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Lack of School Nurses in California Puts School Children at Risk

Much of the work we do at SRI Education looks at policies and their effects on children and youth, especially those at risk for academic failure because of poverty or disability. Research has long established that children with special health care needs are at increased risk of school failure for a number of reasons including increased absenteeism. School systems need to address health as well as academic needs for these children to succeed in school.

As part of a team that included professionals from Sacramento State University, University of California, Berkeley, and University of Wisconsin-Madison, SRI Education researchers examined how California schools are meeting health service needs during the school day. The SRI team applied our research skills to design and administer a survey to 446 practicing California school nurses, and to compile and analyze 2011–12 data reported to the state from California’s school districts.

The findings of our recently completed study show that there is a lot of room for improvement.

Approximately 1.4 million school age children in California are considered to have a special health care need, which includes chronic conditions—such as allergies, heart problems, seizure disorders, or diabetes—that require more services than what a typical child requires. Although our study looked specifically at services for children with special health care needs, the findings have implications for all children in California’s public schools. Any child can break an arm, be stung by a bee for the first time, or suddenly develop a high fever. Having limited access to a school nurse could problematic for any child.

One of our major findings was that a large population of children does not have access to minimal health services during the school day. We found that only 43 percent of school districts reported that they employed a school nurse. This means that 1.2 million California students are in school districts without a school nurse.

So what is happening in the 57 percent of school districts without school nurses? We don’t have a definitive answer, but it is not a stretch to speculate that all children—and especially children with special health care needs—are experiencing poorer health and academic outcomes because they don’t have access to school nurses.

And what is happening in those school districts that do employ school nurses? Unfortunately, the picture that emerges in these districts also is disturbing. We found very high nurse to student ratios—39 percent of districts had nurse-to-student ratios of more than one nurse to 3,000 students. (The nationally recommended ratio is 1 to 750.) School nurses reported providing services in an average of six or more buildings. Our school nurses are serving so many students in so many different buildings that the student would almost have to schedule a health event to stand a chance of the nurse being in the building or even close by.

Another barrier to meeting the needs of children with special health care needs is that the school nurse may not always know who they are. Only about half of nurses reported knowing which students had special health needs. As a direct consequence of so few nurses in the schools, a variety of individuals with little to no health care experience are providing health services during the school day.

We learned that health assistants, teachers, and secretaries are performing medical procedures such as catheterization, blood testing, and gastrostomy feeding and care. In most cases these individuals are trained by a school nurse, with the nurse reporting varying levels of confidence in the trainee’s ability to carry out the procedure. Our study did not collect information from parents, but we heard many anecdotes of how parents were being expected to carry the burden for ensuring their child’s health care needs were addressed during the school day. By law, public schools must provide the services children with disabilities, including children with health impairments, need to attend school.

Ironically, California has very high standards for school nurses relative to the rest of the country. We have set a high bar for the level of training one has to have to be a school nurse. Unfortunately, there are no requirements that districts must have a school nurse, nor are there regulations addressing the level of training required to administer medical procedures in schools.

If you are the parent of a child with special health care needs, you probably have already encountered the impact of the current situation first hand. The potential for an incident with a bad outcome is high for all children—it is just higher for those whose health conditions are chronic.


While the most obvious recommendation would be to call for more school nurses in California, policy makers we spoke with said that it is unlikely. The school nurse positions were eliminated over many years of budgets cuts by education leaders who had to make difficult choices. At this point, there seems to be little political will to reverse the damage that has been done over many years because of the significant cost implications.

With that in mind, we focused our recommendations on what would be possible.

  • Data collection of children with special health care needs: Right now, we only know how many children there are and how extensive their needs are when special studies are commissioned. School personnel need a procedure for identifying these children when they enroll in school. The districts and the state need to be able to track these data over time.
  • Standards for who can perform medical procedures in schools: This could require changes in the education code or legislation. A related policy question is whether there should be a minimum nurse to student ratio for all districts—but, of course, a minimum ratio has budget implications.

This study was funded by the Lucile Packard Foundation for Children’s Health, a 501(c)(3) public charity. SRI staff who worked on this study: Kathleen Hebbeler, Taletha Derrington, Sara Gracely, Cornelia Taylor, and Ron Orpitelli.

This work was published online in April 2015 in the Journal of School Nursing. Summaries of key findings also are available from the Foundation at

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