Data Fixes Needed to Sustain the School Nurse Specialty

“What is the return on investment?” is a question leaders and other decision-makers frequently ask about public health nurses (PHNs), including school nurses. With ongoing limitations in public health funding, PHNs are often the first to be at risk of being laid off or having their position eliminated due to being viewed as “expensive,” difficult to recruit, and, at times, a “nice to have, but not essential” specialty in the public health workforce. Indeed, the PHN workforce is shrinking rapidly overall and as a percent of the public health workforce, with recent data showing that in 2022 they encompassed only 12.7% of the governmental public health workforce, down from 20.5% in 2008.

School nurses are a large part of this overall PHN workforce with a practice that goes beyond individual clinical care to “promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (Bekemeier et al., 2015; National Academies of Sciences, 2021). As PHNs focus on the health of their school populations, they contribute substantially to promoting the health of whole communities (National Association of School Nurses, 2022). The issues school nurses face echo those of the broader PHN workforce, and as such, the use of PHNs in the following text is inclusive of school nurses. Where school nursing concerns diverge, these will be explicitly called out.

The reasons for such a decrease among PHNs are complex. A large underlying reason relates to the limited availability of quality data that can demonstrate PHNs’ effectiveness. The research that does exist demonstrates critical skills PHNs bring to the public's health, but generally falls short of answering return on investment questions, mainly due to limited PHN data with detailed costing information and information on functions and activities (Bekemeier et al., 2025; Davis et al., 2021; Kneipp et al., 2022; McCullough, 2019; National Association of School Nurses, 2022, 2025).

There are several datasets with information on the public health nursing workforce that provide specific information on school nurses. Examples include the National Sample Survey of Registered Nurses (NSSRN), National Council of State Boards of Nursing (NCSBN) Workforce Survey, and the Public Health Workforce Interest and Needs Survey (PH WINS). While these sources provide a relatively large amount of data, there are major limitations. For example, PH WINS provides data on PHNs working solely in local and state governmental public health agencies. PHNs working in public schools may or may not be captured by data on the governmental public health workforce, depending on the regulatory and funding structure of public health agencies in a state or county, and/or failure in the data to differentiate school nurses from those working in school-based health centers. Surveys examining the broader nursing workforce, such as the NSSRN and NCSBN, rely on setting as the identifying mechanism for PHNs. This may result in inaccuracies with measurement due to the previous point that PHNs work in a range of settings and due to some PHNs practicing in non-public health specialties while identifying “public health” or “school” as their setting (Bekemeier et al., 2025). Additionally, in these surveys, “school setting” may also include pre-schools and college health centers (Willgerodt et al., 2024). PHNs tend to be more accurately identified by functions and activities rather than setting, which accounts for their population-based focus. Put more bluntly, national data collected on both nursing and public health workforce groups are not collected with an eye toward the complexities of measuring PHNs, and thus end up being relatively invisible in these data.

The National School Nurse Workforce Study has been conducted twice because of these limitations of existing data. Through this data collection, more information has been collected, enumerating the number of school nurses as well as describing their demographics, employment experiences, funding models, and major activities (Willgerodt et al., 2018, 2024). A survey of PHNs in local and state health departments was conducted in 2012 with similar aims (Beck & Boulton, 2016). However, the availability of funding has limited the frequency of these workforce surveys and, in the case of the school nurse workforce survey, the quantity of data that could be collected. This has resulted in individual states conducting workforce (or workforce-related) surveys, but funding challenges also limit the scope of these studies (Gratz et al., 2023; Ramos et al., 2024; Zahner et al., 2025).

Despite these serious data limitations, PHNs have been found to have a unique impact on health and bring vital skills to public health systems and schools (Gratz et al., 2023; Kett et al., 2025; Ramos et al., 2024) (cite). Thus, the fragility of this workforce is a concern, and frankly, a crisis that deserves attention. But along with this, there is a critical need for improvements to how nursing workforce data are being collected and the content of such data.

These improvements include:

Incorporate measurement of functions and activities in future data collection to better identify PHNs across all areas where nurses are doing public health work, including schools.

This call for improvements is echoed by the National Association of School Nurses, which has also specified the need to build evidence on the effectiveness and outcomes related to school nursing practice through better data collection, including that which would demonstrate the cost-effectiveness of school nursing services (National Association of School Nurses, 2025).

Nursing leaders should be ringing alarm bells across their collective networks to highlight and develop solutions to address these data concerns. Such work is within the nursing scope and, frankly, responsibility as scientists and leaders in nursing workforce research and development. As highlighted at the beginning, school nurses are part of the larger PHN workforce, and as such, there is an opportunity to work together on these data concerns. Ultimately, demonstrating a return on investment for the PHN workforce will only be possible when data is being collected that clarifies, quantifies, and defines PHN work. Such data need to be collected over time—this will not only be important for connecting to outcomes but also for cementing a clearer understanding of the PHN role overall and demonstrating the value of investing in this critical component of the nursing workforce. Along with collecting these data, changes are urgently needed in how nurses are trained and educated, as well as with how those in organizational leadership roles are educated regarding PHNs. Without all of these pieces working together, this specialty will continue to be at risk.