School Days

Little Joey (not his real name) was blue–literally. Born with a heart defect that left him breathless, he couldn’t climb the stairs or run around the playground at his Dallas school with the other children.

But a team of professionals, led by the school nurse, had a plan to remove the barriers created by the preschooler’s condition. School medical and social workers, his teacher and the hospital where Joey received treatment showed staff and other teachers how to adapt activities for him. They educated his classmates. They worked with his parents, fine-tuning solutions perfectly suited to his personality and physical needs.

Surrounded by people who cared, Joey excelled academically and became popular among his classmates.

“We had to be sure that normal school activities could be adapted to his physical condition,” recalls Suzanne Medrano-Kubelka, RN, MSN, APRN, BC, director of health services for the Dallas Independent School District. “He’s in the second grade right now.”

Much has changed in the specialty field of school health since Lina Rogers–generally acknowledged to be America’s first school nurse–was placed in a New York City school more than 100 years ago. Given a month to make a difference in the absentee rate of children (New York was one of the first cities in the world to mandate attendance), Rogers was successful, and on November 4, 1902, she had a permanent job.

But one thing hasn’t changed: The goal of school nurses is still to advance the well-being, academic success and lifelong achievement of students.

If you love children, enjoy being a health resource in a non-medical setting and work well both on your own and in a team, school nursing could be the ideal career for you. While hiring prospects vary widely among school districts, depending on budget allocations, never has there been a greater need.

“The biggest [reason why nurses choose this specialty] is the kids. Working with them, you know you make a difference,” says Judith Robinson, RN, PhD, FAAN, executive director of the National Association of School Nurses (NASN). “You’re giving kids the ability to do their best.”

Cultural Competence Goes to School

Thirty years ago, a child like Joey probably would not have been in school at all. But when Congress passed the Individuals with Disabilities Education Act (IDEA) in 1975, students with severe medical conditions became mainstreamed into standard classrooms.

These days a school nurse is as likely to insert a urinary catheter as to check a temperature. Children who once required hospitalization or 24-hour institutional care now come to school. They have a variety of conditions that require monitoring, including bone and muscular diseases (such as spina bifida), seizures, heart disease, diabetes, asthma and other chronic illnesses. They need tube feedings, insulin shots and nebulizers.

The medications and procedures that school nurses can administer vary according to the laws of each state. But “anything you ever saw in a hospital you now see in a school,” Robinson says.

Naturally, school nurses provide life-saving care during emergencies and a place to rest for students who are feeling feverish. But they also screen for diseases, including a burgeoning number of asthma and diabetes cases, especially in racial and ethnic minority children.

“We have a significant number of children with asthma [in the nation’s schools],” Robinson reports. “And we’ve seen a significant increase in the number of children with type 2 diabetes and excessive weight gain early in life.” Type 2 diabetes, which used to occur primarily in adults, is linked to poor eating habits, excess weight, inactivity and a predisposition to the disease. According to the American Diabetes Association, 15% of American Indians and Alaska Natives and nearly 11% of Hispanics are now thought to have type 2 diabetes, compared to roughly 6.2% of the nation overall.

Students in low-income urban and rural areas are especially prone to the insufficient nutrition and sleep that lead to poor health. As a result, health education is a major priority for school nurses in these communities. It is the school nurse who educates students and teachers about health issues. One-on-one and in front of a class, nurses guide students to take responsibility for their own wellness. They also show teachers and staff how to handle medical emergencies and meet the special needs of mainstreamed students with serious medical conditions.

School nurses also perform a community service role, advocating for children who are experiencing family or social problems and assessing students’ mental health. Because this kind of work requires the nurse to build a relationship of trust with the student and family, nurses who share the same ethnic or cultural background as a minority student are often in a better position to establish such trust. At the very least, they are more likely to be aware of potential cultural barriers that can keep students from reaching out.

“School nurses need to be sensitive to the cultural and social differences among students,” says Medrano-Kubelka, who is Hispanic. “Each culture brings with it some differences.” In her Texas school district, students speak more than 57 different languages. The area has a large Hispanic population and a growing number of Asian Americans.

School nurse Olivia Hernandez, RN, who speaks Spanish “mas o menos” (“more or less”), worked in a doctor’s office and a hospital coronary care unit before settling comfortably into what she calls her niche 29 years ago. “I knew [school nursing was right for me] the minute I came in,” she remembers. “I feel like I touch a lot of children’s lives, and their parents’ as well.”

Hernandez, who works at Urban Park Elementary School in East Dallas, Texas, sees her role not only as that of a health care provider but also as an open-door health educator and community resource. Her clinic walls are covered with brightly colored posters that teach health lessons, like handwashing and asthma care. She helps families track down insurance coverage, fill out forms, find doctors and dentists.

She also enjoys being a role model for the school’s largely Hispanic population. Posters in her clinic proclaim “I want to be a doctor” and “I want to be a nurse,” prompting questions from curious students. She tells them she went to nursing school and had training to do her job, and that they, too, can find a rewarding career in the health care field.

Reaching Out to Troubled Teens

Other school nurses agree that being an advocate and role model for students is a vitally important part of their job. In fact, their work often has just as much to do with keeping a student on track as dealing with the medical issues he or she may have.

For example, Sharon Gooden, RN, was teaching a student newly diagnosed with diabetes how to live with his disease when she noticed other problems that needed addressing. The teenager was coming to school on an empty stomach and without taking his insulin. The health issue became a social one when she realized his mother wasn’t caring for him properly. Gooden enlisted the help of a social worker and doctor to get the whole family on board to treat the student’s illness.

“You’re an advocate, definitely,” says Gooden, an African-American school nurse who works on temporary assignments through Comprehensive Resources, Inc., a staffing agency that provides nurses and other health professionals to schools in New York City. “In many cases, a school nurse may be the first to pick up on these kinds of issues.”

Her goal now is to teach the student to manage his diabetes, because he’ll have it all his life. For teenagers wrestling with the challenges of puberty, this can be a tricky proposition. Learning to manage a chronic medical condition on top of everything else can seem overwhelming to them. School nurses can help not just by teaching but also by applying their negotiating skills.

“Sometimes there’s a lot of resistance and denial [in teens],” Gooden explains. “Sometimes we actually have to physically go look for them because they will not come into the clinic on their own, either because of denial or because they don’t see the importance. But other times, I lay back and keep silent so that I leave an entrance for them to come back in my door.”

For Gooden, who has been an RN since 1968, school nursing offers an ideal setting to help prepare teenagers for the responsibilities—health-related and otherwise—of adulthood. She particularly enjoys talking with girls about careers and self-esteem.
“We have a lot of students who really just come by because they need nurturing,” she says. “If you are approachable, they’ll start telling you about other issues you can help them with.”

A Great Career–But Are There Any Jobs?

Many specialty areas of nursing have been hit particularly hard by the current RN shortage, and school nursing is no exception. The U.S. Department of Health and Human Services recommends a ratio of one school nurse for every 750 students. Yet in some parts of the country, such as Virginia and Oregon, nurses are actually facing nurse-to-student ratios of one-to-2,000 or even higher.

Unfortunately, a lack of nurses is only part of the problem. While many of the nation’s hospitals are going to unprecedented lengths to recruit more nurses, the school nursing shortage is a more complicated situation. Ironically, even though school nurses are urgently needed all over the country, some school districts aren’t hiring–because they can’t afford it.

Education budgets are tight these days, and educators have a sharp eye on the bottom line. Unless a school has special health issues or needs, nursing can be one of the last priorities for funding. Most school nurse salaries are paid by federal and state education dollars–money that educators are likely to funnel elsewhere, especially in cash-strapped districts where there aren’t enough textbooks to go around.

Sometimes schools are not even aware that they are allowed to allocate government-provided education funds to health care. When the federal Elementary and Secondary Education Act, also known as the No Child Left Behind Act, came up for renewal last year, the NASN successfully lobbied for language changes that included school nursing services. The goal, says Robinson, was to let schools know without a doubt that they can use those education dollars to hire and retain nurses.

In passing IDEA, the federal government ensured that all students, including those with disabilities, would have access to education. But how a school district addresses students’ health needs is an entirely local decision.

As a result, some school districts aren’t recruiting nurses–but many are, driven by local and state mandates for reasonable nurse-student ratios. One of the best examples is Vermont, where state law requires that a school nurse be available for every 500 students and that every school have a nurse. On the other hand, says Robinson, one of the most challenging job markets is Colorado, where the ratio at some districts is one nurse to 8,000 or 9,000 students.
The severe shortage of nurses in many school settings often means unqualified people, such as teachers, are performing nursing procedures out of necessity for the students who need them–essentially practicing nursing without a license, which is against the law. But budget constraints prevent many schools from filling those roles with qualified nurses.

To bridge the gap, some districts around the country hire LVNs and LPNs as school nurses. Others, like Vermont, continue to insist that a school’s primary nurse be an RN.

Fortunately, many inner city schools have survived health staffing cutbacks because budget officials are aware that school nurses provide essential services to students who are more likely to have limited or no access to other health providers, Robinson notes. On the other hand, some rural districts in the South would love to find nurses but have been unsuccessful, in part because they cannot afford to pay a competitive wage.

But despite the difficulties of the current job market, school nurses have one of the highest rates of job satisfaction in the nursing profession, according to a survey by the Health Resources and Services Administration’s Bureau of Health Professions, Division of Nursing.

“What we find is that most people who get into school nursing either leave within a year if it’s not a good fit for them, or else they stay for the rest of their career,” Robinson says.

As for school nurse salaries, a recent NASN member survey found that most respondents earned between $20,000 and $49,000 a year. (Information on hours worked was not asked.) Sixty-eight percent are paid on a teacher salary scale, and roughly 26% earn less than teachers. Nurses on a teacher pay scale usually work 180 days a year, earning a starting salary of $20,000 to $28,000. Some school nurses supplement their income during the summer by covering for vacationing hospital nurses or working as summer camp nurses.

The Dallas Independent School District is in the midst of beefing up its nursing ranks, Medrano-Kubelka says. Two years ago, when the district’s ratio had increased to one nurse for every 1,300 students, the board of education approved a measure to lower the ratio to 500 students per nurse. With about 165 nurses in 216 schools, the ratio is improving, but the district is continuing to hire more nurses.

According to Medrano-Kubelka, the district is looking for RNs with a bachelor’s degree in nursing and experience in a number of areas, including ICU, emergency and community health. Depending on previous school nursing experience, the beginning salary is approximately $35,000.

“We are always willing to consider an applicant,” she adds. “If we’re not hiring just then, we’ll always get back to them. The potential to be hired is good.”
To attract more candidates, the district offers a mentoring program which pairs new school nurses with experienced leaders during their first two years. The mentors and mentees meet every two weeks or so to go over competencies in key areas.

Getting Your Foot in the Schoolhouse Door

Some school nurses, like Gooden, find that working for a staffing agency is a good option. These agencies contract with school districts to fill gaps in nursing coverage. For instance, Comprehensive Resources has a contract with New York City public and other schools to provide nurses for a variety of assignments. The nurses can work in a wellness setting or choose to assist children with special medical needs. And they can pick the age group they prefer.



“It’s important for the agency to make the right fit,” says Lynette Lewis, MBA, MLS, Comprehensive’s director of nursing services. “The nurses have to suit the students and the school has to suit the nurse. Some nurses may want to do more wellness work, while others might want to focus on medically fragile children.”


School health is unique among nursing jobs in one important way, Robinson notes: The culture is different. The education field has a rhythm distinct from that of a hospital or other acute-care setting. While there’s plenty to keep nurses busy, the pace is less frenetic, the emergencies fewer. Here the emphasis is on promoting health and preventing disease.

Robinson advises nursing students who are considering this specialty to do a pediatric rotation in a school to get a feel for the job. Training or experience in pediatrics and community or public health is the ideal background for a school nurse. Some nursing schools even offer degree programs in school nursing. One of the best known is the Advanced Practice in Primary Health Care: School Nurse Practitioner MSN program at Seton Hall University College of Nursing (South Orange, N.J.), one of only five such programs in the U.S. listed in the National Directory of Nurse Practitioner Programs.

Gooden doesn’t hesitate to recommend her chosen specialty to other minority nurses. “Hospital nursing is not the only thing out there,” she emphasizes. “You have other choices. And school nursing is an excellent one.”

Reading, Writing and Fighting Health Disparities

In true school nurse fashion, Cynthia Samuel, R.N., M.S., Ph.D.-C, calls everyone “dear” or “sweetie.” But her nurturing disposition belies a certain tenacity. She is determined to eliminate the health disparities she sees every day working in an urban elementary school in Irvington, New Jersey. “I became a nurse because I love working with children, especially underserved, underprivileged children in the urban community,” Samuel says.

Samuel’s students are part of the most vulnerable population suffering from health and economic disparities, so often disproportionately tied to race and ethnicity. But at school, through the nurse, they have access to potentially life-changing care and support.

Each morning, students of varying ages greet nurse Samuel at her office door. Often, their basic needs have not been met. They are hungry, tired, and they don’t want to be at school. “These children are very needy,” she says. And it goes beyond food and shelter. “They need love. They need encouragement.”

A visit to Samuel’s office may be the only professional health care some students receive, as parents choose to avoid a trip to the pediatrician they cannot afford. “They don’t receive immediate health care. Oftentimes it’s delayed until they see the nurse,” Samuel says. And ongoing problems that do make it to a clinician, like a persistent cough, have often been ignored too long. “By the time they reach the doctor, the situation has evolved into a complex matter.”

The ins and outs of school nursing

Without a doubt, school nurses are on the front line of pediatric health. The stereotype that school nurses only distribute children’s aspirin, bandage schoolyard scrapes, and watch over anyone lying down with a headache is largely misguided. They provide physical and emotional health services, including acute and urgent care in response to illness and injury. They monitor chronic diseases and counsel students and parents regarding condition management. They provide health education for individuals and classrooms, health assessments (vision, hearing, height/weight, scoliosis, etc.), and referrals to primary health care providers and emergency rooms. They also communicate with school staff, parents, and health care providers related to individual student needs, explains Linda Davis- Alldritt, R.N., M.A., P.H.N., F.N.A.S.N., F.A.S.H.A., the president-elect of the National Association of School Nurses (NASN). On the administrative side, nurses review immunizations and maintain students’ medical histories.

“School health is a specialty,” Samuel says. “It is not the cushy, cushy job many people envision it to be.” In an urban setting, where socioeconomic inequalities are most prevalent, a school nurse’s practice extends beyond the school building to the community and the students’ parents.

Samuel encounters the same health disparities she sees in her school working with residents in outlying neighborhoods. Among parents, she addresses health issues like hypertension, obesity, heart disease, and nutrition. Oftentimes, what they know about health care is from what the school nurse has instilled in them,” she says. And if the nurse does not talk directly to parents, children often serve as a vital link to their families at home, sharing what they have learned about health and nutrition in an unconventional position of influence.

It is an eye opener to the needs of children as well as the needs of communities that people just aren’t addressing, says Susan Fletcher, R.N., M.S.N., Ed.D., an associate nursing professor at the Chamberlain College of Nursing in Downers Grove, Illinois. Before coming to Chamberlain, she worked as a school nurse at an inner city elementary school in St. Louis, Missouri.

“I would have kids coming to me with gun shot wounds and stabbings from gangs,” Fletcher says. “They would come to me because they trusted me.” Some of her students lived in neighborhoods where gang members assaulted children who refused to join their ranks. One boy managed to resist the constant pressure with help from his mother, grandmother, and Fletcher. The abuse escalated to the point where he eventually came to school with a broken leg and arm. But Fletcher and the boy’s family maintained their support. Years later, a policeman approached her in a hospital, asking her if she recognized him. After a moment she realized it was the same boy, grateful and happy. “That’s why you stay in it,” Fletcher says. “That’s why you do school nursing.”

Community influence

Often, school nurses are the sole medical expert in a notorious breeding ground for germs. “You need community health training to become aware of the demographic in which you practice,” Samuel says, stressing the need for seasoned, veteran nurses. Samuel recommends hospital training; it gives school nurses the experience necessary to become an independent practitioner working under pressure.

Part of her work includes collaborating with the school’s cafeteria staff to ensure the healthfulness of the childrens’ food. The cafeteria workers must do more with less, she says, providing balanced meals in the midst of extreme budget cuts. She would like to see healthier school lunches in general, but it’s especially important in schools like hers, where the economic gaps are widest. Lunch may be the only nutritionally sound meal—or the only meal—some children get. Parents have been known to steal food from the cafeteria as well.

“A lot of the parents don’t know what fresh vegetables are, fresh fruits,” Samuel says. “They’ve never been exposed to it,” and it’s not readily available to them. As a result, their children consume inordinate amounts of processed, canned food for dinner and bring in things like potato chips and blue “juice” to school for lunch. “Salt and sugar—that’s all they’ve had,” Samuel says. “We have to be change agents in the behavior.” She references Michelle Obama and her focus on fresh, well-prepared foods as an example. (An initiative lead by the First Lady, sponsored by the White House Task Force on Childhood Obesity, released 70 recommendations for curbing child obesity in May of this year, including a 17-point section pertaining to healthier foods in schools. Read the full report and recommendations at

However, it is possible to implement changes in the greater community as a school nurse, Fletcher says. The key to a successful health campaign is incorporating the needs of the community. In her experience, promoting an agenda the people do not support is ineffective. “We’re so quick to come up with solutions that we don’t really listen,” she says. Instead, school nurses must talk to parents and other members of the community, gauge their interests, and integrate their ideas.

Working with young children from disenfranchised families presents another unique aspect of school nursing: it can be an emotionally draining job. School nurses must address psychosocial issues, as children recover from the trauma of homelessness, or intervene with children suffering abuse and neglect. Samuel has attended conferences with parents, child protective services, and school administration, sharing her findings and recommendations regarding children’s wellness. Parents also seek her input with less severe problems at home and general child rearing issues.

Other school workers may turn to the nurse, knowing he or she can act as a child advocate. A cafeteria worker once came to Fletcher after seeing a child scrounge for food in the school garbage; his mother, a drug addict, could not feed him. Fletcher and school administrators worked with the mother, giving her food and rehab information, and the child eventually moved in with another family member. School nurses need to be able to address these situations as well. “The kids are an inspiration and the families are an inspiration,” Fletcher says. “Even with all the heartache, you’ll see bright spots.”

The future of the field

“We have to reform health care in the schools,” Samuel says, calling for increased research and funding, particularly promoting pediatric health in urban communities. Many schools are under funded and under staffed. “We have issues of wide disparity between states on the caseloads of school nurses,” says Davis-Alldritt. “Some nurses are expected to care for thousands of students in multiple buildings.” She notes that nurses practice in only 75% of U.S. schools. “School nurses will always provide a safety net, ensuring that children are ready to learn,” Davis-Alldritt adds. In order for that net to be secure, a nurse must first be present and supported.

A drastic shift in the allocation of education funds during the past 15 years has also cut into the nursing budget. “Many districts respond by lowering the standards of [nursing] care, assigning procedures like catheterization, suctioning, and diabetes management to school secretaries and other personnel who are not prepared,” Davis-Alldritt says. “In any other setting, this would not happen—it would be considered unsafe.” While the recently passed Patient Protection and Affordable Care Act will eventually impact school nurses and their work, “it will be several years before these measures are implemented, and even then, not all children will be covered.”

NASN is working to identify research priorities to determine how to best utilize school nurses. There are also plans to commit government stimulus money to create uniform electronic medical records in schools, allowing nurses to more easily share information with other local health care providers, ensuring the most accurate, up-to-date information. They are small steps on an administrative level, but Samuel cites strength in numbers.

“We need to be unified. We need to have a strong voice collectively to make elected officials aware of who we are, what we do,” Samuel says. “We need to be recognized and we need to be advocated for.” Samuel says she wants to fill that role, consulting on a state and national level, in addition to her work with students. “I want to be the voice for underserved, underprivileged children,” she says. Samuel already campaigns for pediatric health by speaking out on the subject. Healthy children perform better academically, and Samuel says her doctoral research shows the relationship between pediatric health and increased learning readiness. It’s easy to use the resources obtained as a nurse to become an advocate for the children, Samuel says. “We do make a difference by being here.”

School nurses become enmeshed in the whole life of the school and surrounding community, Fletcher says. Families even came to her for a second opinion after seeing doctors at their local clinic. At times, they function as case manager, policy maker, and consultant. Unique health care challenges, socioeconomic issues, and the public health factor make school nursing a demanding, but rewarding specialty. “You have to love it,” Fletcher says. “It’s transformative. It changes the way you look at life.”