JAMA Forum
Role of School Nurses in the Health and Education of Children
Elizabeth Dickson, PhD, RN; Robin Cogan, MEd, RN; Rosa M. Gonzalez-Guarda, PhD, MPH, RN
The media headlines highlighting stories about schools over the past 5 years have been Author affiliations and article information are
overwhelmingly focused on the increasing levels of young people’s mental and behavioral distress, listed at the end of this article.
the threat of firearm violence, and the management of student health during the pandemic.
Epidemiological data documents declines in the behavioral, mental, and physical health of US
children, their educational outcomes, and inequities among racial and ethnic minoritized youth
during this same period. Although there has been a range of resources proposed to help mitigate
these challenges, one key resource may hold a critically important role in ensuring the safety, health,
and educational outcomes of children in the US—the school nurse. We provide justification for
investing in school nurses, identify challenges in supporting school health programs, and provide
recommendations for investing in school nursing as a key strategy for improving children’s health,
equity, and well-being.
Historically Critical Roles of School Nurses
School nursing has undergone a remarkable transformation since its inception in the early 20th
century.1 Originally focused on combating contagious diseases, current school nursing practice
requires a specialty focus to address the multifaceted health needs of students within educational
settings. School nursing in the US began in 1902 when Lillian Wald, founder of the Henry Street
Settlement appointed Nurse Lina Rogers to address contagious diseases and promote hygiene
among students on New York City’s Lower East Side (an area with limited resources at that time).
The results of the work of Rogers demonstrated the profound effect of health interventions on
education—in 1 year, the number of absent students dropped from 10 000 to just over 1000, a
remarkable success that catalyzed school nursing expansion across New York City and throughout
the US.1 Today, more than 120 years later, the presence of a school nurse continues to demonstrate
profound improvement in student absenteeism and other outcomes.2
The scope of practice for school nurses is illustrated by the National Association of School
Nurses School Nursing Practice Framework,3 an evidence-based framework defining school nursing
practice, leadership, research, and collaboration. The framework represents the comprehensive
work of school nurses, emphasizing evidence-based best practices supporting student health,
safety, and academic readiness. The evolution of school nursing reflects a growing understanding of
the relationship between the health of students, especially those who are systematically
disadvantaged and would otherwise have limited access to health care, and their educational
progress and overall well-being.
Justification for School Nurses
School nurses are responsible for a plethora of health care needs of children, families, and the
broader community. Despite often working alone, they (1) provide essential management and
supervision of care for students with a chronic condition or disease (eg, diabetes, seizure response,
gastrostomy tube feeding); (2) teach health education; (3) screen for and manage depression,
anxiety, vision, and hearing disorders; (4) oversee accessibility plans for students with
accommodations (eg, attention-deficit/hyperactivity disorder); and (5) refer students to external
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Health Forum. 2025;6(1):e250116. doi:10.1001/jamahealthforum.2025.0116 (Reprinted) January 23, 2025 1/3
Downloaded from jamanetwork.com by guest on 09/18/2025
JAMA Health Forum | JAMA Forum
health professionals. Some school nurses have health aides to help manage the needs of students.
During the COVID-19 pandemic, while politicians and school leaders argued about how best to
implement strategies to prevent the transmission of the virus in school settings, school nurses
responded to the growing health needs of students.4 School nurses also offer vital mental health
support and serve as a bridge between schools, families, and community health resources. Research
shows that school-based health centers and school nursing services are cost-effective, with
significant returns on investment, especially in the areas of chronic conditions, immunizations, and
mental health and in addressing income-based disparities in outcomes among children.
The influence of school nurses on student health outcomes is well-documented,2 and effective
school health programs have demonstrated improved academic outcomes by addressing safety,
physical, and mental health needs. School nurses are at the forefront of identifying health issues such
as asthma or diabetes, and mental health issues that may hinder a student’s ability to learn. For many
students, particularly those from underserved and historically marginalized populations,
geographically rural communities, and low-income families, school nurses may be their only access
to a health care professional. This reality underscores the vital role school nurses play in addressing
health equity.
Current Challenges and Emerging Issues
Despite their essential contributions, school nurses face numerous challenges that impede their
effectiveness. One of the most pressing issues is inadequate funding for school health services.5
Many schools operate with limited budgets that do not allow for sufficient staffing or resources
necessary for comprehensive health care delivery, and many districts do not have the capacity to bill
for reimbursement of nursing services. This chronic underfunding leads to inequities in health
services for students who rely on school nurses as their primary health care clinicians.
The increasing demand for mental health support for students can be exacerbated by social
media use and academic pressures. School nurses can collaborate with mental health professionals
to meet the mental and emotional health needs of students. The threat of gun violence in schools
has introduced a new dimension to the responsibilities of school nurses. They must now be prepared
for emergencies created by violent acts, requiring additional training in crisis management and
trauma response.6 As an extension of local public health systems, school nurses must also navigate
ongoing public health concerns, managing potential disease outbreaks, implementing safety
protocols, and supporting students and staff in adapting to new health guidelines.7
How to Support School Nurses and Leverage Their Effects
Children need safe and healthy places to learn, grow, and thrive. To create and maintain that
environment for students, communities and schools need to support and expand health access to
school nurses by
1. Investing in at least 1 school nurse in every school. Ensuring adequate staffing for school health
services is critical for the health and well-being of children. The National Association of School
Nurses8 recommends a registered professional nurse all day, every day in every school to improve
the health and educational outcomes of students. This requires federal, state, and local
jurisdictions to allocate appropriate funding as an investment for the future.
2. Supporting school nurses as advocates of data-driven approaches to promote health equity.
School nurses not only generate data, but use that data to advocate for improvements in federal,
state, and local programs and policies that promote optimal child development. Data-driven
approaches leveraged by school nurses to address the social drivers of health can give voice to
historically marginalized communities.
3. Integrating school nurses as leaders in the broader ecosystem. School nurses are well
positioned to partner with health, social services, government, and other sectors to promote
JAMA Health Forum. 2025;6(1):e250116. doi:10.1001/jamahealthforum.2025.0116 (Reprinted) January 23, 2025 2/3
Downloaded from jamanetwork.com by guest on 09/18/2025
JAMA Health Forum | JAMA Forum
access to evidence-based health care services in schools and other community settings. School
nurses should be provided opportunities to sit on decision-making boards (eg, school boards) to
inform evidence-based investments, programs, and policies.
4. Investing in specialized training and certification for school nurses. Given the
multidimensional roles of school nurses, it is important to equip them with the unique skills
needed to address both historical (eg, disease outbreaks) and contemporary (eg, mental health
and gun violence) health challenges in school environments.
Conclusions
By investing in and recognizing the contributions school nurses make to student well-being, schools
can create healthier learning environments where all children can succeed academically and develop
into healthy adults who contribute positively to society. Investing in school nursing is not only about
fostering a healthier future for children, but also strengthening communities for generations
to come.
ARTICLE INFORMATION
Published: January 23, 2025. doi:10.1001/jamahealthforum.2025.0116
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2025 Dickson E
et al. JAMA Health Forum.
Corresponding Author: Rosa M. Gonzalez-Guarda, PhD, MPH, RN, Duke University School of Nursing, 307 Trent
Dr, Durham, NC 27710 ([email protected]).
Author Affiliations: College of Population Health, University of New Mexico, Albuquerque (Dickson); School of
Nursing, Rutgers University, Camden, New Jersey (Cogan); School of Nursing, Duke University, Durham, North
Carolina (Gonzalez-Guarda).
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Bergren MD. School nursing and population health: past, present, and future. OJIN. 2017;22(3). doi:10.3912/OJIN.
Vol22No03Man03
2. Best NC, Oppewal S, Travers D. Exploring school nurse interventions and health and education outcomes: an
integrative review. J Sch Nurs. 2018;34(1):14-27. doi:10.1177/1059840517745359
3. National Association of School Nurses. A contemporary framework update for today’s school nursing
landscape: introducing the School Nursing Practice Framework. NASN Sch Nurse. 2024;0(0). doi:10.1177/
1942602X24124109
4. Lowe AA, Ravi P, Gerald LB, Wilson AM. The changing job of school nurses during the COVID-19 pandemic:
a media content analysis of contributions to stress. Ann Work Expo Health. 2023;67(1):101-117. doi:10.1093/
annweh/wxac053
5. Maughan ED. School nurses: an investment in student achievement. Phi Delta Kappan. 2018;99(7):8-14. doi:10.
1177/0031721718767853
6. Idowu T. Supporting school nurses: training resources to identify risks and mitigate school shooting incidents.
OJIN. 2023;28(3). doi:10.3912/OJIN.Vol28No03Man04
7. Merkle SL, Ingels J, Jung D, et al. Reported impact of COVID-19 workload and stressors on school nurses’
provision of care during the 2021-2022 school year: a secondary analysis of US school nurse survey data. J Sch
Nurs. 2024;40(5):523-535. doi:10.1177/10598405241248429
8. National Association of School Nurses. School Nursing: Scope and Standards of Practice. 4th ed. National
Association of School Nurses; 2022.
JAMA Health Forum. 2025;6(1):e250116. doi:10.1001/jamahealthforum.2025.0116 (Reprinted) January 23, 2025 3/3
Downloaded from jamanetwork.com by guest on 09/18/2025
