The Journal of School Nursing
2021, Vol. 37(3) 166-175® The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519850877journals.sagepub.com/home/jsn
Despite tremendous challenges, in the early 20th century school nurses provided the first, and often only, medical care for thousands of schoolchildren and their families. However, multiple barriers impeded the developing role. Influences of historical events, financial support, lack of knowledge regarding benefits of the school nurse role, limited access to training, and issues of poor pay affected the Commonwealth of Virginia’s attempts to develop and provide school nursing throughout the diverse rural counties across the state. School nurses continue to face these challenges today. The purpose of this social historical research is to identify, describe, and analyze the origins and evolving role of the school nurse in the rural counties of Virginia, 1900–1925; investigate how this history influences school nursing today; and offer several suggestions rooted in findings for moving the profession forward as outlined by Cowell’s response to recommendations made by the Institute of Medicine.
school nurse promotion, school health, school nursing policy activism, school nursing funding, school nurse education
The history of school nursing in the United States is not only important to the understanding of the development of the role, it is also relevant to issues being debated today. Among these are the need for evidence-based research and adequate funding, as well as clarity of the school nurse role and increased advocacy efforts to address the public’s confusion (Houlahan, 2018). School nursing in the United States began in the affluent and industrialized North at the turn of the 20th century, and training outside the region was scarce. Moreover, conditions in the north were dramatically different from those in the south. Discrepancies included poverty, rurality, issues caused by civil and world war, and a general lack of social support for the school nurse role. This hindered the growth of the profession and consequently the health of schoolchildren and their communities. The purpose of this historical research study is to identify, describe, and analyze the origins and evolving role of the school nurse in the largely rural counties of Virginia, 1900–1925; investigate how this history influences school nursing today; and offer several suggestions rooted in findings for moving the profession forward as outlined by Cowell’s (2012) response to recommendations made by the Institute of Medicine (IOM, now the National Academies of Sciences Health and Medicine Division [HMD]).
How have the historical, social, and economic contexts surrounding the creation of school nursing in the rural southern state of Virginia in the early 1900s influenced the practice and profession today, and how can we improve upon the role and its effects to enhance the health of schoolchildren today?
“History teaches us who we are. We, as a profession, need to understand this as history offers us an identity that we can use to help us grow and evolve” according to prominent nursing historians Sandra Lewenson, EdD, RN, FAAN, and Eleanor Krohn Herrmann, EdD, RN, FAAN (2008, p. 2). Thus, “the ability to capture and study the past becomes a core mission of the profession” (Lewenson & Herrmann, 2008, p. 2). Historical frameworks (such as political, cultural, or biographical) dictate the research questions, data collection, and analysis. Traditional historical methods including archival research with a social history framework provide a lens with which to interpret historical events and people’s past experiences to assist in identifying potential solutions to problems today (Lewenson & Herrmann, 2008, p. 39).
Numerous primary and secondary historical sources were analyzed to investigate the social, political, economic, racial, and class factors at play at the turn of the 20th century. Archival sources included two separate Lillian Wald Collections: the Lillian D. Wald Papers, 1889–1957, from the New York City Public Library Humanities and Social Sciences Library (Wald Papers, NY Library), and the Lillian D. Wald Papers, 1895–1936, Columbia University’s Rare Books and Manuscripts Library (CU Wald Papers). The Lavinia Dock Collection, located in The Johns Hopkins School of Nursing Archives (Lavinia Papers), and Alan Mason Chesney Medical Archives at Johns Hopkins Medical Institutions (AMCM Papers) were also examined, as were the archives of The Instructive Visiting Nurse Association (IVNA Papers; Tompkins McCaw Library, Virginia Commonwealth University [VCU]). Additionally, published works written by Lillian Wald, Lavinia Dock, Lina Rogers, and other prominent nursing leaders of the early 20th century were evaluated. Also utilized were government documents such as Annual Reports from the Commissioner of Health to the Governor of Virginia, 1905–1926; Annual Reports from the Superintendent of Education to the Governor of Virginia; A Sanitary Survey of the Schools of Orange County, Virginia; The Virginia Health Bulletin; The Virginia Journal of Education; and the Biography of the Richmond Professional Institute. Select primary source newspapers and journals included The American Journal of Nursing, The Public Health Nurse, The New York Times, The New York Tribune, and the Charities and the Commons. Secondary sources reviewed included published books, government websites, and nursing, history, and public health journals and textbooks.
This study is presented as a broad social historical review; the intricacies and the hardships faced during the infancy of school nursing cannot be adequately summarized within a short research article nor could the complexities of race be respectfully fully addressed herein. Rather, this is an intersectional social historical approach that lends insight to the profession’s current roles, support, and financing, which are vital keys to a successful future. Therefore, additional space should be given to more deeply explore the role of race in the development of public health and school nursing (see Minor, 1924). (Authors specifically discuss the racial issues surrounding the inception of school nursing in a related article [forthcoming].) Finally, all attempts were made to remove researcher/author bias including following standard historical research practices, utilizing extremely reliable and verified corroborating sources, capturing both favorable and unflattering results, and adhering to a clearly defined study population and focus (Pannucci & Wilkins, 2011, p. 620). However, it should be noted that the cited historical social and political documents encompass well-documented biases of their authors (Ambrose, 2002).
In 1902, progressive nurse activist and public health pioneer Lillian Wald established U.S. school nursing in New York City as an innovative public health project to address schoolchildren’s health (Houlahan, 2018). Her work was a logical extension of the Henry Street Settlement (HSS), founded by Wald and Brewster in 1892 to care for immigrants on the Lower East Side of the city (Houlahan, 2018; HSS, 2018). Around the same time, Sadie Heath Cabaniss, a colleague of Wald’s and other nursing founders, was working in a similar capacity in Richmond, VA, to establish school nursing with a number of her colleagues through the Instructive Visiting Nurse Association (IVNA). In the summer of 1910, Richmond’s governing organizations responsible for budgetary oversight approved funding for the school nurse program. By 1916, the public schools of Richmond employed eight school nurses, each of whom provided instructive visits to the home as needed. This later served as a framework for the establishment of rural school nursing in Virginia (IVNA papers, VCU Library).
Outside of Richmond, however, the health needs of people in rural areas of Virginia were a particularly great concern. Across the state, rural people were in desperate need of care. This lack of health resources included medical inspection of schools and school nursing services. Virginia’s State Health Commissioner (SHC) Ennion G. Williams, MD, spearheaded the public health movement in the Commonwealth. Williams graduated from the University of Virginia with a medical degree in 1897 (Bruce, 1929). From 1901 to 1908, he held the chair of histology, bacteriology, and pathology in the Medical College of Virginia and from 1916 to 1923 was a professor of preventive medicine at that institution (Bruce, 1929). Williams assumed the duties of Virginia SHC from 1908 until 1928 (Bruce, 1929). For the next 20 years, he became known as a prolific national expert on public health, writing a multitude of articles, and a leader of many public health and medical societies (Bruce, 1929).
Concerned about the issue of rural population health, the Virginia State Board of Health (VSBH) recruited health officials to institute inspections of schools and schoolchildren across the state to assess pupils’ health. The data from these findings were conclusive: SHC Williams (1910) reported, “the sanitary arrangements of a majority of country schoolhouses are without doubt deplorable” and “veritable breeding places for contagious disease” while noting one must consider “the relationship of schools to hookworm, tuberculosis, and diseases of the nose and throat” (p. 34). Both the SHC and the superintendent of education requested funds from the general assembly to address this problem through the medical inspection of schools and schoolchildren and the development of a rural school nurse program. However, they were denied. Williams (1911) reported, “it became apparent this was a problem of considerable magnitude” as “a large portion of the state was heavily infested” (pp. 24–25). Within 3 years, that report would result in action.
Concerns over rural children’s health and hygiene became so problematic that in 1912, the VSBH, the State Board of Education (SBE), and the Department of Education (DOE) of the University of Virginia joined together to address school health and sanitation (Williams, 1915). In collaboration, the Commission for the Eradication of Hookworm, funded by the Rockefeller Sanitary Commission, and the U.S. Commissioner of Education completed “an intensive survey of the white and colored [sic] schools and schoolchildren of Orange County, Virginia” (Flannagan, 1914, p. 590). Health officials chose Orange County because they believed it was reflective of most other rural counties in the state in relation to socioeconomic status, race, education, and resources (Williams, 1914, p. 98). The report evaluated the enrollment, attendance, and physical condition of children as well as the conditions of grounds and buildings (Flannagan, 1914).
According to Williams (1915), the results of the Sanitary Survey of Orange County Schools “were startling, almost appalling” (p. 57). Roy Flanagan, MD, director of the State Bureau of Inspection and the Sanitary Survey of Orange County, reported that examination of black and white children demonstrated multiple defects such as problems with eyes, ears, teeth, adenoids, tonsils, malnutrition, anemia, whooping cough, measles, mumps, and intestinal parasites (Flannagan, 1914). Findings showed that of the 49 schools that had been inspected, including both black and white institutions, most were isolated and remote one-room structures, with peeling paint, poor ventilation, contaminated water, and unsanitary “water closets” (toilets); 6 of the 49 schools provided no water closet at all (Flannagan, 1914). The survey also reported that although the potential combined number of enrolled black and white students was 4,008, only 2,609 children were registered during the time of inspection, and in actuality only 1,793 students attended during the medical inspection. This discrepancy was of further concern to state health officials and taxpayers alike; Virginians were paying for an education the children were not receiving, and more importantly, children were not being educated to become good citizens (Flannagan, 1914). While weather, distance, indifference, poverty, and work were found to affect attendance, most often the cause of absenteeism was illness (Flannagan, 1914). Results of the Orange County Survey were considered representative of the entire state. The first detailed examination of its kind, the report was considered profound on a national scale (Williams, 1921).
The survey findings also highlighted the great disparity in rural children’s health. In cities, children were regularly examined by a physician at school, and as needed were followed up by a visiting nurse at home. Based on survey results, the Board of Health proposed the same should be implemented for rural schoolchildren (Williams, 1915).
Thus, the evidence from the Sanitary Survey of Orange County became a turning point for families living in the rural areas of the state. In 1916, Health Commissioner Williams began a campaign to establish the position of a school nurse in every county in Virginia. Williams (1917) endorsed the school nurse’s role as the most effective means of securing the health and welfare of the citizens of the Commonwealth, particularly those individuals from rural counties who had limited knowledge of sanitary practices and little access to any form of health care. Writing to the Governor, Williams advocated for the role (p. 14):
In a larger sense, the school nurse is a sanitary educator, occupying a strategic position and opening the way for more adequate organization. It is our belief that the school is the first place for the nurse to begin her work. We have reached this conclusion because as there are manifest limitations to the results that can be accomplished with the time and physical energy of a single nurse, by operating in the schools she can reach a considerable element of the population in a very short while. More than this, the school offers, perhaps, the most effective point of contact between sanitation and the home.
He declared, “it is a conservative estimate to say that twenty percent of the funds spent on education are wasted because of physically defective children” (Williams, 1921, pp. 5–6). He also reported,
Children repeat grades year after year, hold back the normal [sic] children—waste the time, energy and nerves of the teachers and are handicapped themselves from receiving an education—and are liable to more serious physical ailments in later life. (pp. 5–6)
Most disgraceful, Williams (1921) concluded, was that “these defects and handicaps can be corrected or removed” with the implementation of the school nurse (pp. 5–6).
In response to the call to effectuate rural school nursing, funding was allocated and the VSBH established the Department of PHNs in 1916. The department identified the locations of PHNs currently working across the state and formalized the expectations and responsibilities of the role. The Department of PHNs also provided a means of support for the nurses through collaboration including streamlining documentation, protocols, and providing opportunities for communication (Ranson, 1917).
The VSBH determined that the PHNs’ first priority was to school health and sanitation. This priority extended to all areas of the state, both urban and rural and black and white schools. As the scarcity of trained nurses suitable for school nursing was a major problem in 1916, the Department of PHN focused on coordinating large portions of public health nursing practice in the schools and visiting children’s homes to instruct on communicable disease and health promotion strategies for the well-being of schoolchildren and adult citizens (Ranson, 1917). Consequently, in Virginia at the turn of the 20th century, the role of the PHN was primarily that of a school nurse, with her duties often extending into the community she served (Ranson, 1917).
Leading the Department of PHN was Jane Ranson (1917), a graduate of St. Luke’s Hospital in Richmond, VA, and former school nurse in Lynchburg, VA. Her primary objective was the coordination of the current 88 practicing PHNs, 27 of whom were actively engaged in work within schools. However, specialized training in PHN was not yet readily available in the south and was therefore obtained through programs in northern states where conditions were quite different. In his 1916 Annual Report to the Governor, Williams (1917) reported, “the greatest obstacle to the extension of school nursing in the Commonwealth is not the indifference of the people but the scarcity of trained nurses” (p. 71). None of the state’s several existing nursing schools offered any formal instruction on PHN or school nursing, particularly to meet the specific needs of rural citizens. Ranson (1917) similarly decreed, “the fact that no nurses without either successful experience or special training in public health work are ever recommended to [school nursing] positions is having a marked effect on the confidence people feel in the [school nurse] movement” (p. 172).
In response to this need for training opportunities, in October 1917 Director Henry Hibbs (1918), MD, spearheaded the Richmond School of Social Work and PHN, “the first of its kind in the South” (p. 13). Distinguished community members who volunteered their expertise in seminars included SHC Williams, Assistant Health Commissioner Roy Flannagan, and Nannie Minor, IVNA Chief Nurse (Hibbs, 1918).
Defining, funding, training, and filling Virginia’s school nurse role, especially rurally, proved a considerable challenge. The Progressive Era smoothed the path for women’s activism in the development of grassroots social welfare programs including the IVNA, which later provided a framework for the establishment of rural school nursing. Progressivism and reformers were instrumental in the expansion of public health works in Virginia and rural school nursing: “Progressivism stressed the importance of the people against the interests thereby making it possible for political activism to take nonpartisan forms” and thus paved the way for “localized voluntary efforts” including rural school nursing (Green, 2005, p. 282).
This era also illuminated knowledge deficits regarding health benefits of interventions and sanitation, particularly among rural Virginians who did not support the school nurse movement. Some rural Virginians saw school nursing as an unwanted government mandate instructing them on how to care for their children (Link, 1988, p. 626). SHC Williams (1921) emphasized, “The people must be made to understand that communicable diseases can be made incommunicable through individual or community effort ... if an intelligent public could be made to understand how to care for itself” (p. 14). Furthermore, so as not to offend parents, “careful and considerate” methods of discourse had to be used in reporting health deficits of schoolchildren to rural parents; otherwise, the necessary interventions would never be adopted (Link, 1988, p. 641). This resistance became another obstacle to the implementation of rural school nursing.
Regardless of apparent progress made, only 50 years after the Civil War citizens vocalized governmental distrust. Virginia had been occupied by Northern troops and war torn, with the state consequently split into two (forming West Virginia), and many left bankrupt with the abolition of slavery and carnage of battle. Noted by historian William Link, they were especially suspicious of modifications generated by wealthy northern progressives such as the Rockefeller Foundation, with local government and citizens often viewing reforms as personal rights infringements—even in public health and education. Many southerners considered medical inspection of schoolchildren “bureaucratic coercion” (Link, 1988, p. 626). Moreover, the survey findings gave permission for government reformers to assume “responsibility for public health” and to secure an endorsement to assert state power to create a healthy school environment (Link, 1988, p. 626). Thus, despite overwhelming positive results of healthy children following treatment for hookworm and other diseases, public health laws and reforms were scrutinized as they allowed for government jurisdiction over the child’s health that was “formerly the exclusive prerogative of the parents” (Link, 1988, p. 626).
These efforts also included establishment of prominent federal government organizations in 1912 that provided support and funding for the expansion of visiting and school nurses including the American Red Cross (ARC or “the Red Cross”) Town and Country Nursing Service. With the backing of the VSBH, Williams advanced the development of the Department of PHN in 1916 and secured financial resources for an administrative position through the Metropolitan Life Insurance Company (Williams, 1917). Jane Ranson, registered nurse (RN), became the first supervisor.
Effects of war again impacted public health in Virginia, as it did many states, during the First World War. SHC Williams (1921) noted that the draft examinations revealed an excessive number of young men—29%—ineligible to serve in the military primarily due to poor health as a result of preventable childhood illness. Disgusted, Senator Colonel Julius West introduced The West Law in 1918 (Williams, 1921). This mandated teachers to complete specific training to properly inspect all incoming schoolchildren for ailments like defective vision, deafness, bad teeth and malnutrition, and teach simple hygiene and sanitation; West was supported by both the Board of Health and the Board of Education (Williams, 1921). When questioned about the absurdity of having nonmedically prepared personnel to complete the school inspections, SHC Williams (1921, p. 18) responded:
If, when the annual inspection of schoolchildren was inaugurated, there had been a trained nurse doing public health work in every county it is possible that teachers might not have been required to do the work. But, because there were not ... there wasn’t a choice to make between the two and fortunately the inspection of schoolchildren by teachers has turned out to be far better than hoped for at the initial stages.
Nannie Minor, then State Supervisor of PHN, noted changes in the school nurse role following implementation of West’s law. With thousands of teachers inspecting many children, huge numbers were identified with defects; it was the school nurse’s responsibility to follow-up with children and parents in their homes to educate and ensure corrective work (Minor, 1925). Additionally, the nurse was instrumental in areas including the establishment of community and school health leagues, ongoing health and physical education of school children and community citizens through clubs, teaching high school girls’ home nursing, and managing health epidemics, home visits, and prevention including vaccines (Minor, 1925). She was therefore a valuable community health resource.
Amid global conflict during World War I, the school nursing movement faced new financial barriers. With Richmond School of Social Work and PHN’s inception coinciding with the mobilization of troops, limited resources were available. Hibbs (1918) declared, “No new agency could live during a war unless the organizers could clearly show that it contributed to the war effort” (p. 19). With the help of Williams and Flannagan, the new school’s slogan became “Train Nurses to Take Doctor’s Places”; as most physicians had left the Commonwealth for war service overseas, nurses trained in public health works could meet the needs of the people at home (Hibbs, 1918, p. 20). Thus, the Richmond school received government allocated war effort funds and remained open. Likewise, financial backing by prominent organizations including the ARC provided resources including personnel support for the expansion of visiting and school nurses (IVNA papers, VCU Library).
Yet money alone could not solve all the problems within the burgeoning profession. As a tremendous number of doctors and nurses left for military service, few were available for public health work—including school nursing. Even Jane Ranson joined the war effort in France. As noted by her replacement Morse (1919), RN, the Acting State Supervisor of PHN, “poor social vision” and “lack of proper training” eroded momentum in the establishment of school nursing in rural counties (p. 46).
After the war, the ARC and the War Work Council of the Young Women’s Christian Association (YWCA, now YWCA USA, Inc.) facilitated a plan whereby army and navy nurses could attend public health schools with expenses financed from the United War Work Campaign (Hibbs, 1918). These organizations donated money to assist nurses in relocating to Richmond to pursue a 4-month course in PHN; this continued for 3 years following the end of the war, with over 100 nurses trained (Hibbs, 1918).
The VSBH also offered scholarships to the Richmond School of Social Work and PHN. Yet the plan did not result in satisfactory employment of nurses who took positions outside the Commonwealth. The funding program was thus redeveloped to require nurses to work for Virginia following their education as reimbursement. According to Brydon (1925), director of the Bureau of Child Welfare, “This is a problem that every State Board of Health seems to have—that of getting trained public health nurses and keeping them in the field” (p. 238).
The continued existence of school nursing programs is based on funding, which has been historically difficult to obtain. Limited monetary support and low financial incentives for school nurses when compared to the degree of difficulty of the work proved to be monumental obstacles in promoting Virginia rural school nursing. In 1916, Ranson (1917) advocated for raising private funds, the implementation of community programs, and marketing of the role of school nurses. She noted in her annual report “school nurses should be paid out of public funds, just as school teachers, health officers, county farm demonstration agents, and other public servants are paid” (p. 170). Instead, often school nurses’ salaries were secured through women’s clubs, private donations, and selling refreshments at county fairs (Ranson, 1917).
Economic issues across the state also influenced financial resources for school nursing. In 1921, Commissioner Williams (1922) explained,
The people of rural VA, depressed by the unexpectedly rapid and drastic decline in the prices for farm products ... have less money to spend for self-protection and county boards have hesitated to appropriate public funds for anything except imperative and tangible undertakings. (p. 3)
Furthermore, Williams (1922) articulated in his annual report to the Governor, in a boldface-typed heading: “Need More Nurses” (p. 28). He requested additional state funds “to enable us either to increase our allotment to existing services or enable us to aid more services” (Williams, 1925, p. 28). Minor (1921), as Virginia State Supervisor of PHN, provided funding statistics in 1921 for the 25 of the 100 counties that had PHNs or school nurses: of the 28 PHNs, 9 were financed through their county, 11 by ARC, 3 funded jointly between the county and ARC, 2 paid for by school boards, and 3 from private sources, including 1 funded from a “colored [sic] county.” The survival of school nursing was hence dependent upon northern progressive reforms and the goodwill of Virginians.
Likewise, little financial incentive existed for nurses to pursue a career in rural school nursing in the Commonwealth. In 1918, Morse (1919) commented, “Virginia will fail to get better trained nurses as long as some communities can offer only such a low salary of US$75.00 per month. Those offering US$100.00 are getting far better equipped nurses” (p. 47). Additionally, “as a result of poorly trained nurses placed in school nursing positions they were not prepared to do, four communities have decided to let go of their nurse and are not planning on replacing them” (Morse, 1919, pp. 46–47). In 1924, Virginia’s PHN Supervisor was paid only US$1,800 per year, the lowest salary level for PHN supervisor positions in the country; comparatively, New York City’s PHN Supervisor was paid the highest salary at US$4,000 a year (Minnigerode, 1924). The low pay also failed to consider the degree of difficulty for providing care to rural citizens with minimal resources, limited road access, and great distances between schools.
These financial fluctuations across states are still present today, which sway nurses’ decisions regarding where to practice. In 2018, the median annual salary of RNs in the United States overall was US$70,000; Virginia’s median was US$66,000, compared to New York state’s US$84,000 (U.S. Department of Labor Bureau of Labor Statistics [BLS], 2018). California RNs earned approximately US$101,000, whereas the yearly median salary in Mississippi and Alabama was US$57,000 (BLS, 2018). The added practical difficulties of rurality clearly are not correlated with wage.
The need for a nurse in each school is a problem we continue to face more than 100 years later. This initiative is now backed by the American Academy of Pediatrics (AAP) in a policy statement declaring the need for one full-time RN per 550 students to provide surveillance, management of skyrocketing chronic disease such as obesity and diabetes, behavioral assessments, and many other important tasks (Virginia Association of School Nurses [VASN], 2018; see World Health Organization, 2017). Today, Virginia has set no required minimum staffing for school nurses; rather, local school boards fill these positions at their discretion, creating a wide variability across the Commonwealth, with choices impacted by factors like funding, geographic location, and population density (Virginia Nurses Association, 2018). Virginia law states “each school board may strive to employ, or contract with local health departments for, nursing services consistent with a ratio of at least ... one nurse per 1,000 students by July 1, 1999” (Virginia Law Code 22.1-274, VA Legislative Information System, last revised, 2013). This position has become an unfunded mandate. Mandates begin as bills in the Virginia General Assembly and passed to the DOE as a directive for implementation. When bills are unfunded, the law remains, but schools cannot be mandated by the state to comply. School divisions make decisions to find the means with which to comply, potentially sacrificing other programs, resources, and positions if necessary (County of Spotsylvania, Virginia, 2018). However, because the mandates are unfunded, there is no recourse for school systems that do not comply. Similar situations exist across the United States.
One potential way to fill this gap is through beneficial policy implementation. Budget amendments are introduced by bill patrons and supporters yearly to increase state funding for additional school nurses to achieve the AAP’s recommendations (VASN, 2018). Three 2018 Virginia House bills addressed the school nurse to student ratios, including HB 1046 (Torian) and SB 366 (Stuart), stricken from the docket, and HB 791 (Pogge), left in Appropriations; all proposed the removal of school nurses pay from the category of student support positions, such as administration, and would require each local school board to install a nurse per 550 K–12 students (Bowers-Lanier, 2018).
Policy initiatives can create practical benefits for nurses in the Commonwealth and across the states. Following the successful implementation of legislation in Virginia to address the nurse shortage by increasing faculty salaries and promoting nursing education, Eaton (2012) published an example and tool kit for future advocacy initiatives after more than 1,000 nurses, nursing students, and other professionals marched to the Richmond Capitol to meet with their governor and legislators. Four critical aspects contributed to this success: fully defining their problem, forming a unified coalition, developing a solution, and finding a favorable political environment for policy change. Moreover, a nursing student health policy fellowship in Richmond was found to have a significant impact on political involvement at practical and professional levels to promote policies and advocacy for citizen well-being (Carnagor, Eaton, Bowers-Lanier, & Deveneau, 2018). Perhaps these methods can yet be successfully applied to address our school nurse national health hazard.
In 1925, the VSBH and the SBE initiated several creative programs to stimulate interest and involvement in school health reforms. One idea was May Day, or Child Health Day, created to increase the attention of parents, children, and the general public to the importance of child and school health through entertaining community endeavors—parades with health floats and banners, health songs and plays, and Maypole dances (Vance, 1925). Unfortunately, some communities had already closed for the year due to the farming season and the schoolchildren were thus unable to attend (Vance, 1925), again underscoring difficulties of rurality.
Another innovative idea for inclusion came from Nancy Vance, the designated State School Nurse for the Commonwealth of Virginia in 1925. She developed The Five-Point Child Certificate Program to encourage students to meet and maintain good health. Schoolchildren who met the standard in each of the identified areas of weight, vision, hearing, throat (tonsils and adenoids), and teeth were awarded the highly sought after Five-Point Certificate to obtain special privileges (Vance, 1925). Enrollment in promotional Health Leagues and clubs was also considered an honor. Similarly, involved and revered programs could be developed and implemented today to gain community support and much needed funding for the school nurse role while promoting school and community health.
Historical research shows obstacles of poverty, rurality, war, and lack of social support to be pervasive within the school nursing profession. Resulting from an initiative to transform nursing following the unprecedented Affordable Care Act of 2010, the IOM (now the National Academies of Sciences HMD) issued a landmark report. The Future of Nursing: Leading Change, Advancing Health (IOM, 2011, p. 12) outlined four key recommendations for the profession. Nursing editors participated in a telebriefing to disseminate details of the Future of Nursing: Campaign for Action, funded by Robert Wood Johnson Foundation. Cowell (2012) presented each of the campaign foci as they relate to school nursing—practice, education, leadership, and workforce—and provided recommendations for each. To improve practice, for example, Cowell (2012) and the IOM support the removal of barriers in order to allow nurses to practice to the full extent of their scope and education, particularly concerning nurse practitioners. This statement echoes historical evidence contained herein; identified barriers included understanding the benefits of the role, the need to back funding for school nurses’ salaries, and support for school nurses to utilize all their skills and capabilities to address the health and wellbeing of schoolchildren.
Another current challenge facing this profession is one connecting career/workforce, financial, education, and leadership issues. Historically, this was noted to be a concern evidenced by the Commonwealth of Virginia’s unsuccessful attempt to secure enough nurses to meet the needs of rural citizens at the turn of the 20th century. Cowell (2012) states:
School nursing and other nursing specialties in the community may be at a disadvantage for accepting the challenge to advance their practice and meet the needs of the diverse American population. A disadvantage lies in the availability of financial support for education, be it degree advancement or continuing education. Across the country, many school nurses are deemed ineligible for nursing loan repayment and scholarships ... .(p. 89)
In many states, this exclusion applies to nursing professionals engaged in population, rather than direct, patient care (Cowell, 2012). Finally, based upon IOM’s data and recommendations, “the Campaign for Action calls for nursing organizations to collaborate with funders, health care organizations, colleges of nursing and decision makers” to ensure a responsive school nurse workforce (p. 89).
By working with those within and outside of the profession, including the National Association of School Nursing and the National Association of State School Nurse Consultants, we can create powerful partnerships and impact within the community and nationwide (Cowell, 2012). However, financial support is often paramount to the success of a health-care initiative, as seen throughout history. Thus, garnering important relationships and economic support are key tasks of current nursing and school nursing leaders (Cowell, 2012).
The school nurse position is both preventive and curative. Benefits range from increased student attendance and graduation rates to monitoring and preventing outbreaks of communicable diseases, promoting health education, and assisting in the maintenance of chronic disease, all impacting the health of schoolchildren and communities (Centers for Disease Control and Prevention [CDC], 2017). Importantly, for some students, the school nurse is their only available access to health care (CDC, 2017). School nurses are also shown to positively impact immunization rates, student health record accuracy, and student health management (Baisch, Lundeen, & Murphy, 2011). Moreover, school nurses support the overall learning process by allowing teachers to focus on instruction. When a nurse is employed, the average time teachers spend on matters regarding children’s health decreases from 26 min to 6 min per day (Wang et al., 2014). The AAP calls for a minimum of one full-time RN per 550 students (VASN, 2018). As children are our greatest resources, every measure should be taken to ensure a healthy and successful start in life, including securing access to a school nurse for each student.
More than 100 years after the efforts of school nurse founders and advocates including SHC Williams, Cabaniss, Minor, and Ranson, schools in the United States are not mandated to hire a full-time nurse. In addition, the role remains misunderstood, creating barriers to the backing of the school nurse movement. History can help explain and address some of these blocks while offering solutions. For example, communities continue to be largely untapped resources. Garnering civic support through engagement can lead to successful policy initiatives such as to procure a nurse for each school and secure funding, while student health policy fellowships can promote political involvement as well as practical and professional advocacy roles (Carnagor et al., 2018; Eaton, 2012).
Building greater collaborative partnerships to address the significance of the school nurse role includes addressing issues of financial support, career and leadership opportunities, interprofessional education, and health-care policy (Carnagor et al., 2018; Eaton, 2012; Eaton et al., 2017). By making simultaneous and interconnected improvements in areas of practice, education, leadership, policy, and workforce, the nursing profession—including school nurses—can better respond to the diverse needs such as caring for today’s most vulnerable (Cowell, 2012; Eaton, 2012; Eaton et al., 2017).
School nurses continue to face practice barriers of poverty, rurality, and lack of social support; grounded in historical events, these still hinder nurses’ ability to care for schoolchildren today despite overwhelming evidence for the need of such services. At the turn of the 20th century in the Commonwealth of Virginia, community support and finances were difficult to garner. Resistance on these fronts exists today, as do several examples of gaining support for this important profession. Cowell (2012) identified the lack of financial support for school nursing and other specialty education as one current serious barrier to the success of the profession. As such, she calls for collaboration among colleges of nursing and education systems, health-care organizations, financiers and donors, and other decision makers to advance school nursing as a means to address the diverse health-care needs of our nation’s children and communities (Cowell, 2012). Collaborative, interprofessional, and leadership initiatives to expand and strengthen the profession are vital, and can include health policy to remove barriers to practicing within the full extent of one’s education and practice (Carnagor et al., 2018; Eaton, 2012; Eaton et al., 2017). These can be further expanded upon and implemented to support schoolchildren’s health now through FUNDED initiatives such as mandating a full-time RN in each school as per AAP recommendations (VASN, 2018), a quest that began over 100 years ago.
Both authors equally conceptualized the manuscript as well as drafted and revised it. Both authors were involved in the analysis and interpretation of the data included in this manuscript and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Bridget Houlahan, PhD, RN https://orcid.org/0000-0001-8561-5482
Lilanna Deveneau, BA, BS https://orcid.org/0000-0001-9426-2519
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Bridget Houlahan, PhD, RN, is assistant professor of Nursing in James Madison University.
Lilianna Deveneau, BA, BS, is an MA student at George Mason University, Fairfax, Virginia.
1 James Madison University, Charlottesville, VA, USA
2 George Mason University, Fairfax, VA, USA
Corresponding Author:Bridget Houlahan, PhD, RN, Assistant Professor of Nursing, James Madison University, RN, 3395 Turnberry Circle, Charlottesville, VA 22911, USA.Email: bridgethoul@yahoo.com
