The Journal of School Nursing2024, Vol. 40(5) 514–522© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231197836journals.sagepub.com/home/jsn
Abstract
This study is a cost-benefit analysis examining an urban district’s partial school nurse coverage conversion to full-time coverage. Through a partnership with a health care system, the district received funding, resulting in the hiring of full-time nurses to cover all K-8 elementary schools. Researchers compared the cost of nursing services to the savings in teacher, secretary, principal, and parent productivity, reduced medical procedure costs, and grants nurses managed. The year before implementing additional nurses, the return on investment (ROI) to the community for nursing services was calculated to be $1.59 for every dollar invested in schools with full-time coverage and $1.29 for schools with partial coverage. After implementing fulltime nurses in each school, there was an ROI of $1.50 during the 2015–2016 school year, $1.64 for 2016–2017, and $1.67 for 2017–2018. The analysis provides evidence that full-time coverage could result in a positive ROI for schools and the community.
Keywordscost-benefit analysis, return on investment, economic study, full-time nursing coverage, part-time nursing coverage, school nurse funding
Schools are one of the most efficient places to improve access to health services for children and adolescents because schools serve students of all demographic backgrounds, and a high percentage of students attend public and private schools (Cruden et al., 2016; Kolbe, 2019). Even though there is support to provide health services in schools, financial barriers limit districts’ ability to provide health services (Cruden et al., 2016). A lack of efficient funding streams is a common barrier to providing health services to children and adolescents in schools (Cruden et al., 2016). However, utilizing funding from outside of the educational system is a promising strategy to reduce this barrier. Funding from different sectors creates an opportunity for collaboration across disciplines to improve students’ health and well-being so they are healthy and ready to learn (Becker & Maughan, 2017; Cruden et al., 2016).
Wang et al. (2014) conducted the first cost-benefit study of school nursing services and laid the foundation for future economic studies examining school health services. The study concluded that for every dollar invested in the Massachusetts Essential School Health Services program, society would gain $2.20. This study filled a gap in the scientific community regarding examining the cost-benefit of school nursing services delivered by full-time registered nurses in the state of Massachusetts. Results from Wang et al. (2014) provide evidence that employing full-time nurses in schools is a wise investment of public money and should be considered by decision-makers when allocating resources.
Researchers recommend that school nursing services’ financial value needs to be explored further by summarizing group data, collaborating across sectors, and working with researchers who can study the cost-benefit of nursing in terms of population health care (Cowell, 2018). It could positively benefit both schools and health care systems if partnerships were made between the two sectors to explore using other funding sources like community benefit funding through hospital systems. The cost-benefit analysis by Wang et al. (2014) was the first of its kind and provided an analytical approach that can be used by states or districts to assess their programs. Only a handful of other economic studies examine school nursing services (Baisch et al., 2011; Miller et al., 2016). More research is needed that builds on previous economic studies to examine other types of school settings, differences in cost-savings between part-time and full-time school nurse coverage, and savings across multiple school years. The National Association of School Nurses (NASN) 2022 research priorities include investigating the funding for school health, specifically by investigating the cost-benefit of alternative funding models of school nurses (NASN, 2022).
In April 2015, a large urban school district in a Midwest city and a large health care system in the city announced they would work together to increase health services throughout the school district. The two groups partnered and hired 12 additional school nurses in the elementary schools to bring the total to 40 school nurses, one for each building. In the years prior to this agreement, 28 elementary school nurses managed all 40 schools, which meant that there were always times when no school nurse was available to meet students’ needs, should something arise. Because of the growing body of literature linking student health, school nurses, and academic performance, the health care system announced it would invest $600,000 annually for 3 years. The funding for additional nurses came from the hospital system’s community benefit as a part of their tax-exempt status as a nonprofit hospital. The funding’s purpose was to support a school nurse in each building and to contract with a university research team to evaluate the impact of the investment. The analytic framework for the study was based on Wang et al. (2014) and utilized a cost-benefit analysis from a societal perspective to examine the impact nursing services has on everyone in society (Brent, 2023).
The purpose of this 4-year longitudinal study was to conduct a cost-benefit analysis of the conversion of partial school nurse coverage of the elementary schools (2014–2015 school year) to full-time school nurse coverage of each school (2015–2016 through 2017–2018 school years). The study data was collected prior to the COVID-19 pandemic.
(1) To examine if there is a difference in return on investment (ROI) to the local community between having rotating part-time school nurse coverage and full-time nurse coverage.
(2) To examine the ROI for the local community for the schools with part-time school nurse coverage during the 2014–2015 school year.
(3) To examine the ROI for the local community for the schools with full-time school nurse coverage during the 2014–2015 school year.
(4) To examine the ROI for the local community with having full-time school nurse coverage in all schools during the 2015–2016, 2016–2017, and 2017–2018 school years.
A cost-benefit analysis was conducted for 4 years: The year prior to full-time nurse coverage at a large Midwest urban district, and 3 years of full-time nursing services. The authors adapted methods from Wang et al. (2016) and Wang et al. (2014). Table 1 displays the calculations and sources used to conduct the analysis. The University of Toledo’s Institutional Review Board approved this study and considered it not human subject research.
The district costs for health services included the nurses’ salary and fringe benefits and the medical equipment supplies. The district’s Human Resource Department provided the aggregate data on the salary and fringe benefits. The district’s Health Service Department provided the data for medical equipment and supplies.
The benefits the nurses provide are the savings in productivity of teachers, secretaries, and principals for not having to take time from their regular job responsibilities to help students with medical needs; parents’ productivity from not taking time off work due to students’ early dismissals when a nurse is not present; reduced medical procedure costs for students seen at school instead of a health system; and the grants nurses were now able to manage.
The Human Resource Department provided aggregate data for the teacher, secretary, and principal’s salary and fringe benefits. The data for the district’s number of school staff was publicly available from the Ohio Department of Education (Ohio Department of Education [ODE], n.d.). The salary and fringe benefit data for each professional was multiplied by the number of professionals that were employed in the K-8 buildings during each school year and then multiplied by the estimated amount of minutes that each professional spends per day dealing with illness or injuries when a nurse is and is not present. Researchers derived the estimated amount of time each staff position spends addressing student health concerns from a study conducted by Baisch et al. (2011). They determined the amount of time the staff members take out of their day to address student health concerns when there is and is not a nurse present. Since there was no information available for the time these staff members spend on student health issues when there is part-time nurse coverage available, researchers worked with the Health Services Coordinator to create an estimated number of minutes that the staff deal with student health concerns when there is a rotating school nurse in the buildings, based on anecdotal evidence from school staff.
The parent or guardian productivity loss was the product of a lost hour’s value, the number of early dismissals for the school year, the early dismissal rate, and 3 h missed for each early dismissal. Researchers determined parent productivity by the loss of income a parent or guardian would experience when a student leaves early from school. Parent or guardian income was calculated based on the United States Census Bureau estimates for the school district’s per capita income (United States Census Bureau, 2018). Wang et al. (2014) estimated that a parent or guardian would lose about 3 h when a student leaves early. The local district Health Services Director verified the estimate was accurate for this district. Lastly, the number of early dismissals was provided to researchers by the district’s Health Service Director from the Electronic Health Record (EHR).
Researchers calculated the medical procedure savings by multiplying the value of nurses’ medical procedures by the corresponding number of student nurse visits considered skilled nursing care. The Ohio Department of Medicaid’s publicly available fee schedule was utilized to determine the value of the procedures considered as skilled nursing care (Ohio Department of Medicaid, 2018). Skilled nursing visits include blood glucose testing, blood pressure monitoring, catheter care, checking ketones, nebulizer treatment, peak flow monitoring, suctioning, tube care or usage, and wound care (Wang et al., 2014). The Health Service Department provided the total number of student nurse visits for each school year from the EHR for each category of skilled nursing care. Table 2 shows a detailed breakdown of the medical procedures.
Unlike Wang et al. (2014), who did not gather grant data, the present study included grants as a category. Some nurses wrote grants to secure more funding that would not have been applied for if a school nurse was not present or managed grants during the school year. If a nurse was not present, the grants would not have been applied for, or another staff member would have needed to manage it. The district’s Health Services Department provided the award amount for each grant for any of the elementary schools in which the nurse was responsible for managing.
Tables 3 to 6 display the results of the cost-benefit analysis. Across all years examined, the benefit of having full-time nurses resulted in substantial increases in the ROI compared to schools with rotating nurse coverage. The year before each school had a full-time nurse, the schools with rotating nurses had a benefit-cost ratio of 1.29, while the schools that already had a full-time nurse had a benefit-cost ratio of 1.59.
Each year after full-time nurses were in each school, the ROI to the community increased. During the first year of fulltime school nursing services in all buildings (2015–2016), the district started with a 1.50 benefit-cost ratio or ROI, meaning for each dollar invested into school nursing, the community would gain $1.50. In the year following (2016–2017), the ROI increased to $1.64. In the final year of funding (2017–2018), for every dollar invested into the district’s nursing program, the community would gain $1.67.
This study provides evidence from one large urban school district that school nursing services are a wise investment for the community from a societal perspective. Using external funding streams to financially support school nurses and school health services is a sensible strategy. The funding for additional nurses for this current study came from the local hospital system’s community benefit as a part of their tax-exempt status as a nonprofit hospital. Researchers have explored the opportunity of school districts partnering with hospital systems to utilize community benefit giving as a way to increase access to health services outside of a traditional medical setting (Becker & Maughan, 2017). Articles analyzing community benefit funds suggest that the majority of funding hospitals distribute to fulfill their requirements goes towards patient care, followed by community services, including community health improvement activities, contributions to community groups, research, and health professions education (Leider et al., 2017; Rozier, 2020). Trends based on previous research show that most community benefit is allocated for direct clinical care rather than preventative programs or services to improve population health (Rozier, 2020). Additionally, Rozier and Singh (2020) state that hospital organizations have little consistency in budgeting and allocating resources for community programs to improve population health. Nevertheless, by providing hospital systems with current evidence on the return their funding could have on the community, public health and school health researchers can explore this emergent funding opportunity to benefit from shared goals of community health improvement and improved population health.
Previously conducted economic studies on school nursing occurred in various locations throughout the United States, for example, a nationally representative sample, a midwestern city, and Massachusetts (Baisch et al., 2011; Miller et al., 2016; Wang et al., 2014). Miller et al. (2016) reported that students who are economically disadvantaged and students from racial and ethnic minority groups are impacted disproportionately by chronic health conditions compared to students with a higher socioeconomic status and nonminority students. The current study’s location was in an urban area of a Midwest state, with the students’ demographic makeup being very diverse. Approximately 44% of students are non-Hispanic black, 13% Hispanic, 11% multiracial, 31% non-Hispanic white, 22% have a disability, and 87% are economically disadvantaged. Considering the research surrounding the health disparities among low-income and racial and ethnic minority students, conducting an economic study in a district with a diverse study body gives a more comprehensive picture of the benefit nurses bring to students who can seek essential medical care.
This study is the first published cost-benefit analysis examining rotating nurses and nurses stationed at each building. Both options resulted in a positive ROI, demonstrating the monetary value that nurses bring to schools and the community. It is financially more cost-effective to have one nurse in each building; however, due to having a positive ROI even for the rotating nurses, schools with part-time nursing services are still an advantage for schools and are better than having no nursing services at all. The difference in ROI between full-time nursing coverage ($1.59) and part-time coverage ($1.29) is $.30 during the 2014–2015 school year, with full-time coverage always resulting in a greater return to society for each year of the study.
At the beginning of the school year with full-time nursing coverage, each of the nurses attended a training session. Topics of the session included establishing and leading a School Health Advisory Council (SHAC) and completing the Center for Disease Control and Prevention’s (CDC) School Health Index (SHI) for elementary schools. A requirement to receive funding from the health care system was for each school nurse to lead their SHAC, creating an opportunity to implement programs or initiatives throughout the school year based on their school’s SHI completed each year for each school building (CDC, 2017). The calculation for the number of grants awarded that nurses oversee provides an example of how the nurses worked with other health and school professionals participating in the SHAC’s, such as nutrition services, teachers, counselors, and Safe Routes to School coordinators. The SHAC’s gave the nurses the opportunity to collaborate with other staff members to implement grants at more schools than when there were rotating nurses and for higher dollar amounts than before.
Our findings cover 4 years of nursing services after hiring 12 new nurses in the 2015–2016 school year, and 26 schools adjusted from having rotating nurses to one nurse stationed in the building. The increase in the ROI from 2015–2016 to 2017–2018 equaled $0.17. The seventeen cent difference between school years is a significant increase, representing thousands of dollars within the computation. The increase could be partly explained by the relationship built between the students, staff, and nurses having a better relationship and understanding of the nurse’s role. By being members of the SHAC’s, teachers and staff may have improved their knowledge of school nurses’ responsibilities and increased their engagement with nurses over the years. The increase is further evidenced by the number of student visits to the nurse increased each year of the program besides the last year, potentially indicating that students were more comfortable going to the nurse for medical care or that teachers encouraged more students to visit the nurse. As Cruden et al. (2016) discuss, communication between the educational and health care systems is vital to building relationships and essential to creating an effective program.
The benefit-cost ratio from Wang et al. (2014) was higher than this current study’s ratios. The benefit-cost ratio for 1 year in Wang et al. (2014) was 2.20, while the current study’s highest ratio was 1.67. Some calculations were modified from Wang et al. (2014) for the present study to account for differences in state laws and data available to researchers. First, Wang et al. (2014) counted procedures performed for both students and staff. The current study’s EHR includes only nurse visits for students, so the category for savings in medical procedure costs is only for student health encounters. Second, in Massachusetts, where Wang et al. (2014) were conducted, prescription medication can only be administered if a school nurse is on duty in the school system when administered by a delegated unlicensed school personnel. It was assumed that parents would have to go to the school to administer the prescription medication if there was no nurse on duty in the school system. Therefore, the calculation by Wang et al. (2014) for parent productivity included the time a parent would have to leave for each prescription administered for their child in schools without a school nurse on duty. For the current location, delegated unlicensed school personnel could administer prescription medications. Hence, the parent productivity category for the current study only used the time a parent had to be away from work if their child was sent home early from school. Lastly, grants awarded to the schools for initiatives that the nurses managed were added to the cost-benefit analysis, which was not a measurement included by Wang et al. (2014). Nurses were able to secure more funding and manage more grants when a nurse was stationed at each building that otherwise would not have been applied for if they were not there, or another staff member would have needed to manage.
Few studies have examined the financial ROI of school nursing services (Baisch et al., 2011; Miller et al., 2016; Wang et al., 2014, 2016). This study provides economic impact findings from a new geographic location with different student demographic backgrounds, examines differences between rotating part-time coverage and full-time coverage, and explores changes over time, providing a different perspective than other published studies on this topic.
Some elements of school health services provided by nurses could not be calculated in this study because of the inability to collect or calculate the monetary return of providing those services. The study is limited to one large urban public school district in the Midwest, so results cannot be generalized to other geographical areas or different types of schools. Lastly, researchers relied on the accuracy of the records retained by the school, and any missing records are not measured in the calculation.
The results from this analysis are conservative estimates. For the analysis, researchers assumed that all of the students had Medicaid insurance coverage since it is unknown what type of coverage each student has. Considering 87% of the enrolled students are economically disadvantaged, the insurance status was calculated as if all nurse visits would have been billed through Medicaid. In reality, there would be higher benefits because some students are on private insurance, increasing the ROI. There are emerging opportunities for school districts to expand Medicaid programs to allow billing for medically necessary services delivered to students enrolled in Medicaid (Centers for Medicare and Medicaid Services, 2022; National Healthy Schools Collaborative, 2022).
Nurses also provide benefits that cannot be financially calculated but should be considered. The nurses could influence their school environment regarding health and well-being, resulting in a benefit that cannot be calculated monetarily. Additionally, the teacher, secretary, and principal salaries were included in the analysis as savings in productivity. However, it is more than just the monetary amount of staff’s salary in terms of benefits to the community. The students could gain valuable instructional time by allowing nurses to take the time burden of addressing students’ illnesses and injuries.
Other items not calculated in the analysis include nurses’ monetary benefits identifying undiagnosed conditions, preventing hospitalizations, providing health education or health promotion, screenings, referrals for additional health services like medications or eyeglasses, and educational outcomes. Additional topics that are particularly important to explore after the COVID-19 pandemic are related to the social needs of students, such as homelessness, identification of mental health issues, food insecurity, and navigating Medicaid reimbursement. Thus, the ROI to the community is much higher than calculated in the current study. Future cost-benefit studies should explore how EHR systems can collect more robust data to provide a comprehensive picture of what school nurses do in the buildings and the impact they have on students and the community.
The data provide convincing evidence that full-time nurse coverage in elementary schools results in a positive ROI for schools and the community and positively impacts students’ health and well-being. To fully understand the financial benefits of full-time nursing coverage, future studies should quantify and calculate the ROI of items that this study could not calculate. Studies should also investigate other areas of the USA, including suburban and rural schools, to continue exploring the impact of nursing services across the nation. A strong evidence base for full-time school nurse coverage benefits would provide decision-makers with the data to make informed decisions about allocating resources toward these necessary services. Potential funders could also use this information to evaluate the impact their contributions would have. Therefore, it is essential to continue exploring and advocating for innovative funding streams to increase nursing services to improve students’ health and well-being and meet the needs of the nation’s youth.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.
Mallory C. Ohneck https://orcid.org/0009-0004-9876-200X
Erin D. Maughan https://orcid.org/0000-0002-0176-1499
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Mallory C. Ohneck, Ph.D., MPH, CHES, School of Population Health, College of Health and Human Services, University of Toledo, Toledo, OH, USA.
Joseph A. Dake, Ph.D., MPH, School of Population Health, College of Health and Human Services, University of Toledo, Toledo, OH, USA.
Erin D. Maughan, PhD, RN, PHNA-BC, FNASN, FAAN, School of Nursing, College of Public Health, George Mason University, Fairfax, VA, USA.
Susan K. Telljohann, H.S.D., CHES, Professor Emeritus, School of Population Health, College of Health and Human Services, University of Toledo, Toledo, OH, USA.
Tavis Glassman, Ph.D., MPH, MCHES, School of Population Health, College of Health and Human Services, University of Toledo, Toledo, OH, USA.
1 School of Population Health, College of Health and Human Services, University of Toledo, Toledo, OH, USA
2 School of Nursing, College of Public Health, George Mason University, Fairfax, VA, USA
Corresponding Author:Mallory C. Ohneck, School of Population Health, College of Health and Human Services, University of Toledo, 2801 West Bancroft Street, MS 119, Toledo, Ohio 43606, USA.Email: mallory.rinckey@rockets.utoledo.edu
