Nursing News

Most States Fail to Make the Grade with School Nurse-to-Student Ratios

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By Megan M. Krischke, contributor

February 15, 2010 - The National Association of School Nurses (NASN) recently released their 2009 “ruler,” a compilation of data on school nurse-to-student ratios across the United States. Again this year, Vermont had the most favorable ratios with one school nurse to every 311 students and Michigan edged out Utah for the lowest spot on the ruler with a 1:4,836 ratio. Only 13 states met the NASN recommended ratio of nurses per well students of 1:750.

Linda Cook, Ph.D., CNS, CNE
Sandi Delack, RN, M Ed, NCSN, president of NASN, explains that Nurse Practice Acts, funding issues and expectations affect each state's school nurse-to-student ratio.

Many East Coast states, particularly in New England, hold top positions on the ruler.

“Typically in New England there is a nurse in every school. Nurses are the ones delivering care and giving medication. In states that are lower on the ruler, nurses oversee a lot of unlicensed people who are delivering care to students,” explained Sandi Delack, RN, M Ed, NCSN, NASN president.

“One significant factor for where a state falls along the ruler is how strict the regulations are in the state’s Nurse Practice Act (NPA),” said Delack. “The act determines what care must be delivered by a nurse. In Rhode Island, where I work, the NPA says that medication administration can’t be delegated to an unlicensed person, so that means there needs to be a nurse in every school.”

There are more than 56,000 public school nurses currently working part- or full-time, according to the latest information from the National Center for Education Statistics.

“Another determining factor for the ratios is expectations. Even in eastern states that don’t have mandates, having a school nurse on site is expected by parents and teachers, because they grew up with nurses in their schools,” added Martha Bergren, DNS, NASN director of research.

May L. Wykle, Ph.D., RN, FAAN
Martha Bergren, DNS, NASN director of research, reports that a growing number of students are medically fragile or have chronic health conditions, and need a nurse's expertise.

Funding, of course, is another major issue. While public health monies, grants, or even Medicaid funds in certain situations can provide funds for school nurses, most positions are paid through local school districts.

“Often school administrators don’t understand what a school nurse can do for them or feel that they can’t afford a nurse, so they spend their funds other places,” said Bergren. “Yet, we have good research to say that an RN is 57 percent less likely than an unlicensed person to send a child home from school. RNs are better equipped to determine the severity of a child’s complaint and to provide the appropriate treatment. This means children stay in school and parents are able to stay at work. The presence of a school nurse is especially key to helping students with chronic conditions such as diabetes and asthma stay in class.”

“One of the biggest obstacles to people understanding the importance of a school nurse to the health of children is that very few states are tracking their students’ medical needs,” Bergren explained. “Since we don’t bill for our services and most data is collected through the reimbursement process, there is very little recorded on the services school nurses are providing children. Districts are making decisions to cut school nurses without realizing what they are going to lose because there isn’t data to show the value of school nurses.”

Fast Facts About School Nurse Ratios
The National Association of School Nurses (NASN) recommends these school nurse-to-student ratios:
- 1:750 for well students;
- 1:225 for student populations which require daily professional nursing services;
- 1:125 in student populations with complex medical needs; and
- 1:1 may be necessary for individual students with multiple disabilities.
In the lastest NASN "Ratio Ruler:"
- Only 13 states met the recommended 1:750
- The state with the healthiest ratio was Vermont, at 1:311
- The state with the worst ratio was Michigan, at 1:4,836
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Bergren would like to see more states follow the example set by Delaware, Massachusetts and North Carolina (ranked 5, 9 and 32 on the “ruler,” respectively). She says these states keep track of important student medical information such as how many 911 calls were made from schools and the number of children with diabetes in their public schools. Additionally, the NASN is asking the National Center for Education Statistics to collect more information about school nurses.

For nurses who would like to see better ratios in their state, Delack urges them to spend time advocating in their state legislature for a stricter NPA and/or mandates about the number of nurses per student.

In Utah, legislation was passed which improved their ratio from 1:4,893 to 1:4003 over the past year. Additionally, the District of Columbia moved up from number 12 to number 3 on the NASN ruler after increased awareness about the value of school nurses led to the creation of more positions.

“You need to do a lot of education,” said Delack. “People need to know why is it important for a nurse to administer care, rather than an unlicensed person. It takes time for people to understand that, because schools didn’t used to have such a large population of kids with complex medical needs.”

For more information, including the full list states and their school nurse-to-student ratios, visit the NASN web site.

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