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 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

nations 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 WisconsinMadison, 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

The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1059840520930075 journals.sagepub.com/home/jsn

2022, Vol. 38(2) 126137

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 subgroups 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 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 1120 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 04 17 2.3 510 56 7.57 1120 155 20.95 21 512 69.19

School nurse years 04 139 18.66 510 195 28.17 1120 258 34.63 21 153 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

2030 15 2.02 3140 68 9.14 4150 71 22.98 5160 326 43.82 61 164 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 020 27 3.63 2130 27 3.63 3140 512 68.91 41 177 32.82

Student caseload 1250 55 7.42 251500 126 17 501750 145 19.57 7511,000 112 15.11 1,0012,000 143 19.3 2,0013,000 49 6.61 3,001 52 10.79

Schools served 1 359 49.31 24 186 25.55 56 52 7.14 78 20 2.75 910 11 1.51 11 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 PreK 15 2.01 K12 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 RatingsThree 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 04: 0 of no importance; 1 of little importance; 2 of moderate importance; 3 important; 4 very important. bFrequency rated on a scale of 04: 0 never; 1 seldom; 2 occasionally; 3 often; 4 very often. c Tie for third highest mean importance.

Table 3. School Nursing Knowledge RatingsThree 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 04: 0 of no importance; 1 of little importance; 2 of moderate importance; 3 important; 4 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, , 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 Im 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 professionaleven a seasoned

expertknows 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

(Reutersward & 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.