The Journal of School Nursing2024, Vol. 40(5) 482–490© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221119516journals.sagepub.com/home/jsn
Abstract
The professional experiences of school nurses who work outside of urban areas are not often described. We used data from a 2019 statewide survey of school nurses to describe differences between the urban and non-urban (urban cluster and rural) school nurse workforce in New Mexico. Non-urban school nurses were twice as likely as urban nurses to provide clinical services to multiple school campuses (P < .001) and more likely to serve both elementary and secondary school settings (P = .002). They were less likely than urban school nurses to be bachelor’s prepared, or to have received recent continuing education on diabetes (P <.001), reproductive health (P = 0.02), LGBQ+ and transgender student health (P <.001, for each), and suicide risk assessment and screening (P = .012). Our findings underscore concerns about geographic differences in the school nursing workforce in terms of educational preparation and student access that could potentially limit the school nurse role in advancing child health equity.
Keywordshealth disparities, health services research, nursing, non-urban health, school health, school nurses, rural
In 2021, when the National Academy of Medicine (formerly, the Institute of Medicine) released its report, The Future of Nursing 2020–2030: Charting a path to achieve health equity (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021), it affirmed that school nurses play a vital role in advancing health equity. As front-line providers, school nurses connect students to healthcare and accordingly, “access to a school nurse is a healthcare equity issue for some students, especially in light of the increasing number of students who have complex health needs.” (NASEM, 2021).
The National Association for School Nurses [NASN] identifies health equity as a component of its Framework for 21st Century School Nursing PracticeTM (NASN, 2016) and the potential for school nurses to address child health disparities has been well-described (Gratz et al., 2023; Johnson, 2017). School nurses provide health screenings, immunization status checks, medication administration, emergency management, care coordination, health education, assessments of mental and behavioral health, and other services, without the need for appointments, transportation, insurance, referrals, or prior authorization (Fleming, 2011; Holmes et al., 2016; NASN, 2020). Moreover, school nurses provide care where children and adolescents spend most of their waking hours during the school year (Centers for Disease Control and Prevention [CDC], 2021; Brixey, 2020). School nurses provide a key safety net for the wellbeing of youth and families (Barnby & Reynolds, 2018; School-Based Health Alliance, n.d.) and play a key role in public health and population health management (NASN, 2020) and emergency preparedness (NASN, 2019). A growing body of literature links access to a school nurse with improved health and educational outcomes (Best et al., 2018; Harrington et al., 2018; Kindi et al., 2022; Yoder, 2020).
However, despite the vital role of school nurses in addressing child health disparities and advancing health equity, relatively little is known about the school nurse workforce in rural areas or towns (e.g., urban clusters) where disparities in access to pediatric services are most evident and where school nursing services may be especially important. Non-urban areas have less behavioral health professionals and medical providers per capita than urban areas (Larson et al., 2016; Rural Health Information Hub, 2020). Children outside of urban areas are also more likely to live further from hospitals (Peltz et al., 2016; Shipman et al., 2011). Regarding the distribution of school nurses, it is known that non-urban areas are less likely to have school nurses in their schools and that non-urban school nurses are more likely to cover multiple schools (Ramos et al., 2014; Willgerodt et al., 2018).
Thus, school nurses are essential for child health equity, particularly in rural or non-urban settings where access to healthcare is limited and healthcare needs are high. Yet school nurses in non-urban areas may have less education than urban school nurses and may experience other professional challenges. We conducted this study to illuminate professional differences between the urban and non-urban (i.e., urban cluster and rural) school nurse workforce in New Mexico. We hypothesized that the school nursing workforce outside of urban areas would have less educational preparedness while having work responsibilities at least commensurate with their urban counterparts.
For this study, we conducted a secondary analysis of selected data from the 2019 New Mexico School Nurse Workforce Survey (Sebastian et al., 2021), which collected information on the demographics of school nurses, their work responsibilities and environments, and their educational priorities. The sampling frame for the 2019 survey included all school nurses currently working in a public, public charter, Bureau of Indian Education or Tribal, or private school in New Mexico. The list of school nurses included in the sampling frame was developed in collaboration with state agencies, the New Mexico Department of Health and the New Mexico Public Education Department, and schools and school districts in the state. Potential respondents were emailed an invitation to participate that included a link to an on-line survey. Of the 520 potential respondents, 320 completed the survey for a response rate of 61.5%. Study procedures were approved by the researchers’ Institutional Review Boards and relevant school district research review boards.
Demographic characteristics measured include age, gender identity, ethnicity, race, and sexual orientation. Respondents were asked to provide their zip code of employment. Other professional characteristics included education level, national certified school nurse status, years of experience as a school nurse, numbers of school campuses served, and school settings served, i.e., pre-kindergarten, elementary, middle, or high school.
Respondents were asked about the presence of children with special needs in the schools they served as well as student emergencies they had managed in the previous school year. They were asked about continuing education received in the three years prior to the survey and preferred means of receiving continuing education.
For this study, we included all respondents who worked as a school nurse in any type of school (e.g., public, private, etc.) serving any grade level and who identified their zip code of employment (N = 298). A total of 22 survey respondents, among the 320 total, who did not provide their zip codes were excluded from this secondary analysis. Urban areas, urban clusters, and rural areas were defined by zip code per US Census definitions (United States Census Bureau, 2021). School nurses who worked in urban areas were considered “urban”; those who worked in urban clusters and rural areas were considered “non-urban.”
The study design was cross-sectional. We used SPSS v. 27.0 (IBM, 2020) to perform descriptive and bivariate analyses, including Chi-square and Fisher’s exact tests (for variables with small cell sizes) to determine statistical significance.
School nurses included in the present analysis (Table 1) were predominantly non-Hispanic white (59.9%), female (94.1%), and heterosexual (88.2%). A quarter of school nurses, 28.7%, self-identified as Hispanic. Half of school nurses, 52.9%, were less than 50 years old. Fewer than half, 131 (44.0%), worked in urban areas. No significant differences in demographic characteristics (i.e., race, ethnicity, gender, age, sexual orientation) were found between school nurses working in urban and non-urban areas (Table 1).
Compared with school nurses from urban areas, school nurses working in non-urban areas were less likely to be nationally certified as a school nurse and less likely to have a bachelor’s degree or higher in nursing (Table 1). Non-urban school nurses were twice as likely as urban school nurses to work at multiple school campuses and were also more likely to work in both elementary and secondary school settings (Table 1).
Most school nurses in both urban and non-urban areas reported having at least one student in their school(s) with each of the following special healthcare needs: asthma, history of anaphylaxis, seizure disorders, and type 1 diabetes (Table 1). School nurses in urban areas were more likely to report having at least one student requiring mechanical ventilation at their school(s); school nurses in non-urban areas were more likely to report having at least one pregnant student at their school(s) and at least one student with type 2 diabetes (Table 1).
Few differences were observed in the kinds of student emergencies managed by school nurses working in urban and non-urban areas of the state. In both urban and non-urban areas, most school nurses managed student emergencies related to injury or trauma, asthma, abdominal pain, altered mental status, child abuse or neglect, and self-injurious behavior. School nurses in urban areas were more likely than school nurses in non-urban areas to report managing students with suicidality in the past year, 61.9% and 49.0% respectively, (P = .037) (Table 2).
Compared with school nurses from urban areas, non-urban school nurses were less likely to report having received CE within the previous three years on many educational topics (Table 3). Non-urban nurses were less likely to report having received CE on medical topics including reproductive health, diabetes, oral health, lesbian, gay and bisexual student health, and transgender student health (Table 3). Non-urban nurses were also less likely to report having received CE on suicide risk assessment and screening, suicide prevention, changing the social and emotional climate of school, and human trafficking (Table 3). Finally, non-urban school nurses were less likely to report having had CE in the previous three years on policy and practice topics such as cultural competency, medical cannabis, and special education laws. For no CE topical area were non-urban nurses more likely to have received CE than their urban counterparts (Table 3).
On-line CE was named the preferred means for receiving CE for non-urban school nurses, followed by conferences, and then district in-services (Table 4). Urban school nurses were more likely than non-urban nurses to name their district in-services as a preferred means of receiving CE, 39.5% and 15.8%, respectively, (P<.001). Urban and non-urban school nurses alike indicated self-study with hard copy materials was their least preferred method for CE.
Using data from a 2019 statewide survey of school nurses in New Mexico, we found important differences in responsibilities and educational preparedness between the urban and non-urban school nurse workforce. These disparities may have implications for student health and health equity for students living outside of urban areas.
Consistent with a previous New Mexico study that used county of employment to classify school nurses as metropolitan or rural (Ramos et al., 2014), in the present study, using a more granular assessment, zip code of employment, we found that non-urban school nurses were twice as likely as urban nurses to provide clinical services to multiple school campuses and were more likely to cover both elementary and secondary school campuses. This finding is consistent with the previous literature (Ramos et al., 2014; Willgerodt et al., 2018) and raises concerns that outside of urban areas, students may have less access to school nursing services and may receive more generalist school nursing services, as opposed to having services from a school nurse dedicated to working in either the elementary or secondary school setting.
Furthermore, we found that school nurses outside of urban areas were less likely than urban school nurses to hold a nursing degree at the baccalaureate level or higher. The proportion of Bachelor of Science in Nursing-educated nurses has been correlated with better health outcomes across in-patient and out-patient settings (IOM, 2011; NASEM, 2021). Baccalaureate-prepared nurses receive education critical to school nursing, including health policy, leadership, and systems thinking; they acquire skills in research, teamwork, and collaboration; and are better equipped to meet the increasingly complex demands of care across all settings (IOM, 2011; NASEM, 2021).
In 2011, The Future of Nursing report recommended that the percentage of nurses who hold a baccalaureate degree or higher be increased to 80 percent by 2020, a goal that was not realized. In 2008, 50.4 percent of employed nurses held a baccalaureate degree or higher; as of 2018, that proportion had increased just to 66.1 percent (NASEM, 2021). Both the National Association of School Nurses and the American Nurses Association continue to support the recommendation of baccalaureate-level nursing education for professional entry ANA & NASN, 2017; NASN,2021a). Our finding that the school nurse workforce outside of urban areas were significantly less likely than their urban counterparts to be baccalaureate prepared (58.7% vs. 86.3%, respectively) underscores the need for targeted supports for non-urban school nurses to pursue professional nursing educational opportunities. These findings also suggest the need to better equip rural school districts to be able to recruit and retain baccalaureate prepared school nurses.
We also found that school nurses outside of urban areas were much less likely (6.6% vs. 21.4%) than their urban counterparts to hold specialty certification in school nursing. Specialty certification objectively demonstrates a level of expertize in a focused area of practice (Coelho, 2019). Both the American Nurses Association and the National Association of School Nurses assert that the “specialty practice of school nursing requires advanced skills to competently address the complex health needs of students within a school community setting” (ANA & NASN, 2017) and that “these skills are attained through a minimum of a baccalaureate degree in nursing and validated by specialized certification in school nursing” (NASN, 2021a). Disparate levels of national specialty certification compound the disparate levels of bachelor’s preparedness seen in non-urban versus urban school nurses.
Furthermore, school nurses outside of urban areas reported being less likely to have had CE within the previous three years on many fundamental topics related tomedical and behavioral health issues important to school nursing practice. This disparity in ongoing school nursing professional education even further exacerbates geographic disparities in children’s access to school nursing care and thus healthcare in general.
We found that non-urban school nurses were significantly less likely to report recent receipt of continuing education on diabetes (68.7% vs. 86.3%) than their urban counterparts. This is concerning for several reasons. Type 2 diabetes presents a particular challenge for school nurses outside of urban areas. Consistent with national data indicating that obesity and type 2 diabetes are both more prevalent in nonurban areas in the US (Lundeen et al., 2018; Rural Health Gateway Research, 2018); we found that non-urban school nurses have a significantly higher burden of students with type 2 diabetes in their schools (41.3% of non-urban school nurses reported providing care for a least one student with type 2 diabetes compared with 29.8% of urban school nurses). Furthermore, the prevalence of type 1 diabetes, type 2 diabetes, and obesity among school-aged children are all significantly increasing in the U.S. (Anderson et al., 2019; Lawrence et al., 2021). Sufficient education and supports for diabetes care, particularly for non-urban school nurses, is needed.
Non-urban school nurses also appear particularly unprepared for the increasing mental health needs of youth. Youth from non-urban areas of the U.S. have double the suicide rates of youth from urban areas, and suicide rates are increasing faster in non-urban areas (Fontanella et al., 2015; Graves et al., 2020), yet school nurses outside of urban areas were less like than urban school nurses to have had recent CE on suicide prevention or suicide risk assessment and screening. Youth in non-urban areas have fewer mental health facilities serving youths and fewer suicide prevention services than youth in urban areas (Graves et al., 2020). Especially in these settings, school nurses are important access points to address the behavioral health needs of children and adolescents and they need the education and supports that are commensurate with their responsibilities.
School nurses working in non-urban areas were less likely to have had CE on lesbian, gay, bisexual and transgender (LGBT) student health issues than their urban counterparts. In fact, only a minority of school nurses outside of urban areas had received CE on either of these topics: 42.8% and 35.5%, respectively, had received CE on lesbian, gay and bisexual student health issues and transgender student health issues. LGBT youth attempt suicide at two to three times the rate of heterosexual cisgender youth, and school climate is an independent risk factor for suicide and depression among LGBT youth (CDC, 2017).
In their 2021 position statement, “LGBTQ Students,” The National Association of School Nurses re-affirmed that “school staff and communities should institute affirming policies that support lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth and that “to reduce these health disparities and to provide comprehensive care, school nurses should collaborate with educational teams to create welcoming, healthier, and thus safer environments for all students, while addressing stigma, discrimination, and marginalization of LGBTQ students” (NASN, 2021b). Our findings, similar to previous reports (Mahdi et al., 2014; Ramos et al., 2014) suggest that education and training on LGBT health disparities and healthcare may be lacking and needed for school nurses, regardless of geographic setting. However, professional development for school nurses on LGB- and trans-affirming healthcare and health policy may be especially important for those working outside of urban areas, where negative attitudes towards LGBTQ+ youth may prevail and where there are well described gaps in the provision of LGBTQ-affirming care in primary care settings (Kano et al., 2016).
We found that on-line educational courses were the most preferred means of receiving continuing education for school nurses outside of urban areas, a finding that is consistent with previous studies addressing educational needs for non-urban healthcare providers that suggest that online educational courses are helpful (Abelsen et al., 2020). Given the barriers to traveling off-site for CE (including patient care responsibilities at multiple school campuses), online courses with asynchronous learning opportunities may be especially appropriate venues for professional education for non-urban school nurses. It has been noted that “hands on” sessions for school nurses are also invaluable for the acquisition of certain technical skills important to school nursing (Burch and Stoeckel, 2023).
Our study has several limitations and noteworthy strengths. Findings from New Mexico may not be generalizable to other states or regions within the United States; however, our school nurse workforce is remarkably similar to the national school nurse workforce in being predominantly non-Hispanic White, female, and bachelor’s prepared (Willgerodt et al., 2018). Our study design was cross-sectional and thus causality cannot be inferred. The survey instrument, although created with subject matter experts and cognitively tested with school nurses prior to administration, was not otherwise validated, nor was there formal testing of its reliability. Strengths include a sampling frame collaboratively developed with state agencies that used the entire known census of school nurses in a state as well as the high response rate that was achieved.
In conclusion, we found significant differences between the urban and non-urban school nurse workforce that might contribute to, as opposed to ameliorate, geographic healthcare disparities for children and adolescents. In our statewide study, school nurses outside of urban areas were less likely to be baccalaureate prepared or to have national school nurse specialty certification. Non-urban school nurses had also received less continuing education than urban school nurses on a number of fundamental child and adolescent health and school nursing topics.
Our study findings underscore the importance of policies and programs that support baccalaureate-level preparation for non-urban school nurses and that allow access to CE opportunities for non-urban school nurses. The importance of adequate training, clinical preparation, and leadership development for the school nursing workforce to address geographic disparities in child and adolescent health and to improve health outcomes will continue to be highly relevant as child health issues are becoming increasingly more complex (NASEM, 2021).
Our study also underscores the value of community academic partnerships in advancing school nursing research. For this study, we conducted a secondary analysis of an existing data set from a statewide school nurse workforce survey. A census workforce survey of school nurses has been conducted regularly in New Mexico since 2009 through a longstanding academic-public health partnership. Although data from these survey efforts have been primarily used to inform state support for school nursing, secondary analysis of data sets such as these allow for contributions to the, as yet, limited extant literature about the school nursing workforce.
We would like to thank New Mexico school nurses for their work and participation in this study.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the New Mexico Department of Health, (grant number PIRE).
Mary M. Ramos https://orcid.org/0000-0002-5260-7395
Daniel Shattuck https://orcid.org/0000-0003-4689-863X
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Mary M. Ramos, MD, MPH, is a associate professor at University of New Mexico School of Medicine, Albuquerque, NM, USA
Rachel Sebastian, MA, is a research associate II at Pacific Institute for Research and Evaluation - Southwest, Albuquerque, NM, USA
Daniel Shattuck, PhD, is a associate research scientist at Pacific Institute for Research and Evaluation - Southwest, Albuquerque, NM, USA
Susan Acosta, RN, BS, is a state school health consultant at New Mexico Department of Health, Office of School and Adolescent Health, Albuquerque, NM, USA
Kim Zamarin, MPH, is a program director at Pacific Institute for Research and Evaluation - Southwest, Albuquerque, NM, USA
1 Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, USA
2 Pacific Institute for Research and Evaluation - Southwest, Albuquerque, NM, USA
3 New Mexico Department of Health, Office of School and Adolescent Health, Albuquerque, NM, USA
Corresponding Author:Mary M. Ramos, Department of Pediatrics, University of New Mexico School of Medicine, MSC11-6145, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. Emails: mramos@salud.unm.edu; marym.ramos@state.nm.us
