Education is a Social Determinant of Health: School Nurses Level the Playing Field.

Abstract

Each of the five social determinants of health (economics, education, healthcare, the built environment, social and community context) is equally important, however, the most powerful determinant of health is education. Education is directly correlated with good health and social mobility (Zajacova & Lawrence, 2018); it is the great equalizer. Unlike grocery stores, hospitals, and clinics, schools exist in all communities, and most provide resources beyond education for children and their families. School is where hungry children eat and access all levels of health (primary, preventive, acute, and chronic) dental, mental health, and rehabilitative services. These services are coordinated and sometimes provided by school nurses. School nurses moderate the effects of poor social determinants of health through health screening, disease surveillance, care coordination, and social service referrals. Their actions facilitate school attendance and optimal learning. For many children, the school nurse is their only access to a healthcare provider, yet research findings from Gratz et al. (2023) remind us that disparities in students’ access to a school nurse persist. Gratz et al. (2023) found several reasons for school nurse access disparities, however the most notable were geography and distribution. Not surprisingly, researchers found that most school nurses practice in urban areas. Even though the American Academy of Pediatrics (2016) states that there should be a nurse in every school and the National Association of School Nurses (2022) states that children should have access to a school nurse, inconsistencies remain. Some schools have full-time nurses, others have part-time nurses and others are without a nurse. Despite these inconsistencies, urban schools fare better than rural schools. In rural school districts school nurses may be fulltime, but they often provide care to multiple schools, diluting nurses’ assessment and caring for students. In some rural communities, there are no school nurses. This is concerning because rural communities are more likely to be designated as medically underserved areas with limited access to primary and other healthcare providers, clinics, and hospitals (HRSA, 2023). For many children in rural communities, the school nurse may be the only healthcare provider they see all year. To close the health disparity gap, school nurses must be present where they are needed. Unequal distribution of health care providers is not a new issue for rural communities, but even within urban settings, there are more school nurses in elementary schools than in secondary schools. All students need access to school nurses, not just the youngest ones. Like nurses in other specialties, school nurses are aging out of the workforce, or leaving prior to retirement due to burnout, and low salaries (Jameson & Bowen, 2020). Replacing school nurses will be challenging due to the global nursing shortage. Children attend school with insulin pumps, vagal nerve stimulators, cardiac pacemakers, prosthetics, ventilators, feeding tubes, bipolar and other mental health disorders, and the list goes on. To attract nurses to the specialty, salaries must reflect that school nurses are highly skilled professionals. Their positions are often funded with local education dollars, which are largely reliant upon property taxes (Willgerodt et al., 2018). Systemic racism through policies like redlining has resulted in communities where homes and property are undervalued, limiting tax revenue for schools. Furthermore, the decision to hire a school nurse, where they will be deployed, and their practice autonomy are usually made by local school administrators who do not understand nursing, let alone school nursing. School nurses are a vital part of the nation’s public health infrastructure. To optimize students’ education and diminish the impact of adverse social determinants of health, we need a national policy that ensures a stable funding mechanism for school nurses. Adequate funding of school health and school nurses is imperative to elevate school nursing salaries, attract nurses to the specialty, and ensure full-time nursing services are available to all children in all communities. School nurses level the playing field and ensure all children have the opportunity to excel academically.