Abstract
Despite the recognized importance of school nurses, the ratios of nurse to pupil are insufficient in many states across the country. The purpose of this study was to describe school nurse-to-pupil ratios by state and to statistically identify factors that may influence these ratios. Funding per pupil unit in general and support services and laws mandating school nurse ratios were some of the factors found to be associated with school ratios. Although the study has significant limitations, this is the first study of its kind to examine factors associated with ratios using secondary databases that are state-specific. Data such as this provide a context for studying those factors potentially influencing ratios. Further studies are needed to explore the numerous potential determinants described in the literature. Once key factors are identified, school nurses can effectively focus their efforts to lower school nurse-pupil ratios.
INTRODUCTION
School nurses are a vital part of the educational team. The American Academy of Pediatrics, Council on School Health (2008) indicates “the school nurse has a crucial role in the seamless provision of comprehensive health services to children and youth” (p. 1052). Schools are the natural place to address health issues, not only because of the captive audience but also because of the impact health has on academic success or failure (Taras & Potts-Datema, 2005). It is generally accepted that—in many states across the country—there are not enough school nurses to address the needs of pupils; we are failing to meet the needs of children/youth and their families.
This is the first of two articles that examine potential factors influencing school nurse staffing ratios. Part I describes how well states perform in relation to trends over time and state-mandated ratios using a large retrospective data set. Part II is an in depth exploration of views of key state informants about the specific factors influencing nurse-to-pupil ratios. Together these two articles provide depth and breadth to our knowledge related to the problem of securing optimal nurse-to-pupil ratios. In this article, the term lower ratios relates to increasing the number of school nurses, which in turn means a decreased school nurse-to-pupil ratio. The goal is to lower this ratio to increase school nursing services in our schools.
BACKGROUND
It is the position of the National Association of School Nurses (NASN) that all children should have the right to coordinated school health programs. Along these lines, much effort has focused on passing legislation mandating states to comply with recommended school nurse ratios and increasing school nurse funding (Taliaferro, 2008). According to the U.S. Department of Health and Human Services Division of Nursing, more than 61,406 nurses work in public elementary and secondary schools in the United States (Steiger, Bausch, Johnson, & Peterson, 2006). The School Health Policies and Program Study of 2006 found that most schools across the country provide some basic health services, but relatively few provide prevention services or more specialized services. Only 45.1% of all schools had a school nurse-to-pupil ratio equal to or lower than 1:750 (Brener, Wheeler, Wolfe, Vermon-Smiley, & Caldart-Olson, 2007).
Others have studied factors influencing nurse-to-student ratios, revealing a wide variety of factors potentially affecting ratios. However, many of these studies were done more than 5 years ago. The factors identified in the past include (a) insufficient funding for all school health services; (b) local acceptance and understanding of the role of school health personnel; (c) various organizational factors such as community beliefs influence school health services; and (d) community protest by the conservative population (Broussard, 2002; Morone, Kilbreth, & Langwell, 2001; Rienzo, Button, & Wald, 2000; Tetuan & Akagi, 2004). This current study examined how well states faired in meeting ratios over time, 1994 through 2006, and statistically compared how state laws, political ideology, and funding influence school nurse-to-student ratios.
METHOD
This is a secondary data analysis. The ratio of nurse-to-student data was obtained for each of 50 states and the District of Columbia. These data were obtained from numbers provided by the NASN and confirmed by the National Association of State School Nurse Consultants (NASSNC). During the data collection process, it became apparent that ratios were determined in a variety of ways. Close to half of the states did not have a systematic reporting program to collect data from all districts or schools. Data were collected through state surveys or other methods to estimate ratios. Furthermore, many states did not measure school nurse staffing as a ratio; other measurements such as one nurse per building was used instead. Still other states preferred using a range of ratios to depict their position on staffing. These inconsistencies of data collection and reporting mechanisms made confirmation of state ratios by state school nurse consultants or other school nurse leaders difficult.
Six public-use sources of data were used to collect information on factors potentially influencing nurse-to-pupil ratios: (a) School Health Policies and Programs Study, (b) NASN, (c) NASSNC, (d) the National Journal (How They Measured Up, 2004), (e) National Center for Educational Statistics (Hill & Johnson, 2005), and (f) U.S. Census Bureau (2000a, 2000b). These data sources provided data regarding factors identified in the literature and factors speculated by the experts in school nursing as influencing school nurse-to-student ratios. The factors included (along with data source):
Mandated school health services (School Health Policies and Programs Study). Mandated specific school health issues such as immunization or screening requirements (School Health Policies and Programs Study). The presence of a state school nurse consultant (NASN membership reports and NASSNC personal communication). The amount of funding per pupil unit for education and school support services (U.S. Department of Education, Hill & Johnson, 2005). Population density of the states (U.S. Census Bureau). State ethnicity (U.S. Census Bureau). Families with children under 18 years of age (U.S. Census Bureau). Socioeconomic level of individual states (U.S. Census Bureau). State political ideology (How They Measured Up, 2004).
Data were gathered and entered into the SPSS program. Measures of correlation between nurse-to-student ratios and potential factors influencing these ratios were conducted using Kendall’s tau (τ) correlation coefficient. Multiple regression analyses were performed to determine the factors significantly associated with the nurse-to-student ratio.
RESULTS
Data were retrieved on all 50 states and the District of Columbia. These data were extracted from a variety of sources as described in the method section of this article.
Nurse-to-Student Ratios by State
School nurse-to-student ratios from 1994, 2004, and 2006 are presented in Table 1. Note that between 1994 and 2006, 30 states decreased or lowered their ratios (data from the District of Columbia, Hawaii, North Dakota, Pennsylvania, and South Carolina were not available for some of the years). Furthermore, for the period between 2004 and 2006, 26 states lowered their ratio, with no change in three states, and no data available in one state. The table indicates a decreased (or lowered) ratio (between 2004 and 2006) as “−” and an increased (or higher) ratio using “+.”
Table 2 displays the ratios for each state that met the nationally recommended ratio of 1:750; the table also includes states with school nurse mandates. Note that only 13 states met the 1:750 recommendation. Furthermore, only 15 states had state mandates regarding staffing ratios, 7 of which stipulate a specific ratio or number. In two of these states (Massachusetts and Vermont), mandates were lower than the national recommendation, while the others had a mandated ratio higher than what is nationally recommended. For those states having mandates and having comparable data, five met or were better than the state-required mandate, while two fell short.
Factors Correlated With Nurse-to-Student Ratios
Tables 3 and 4 present the relationship of several factors that have a potential impact on the school nurse-to-student ratios in all reporting states. In Table 3, correlation coefficients describing the relationship of these factors and ratios are presented. As indicated in the table, five factors were correlated with ratios: (a) funding per pupil unit, in general; (b) funding per pupil, support services; (c) per capita income; (d) the region of the country; and (e) laws mandating school nurse ratios. Several mandated services also correlated with ratios: immunization requirements for seniors in high school (hepatitis B and tetanus); identification of acute conditions; and tracking and managing chronic conditions. For the factor funding per pupil unit in general and for support services, the correlation was moderate and significant. The correlation between tracking of disease, immunization requirements, region of country, per capita income, laws to mandate ratios, and nurse-to-student ratio was weaker but still significant. The results of the multiple linear regression analyses indicated that only one factor, funding per pupil unit, was significantly associated with nurse-to-student ratio (Table 4). The model accounted for 34% of the variance.
DISCUSSION
The results of this study identified both hopeful and disheartening information. It was hopeful to find that in five out of seven states producing comparable data and where ratios were mandated, this mandate was being met. In two states where there was a mandate, this mandate, according to the study’s information, was not being met. Similarly, 13 states met the criteria of 1:750 in 2006; however, over two thirds did not (n = 38, 74.5%).
Looking at the five states with the lowest school nurse-to-pupil ratio, New Hampshire is the only state that had a law mandating school nursing (C. Green, personal communication, June 2, 2005; NASN, 2006). The states with the highest ratios included Utah (1:5,822), Michigan (1:4,274), and North Dakota (1:3,527). None of these states had laws regarding school nurse-to-student ratios. Of the 15 states that did have policies regarding ratios, 7 states had that laws stipulate a specific school nurse-to-pupil ratio that range from 1:500 to 1:11,500. Connecticut, Delaware, Maine, New Jersey, and Rhode Island mandate one school nurse per district or facility but did not indicate specific ratios (NASN, 2004; Conn. § 169-10-212; Delaware § 14–1310; Maine § 20A-223-6403-A; New Jersey § 6A-16; and Rhode Island § 16-21-08).
Some ratio trends were encouraging. Thirty states have made progress in lowering their school nurse-to-student ratios (1994–2006). Of particular interest is Tennessee, which improved its ratio from 1:10,000 in 1994 to 1:3,000 in 2006 (NASN, 1994, 2004, 2006). This improvement was influenced by a law that mandated a ratio of 1 school nurse for 3,000 students (Rose, Detch, & Morgan, 1999; Tennessee § 49-3-359-c-1). The law was passed because of the efforts of key legislators, the governor’s strong initiative on education, and fervent lobbying by school nursing and education groups. Alabama also significantly improved their school nurse-to-student ratio from 1:5,315 in 1994 to 1:1,400 in 2006 (NASN, 1994, 2006).
Statistical Correlations
Findings of this study indicated that funding per pupil unit appears to have the greatest influence on school nurse-to-student ratios. In the context of the multiple regression analyses, no other factor was found to have a significant impact. It is clear that there may be far more factors that influence staffing in general and within specific regions and districts. However, this was not examined due to the limitations of available data. Laws regarding identification of acute illness and tracking and managing chronic illness did correlate with ratios. The higher the ratio, the more likely states had laws regarding these services. This could be due to the fact there were fewer school nurses so other policies or processes were in place to ensure acute and chronic conditions were monitored. The same may be true for the hepatitis and tetanus immunization laws. However, why other immunization requirements and laws show no relationship needs further explanation. Perhaps many decisions are made at a district or school level.
A majority of states mandate some type of school health services or activities, such as vision screenings or school entrance immunizations, regardless of the ratio (NASN, 2004). Other services, such as mandating the reporting of injuries, were not significant perhaps because other school personnel can complete these tasks as well as school nurses. Thus services, which are often conducted by school nurses but could be done by other school personnel, did not have an impact on school nurse-to-student ratios.
States with laws mandating school nursing had lower nurse-to-student ratios. This is an interesting finding, considering that 2 years ago a similar secondary analysis did not find any relationship between laws and school nurse ratios (Maughan, 2006). Laws were identified in the literature to influence school nurse-to-student ratios (Morone et al., 2001). The change in this relationship may be related to the fact that laws may take awhile before their impact is felt and because laws mandating school nursing ratios have considerable variability in their mandates, writing, and influence.
For example, some laws mandate ratios higher than the national recommendation: The law in Alabama is written to decrease school nurse ratios over a period of 20 years (Alabama § 16-22-16). In some states, laws were vague, leaving much room for interpretation. In others, the laws were not enforced or the penalty for breaking the law was minimal. In Pennsylvania, where ratio waivers are allowed, the penalty for not following the mandated 1:1,500 ratio is less costly than employing a school nurse (Anonymous, personal communication, July 3, 2005). Thus, some districts may choose to pay a fine rather than hiring a school nurse. Other state laws, such as Arkansas (§ 6-18-706) and Louisiana (RS 17§28), have unfunded mandates (NASN, 2006). Laws may influence school nurse ratios, but only if they are written clearly (leaving little room for interpretation), are enforceable, and include an appropriate funding source that does not fluctuate.
Limitations
This study has a number of limitations that should be addressed. Several variables identified in the literature as possibly influencing school nurse-to-pupil ratios are not systematically collected and could not be included in this analysis. These variables include the (a) level of understanding of the role of the school nurse; (b) educational, parental, and community commitment and involvement with school nurses; and (c) philosophical beliefs about the role of health in education (Billy et al., 2000). For this reason, these variables were not included in this study.
One of the greatest barriers in this study was collecting data when there was a lack of cooperation from local school nurses and districts (various school nurse consultants, personal communications, June 2005 & May 2007). The majority of state contacts indicated they had a poor return rate of data from school nurses or that often the data returned were “guesstimates.” Although local school nurses generally have access to an incredible amount of data, much of which they should already be documenting as part of the Standards of Practice (NASN, 2005), the data may not be used as it could be. Yet, many software programs have been developed to assist school nurses in systematically collecting and organizing data (Murphy, 2005).
An additional limitation was the availability of data from states. This is important for several reasons. The differences in what data were collected and how systematically they were collected made it difficult to conduct comparisons across states. To address these limitations, it is important to plan for and implement systematic data collection procedures that could be used to track changes in ratios. In other words, all states need to collect similar information in the same manner about school nurse staffing, school nurse activities, and student and family needs. Until standardized data are systematically collected in all states, analyses are preliminary at best. Not all states currently have the capacity and support to develop such a system and may not be mandated to implement or update tracking systems.
IMPLICATIONS FOR SCHOOL NURSING
This was an ambitious study and the first of its kind. Examining school nurse-to-pupil ratios on a national level can assist leaders in identifying trends and possible deficiencies in care due to a lack of school nurses. It should be noted, however, that these ratios are only one measure of services. They represent averages and do not reflect the full picture of many different communities.
Taking into consideration community acuity, geographic location, and regional needs would further inform our understanding of ratios. It was discovered that many states did not measure school nursing numbers in the same way. Many states with lower ratios disliked using ratios as a measurement. They believed it did not reflect their states’ needs accurately. For example, some states with ratios lower than the 1:750 ratio still had various districts without a school nurse. Rural areas may have decreased ratios, but this does not account for the long distances that must be traveled to visit all the students. Since the national recommendation is not based on data or evidence, it may be prudent for national experts, including the NASN and the NASSNC, to review and possibly revise how school nurse-to-student ratios are measured. Experts may also want to better define what constitutes an adequate school nurse-to-pupil ratio or whether it is a range based on an acuity system or adjusted for regional differences.
What is germane to conducting a study of this kind is having a reliable data collection procedure in place. States that successfully collect and use data could be used as models for a national database (Various school nurse consultants, personal communications, June 2005). One approach could be to collaborate with the Division of Nursing at the U.S. Department of Health and Human Services. A nationwide nursing survey is already conducted by the Division of Nursing every 4 years. Currently, however, the sampling procedure does not contain adequate responses for state-level data about school nursing (Steiger et al., 2006). An alternative possibility is to collect data through the U.S. Department of Education.
The finding that the most important factor relating to school nurse-to-student ratios is funding per pupil unit should not be surprising because school nursing is largely funded through education dollars (NASN, 2004). If funding of this kind is inadequate, supplemental funding may be needed, for example, through the following: (a) Title I and special education funding; (b) Maternal and Child Health block grant funds; (c) federal participation programs such as Medicaid and the Child Health Insurance Program; (d) third-party payers; (e) private foundations; (f) community partnerships; and (g) grants from organizations concerned with children (NASN, 2004).
CONCLUSION
This study examined the school nurse-to-student ratios and identified trends over time across the nation. The findings indicate that funding, laws, and policies have the greatest impact on this ratio. Given the fact that ratios do not tell the full story, it behooves us to continue the study of ratios to determine what constitutes adequate ratios or staffing. For school nurses to effectively focus their efforts to increase their numbers and thus address the health of the nation’s children, they must identify other key factors that influence their existence and have an impact on school health services.
Footnotes
Tables
Author’s Note: This study was supported by a National Association of School Research Award, 2006.