Research Paper
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155620606.pdf
U.S. School Nursing Job Analysis
Brenna L. Morse, PhD, RN-BC, NCSN, CNE1 , Lori Anderson, PhD, RN, CPN-PC, NCSN2 , Laurie G. Combe, MN, RN, NCSN3 , Sandi Delack, MEd, RN, NCSN, FNASN4, Lynnette Ondeck, MEd, RN, NCSN5, and Carissa Homme, PhD6
Abstract
The complexity and demands of the school nurse role have changed greatly over time. Our aims included determining tasks and knowledge relevant to modern school nursing in the United States, identifying continuing education needs of school nurses, and describing anticipated changes to the professional role. A secondary analysis of a cross-sectional web-based survey of 750 school nurses was performed. The study team evaluated calculations of mean importance and frequency for school nursing task and knowledge statements. Conventional content analysis was used to analyze open-ended responses. School nurses rated most tasks and knowledge as relevant to practice, underscoring the great depth and breadth of education and training school nurses need to meet the demands of students today. The results of this secondary analysis may be leveraged to accurately describe the school nurse role, advocate for nursing services, and support school nurses as they strive to better the health of school communities.
Keywords
administration/management, leadership, school nurse characteristics, school nurse knowledge/perceptions/self-efficacy, school nurse education
School nursing was born out of legislative mandates in the
late 19th century that supported student success through
identification of communicable diseases and other health
problems affecting attendance and learning. School nurses
have stood at the intersection of health and education for
over 120 years, working to keep children healthy and ready
to learn (Johnson, 2017). However, over the past century,
the role of the school nurse has evolved in response to
social, cultural, and political influences. This has led to a
change of the ways in which school nurses must carry out
their work to meet the goal of keeping children healthy,
safe, and ready to learn.
The school-based care of students has increased the com-
plexity and demands of the school nurse role (Davis et al.,
2019). School nursing duties have both maintained consis-
tency, as in the arena of disease surveillance and improving
student attendance, and progressed as school nurses now
address complex physical and emotional needs of students.
Today, school nurses are the only providers that most of the
nation’s public schoolchildren may access for health care
without barriers such as insurance, transportation, appoint-
ments, and fees (Fleming, 2011). As such, school nurses are
strategically placed and uniquely qualified to provide care to
schoolchildren and other members of the school community
in support of student health and academic success (Butler &
Diaz, 2016; Leroy et al., 2017).
Student needs are evolving quickly: Researchers recently
identified a 35% increase in the number of students receiv-
ing case management services for conditions such as asthma,
diabetes, and seizures over only 1 academic year (Daughtry
& Engelke, 2018). This increase in care need was in part due
to improved school nurse staffing, which allowed students to
actually receive the care. Although, in some regions,
increases in the complexity of student needs have been fol-
lowed by decreases in school nurse student caseload through
1 Solomont School of Nursing, University of Massachusetts Lowell, MA,
USA 2 School of Nursing, University of Wisconsin–Madison, WI, USA 3 Klein Independent School District, Houston, TX, USA 4 Johnston Public Schools (Retired), RI, USA 5 Nooksack Valley School District, Everson, Washington, DC, USA 6 Competency and Credentialing Institute, Denver, CO, USA
Corresponding Author:
Brenna L. Morse, PhD, RN-BC, NCSN, CNE, Solomont School of Nursing,
University of Massachusetts Lowell, 113 Wilder Street, Suite 200, Lowell,
MA 01824, USA.
Email: [email protected]
The Journal of School Nursing
ª The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1059840520930075 journals.sagepub.com/home/jsn
2022, Vol. 38(2) 126–137
Original Research Report
support of additional school nurse positions (Best et al.,
2020), this is not widespread practice. Care for some stu-
dents is complex enough to require care coordination, which
is typically more complex than case management and
involves school nurses leading communication among fam-
ilies, teachers, health care providers, and other individuals
responsible for students’ medical and academic needs
(McClanahan & Weismuller, 2015).
As school nurses and other stakeholders have realized
that the bulk of the work done in health offices is not neces-
sarily direct care, leaders of the specialty have called for a
focus on workload over caseload (Jameson et al., 2018).
Student caseload reflects the number of students, and at
times, the clinical acuity of student needs. Workload, on the
other hand, may describe the work of school nurses today in
a more comprehensive manner (Endsley, 2017). In addition
to direct care provision, factors such as documentation,
reporting, and leading communication with the interprofes-
sional team are included in school nurse workload (Combe
et al., 2015; Davis et al., 2019). Further, inequities in access
to care as well as the increase in both evidence and aware-
ness of social determinants of health and social injustices
have contributed to increases in school nurse workload.
School nurses must spend more time caring for families
without resources for optimal care or adequate community
supports in order to help these families be healthy (Daughtry
& Engelke, 2018).
Purpose
Despite evidence of student health needs increasing, a mis-
understanding of the school nurse role continues to create
barriers to funding and availability of school nursing posi-
tions in communities across the United States (Houlahan &
Deveneau, 2019). This is ultimately harmful to populations
at large, as students, families, and other members of the
school community need to access a school nurse who can
support physical, emotional, and academic well-being.
There is a critical need for school nurses to identify and
publicize what we do, what we need, and where we are
going. To that end, the purpose of our study was to deter-
mine tasks and knowledge relevant to modern school nur-
sing in the United States, identify continuing education (CE)
needs of school nurses, and describe anticipated changes to
the professional role.
Method
The present study is a secondary analysis of a job analysis
(also known as a practice analysis or role delineation study).
A job analysis identifies specific key responsibilities, knowl-
edge, and competencies required for effective performance
in a job (Prometric, 2019). The primary study was conducted
as market research to validate concepts for the National
Board for Certification of School Nurses (NBCSN) volun-
tary exam and was not externally published. The University
of Massachusetts Lowell Institutional Review Board
deemed the study exempt from full review.
Instrument
A national cross-sectional job analysis survey conducted in
April 2018 was developed and implemented according to
certification industry standards (Chinn & Hertz, 2010) and
in accordance with regulations set forth by the Accreditation
Board for Specialty Nursing Certification (2019). The sur-
vey was developed with input from subject matter experts
who volunteered their time during focus groups, cognitive
interviews, and pilot tests. Subject matter experts also served
as volunteers for the review and confirmation of results
during the primary study. Figure 1 displays a flow diagram
of survey development activities and results verification. A
review of respondent subgroups was also conducted for each
demographic group of the primary study (e.g., practice set-
ting) holding at least 30 respondents. Indices of agreement
(IOA) were calculated from each subgroup’s ratings of the
task and knowledge statements. IOA values were then com-
pared to identify any differences in how subgroups rated
statements. A threshold of 0.80 was selected to indicate
strong agreement between subgroups. All calculated values
for the primary study were above the threshold, indicating
agreement among nurses with different personal and profes-
sional characteristics.
As the survey was lengthy and the credentialing organi-
zation national, the questionnaire was sent to large groups of
practitioners representative of the professional community
(Chinn & Hertz, 2010). A total of 4,070 nationally certified
school nurses and approximately 16,000 members of the
National Association of School Nurses who were not
included in the mailing to certified school nurses received
the survey by email.
The survey instrument included a total of 684 quantitative
items, which prompted participants to rate the importance
and frequency of school nursing tasks and the importance of
school nursing knowledge. Participants rated the importance
of task and knowledge statements on 5-point scales, with 0
representing of no importance and 4 representing very
important. Participants rated the frequency of performing
each task on a 5-point scale, with 0 representing never and
4 representing very often. In addition to task and knowledge
statement rating opportunities, the survey contained two
open-response opportunities: (1) what additional profes-
sional development and/or CE could you use to improve
your performance in your current work role? and (2) how
do you expect your role to change over the next few years?
Further, what tasks will be performed and what knowledge
will be needed to meet changing job demands?
Data Analysis
For the primary analysis, mean importance ratings were cal-
culated for each task and knowledge statement, as well as
127Morse et al.
median frequencies for task statements, using SPSS statisti-
cal software (IBM Corp, 2017, version 25). The study team
evaluated these calculations for the secondary analysis.
Responses to open-ended survey items were provided in
unanalyzed form. We exported these responses to NVIVO
(QSR International [Americas], 2015) for a descriptive con-
tent analysis adapted from Hsieh and Shannon (2005). Anal-
ysis of the open-ended responses used an iterative process to
develop themes, categories, and codes. Coding and analysis
of the data were done by one researcher and themes were
confirmed by four study team members.
Results
Respondents
The primary study included 750 complete responses from
school nurse participants. These complete responses repre-
sented a 3.73% response rate. Most respondents were White
(93%) females (98%) who practiced as nurses for over 21
years (69%) and school nurses for 11–20 years (34%) in
elementary schools (31%) serving between 501 and 750
students (19.5%). Table 1 displays characteristics of the sur-
vey respondents.
School Nursing Tasks
Of all of the tasks school nurses are charged with, select
activities were rated as more important than others. School
nurses considered maintaining privacy in accordance with
HIPAA/FERPA (3.91), practicing according to state and
national guidelines, policy, licensure (3.88), documenting
medication administration (3.87), protecting student (per-
sonal/body) privacy (3.87), and communicating with par-
ents/guardians (3.86) as job tasks with the highest
importance. School nurses rated administering fluoride
treatments (1.61), administering immunizations to staff
(1.82), serving as advisor for student activities (2.06), con-
ducting home visits (2.21), and leading support groups
(2.21) as least important to their role.
Job tasks were performed with varying frequency. School
nurses reported performing 124 specific tasks very often, 6
tasks often, 33 tasks occasionally, 19 tasks seldom, and
never performing 60 tasks. Table 2 displays the three tasks
rated as most important across each professional practice
category with frequencies.
School Nursing Knowledge
School nurse participants rated all included job knowledge
components as important or very important. Knowledge com-
ponents rated on the higher end of importance included
knowledge of anaphylaxis (3.93), prescription administration
(3.92), medical authorization for prescriptions (3.92), head
trauma (3.91), and documentation (3.91). Although respon-
dents did not indicate that any knowledge components were
irrelevant to their job, some areas scored on the lower end of
importance. These components include health education of
communities/stakeholders (3.1), assistive technology (3.15),
gender identity (3.19), special health needs assistive care
(3.2), and pregnancy/parenting (3.2). Table 3 displays the
Figure 1. Survey development and results confirmation flow diagram.
128 The Journal of School Nursing 38(2)
three most important knowledge items across each knowledge
domain. A complete listing of ratings of the school nursing
knowledge areas is available as an Online Supplement.
CE Needs
Respondents were asked to identify CE topics that would be
helpful in improving their work as a school nurse. Following
analysis of 277 responses, three themes were identified:
course topics, no time to learn, and anything.
Course topics. Participants reported a need for CE topics spe-
cific to care delivery, such as individualized health plan
(IHP) development. Even when respondents felt confident
in developing IHPs, they called for education on how to
increase efficiencies around the work, noting “students are
enrolling with more complicated issues . . . [I am] spending
more and more time coordinating and implementing plans.”
Participants want to know how to best support students
experiencing mental illness or adverse childhood experi-
ences (ACEs), including training specific to fostering colla-
boration between school nurses, clinical specialists,
administrators, educators, and outside providers to ade-
quately address mental health concerns. One participant
reported,
due to the increase in incidences of students with complex
health needs and concerns such as violence, bullying, human
trafficking, homelessness, drug and substance abuse, school
nurses need interdisciplinary collaboration with school social
workers, school counselors, and school psychologists as well as
community health care providers to enhance the ability of stu-
dents, families, classroom teachers, and school personnel to
recognize and respond appropriately to the physical and mental
health of students.
Table 1. Participant Characteristics.
Characteristic n a % a
Nurse years 0–4 17 2.3 5–10 56 7.57 11–20 155 20.95 21þ 512 69.19
School nurse years 0–4 139 18.66 5–10 195 28.17 11–20 258 34.63 21þ 153 20.54
Highest level of education Diploma 14 1.87 Associates 52 6.96 Bachelors 393 52.61 Masters 265 35.47 Doctorate 8 1.07
National certification 281 37.47 State certification 385 52.38 Age
20–30 15 2.02 31–40 68 9.14 41–50 71 22.98 51–60 326 43.82 61þ 164 22.04
Gender Male 9 1.21 Female 730 98.52 Other/decline 2 0.26
Race White 692 93.39 Black 32 4.32 Asian 4 0.54 American Indian/Alaska Native 3 0.4 Other 10 1.35
Weekly school nurse hours 0–20 27 3.63 21–30 27 3.63 31–40 512 68.91 41þ 177 32.82
Student caseload 1–250 55 7.42 251–500 126 17 501–750 145 19.57 751–1,000 112 15.11 1,001–2,000 143 19.3 2,001–3,000 49 6.61 3,001þ 52 10.79
Schools served 1 359 49.31 2–4 186 25.55 5–6 52 7.14 7–8 20 2.75 9–10 11 1.51 11þ 75 10.3
District type Suburban 352 47.5 Urban 166 22.4
(continued)
Table 1. (continued)
Characteristic n a % a
Rural 27 26.45 Entire state, county, or region 27 3.64
Practice setting Pre–K 15 2.01 K–12 586 78.66 Administrator or state consultant 62 7.51 Other 82 11.82
Geographic region Northeast 1,694 26.29 Southeast 149 18.71 Southwest 91 13.82 Midwest 172 23.32 West 123 10.45 International 9 1.22
aDue to missing data, n and % may not equal the respondent population size and 100%, respectively.
129Morse et al.
School nurses would like to learn about leadership topics,
such as how to best work with nonnursing administrators,
and best practices to employ when working with a student or
family who may be seen as challenging, defiant, or
Table 2. School Nursing Task Ratings—Three Most Important by Professional Practice Category.
Task Statement Mean
Importance a Median
Frequencyb
Assessment and diagnosis Assess blood glucose 3.83 4.0 Interview student regarding chief
complaint 3.73 4.0
Assess respiratory status 3.72 4.0 Practice and treatments
Protect student privacy 3.87 4.0 Provide first aid 3.84 4.0 Document all health office visit 3.83 4.0
Health education and promotion Educate and support staff regarding
specific health care needs of students
3.77 4.0
Train staff to recognize and respond to life-threatening health problems
3.71 3.0
Teach and promote infection control practices
3.64 3.0
Planning Communicate with parent/guardian 3.86 4.0 Develop an emergency care plan 3.77 4.0 Develop an individualized health
care plan 3.66 4.0
Professional performance Maintain privacy in accordance with HIPAA and FERPA
3.91 4.0
Practice according to state and national guidelines, policy and licensure
3.88 4.0
Maintain professional boundaries c 3.81 4.0 Obtain continuing education to
maintain school nursing competencies c
3.81 4.0
Management Document medication
administration 3.87 4.0
Document and report suspected child abuse and/or neglect
3.85 2.0
Document communications with parents
3.82 4.0
Personnel Delegate tasks according to Nurse Practice Act
3.61 3.0
Monitor performance of delegated task
3.54 3.0
Mentor new school nurses 3.48 2.0
aImportance rated on scale of 0–4: 0 ¼ of no importance; 1 ¼ of little importance; 2 ¼ of moderate importance; 3 ¼ important; 4 ¼ very important. bFrequency rated on a scale of 0–4: 0 ¼ never; 1 ¼ seldom; 2 ¼ occasionally; 3 ¼ often; 4 ¼ very often. c Tie for third highest mean importance.
Table 3. School Nursing Knowledge Ratings—Three Most Important Across Knowledge Domains.
Knowledge Statement Mean
Importancea
Health appraisal Intervention/referral-general physical health 3.72 Respiratory intervention/referral 3.71 Respiratory data collection 3.70
Emergency health problems and nursing management Anaphylaxis 3.93 Head trauma 3.91 Respiratory system 3.88
Acute, episodic, chronic conditions, and nursing management Respiratory system 3.81 Allergies 3.78 Cardiovascular system 3.75
Communicable/noncommunicable diseases and nursing management
Bacterial infection 3.71 Viral infection 3.70 Fungal infection 3.55
Risk reduction and infection control Immunizations 3.88 Identification of risk factors 3.68 Self-care skills for prevention 3.55
Health education Students 3.76 Staff 3.41 Families 3.42
Health promotion/disease prevention Safety education 3.55 Disaster preparedness 3.54 Cultural considerations 3.41
Special health issues Emergency action plan 3.81 Abuse and neglect 3.80 Individualized health care plan 3.75
Professional issues Job description 3.79 Documentation 3.89 Scope of school health services 3.77
Electronic and hard copy health records Confidentiality 3.89 Accuracy 3.86 Authorization for release/exchange of information 3.82
Medication policies and procedures Prescription administration 3.92 Medical authorization 3.92 Documentation b 3.91 Nonprescription administration b 3.91 Safety and storage b 3.91
Treatment policy c
Authorization for treatment 3.90 Protocols and procedures 3.89
Legal issues Confidentiality (e.g., HIPAA, FERPA) 3.86 Individual rights to privacy 3.81 Child abuse/neglect reporting of a minor 3.78
aImportance rated on scale of 0–4: 0 ¼ of no importance; 1 ¼ of little importance; 2 ¼ of moderate importance; 3 ¼ important; 4 ¼ very important. b
Tie for third highest mean importance. c Only two knowledge statements in domain.
130 The Journal of School Nursing 38(2)
noncompliant. One nurse reported, “so many times educa-
tional goals and medical goals are not in tandem and can
lead to confusion, miscommunication, or frustration on the
part of the parents.”
School nurses are calling for CE regarding legal issues in
school health. New school nurses as well as those with many
years of experience seek such opportunities, stating
I wish there was one place to find all the laws and rules for
school nursing . . . . I fell into my position 9 years ago and am
still trying to learn all the things that need to be done beyond
nursing care.
Courses including information on legal issues surround-
ing delegation to unlicensed staff members would be helpful
to school nurses, as many participants shared statements
such as “professional development surrounding efficient
delegation would be helpful.”
While online CE courses are convenient, respondents are
seeking opportunities for hands-on skills training. Partici-
pants reported, “there are lots of lectures and online courses,
but it is really hard to get hands-on skills performance and
training.” Participants cited tracheostomy appliance care,
accessing ports, head-to-toe assessment, and use of contin-
uous glucose monitors as specific skills they would like to
practice.
No time to learn. Many respondents reported having little or
no time to participate in CE. Sentiments such as “when you
are caring for students all day and we are hourly employees,
how are we supposed to do [CE]” and “time is limited during
work hours, so it is always done on my own time [and with]
no pay” were common. Respondents reported feeling over-
whelmed by their workload, travel between school build-
ings, and that the hours needed to thoroughly complete
their work exceeded their paid hours without considering
CE time.
Anything. Despite limited time available to engage in profes-
sional development activities, a common response to this
survey prompt was “anything.” Respondents stated “any
CE is welcome and important” and “I’m interested in learn-
ing as much as I can” especially if the course was held after
work hours and for low or no cost. Such responses were
commonly entered enthusiastically, as evidenced by the use
of capital letters and exclamation marks.
Anticipated Role Changes
Following analysis of 338 responses to a survey item
prompting respondents to share expectations of how the pro-
fessional role will change in the future, three themes were
identified: student complexity, staffing, and technology.
Student complexity. Respondents reported caring for a greater
number of students with complex medical issues over time.
Participants commented on needs requiring technical skill
intervention (such as managing implanted devices) as well
as student mental health needs. Regarding the acuity of stu-
dent needs, one respondent said, “the needs of our students
are becoming more and more complex with each year, both
physically and emotionally.” Many respondents expected to
spend more time identifying and addressing socioeconomic
factors, often circling back to the need for specific training,
such as
a school nurse almost needs to have a social work degree, not a
nursing degree in order to meet the demands these days. I have
very few [visits that are] first-aid issues. The problems [I] see
are related more to breakdown of family structure, absent par-
ents, and [emotional/behavioral] issues.
Staffing. Despite an increase in student caseloads and
acuity, school nurses noted a decrease in supports (e.g.,
school nurse hours, wages, clinic assistants). Sentiments
such as “we seem to be an expendable position that often
is asked to cover and do much more than is feasible and
we are stretched and asked to do more with less” were
common across responses. Respondents remained cau-
tiously optimistic about the future, hoping for support and
respect:
I would hope that as the general public realizes school nurses
are becoming an area of nursing that needs very skilled nurses
[with] extremely high responsibility levels . . . . [school nurses]
will be adequately compensated so the high turnover rate will
stabilize.
Technology. Respondents forecast that the use of technol-
ogy will grow in health offices beyond the use of elec-
tronic documentation systems, such as communication
with providers using video chat and other telehealth
applications. Respondents again linked the role changes
to a need for education, stating “technology will be more
and more part of our role. Many school nurses have basic
computer and technology skills and will need to know
much more.”
Discussion
Changes to student well-being have broadened both the
scope and practice of school nursing (Combe et al., 2015;
Daughtry & Engelke, 2018; Davis et al., 2019; Houlahan,
2018; Jameson et al., 2018). Through a secondary analysis of
a nationwide school nursing job analysis, we have deter-
mined tasks and knowledge relevant to modern school nur-
sing in the United States, identified CE needs of school
nurses, and may describe key anticipated changes to the
professional role.
131Morse et al.
Tasks and Knowledge Relevant to Modern School Nursing in the United States
While some tasks, such as following laws and regulations,
were identified as more important than others, school nurses
identified 130 tasks they perform very often or often. These
tasks crossed all areas within the school nursing scope (i.e.,
direct care, health promotion, management and leadership,
public and community health). Similarly, school nurses did
not rate any areas of knowledge that were not relevant to the
job today. This is consistent with the finding of another
research team that determined school nurses thought prac-
tice activities across all five categories of the Framework for
21st-Century School Nursing Practice were important to the
role and were performed frequently (Davis et al., 2019;
Maughan et al., 2016). With the great deal of knowledge
and skills school nurses are responsible for, it is important
to remember that no single professional—even a seasoned
expert—knows everything. School nurses can learn from,
delegate to, and collaborate with interprofessional col-
leagues to strengthen their own skills and ameliorate feel-
ings of being overextended. Given the broad scope of tasks
and knowledge school nurse respondents considered essen-
tial, combining efforts with other school professionals is
crucial to fulfilling the modern school nursing role.
Interprofessional collaborations among school teams is
one way to address barriers to student health (Bates et al.,
2019). Working as an effective member of an interprofes-
sional group is an important skill for all members of a
student team. To the same degree that teachers can provide
valuable input to school nurses about student health (Quinn
& Serna, 2019), school nurses can make valuable contri-
butions as school teams create student accommodation
plans. School nurse respondents reported that collaboration
on interprofessional teams for at-risk students was impor-
tant (importance rating 3.46) and performed often (fre-
quency rating 3.0). Unfortunately, school nurses are often
overlooked as both a resource and intervention even when
student challenges are rooted in physical health. For exam-
ple, only 61% of students with persistent pain had a school
accommodation plan that included access to the nurse
(Logan et al., 2008). While school nurses frequently
address student mental health concerns, teams do not
always consider consultation or partnership with school
nurses when making student plans related to mental illness
(Bohnenkamp et al., 2015; Shannon et al., 2010). Even
when there are legal directives mandating school nurse
participation, nurses have been excluded from student
teams (Yonkaitis & Shannon, 2017).
School nurse participants reported frustration surround-
ing the mismatch of educational and health-related goals for
students, especially those with complex social and health
problems. This finding builds on other reports of school
nurses expressing frustration surrounding the misunder-
standings of their professional role (E. D. Maughan et al.,
2017). School nursing involvement on interprofessional stu-
dent teams can positively impact all students, including
those with disabilities (Pufpaff et al., 2015), concussions
(Weber et al., 2015), pain (Quinn & Serna, 2017), or who
are bullied (Kub & Feldman, 2015) and can even impact the
value parents and teachers place on school nurses (E.
Maughan & Adams, 2011). Whereas misunderstandings sur-
rounding the role of the school nurse may hinder interpro-
fessional collaboration (Fleming & Willgerodt, 2017),
school nurses should make clear their scope of practice,
professional role, knowledge of the problem at hand, and
tasks in which they are skilled that may contribute to student
success when joining an interdisciplinary team. In doing so,
assigned tasks may be more meaningful in terms of the role
of the school nurse and responsibilities they may take on
(Reuterswärd & Hylander, 2017).
Ultimately, the onus is on school nurses to inform school
administrators, teachers, parents, and other community
members of the knowledge and skills they may contribute
to a student team. School nurses must advocate for their own
seat at the table when other colleagues are developing a plan
to meet student needs, even when the needs are not of an
obvious medical nature. Research teams conducting future
job analysis surveys or other studies of school nurse
responsibilities and workload should consider adding items
regarding self-advocacy. Research on nurses’ professional
self-advocacy is limited; study teams have previously
explored nursing political advocacy (Taylor, 2016) and
advocacy skill building among student nurses (Doherty
et al., 2016). Leaders of our specialty field should aim to
determine how nurses are self-advocating, which methods
are most effective, and what skills school nurses may need to
better perform self-advocacy.
CE Needs of School Nurses
School nurses called for education regarding working with
interprofessional teams, as discussed in the previous section.
Understanding the importance and frequency of school nur-
sing tasks may help nurse educators and conference planners
select professional development topics that will improve
nursing competencies and therefore student outcomes.
School nurses may also leverage results of this study to
advocate for the presence of certain topics on conference
itineraries. Specific areas for CE development include
courses introducing nurses new to school health to some
of the common student concerns and promoting the specialty
role. Course planners should also consider a balance of
broad accessibility (e.g., web-based education and sessions
for large audiences) and the need for hands-on skills
training.
Transition to school health primer. Nurses may begin practicing
in the specialty of school nursing after finishing prelicensure
generalist training or following years of experience in
132 The Journal of School Nursing 38(2)
another setting. While generalist preparation and experience
years in other settings are certainly valuable to practice,
contemporary school nursing necessitates a change in the
job onboarding training as well as educational opportunities
for school nurses. Nurses often enter school health without
adequate training on critical student health issues such as
allergies and anaphylaxis (Tsuang et al., 2019). Addition-
ally, the inclusion of students with significant complex spe-
cial health care needs has increased the depth and breadth of
knowledge and skills school nurses must have to meet the
needs of these students (Singer, 2013).
Similarly, school nurses need education regarding
approaches to addressing the mental illness of students and
care of students with ACEs. The need for such training is
especially pertinent when considering school nurses indicate
mental illness as the most prevalent health issue among
students but also report that they do not have enough training
to adequately address it in school (Higson et al., 2017; Mug-
geo & Ginsburg, 2019; Pryjmachuk et al., 2012). School
nurses should also receive training on how to facilitate some
of the community factors that can ameliorate the impact of
mental illness and ACEs on school outcomes, such as safe
communities, supportive neighbors, and consistent meals
with family (Robles et al., 2019).
Promotion of the specialty role. School nurses felt they were
asked to do more with less, even feeling expendable to the
school community. Such expendability places the nurse in a
position where they are not able to meet their professional
and ethical obligations to ensure health and safety of the
school community. This is especially problematic in light
of the secondary analysis finding that the tasks school nurses
find most important to their work center around legal and
ethical principles. While state laws direct the scope of nur-
sing practice, few states have laws mandating the availabil-
ity of nurses (E. Maughan, 2009). As discussed previously,
school nurses are ultimately responsible for advocating for
their involvement on student teams and for the funding and
availability of school nurse positions. Educating parents,
educators, other nurses, and the general public on the role
and responsibilities of school nurses and needs of school-
children is one way to ameliorate expendability, as well as
solidify job positions for school nurses.
Given the increasing medical complexity and influence
of social determinants of health that school nurses must
address so students are healthy and ready to learn, school
nurses must work to change the misguided public perception
that school nurses are present for minor direct care needs
only. Survey respondents did not find it particularly impor-
tant to communicate with the media or policy makers
(importance ratings 2.24 and 2.99, respectively). In fact,
respondents denied communicating with the media and only
occasionally communicating with policy makers (frequency
ratings 0.0 and 2.0, respectively). School nurses must pre-
pare and disseminate data to administrators, colleagues,
parents, and other stakeholders demonstrating the care needs
of their school community. CE opportunities with a focus on
media and policy training can provide school nurses with
knowledge and skills needed to carry out such public advo-
cacy effectively. Efforts in this area will help promote the
professional role through providing transparency regarding
the responsibilities the school nurse holds, as well as inform-
ing the public of the essential role a school nurse plays in the
well-being of the entire community.
Earning specialty certification may be another method for
school nurses to inform the school community and general
public of the importance of school nursing. Across other
nursing areas, researchers have identified relations between
specialty certification and improved patient outcomes
(Boyle et al., 2014, 2015). School nurses should consider
pursuing certification as a nationally certified school nurse
and are encouraged to publicize their professional achieve-
ments across the school community.
CE accessibility. Despite an eagerness to learn and improve
their own practices, participants noted barriers to accessing
CE opportunities. Unfortunately, even when school nurses
are able to further their learning, they do not have time or
adequate resources to implement practice changes (Quinn &
Smolinski, 2018). Therefore, school districts must commit to
meeting the health needs of all students through appropriate
CE support. Such support should include time to complete
CE and registration fees.
Additionally, school nurses are seeking hands-on learn-
ing opportunities. With access to anatomical models, high-
fidelity simulators, and interdisciplinary expert instructors,
one group of college educators provided training to school
nurses on tracheostomy care, carbohydrate counting and
insulin pumps, vision screening, otoscopy, catheterization,
feeding tubes, and emergency seizure medication adminis-
tration (McClanahan et al., 2016). Simulation and practice
laboratories in nursing schools may go unused over week-
ends and college breaks. School nurses or professional nur-
sing organizations (such as state-level associations) may
consider partnering with universities for hands-on training
programs when the practical labs are not in use.
Anticipated Changes to the Professional Role
Despite all that is already required to effectively meet the
needs of students, school nurse respondents predicted that
the needs of future schoolchildren will increase in complex-
ity and that staffing issues will continue to be a threat to
providing adequate care. Increases in student complexity
will necessitate interprofessional collaboration, and the ade-
quacy of staffing may be addressed through professional
advocacy efforts: Both of these anticipated role changes are
addressed in earlier discussion sections. School nurse
respondents also reported that technology has the potential
to change the specialty. Additionally, we have identified
133Morse et al.
increasing diversity among school nurses as a priority fol-
lowing analysis of respondent and workforce demographics.
Utilization of available and emerging technologies. Capitalizing
on all that technological advances have to offer can create a
work environment in which technology is a useful, produc-
tive, and collaborative tool used to improve student health,
safety, and access to care. Two specific areas that have great
potential to improve school nursing practice are telehealth
and electronic record-keeping. Given a geographic misdis-
tribution of pediatric specialists, access to telemedicine can
have a great impact in rural and medically underserved areas
(Marcin et al., 2016). In some states, school nurses may
initiate a mental health services telehealth referral (North,
2020), which further removes barriers to accessing care. An
emerging model of telehealth involves school nurses as the
service provider for students who do not have a school nurse
during the entirety of the school day (Cogan, 2020; Johnson,
2020). Researchers and leaders in this field must ensure
school nurses not only have access to telehealth services but
also are involved in developments and planning for imple-
mentation of telehealth. Electronic health records provide
school nurses with the power of data to tell the story of the
work they do each day to support student health and aca-
demic success. School nurses must thoroughly document
care in order to track their own health office data and con-
tribute to national school health data sets. With access to
electronic recordkeeping, school nurses may harness the
power of data to create systems-level change.
Diversifying the school nursing workforce. While school nurses
may contribute to public health through immunization
administration and tracking, monitoring and reporting com-
municable diseases, and leading school communities in
emergency preparedness, addressing a lack of diversity
among the school nursing workforce is a clear priority emer-
ging from review of participant demographics. Respondents
were nearly homogenous in terms of gender and race (98% female, 93% White) and resemble the gender and racial
makeup of school nurses in the United States (Willgerodt
et al., 2018). Such demographics do not reflect the commu-
nities school nurses serve.
The lack of diversity within nursing as a discipline con-
tributes to health disparities and decreases access to care and
care quality (Spetz, 2016). Additionally, many respondents
of the survey were nurses for over 21 years (69%). Diversi-
fying the workforce should include efforts to recruit nurses
who are earlier in their career trajectories. This may seem
challenging considering that promoting school nursing as a
specialty is not without barriers, given comparatively low
pay (Willgerodt et al., 2018) and misperceptions about the
importance and scope of school nursing work. However,
increasing diversity within the workforce is essential to
ensuring school communities can realize improvements in
care access and quality and a narrowing of the health care
disparities gap (Institute of Medicine, 2011). By welcoming
team members from underrepresented backgrounds, we will
gain unique ideas and perspectives to meet the needs of
diverse populations and decrease health inequities and bar-
riers to wellness rooted in racism and a lack of worker
diversity.
Limitations
Respondents of this survey provided a self-report of profes-
sional opinions and may have answered survey items based
on perceived best practices or socially desirable responses.
With a lengthy survey, there was also potential for survey
fatigue. Researchers of the primary study mitigated fatigue
by allowing respondents to close the survey and return at a
later time to complete the survey.
The data used in this secondary analysis were not col-
lected to address the aims of the present study. Therefore,
some variables that would have been helpful addressing the
study aims were not available. For example, the primary
study included very few survey items related to quality
improvement, population health, and policy work. While the
response rate for the primary survey was low and personal
characteristics relatively homogeneous, the respondents
shared professional experiences from all corners of the
United States, from different school levels and school sizes.
Respondent experiences and personal characteristics may
differ from nonrespondents.
Finally, the range of mean and medians across school
nursing knowledge and task statements was narrow. A nar-
row range of ratings speaks to the breadth and depth of
school nursing responsibilities and perceived importance
of many parts of the job. However, our ability to draw con-
clusions about tasks and knowledge items that are most
important or more important than others is limited.
Conclusion
While central tenets of school nursing practice are still
important in the present day, 21st-century school nursing
requires a different and continually evolving knowledge
base and skill set. Given the need to maintain competence
in a wide variety of knowledge and skills and anticipated
increasing complexity of the job, school nurses are seeking
professional development opportunities to better their pro-
fessional practices in support of student health. School
nurses, leaders, and other stakeholders may leverage the
results of this study to accurately describe the modern school
nurse role, advocate for nursing services, and support school
nurses as they strive to better the health and well-being of
school communities.
Data Availability
The data that support the findings of this study are available
from the NBCSN, but restrictions apply to the availability of
134 The Journal of School Nursing 38(2)
this data set, and it is not publicly available. Data are avail-
able from the NBCSN upon reasonable request with permis-
sion of the executive director of the NBCSN. A table
displaying ratings of the importance and frequency of all
school nursing tasks is available as an Online Supplement.
Author Contributions
All authors contributed to the conception of the manuscript as well
as prepared the drafts. B. Morse and C. Homme contributed to the
acquisition, analysis, and interpretation of the data, while B. Morse
and L. Anderson were involved in the subsequent revisions of the
manuscript. All authors gave final approvals and agreed to be
accountable for all aspects of work ensuring integrity and accuracy.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iDs
Brenna L. Morse, PhD, RN-BC, NCSN, CNE https://orcid.org/
0000-0001-9876-4700
Lori Anderson, PhD, RN, CPN-PC, NCSN https://orcid.org/
0000-0002-0248-6580
Laurie G. Combe, MN, RN, NCSN https://orcid.org/0000-0002-
0796-3390
Supplemental Material
Supplemental material for this article is available online.
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Author Biographies
Brenna L. Morse, PhD, RN-BC, NCSN, CNE, is an assistant
professor at Solomont School of Nursing, University of Massachu-
setts Lowell, Lowell, MA.
Lori Anderson, PhD, RN, CPN-PC, NCSN, is a clinical professor
at School of Nursing in University of Wisconsin–Madison.
Laurie G. Combe, MN, RN, NCSN, is a health services coordi-
nator at Klein Independent School District, Houston, TX.
Sandi Delack, MEd, RN, NCSN, FNASN, is a health services
coordinator at Johnston Public Schools, Johnston, RI.
Lynnette Ondeck, MEd, RN, NCSN, is a district nurse at Nook-
sack Valley School District, Everson, Washington.
Carissa Homme, PhD, is a manager of Test Development and
Certification at Competency and Credentialing Institute, Denver,
CO.
137Morse et al.
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