There are 96,000 full-time school nurses in the United States who are facing an uncertain school year ahead. Even before the pandemic expanded their workloads and altered their day-to-day tasks, the United States was grappling with a shortage of school nurses.
Pandemic sheds new light on old problem
Pandemic aside, the US Centers for Disease Control and Prevention recommends that schools have one full-time nurse for every 750 students. Now, when students and schools may need nurses more than ever, it's estimated that about a quarter of schools still have no nurse at all.
The latest data from a national school nurse workforce study, published in the Journal of School Nursing in 2018, found approximately 39% of schools employ full-time nurses and about 35% employ part-time school nurses, while 25% do not employ school nurses.
The country has had a shortage of school nurses for years, but the burden is clear now.
'You can definitely tell there's a lot of tension'
The division over masks and vaccine requirements within communities tend to reflect the variability among US school districts when it comes to rules and policies.
Nationwide, some schools mandate that students and staff wear masks to reduce the spread of the virus that causes Covid-19. Others don't.
Because Covid-19 policies vary across school districts, the responsibilities of the school nurse can vary as well. And in some schools where mitigation measures to reduce spread of the coronavirus are not followed or enforced, that can increase a school nurse's risk of exposure to the virus.
Rural schools more likely to have no nurse
Some of these differences in school policies, practices and behaviors can vary by geographic region.
For instance, in rural regions of the United States, Covid-19 vaccine uptake generally has been slow -- and it's also in these regions, where positive Covid-19 cases cripple health care systems, that the shortage of school nurses appears to be greater.
Schools in the rural regions of the United States appear to be "significantly more likely" than schools in urban areas to report having no nurse at all, according to the study published in the Journal of School Nursing in 2018. In that study, 23.5% of rural schools report having no nurse compared with 10.3% of urban schools.
"When you get into a rural setting, you've got school districts, pre-pandemic, that saw a nurse once a week or once a month depending on where they were, and they share nurses with multiple districts that could be an hour away from each other -- and then you get in the middle of a pandemic, and the nurses are needed, and we've never been leaned on in that way," said Pray, whose Moses Lake School District is considered to be in a rural area.
To address the nation's school nursing shortage and also improve the number of school nurses in rural regions, funding is needed, Laura Searcy, a pediatric nurse practitioner who is a past president of the National Association of Pediatric Nurse Practitioners and a fellow of the American Association of Nurse Practitioners, wrote in an email to CNN.
"Funding is a key issue. There is an inconsistent mishmash of state and local funding that puts small rural school districts with inadequate tax bases at a disadvantage," she said in the email. "And those areas also are likely to have a shortage of primary care pediatric health care providers as well."
In those schools where no nurse is on staff, often teachers are trained and relied on to provide certain aspects of medical care that typically would be performed by a school nurse.
"We wouldn't accept medication being given to a child from unlicensed support staff in a hospital, for example, so it's always baffling to me that we accept this in the school setting for our medically fragile students," Gloria Barrera, president of the Illinois Association of School Nurses, told CNN.
"As a school nurse, I know that I'm serving as a bridge between the health care and education systems and other sectors, as well as a link to broader community health issues through the students I serve. That continuity of care is why I became a school nurse," Barrera said. "For any nurse that's considering a career as a school nurse as a specialty, it really has historically played an important role in promoting public health within our schools and larger communities -- and you are needed."
School nursing jobs can be hard to fill
Nationwide, there is an overall shortage of nurses -- not just school nurses. The American Nurses Association has even called for the US Department of Health and Human Services to declare the nurse staffing shortage a "national crisis."
But there appear to be several factors driving the nation's school nursing shortage specifically, including the funding needed to hire, no direct pipeline to connect nurses to schools and lower wages compared with other nursing roles in hospitals or other settings.
"I know very few nurses who right when they graduate go into school nursing. They find it along the way, and there's a number of reasons for that," said McCauley, dean of Emory University's School of Nursing.
"Students who are passing their licensure exam and getting their first degree in nursing rarely have rotations in school nursing. It's not impossible, but it's rare," she said. "Students may not have exposure to school nursing."
Therefore, on one hand, younger nurses applying for school-based positions might not have that much experience within educational settings. Then on the other hand, more experienced nurses might not be satisfied with the pay offered in schools.
In May of last year, the median annual wage for registered nurses in US hospitals was $76,840 compared with $64,630 for registered nurses in educational services, according to the US Bureau of Labor Statistics.
The disparity in pay for school nurses compared with other nursing positions could be due to most school nurses not working year-round, McCauley said.
"You have to keep in mind that they work probably 10 months out of the year," McCauley said. "So their salary looks lower than other registered nurses, but I can't seem to tell whether that's adjusted for a yearly salary."
Overall, "there is a national nursing shortage, so school districts find themselves competing against health care facilities for the same pool of applicants," said Searcy, a pediatric nurse practitioner.
"The compensation is not quite equitable, so that's always been a concern," said the National Association of School Nurses' Mendonca.
"I have heard anecdotally too that for nurses who were close to retirement, or thinking about it, that the pandemic has maybe pushed them in that direction sooner than what they may have been planning on," she said. "So that makes the shortage even a little more critical than what we've been dealing with."
Lawmakers push for more school nurses
Some Democratic lawmakers want to help improve funding for school nurses through proposed legislation called the Nurses for Under-Resourced Schools Everywhere Act, introduced by Nevada Congresswoman Dina Titus and Montana Senator John Tester.
The NURSE Act would create a grant program at the US Department of Education to reduce the cost of hiring nurses in elementary and secondary public schools, according to Titus's office. School districts could apply for the grants if at least 20% of their students are eligible for low-cost or free school lunches.
Titus on Wednesday urged Congressional leaders to include the legislation in the upcoming budget reconciliation package. The National Association of School Nurses also has announced support of the NURSE Act.
"For school nursing, we thought for sure that after the wave of Covid went through this last year, you would see nurses wanting to leave the hospital and go to something that had a more firm schedule -- Monday through Friday, potentially summers off -- but we're not seeing them making that transition over because there's such a drop in pay," Pray said.
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