Abstract
NASN Position
It is the position of the National Association of School Nurses (NASN) that equitably meeting essential student health, safety, and educational needs in school requires full-time access to professional registered nurses (RNs), hereinafter referred to as school nurses, who have appropriate workloads. School nurses and administrators should determine school nurse workloads at least annually, through evidence-informed assessment of data specific to the unique health needs and challenges of the local student population and school. This assessment should include factors such as the sociocultural, economic, and environmental influences on health in the community.
Background and Rationale
In every nursing practice setting, including school nursing, workload levels for RNs affect the delivery and outcomes of safe, effective, and quality healthcare (American Nurses Association [ANA], 2020; Jameson et al., 2022). Appropriate school nurse workloads are associated with improved student health, safety, and academic outcomes such as fewer absences, more time spent in class, improved grades, higher immunization rates, greater completion of health screenings and referrals, better self-management of health conditions, and increased graduation rates (Best et al., 2021; McCullough et al., 2020; McKinley Yoder et al., 2022; Ramos et al., 2022; Schroeder et al., 2023). Appropriate school nurse workloads also contribute to school nurse outcomes such as better job satisfaction, less burnout, higher retention/lower turnover, reduced need for substitute or agency/contractual nursing, and fewer potential workforce shortages. These positive outcomes impact the school district by decreasing the administrative burden of recruiting and training new school nursing staff. They also reduce the incidence of medication errors and incorrect treatments and decrease the risk for nursing errors which lessens the potential for lawsuits (Jameson et al., 2022; Jameson & Bowen, 2020; Schroeder et al., 2023).
However, state laws, school district policies, and other recommendations regarding school nurse staffing levels vary widely across the United States (McCabe et al., 2022; Willgerodt et al., 2024). One-third of students do not have full-time access to a school nurse every day, all day in school (Willgerodt et al., 2024). In many school districts, school nurses serve large numbers of students and have responsibilities for multiple school buildings (Ramos et al., 2022; Shattuck et al., 2025). In other schools, students do not have access to a school nurse at all (Willgerodt et al., 2024). In the past, organizations such as NASN proposed school nurse-to-student caseload ratios to set staffing levels (the number of students served per school nurse). While these ratios are a component of school nurse workload determinations, they alone do not adequately represent the range, variability, and wide scope of professional school nursing services needed to meet student needs (Willgerodt & Yonkaitis, 2021). Though no known evidence supports the sole use of a simple ratio for workload determination in school nursing, these ratio recommendations persist (Jameson et al., 2022).
Instead of simple ratio recommendations, an updated, evidence-informed workload analysis approach should be used to determine safe, effective, and appropriate school nurse workloads and should be conducted and reviewed at least annually by school nurses, administrators, board members, and other policymakers. Caseload size should be incorporated in conjunction with information about student population health acuity as well as the unique community health and sociocultural, economic, and environmental influences on health, also called social drivers of health (Center for Health and Health Care in Schools, School-Based Health Alliance, National Center for School Mental Health, 2021; Gebreyes et al., 2021; Willgerodt & Griffith, 2024). This multifaceted approach captures the intensity and complexity of student needs, school nurse and other health services staff credentials and proficiency, and school and community-specific data that identify resource gaps and needs (Gratz, et al., 2023; Jameson et al., 2022; Johnson et al., 2024; National Academies of Sciences, Engineering, & Medicine [NASEM], 2021; Tanner et al., 2024; Willgerodt et al., 2021; Yoder, 2020). Analysis results may indicate the need for more than one school nurse per school building in order to adequately meet the health and safety needs of students.
Evidence-based school nurse workload analysis should include the development and use of valid and reliable instruments or tools such as rubrics with measurable, objective indicators specific to each individual school (Willgerodt et al., 2024). These measures should align with school district and community policy, mission, and vision, and short and long term goals, as well as school nursing scope and standards, the School Nursing Practice Framework™, the Whole School, Whole Community, Whole Child Model, state and federal public health and educational laws, regulations, and the state nurse practice act, all of which guide school nursing practice (ASCD & CDC, 2014; Jameson et al., 2022; NASN, 2022; NASN et al., 2024; National Healthy Schools Collaborative, 2022).
The following factors should be assessed to determine a safe school nurse staffing workload that sufficiently supports student health and educational needs:
Student population health needs—prevalence and intensity of:
average daily student health office encounters daily and PRN medication administrations students dismissed from school early due to illness or injury students with chronic, complex, or disabling physical or mental health conditions students with incomplete immunization records daily health treatments/procedures educational sessions for students, families, and staff care coordination activities students with individualized education programs, individualized healthcare plans, emergency action plans, and 504 accommodation plans state-mandated health records requirements state-mandated health screenings conducted and follow-up
School nurse and other health services staff characteristics:
school nurse licensing, education level, experience, expertise, state and/or national school nurse certification, professional nurse organization membership administrative and clinical supervision, district nurse leader support, state school nurse consultant support, mentoring, and professional development availability of electronic school health records system other school health services support staff composition and skill mix
School characteristics:
total number of students enrolled demographics of students, including age levels Title I or low-performing schools average daily enrollment and attendance/absenteeism rates promotion/graduation rates number and proximity of school buildings served by school nurse geographic location(s) and type of community (urban, suburban, rural)
Sociocultural, economic, and environmental influences on health in the community—number of students/families who are:
without/limited access to other sources of healthcare and other resources unhoused or in unstable housing lacking health insurance on free and reduced lunch/poverty level low in English language proficiency
(ANA, 2020; Center for Health and Health Care in Schools, School-Based Health Alliance, National Center for School Mental Health, 2021; Davis et al., 2021; Gratz et al., 2023; Jameson et al., 2022; McCullough et al., 2020; Morse et al., 2022; NASEM, 2021; Nichols, 2024; Oregon Nurses Association, 2023; Rankine et al., 2023; Schroeder et al., 2023; Steed et al., 2022; Tiu et al., 2021; Willgerodt & Griffith, 2024; McKinley Yoder et al., 2022).
School nurses, administrators, and other supporters need to work together in an ongoing data-driven process to regularly analyze the factors that determine appropriate school nurse workloads. It is essential for all students to have the benefits of equitable access to school nurses with appropriate workloads so that every student can be healthy, safe, and successful in school.
Footnotes
Dates
Acknowledgment of Author
Wendy Doremus, DNP, RN—NASN Clinical Writer
Authors’ Note
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time. To access additional NASN Professional Practice Documents (position statements, position briefs, and joint and endorsed statements), please go to: 