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Who’s Who: School Health Office

Study after study has demonstrated that school nurses improve student health, academic success, and attendance. They also reduce the cost of healthcare by providing preventative services and promoting community health by preventing the spread of infectious diseases, supporting healthy lifestyles, and creating a safe school environment. The immense value that school nurses provide, however, is often diminished by a need for more appropriate staffing in school health services. 


The best school health office staffing model varies depending on factors such as the number and distance between schools, the types of employees, and available funding. While minimum nurse-to-student ratios were once recommended, it is now recognized that staffing should be based on workload. In addition to complying with federal, state, and local statutes and regulations, according to NASN, health office staffing considerations should include the acuity of student body health needs, overall student enrollment numbers, availability of resources, proficiency of health staff personnel, and the prevalence of social determinants of health in the school community. Safe staffing that adequately meets student health needs is an ethical, legal, and professional obligation of school health leadership. 

Alternative Staffing

When a school nurse is unavailable, alternative staffing arrangements must be made to ensure students have access to needed health care while at school. Ideally, schools should establish a team of school nurse substitutes who can fill in for the regular nurse when they are unavailable. Due to historically low compensation, difficulty obtaining necessary credentialing, and the unique skill set and knowledge required for school nurse practice, school nurse substitutes are generally in very low supply. If and when available, substitute school nurses should be familiar with the school's policies and procedures for health care, as well as the individual health needs of the students, including access to all student health records - both paper and electronic.

Without an available nurse substitute, parents must be notified of how care will be provided without a nurse present. Failure to deliver students the health care they need at school could be a violation of their right to a free and appropriate public education and schools. 


To provide appropriate school health services and accommodations under the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973, some schools may allow school nurse delegation of healthcare tasks to non-nurses. Definitions and guidelines for the delegation of nursing tasks vary widely by state, with some states prohibiting any delegation at all. According to the American Nurses Association and NASN, school nurses should understand their state's laws and regulations and, when deciding to delegate, must also remember "the school nurse retains authority, responsibility, and accountability for delegated nursing functions." In addition to adhering to their specific state's Nurse Practice Act, safe delegation requires a comprehensive nursing assessment to determine the stability of the student's health condition and potential for harm. When delegating to an unlicensed assistive personnel, or UAP, school nurses must consider the intervention's complexity and the delegatee's competency while also confirming the UAP is willing to perform the delegated task. Appropriate training, consultation, documentation, and supervision are essential to reducing the risks associated with delegation.

Sufficient and appropriate staffing in the school health office is necessary to provide safe care and ensure students' quality health and academic outcomes. School nurses are critical to helping students stay healthy, learn, and succeed. Still, they can't do it alone and need the support of school administrators to establish commensurate staffing, institute viable substitution procedures, and uphold the laws, statutes, rules, and regulations in place to protect and safeguard student health and wellbeing at school.

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