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Where Have all the Nurses Gone?

Lack of health care professionals in schools affects students', teachers' performance.

By John Rosales

Nurses are so much in demand in today's job market that school nurse Marianne Capoziello cannot open her mailbox without finding recruitment letters from hospitals, nursing homes, prisons, and health care employment agencies.

“I get recruitment offers all the time," says Capoziello, a licensed practical nurse (LPN) for 30 years and member of the Polk County Education Association in Florida. “But I love school nursing."

Health Services Director Irene Rosales visits a nurse station at a district high school where she interacts with students and nursing staff. Despite a growing need for nurses, nursing programs can't meet the demand due to a shortage of nursing instructors, classrooms, and clinical sites.

Hospitals are the most aggressive recruiters, offering to cover moving expenses along with cash signing bonuses and financial assistance with student loans. In 2007, hospitals had a vacancy rate of just over 8 percent, according to the National Association of School Nurses (NASN).

“The nursing shortage is expected to intensify as baby boomers age and the need for health care grows," says Amy Garcia, NASN executive director. “The problem [for schools] appears to be a shortage of adequately funded positions for school nurses."

The average public school nurse cares for 1,151 students at 2.2 schools. About 25 percent of schools have no school nurse, partly because of funding. The average salary for a school nurse is $42,467, or between $33,929 and $53,622, according to a Certified Compensation Professionals' analysis done for

To measure the need for school nurses, districts try to maintain an appropriate ratio of school nurses to students. Ratios vary from state to state. Students in Vermont, for example, have one nurse per 275 students. In Utah it's one nurse per 4,893 students.

States like Alabama (one nurse per 936 students), Georgia (one per 1,734), and Tennessee (one per 1,415) have committed funds during the last 10 years to significantly improve the ratio of school nurses to students. But with their health on the line, it's vital that students have regular contact with a nurse.

Garcia says the increasing health needs of children suffering from asthma, obesity, diabetes, and substance abuse is escalating.

“School nurses struggle to make sure that all students can see, hear, and feel well enough to learn," she says.

K–12 schools aren't the only institutions suffering from a lack of nurses—universities are grappling with a shortage of instructors in their nursing programs.

“Most nursing schools have long waiting lists," Garcia says. “Students with excellent grades are routinely turned away for lack of [nursing school] teaching positions."

According to the American Association of Colleges of Nursing, more than 30,000 qualified nursing school applicants were turned down last year primarily because of a faculty shortage. California currently has wait lists for nursing programs of over three years.

Insufficient clinical sites, classroom space, and budget constraints also hamper nursing programs. By the year 2020, the Health Resources and Services Administration projects that more than

1 million new registered nurses (RNs) will be needed to meet demands for nursing care at schools and hospitals.

To address the nursing shortage, national organizations such as NASN and the National Federation of Licensed Practical Nurses (NFLPN) work on state and federal government committees to supply research and written and oral testimony to legislatures and Congress. These efforts helped produce the Nurse Reinvestment Act, signed by President Bush in 2002. This initiative is intended to encourage people to enter and remain in nursing careers. The law establishes scholarships, loan repayments, public service announcements, retention grants, career ladders, and grants for nursing faculty.

Statewide initiatives are also under way. In Pennsylvania, for example, six new nursing education initiatives were announced to address faculty shortages by encouraging practicing nurses to return to school, earn graduate degrees, and teach nursing. Illinois is unveiling a plan to provide faculty scholarships and grants to nursing schools in order to expand student enrollment.

“We need to develop more nurse educators," says Ottamissiah Moore, an executive board member with NFLPN. “LPNs are helping with the shortage of RNs by returning to school for additional training."

California is trying to expand nursing education through a $90 million initiative.

To bolster interest in a nursing career, two national media campaigns have been launched by Nurses for a Healthier Tomorrow, a coalition of 44 health care organizations. The campaigns are aimed at raising interest in nursing careers among middle and high school students.

But for now, schools are still left to deal with their own lack of nursing staff, even as the need for school nurses continues to grow.

At the United Independent School District (UISD) in Laredo, Texas, the nurse-student ratio is one to 800. The district's 40,000 students and 6,000 employees are served by 45 RNs (with five vacancies), eight licensed vocational nurses (LVN), and 17 health assistants (with six vacancies).

“I wish it would change to 500 students per nurse," says Irene Rosales, health services director. “Some areas have one RN for two or three schools."

The district's largest campus, United High School, has 3,300 students who are served by two RNs, one LVN, and one health technician.

In addition to assessing student health status and making referrals, identifying vision and hearing problems, administering medication and vaccines, and delivering emergency care, nurses also manage insulin pumps, check blood sugars, insert tubes, suction children on ventilators, and counsel pregnant teens.

At UISD, school nurses also teach first aid classes to teachers, conduct drug assessment exams on students believed to be under the influence of drugs, weigh and measure the body mass index of every student from pre-kindergarten to 12th grade, and conduct health-related classes for students and parents.

“People think we sit behind a desk and that's it," says Rosales, an RN who worked at schools for 16 years before becoming a director in 2006. “It's not like that at all."

This false impression about school nursing has partly contributed to the shortage.

“They quit on me when they find out that this is not all fun," she says. “You have to want to be a school nurse."

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Nursing Categories

The National Education Association (NEA) passed a resolution regarding school nurses during the 2002 Representative Assembly. Resolution F-45 states: "The NEA urges its affiliates to enroll school nurses in active membership and to seek legislation that provides licensure/certification and inclusion in collective bargaining agreements. The Association believes that professional development programs should be available to all licensed/certified school nurses to augment their skills in delivering health care services and in dealing with students with disabilities."

Nurses who fall into some of the following categories are employed in school settings.

  • BSN -- Registered Nurse with a bachelor of science degree in nursing from a four-year college program. This category includes training in science, leadership, and public health. Many nurses in this category also go on to earn master of science in nursing degrees.
  • Associate Degree RN -- Registered Nurse who has completed a two-year educational program in nursing. These programs are usually affiliated with community colleges.
  • Diploma RN -- Registered Nurse who has completed a diploma program. Typically, this is a two-year program that is hospital-based. These nurses are usually technically skilled but do not have the same science background or theoretical preparation as those who graduate from a college or university program.
  • ND -- Nursing doctorate program. This is a professional degree similar to a JD for law or MD for medicine. This program focuses on clinical practice with an emphasis on research, although the research training is less extensive than that found in a Ph.D. program. There are only a few ND programs in the U.S. The programs are relatively new to the profession and still considered somewhat controversial at this time.
  • Ph.D. -- Nurses are able to earn a Ph.D. in nursing from a number of institutions. These are not medical doctor nurses as could be perceived. Much of the training at the doctorate level is in nursing administration, preparation for teaching at the master's level or above, research, and theory development. There are a number of nurses with doctoral degrees who continue to work as school nurses because they enjoy working with children. Since doctoral preparation in nursing is relatively new, there are a number of nurses who have PhDs. in other fields, such as health administration, public health, education, and psychology.
  • LPN/LVN -- Licensed Practical Nurse and Licensed Vocational Nurse. Typically, these nurses attend a one-year program but do not receive a degree. They take a state board exam to obtain state licensure. Nurses in this category are required to continue their education to maintain their license.
  • Health aides, health clerks, UAP -- Many individuals work as aides, clerks, or Unlicensed Assistive Personnel in school settings. These individuals have varying levels of education and experience in the health field. Usually, they are trained in first aide and hired as support staff. They are often supervised by the school nurse and may carry out various activities under the nurse's supervision in compliance with delegatory clauses of state nurse practice acts. Some states do not allow delegation. In states where delegation is permissible under state nurse practice acts, UAPs perform various functions, like catheterizing incontinent students and performing gastric tube feedings. Again, their roles differ depending on what is allowed in their state and school district.
  • PNP or SNP, APN -- Pediatric Nurse Practitioner and School Nurse Practitioner are nurses with bachelor of science degrees who have gone on for further training to obtain additional skills in assessing and managing children. They are sometimes called Advanced Practice Nurses when they have preparation at the master's level and/or hold national certification as a nurse practitioner or as a clinical nurse specialist. Certification is earned by taking a certification exam and maintaining a level of continuing professional preparation.
  • CNS -- Clinical Nurse Specialists are similar to PNPs and SNPs because they also go on for further educational training, usually at the master's level. Typically they focus on a particular area of nursing, such as neurology, cardiology nursing, endocrine disorders, or intensive care nursing. 


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