Health as a Foundation for Learning

As with all nurses, school nursing is regulated by the North Carolina Board of Nursing. In North Carolina, a school nurse is defined as “a registered nurse (RN) who provides population-based and individual health services through an assignment to a designated permanent K-12 school(s).”¹ School nurses are required to manage complex, often chronic student health needs, develop individualized plans of care, and ensure compliance with state and federal health regulations. By requiring an RN, North Carolina schools ensure they have professionals that are prepared to independently assess the health needs of students, address physical and mental health concerns, and reduce barriers for students to access their education.¹ In the community-based practice setting of schools, school nurses do not require regulation by another license type due to their educational preparation. Other nursing license types may also work in schools under the direction of an RN school nurse, since their practice is not independent and is required to be directed for them to operate within their scope.¹

The complex nature of nursing activities required in a non-health care setting uniquely sets school nursing apart as a highly skilled specialty. Having established professional standards is essential for school nurses, as they practice to the full extent of their licensure while collaborating with non-nursing staff to integrate academic and health priorities for students. The first national standards of school nurse practice were established in 1998.² The School Nurse Professional Scope and Standards and local school nursing protocols guide the school nurse specialty and are a mechanism for accountability. As trusted health care providers in educational settings, school nurses collaborate with other providers who write medical orders for students to ensure their health needs are met during the school day. As these medical orders are implemented, school nurses ensure the provided care is done in a standardized, compliant manner. An inadequate school nurse workforce puts this process in jeopardy. The potential consequences include negative student well-being and adverse health outcomes, as well as putting school staff at risk.

The scope of school nursing practice is consistent with RNs in all other settings and is based on the same nursing fundamentals. The school nurse’s role as a caregiver, advocate, educator, and problem solver has many parallels to nursing practice in other specialties. The goal of school nursing is what distinguishes the role from others and speaks to the uniqueness of practice. For students to be healthy, engaged in their education, and able to reach their full potential is the purpose of each school nurse.³ As nurses, their role has a holistic approach and is supported by the American Academy of Pediatrics (AAP).⁴ In their position statement, the AAP recognizes the essential collaboration with school nurses to promote health and keep students in school.⁴ In addition to a coordinated approach with practitioners, school nurses must also collaborate with school staff, families, and communities to promote student health and learning.

School Nurse Workforce

Annually, school nurses submit workforce data as part of the North Carolina Annual School Health Services surveys. Table 1 reflects the past six years, including the 2019-2020 school year when the COVID-19 pandemic impacted school closures in the spring of 2020. Despite the school year ending early for public schools, the Annual School Health Services surveys were submitted by school nurses as they have since 1996.⁵ Of note, the trends reflect additional funding related to the pandemic during specific years in which there was an increase in the school nurse workforce. As a result, the ratio between school nurses and students decreased. As these funds have ended, the numbers are now trending in the reverse.⁶ Charter school health services data collection began in the 2021–2022 school year, with the first report brochure published from 2022–2023 data.

Per the National Association of School Nurses (NASN), research supports the benefits of students having access to a full-time school nurse. This includes improved academic outcomes related to reduced chronic absenteeism and an increase in graduation rates. School districts can benefit from the cost savings aspect of employing school nurses. For every dollar applied to the salary/benefits of a school nurse, over $2.00 is saved in health care expenses and time away from work for parents and staff. The majority of parents indicate the importance of having a school nurse as they make decisions about schools for their children.

There is also a time-saving benefit for staff when a school nurse is present. School nurses can address the health needs of students, allowing teachers to focus on education.³ This is evident from data collected during the 2024–2025 school year for the North Carolina Department of Health and Human Services School Health Services Report, Section Two, which is outlined in Table 2.⁷ School nurses reported 3,041,073 student encounters during this time period. After assessing each student, 86% were able to return to class, thus able to participate in their education.

Additional data provided by North Carolina school nurses support that their value is far beyond ice packs or band-aids. For example, the 2024–2025 North Carolina Annual School Health Services Report Brochure reflects that students who participated in case management for chronic conditions such as asthma, diabetes, and mental health demonstrated improved outcomes between 70%–91%.⁶ While not all school nurses provide case management, 5737 students received this service. The outcomes vary by health condition; however, data were consistently collected related to student absenteeism and improved grades.⁶ When school nurses are asked about barriers to offering case management for their students, some of the most common responses are lack of time and serving multiple schools.

The school nurse workforce faces challenges beyond time and capacity. The NASN Workforce Data Study highlights challenges on a national scale that are relevant to North Carolina school nurses. There is a drastic contrast between compensation for RNs working in schools and the RN workforce overall. While 69.5% of the RN workforce makes more than $60,000 per year, only 34.2% of RNs who work in schools earn at the same level. The majority of school nurses have a salary between $40,000–$59,999. Salary impacts recruiting, as most nurses who want to become school nurses have years of experience and make well over this range. The school nursing population is also aging: 68.5% of school nurses are older than 40.⁸

Despite the challenges, there are dedicated school nurses serving students each day. While funding may be limited to address the salary gap, there are measures that could be implemented to improve job satisfaction. As health care providers in educational environments, school nurses can feel isolated. This is supported by the NASN study, where school nurses shared they don’t believe others understand the connection between health and education. Specifically, only 48.1% responded that they feel understood and respected by their educator colleagues.⁸ By including school nurses in committees, in student Individualized Education Program (IEP)/504 meetings, and supporting their professional development, schools can take meaningful steps toward retaining this valuable workforce, which is the cornerstone of education.

Conclusion

In this commentary, national data have been provided as a glimpse into the everyday difficulties experienced by school nurses who seek to be part of collaborative team of educators while addressing complex health needs of students, with a common goal of students reaching their full potential. North Carolina school nurses are reflected in the NASN study and on a regional level; their work is validated by statewide data. These meaningful statistics tell a story of a workforce with devoted caregivers that practice the art of nursing while focusing on improving the lives of students despite the challenges. When students have access to a school nurse, they are much more likely to remain at school, have their physical and mental health well-being needs assessed, and be engaged in their education. Students need to be healthy to learn. It seems like a broad, general concept, yet when implemented by school nurses, it is individual and holistic. School nurses are the custodians of students’ health as they reduce barriers and lay the foundation for their learning.

Financial Support

The author has no financial support to declare.

Declaration of Interests

The author has no conflicts of interest to report.

Correspondence

Address correspondence to Jennifer Corso, NC Department of Health and Human Services, DCFW/Whole Child Health Section, 1915 Health Services Way, Raleigh, NC 27607 (Jennifer.Corso@dhhs.nc.gov).