The Global Shortage of School Nurses

Abstract

Calzolari and colleagues invited others to have an “open…professional dialogue” on how Italy can introduce school nurses into their system. This editorial is a response to that invitation. Although factors such as a broader nursing shortage and limited health resources definitely contribute to a global shortage of school nurses, three foundational reasons continue to challenge the demand for school nursing globally. The three reasons are traditional views and lack of understanding of the role of school nurses to address modern days challenges, inadequate system support and integration within education, and lack of data to illustrate value. These challenges must be addressed when discussing the inclusion of school nurses in education.

School health services exist in over 102 countries, and school nurses are the most common healthcare professional in schools (Baltag & Saewyc, 2017). This is true in low-, middle-, and high-income countries. Yet, as Calzolari and colleagues (2023) indicate, some countries, such as Italy, do not have school nurses. Calzolari and colleagues outline how school nurses can influence students’ health and invite others to have an “open…professional dialogue” on how Italy can introduce school nurses into their system. We welcome this dialogue and believe the discussion needs to expand to address the global need of linking students with health services, through school nursing and other models.

Although factors such as a broader nursing shortage and limited health resources definitely contribute to a global shortage of school nurses, three foundational reasons continue to challenge the demand for school nursing globally. The three reasons are traditional views and lack of understanding of the role of school nurses to address modern days challenges, inadequate system support and integration within education, and lack of data to illustrate value. These challenges must be addressed when discussing the inclusion of school nurses in education.

Traditional Views and Understanding of the Role of School Nurses

Parents, educators, and decision-makers do not fully understand the role and value of school nurses (Maughan et al., 2023). Calzolari and colleagues (2023) highlight that Italy, for many years, have used teachers and public health nurses to address student health. The model seems to work, at least enough not to change. Tradition and status quo are hard to undo. Words are often not enough for change to occur; actions are needed. The recent COVID pandemic highlighted the integration of health and education, which may be a window of opportunity to reinforce the value and current role of school nurses. Leveraging materials like the World Health Organization's (WHO) (2021 Guidelines for School Health Services, and sharing examples from settings who are willing to try innovative and new models of school nursing are crucial in changing long-held beliefs.

Some school nurses continue traditional activities with a focus on sensorial and musculoskeletal deficiencies and classroom health education instead of addressing current and emerging health needs such as mental health, chronic conditions, and violence, with modern means (i.e., using effective individual counseling techniques) (Baltag & Saewyc, 2017). This perpetuates educators misunderstanding of the role, while the school nurses are not working to their full scope of practice. More than ever, a focus on well-being with all its domains—good health and optimum nutrition, connectedness and positive relationships, agency and resilience, education, skills and employability, safe and supportive environments—is required to address youth's current needs (WHO, 2023). Acknowledging this and noting the health sector remains challenged to meaningfully include prevention for adolescents and school-aged children, focusing more on conspicuous health issues, the WHO is advocating for well-child and well-adolescent visits that could be done within the school and other settings (Banati et al., 2022). For example, as part of school nursing individual- and population-based assessments, these visits move beyond traditional screenings for common conditions and expands to other well-being dimensions, integrating social risks, emotional state, as well as individual and family resources delivered with context-specific recommendations at key moments during the first two decades of life. Providing guidance on this modernized role of a school nurse is one way to help the profession advance to meet current demands and address biased views of the role. School nursing professional education and training must also raise to this challenge by educating differently in the role of school nurses as well as how to articulate that role. Finally, partnering with media and other social influencers to discuss the full scope of school nursing by sharing examples of innovative practice will help decision-makers understand the role and value of school nurses.

Inadequate System Support and Integration Within Education

School nurses bridge both health and education sectors. The traditions and lack of integration of health into the education sector are challenging. In addition to a lack of understanding of the role of the school nurse in education, there is also a lack of knowledge on how to integrate school health services into the education sector. This affects school health services in many ways—from poorly identified governance mechanisms and policy frameworks to firmly establish the position of school health services in educational institutions, to poor staffing and professional education and training (Michaud et al., 2021) and discriminatory salary scales (Baltag et al., 2017). Policies and guidance for ministries of education are needed that support evidence-based, current practice, and address appropriate staffing and resources for school nurses to work to their full scope. The WHO is currently undertaking the work to inform a global implementation guidance on school health services that would hopefully address some of these system challenges. Locally, countries and regions can then adapt the guidance to develop standards for health and education system support of school health services and school nursing.

Lack of Data on Outcomes

Data is crucial when articulating the role and value of school nurses and evaluating the infrastructure support needed for school nursing. The evidence is growing that the smartest investments are coordinated investments in health and education that reinforce each other (WHO, 2023). Although evidence exists illustrating the impact of school nurses on chronic condition management, attendance, and health behaviors, it is insufficient. Much of the existing research includes small, short-term, convenient samples that focus on specific knowledge-based interventions that often do not require the skill of school nurses (Maughan et al., 2023). Few long-term studies are found. To move school nursing science and practice forward, and illustrate the value of school nurses, funding for robust research is needed.

Even in countries with established school nursing programs such as the United States or Sweden, there is a lack of evidenced-based uniform school nurse outcome indicators that are regularly collected. Most data collected are process outcomes of activities completed, not the outcome of those activities. Even though the variability of roles and workload make this challenging, to move school nursing forward, research must prioritize the identification of key school nurse outcome indicators. The Global School Nurse Research Consortium (n.d.) have begun this work, and more efforts are needed.

International collaboration is crucial in overcoming these three pivotal challenges to advancing school health services and school nursing worldwide. The variability for school nursing across countries, (e.g., in terms of school nurse staffing workloads, job description, requisite competencies) warrants continuous learning and experience sharing to inform recommendations that would speak to various contexts. The discussion must be a global, broader discussion, it must continue and include actions.