educators are not trained with

identifying associated behaviors linked to mental health, students will not get the proper care

they need and situations like the Robb Elementary School shooting could continue.

Current Legal Actions and the Need for Nurses to Partake

The Nurses for Under-Resourced Schools Everywhere Act (NURSE Act) was introduced

by Montana Senator Jon Tester under Senate Bill 1602 and Nevada State Representative Dina

Titus under U.S. House of Representatives Bill 3166 (Congress.Gov, n.d.). The bill was created

in an attempt to create and implement grants to eligible local educational agencies for the

purpose of increasing the numbers of school nurses in public elementary schools and secondary

schools. The NASN supported the NURSE Act and urged congress to enact it (National

Association of School Nurses, 2021). Unfortunately, the bills never made it past their

introduction dates of May 13th 2021 and May 12, 2021 into the Senate and U.S. House of

Representatives for further voting or implementation.

In order to see change like the NURSE Act in the future, school nurses should be

educated on how to advocate for themselves. With the numerous certifications and trainings

offered to school nurses regarding state regulations and district polices, school nurses should also

have the opportunity to understand how they can make a difference. As part of the public health

system, school nurses should be responsible and support their role through advocacy and

participation in public policy and development and social justice.

Conclusion

School nurses play a critical role in a child’s life as they go through their school journey.

They empower students to be well by teaching, treating, counseling, and supporting them with
SCHOOL NURSING: THE CHALLENGES 13

physiological and psychological support. In return, the support and care that school nurses give

their students helps increase school participation and attendance. School nurses are often the first

to identify and address student behavioral health concerns and serve as resources for families in

crisis. Despite the importance school nurses play in students’ development, there is a lack of

support for school nurses in regards to their workload and utilization. In order to ensure the

health and safety of today’s school youth, more regulations need to be in place regarding the

presence of school nurses and the training they receive. By ensuring these community health

experts are given the proper support they deserve, the health and wellbeing of students will

continue to have support and care.

 SCHOOL NURSING: THE CHALLENGES 14

References

American Nurses Association (2012). ANA’s principles for delegation by registered nurses to

unlicensed personnel (UAP). Retrieved from

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.nursingworld.org/~4af4f2/

globalassets/docs/ana/ethics/principlesofdelegation.pdf

Congress.Gov (n.d.) S.1602 - NURSE Act. Retrieved from https://www.congress.gov/bill/117th-

congress/senate-bill/1602/all-info

Davis, W. (2022) A report detailed the missed warning signs and motives of the Uvalde gunman.

NPR. Retrieved on July 22, 2022 from https://www.npr.org/2022/07/17/1111945402/uvalde-

shooter-warning-signs-report

Bohnenkamp, J. H., Hoover, S. A., Connors, E. H., Wissow, L., Bobo, N., & Mazyck, D. (2019). The

mental health training intervention for school nurses and other health providers in schools. The

Journal of School Nursing: the Official Publication of the National Association of School

Nurses, 35(6), 422–433. https://doi.org/10.1177/1059840518785437

J. Ritter, personal communication, June 18, 2022

King, K. (2014). Violence in the school setting: A school nurse perspective. OJIN: The Online

Journal of Issues in Nursing, 19(1). Doi: 10.3912/OJIN.Vol19No01Man04

Lineberry, E.M., Whitney, P.E., & Noland, P.M. (2018). The role of school nurses, challenges, and

reactions to delegation legislation: A qualitative approach. Journal of School Nursing, 34(3),

222-231. https://doi-org.libproxy.dtcc.edu/10.1177/1059840517741526

M. Watson, personal communication, July 10, 2022.

 SCHOOL NURSING: THE CHALLENGES 15

National Association of School Nurses (2018) IDEIA and section 504 teams – The school nurse as

an essential member. Position Statement. https://www.nasn.org/nasn-resources/professional-

practice-documents/position-statements/ps-ideia

National Association of School Nurses (2020). School nurse workload - staffing for safe care.

Position Statement. https://www.nasn.org/nasn-resources/professional-practice-documents/

position-statements/ps-workload

National Association of School Nurses (2021). Nurses for under-resourced schools everywhere

(NURSE) act. Retrieved from

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://higherlogicdownload.s3.amazona

ws.com/NASN/8575d1b7-94ad-45ab-808e-d45019cc5c08/UploadedImages/PDFs/Advocacy/

2022_Priority_School_Nurse_Grant.pdf

National Institute of Mental Health (2020, November). Mental illness. United States Health and

Human Services. https://nimh.nih.gov/health statistics/mental-illness.shtml

S. Rivas, personal communication, July 9, 2022.

Savage, T.A. (2017) Ethical issues in school nursing. OJIN: The Online Journal of Issues in Nursing,

22(3). https://doi.org/10.3912/OJIN.Vol22No03Man04

Texas Center for Nursing Workforce Studies (2021). School nurses in texas k-12 public & charter

schools. Texas Department of State Health Services.

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://dshs.texas.gov/chs/cnws/

WorkforceReports/2021/2021_School_Nurses.pdf?terms=school+nurse