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608183

research-article2015

NASXXX10.1177/1942602X15608183NASN School NurseNASN School Nurse

Feature Article

The 2015 NASN School

Nurse Survey
Developing and Providing Leadership to Advance
School Nursing Practice
Anantha Sameera Mangena, BGS, JD(c)
Erin Maughan, PhD, MS, RN, APHN-BC
This article summarizes the results of
the 2015 NASN School Nurse Survey,
identifies similarities and differences
between this survey and the 2013 NASN
School Nurse Survey, and evaluates
the possible impacts of this data on the
organization.
Keywords: school nurse survey; needs
assessment; demographics; NASN

ASN supports school nurses in their

effort to improve the health and
academic success of all students. As
part of that goal, NASN periodically
conducts an assessment of school nurses
needs and uses that information to
identify where resources should be
allocated. This survey has traditionally
been conducted every two years and
includes information about the
demographics of school nurses and their
practice. The assessment results provide
NASN with information to develop
targeted programs that support school
nursing practice. This article summarizes
the results of the 2015 NASN School
Nurse Survey, identifies similarities and
differences between this survey and the

2013 NASN School Nurse Survey, and

evaluates the possible impacts of these
data on the organization.

Methods
The 2015 NASN School Nurse Survey
was shorter than the 2013 survey and
focused on questions regarding
demographic, training, and
membership needs. NASN has decided
to do shorter assessments each year
instead of a longer one every other
year. The 2016 survey will focus on
other NASN priorities. The shorter
surveys allow for quicker completion,
increased participation, and more
frequent contact with school nurses
nationwide.
In early spring of 2015, NASN
distributed the 2015 survey through
several media venues, email, and the
NASN website. Both this survey and the
2013 survey targeted all school nurses
and elicited responses from members
and non-members of NASN. NASN
worked with affiliate chapters and state
school nurse consultants to further
disseminate the link to increase the reach
of the survey. As an incentive for
individuals to participate, respondents
who completed the survey became

DOI: 10.1177/1942602X15608183
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2015 The Author(s)

eligible to win one of four scholarships:

two scholarships to attend the 2015
NASN Annual Conference and two
scholarships for NASN bookstore
purchases, which were proudly
sponsored by Lysol.
Qualtrics, an online, secure survey
program, was used to collect and
compile the survey data. This was the
first time NASN used Qualtrics for this
needs assessment. After results were
collected, unfinished responses and
duplicates were removed from the data
set, which was then analyzed for
significant trends and indicators. Some of
the questions included skip logic, an
option that did not appear to those for
whom it did not apply (as determined by
how the respondent answered a previous
question), and as a result, percentages
included in this article indicate the
percentage of respondents who
answered that particular question. Many
of the demographic questions in the
2015 survey were identical to questions
asked in 2013, to compare the results
with the 2013 School Nurse Survey and
notice any trends.
In 2015, NASN had enough respondents
to look at differences across regions,
since school nursing is practiced

November 2015 | NASN School Nurse

329

Table 1. States in Each of the Federal Regions (shading indicates NASN grouping)
Federal Regions

States Included in Region

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont

New Jersey, New York, Puerto Rico, and the Virgin Islands

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee

Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin

Arkansas, Louisiana, New Mexico, Oklahoma, and Texas

Iowa, Kansas, Missouri, and Nebraska

Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming

Arizona, California, Hawaii, Nevada, American Samoa, Commonwealth of the Northern Mariana Islands,
Federated States of Micronesia, Guam, Marshall Islands, and Republic of Palau

10

Alaska, Idaho, Oregon, and Washington

differently in different parts of the

country and is influenced by geography,
state laws, and nurse practice acts (which
influence ability to delegate). NASN used
the 12 designated regions of the U.S.
Department of Health and Human
Services Health Resources and Services
Administration (n.d.) as a beginning point
and then combined some of the regions
due to number of respondents. The four
combined regions were compared for
differences in demographics and
educational needs (Table 1).

Table 2. Average Demographics, 2013 and 2015

Demographic Characteristic

2013 Average

2015 Average

46-54

47-55

$44,984-$54,726

$51,906-$56,865

Years as a school nurse

11

19

Years as a nurse

23

31

Number of students served

946-1,259

924-1,072

Number of buildings served

Age
Salary

Findings
Response to this 2015 assessment was
larger than previous years. Qualtrics
collected over 9,000 total responses.
After incomplete responses were
removed from the data set and the
remaining responses checked for
duplicates, 8,006 responses remained.
This was substantially more respondents
than the 2013 NASN school nurse survey
(6,841 respondents) and the 2011 survey
(3,138 respondents). The larger number
of responses is probably a result of
expanding the survey to members and
non-members of the organization,
decreasing the size of the survey, and
increasing collaboration with local
affiliate and state school nursing leaders.

330NASN School Nurse|November 2015

Respondent Demographics
Although a few demographics such as
the age and experience of school nurse
respondents increased, the overall school
nursing demographics remained about
the same. See Table 2 to view average
demographics for 2015 compared to the
2013 results. Similar to the 2013 survey,
respondents of the 2015 survey
represented all 50 states, the District of
Columbia, several U.S. territories, as well
as overseas schools.
The percentage of respondents who
were NASN members was almost the
same in the two surveys, although there
were a smaller percentage of

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respondents in 2015 who were active

members than in 2013. In 2015, 57.1% of
respondents were active members and
26.6% of respondents were nonmembers, as compared to 2013, when
65.6% of respondents were active
members and 30.5% were non-members.
One 2015 survey question asked who
paid for respondents membership, with
66.7% of members answering they
personally paid their dues (66.4% of
members personally paid their dues in
2013). In contrast, 29.1% of members
responded their employer paid for their
dues, which is about the same compared
to 2013 (27.9%).

The assessment asked about annual

full-time salary (with options given in
ranges). One change in the 2015 is the
options for salaries were in $5,000
increments instead of $10,000 increments
as in 2013. In 2015, members of NASN
(13.3%) were most likely to be paid
$50,000 to $54,999, and non-members
(14.6%) were most likely to be paid
$40,000 to $44,999. These numbers fall
within the range of likely salaries for
school nurses in 2013, when members of
NASN (45.7%) were most likely to be
paid $40,000 to $59,999, and nonmembers (47.7%) were most likely to be
paid $30,000 to $49,999. Table 3 provides
additional comparisons of salary.
Another important question was the
average age of school nurses. As in
years past, the average was over 55
years old, which means many may
retire in the next 10 years (Maughan &
Mangena, 2014). Two years ago in 2013,
over half of the respondents (58.4%)
indicated they were 51 years of age. In
2015, the percentage increased to 59.7%
with a slightly smaller percentage
(67.2%) of respondents aged 41 to 60
years old as compared to 2013 (70.5%).
By contrast, only 15.8% of respondents
to both the 2015 and 2013 surveys were
under the age of 40. Figure 1 further
breaks down the ages of school nurses
in 2015.
Education, Licensing, and
Certification. Questions regarding
education, licensing, and certifications of
school nurses were asked in both 2013 and
2015. Nearly half (45.3%) of respondents to
this survey had a bachelors degree (BS) in
nursing, 15.1% of respondents had an
associates degree (AD) in nursing, and
11.5% of respondents had a masters
degree (MS/MSN) in nursing. These results
were very similar to those of the 2013
NASN Membership Survey; the percentage
of respondents with a BS in nursing was
44.4%, the percentage of respondents with
an AD in nursing was 15.1%, and the
percentage of respondents with an MS/
MSN in nursing was 10.9%. The percentage
of certified nurses increased slightly in
2015. In the 2015 survey, 22.7% of
respondents were nationally certified by

Table 3. Full-Time Salary, 2013 and 2015

Salary

2013

2015

$19,999-$39,999

27%

27%

$40,000-$59,999

42%

40%

$60,000-$79,999

16%

17%

$80,000 or more

5%

6%

Note: Does not add up to 100% because some respondents were retired or only part-time.

Figure 1. Age Distribution, 2015

the National Board for the Certification of

School Nurses, compared to 20.9% in 2013.
Furthermore, only 55% of respondents to
this survey were state certified, as opposed
to 48.5% of respondents with state
certification in 2013.

25.1% who worked in an urban area.

These are similar to respondents of the
2013 survey where (49.7%) worked in a
suburban area, followed by 30.8% who
worked in a rural area and 23.9% who
worked in an urban area.

Work Setting. Other questions asked

about employer, funding, grade level
school nurses served (see Table 4), and a
description of the population. The
majority of respondents (83%) work for
public school districts (Table 5), with
90% of respondents indicating funding
for their position came from public
education (73.4%) and special education
(16.6%) funding. Respondents to the
2015 survey were most likely (50.9%) to
work in a suburban area, followed by
30.6% who worked in a rural area and

Models of Practice and Workload.The

organizational structure of school nursing
differs throughout the country, as do the
work settings. Only 36.2% of respondents
indicated their immediate supervisor is a
registered nurse. Half (50.7%) of
respondents described their current
model of practice as RN who provides
direct care to students on a daily basis
(one nurse in one building). This model
of practice has not changed drastically
since 2013, although it is slightly less
than 2013 (see Figure 2 for comparison).

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November 2015 | NASN School Nurse

331

Table 4. Populations School Nurses Serve, 2013 and 2015

Figure 3. Buildings Covered,

(Percentage of Respondents)

2015

Population

2013

2015

Head Start/pre-k/nursery

27

27

Elementary

67

65

Middle/junior high

44

43

High school

37

39

Special education

42

43

Alternative, charter, magnet

Private/parochial/boarding school

Other/none

Table 5. Primary Employer, 2013 and 2015 (Percentage of

Respondents)
Primary Employer

2013

2015

Public school district

84

83

Private/parochial/boarding school

Public health department

Hospital/HMO/health system

<1

Retired
Other

Figure 2. School Nurse Models of Practice, 2013 and 2015

Respondents were most likely to work in

one building (51.3%) with 251 to 500
students (21.7%), although the average of
responses indicated an average of three
buildings and with an average of 924 to
1,072 students (Figure 3).
Regional Differences. Responses from
different regions of the country (see
Table 6) indicate that many
demographics and educational requests
were similar across country. Two notable
variations are the differences of school
nurses living in the western United States
who have, on the average, a higher
number of students in their workload.
Also, the western region and eastern
regions had a slightly higher average
salary than the middle of the country.
Specific Roles of School Nurses
Reimbursement and Direct Services.The
vast majority of respondents to both
surveys (2013 and 2015) indicated that
they provide direct health services to
students (98.2% in 2013, 96.8% in 2015).
As budgets tighten and new
reimbursement models arise, respondents
were asked whether they or their
employers billed for Medicaid
reimbursement and how the reimbursed
funds were used. Little change occurred

332NASN School Nurse|November 2015

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Table 6. Regional Differences, 2015

Salary

Regions 1, 2, 3
n = 2,835

Regions 4, 6
n = 1,495

Regions 5, 7
n = 1,527

Regions 8, 9, 10
n = 1,436

$51,681-$56,606

$40,779-$45,652

$45,844-$50,707

$48,919-$53,763

588-849

942-1,244

945-1,253

1,351-1,685

48-56

46-54

46-54

47-55

Number of students per nurse

Age (years)

Regional Differences, 2015 (refer to Table 1 for listing of regions).

between 2013 and 2015, with 57.6% of

respondents in 2015 indicating they or
their employers billed for Medicaid
reimbursement, compared to 59% in
2013. Among those nurses who indicated
they or their employer did bill for
Medicaid, most (67.7% in 2015; 62.9% in
2013) noted that they were not sure how
the reimbursed money was used. There
was a decline in the percentage who
indicated the reimbursed money was
specifically used for school nursing (5.8%
respondents in 2015 compared to10.3%
in 2013).
Assistance in Enrollment in Health Care
Programs. School nurses assist students
and parents with health insurance
enrollment and obtaining access to
health care providers. A smaller
percentage of 2015 respondents (33.1%)
had assisted a student or parent with
enrollment in Medicaid or a state health
insurance program than the 2013
respondents (45.6%). Most respondents
in both surveys, although a smaller
percentage in 2015 (76.1% in 2013, 69.4%
in 2015), had helped a student or parent
gain access to free or low-cost health
care, such as a school-based health
center or a federally qualified health
center. Roughly half of respondents in
both surveys also indicated that they
connected a student or parent to a local
health care provider that would accept
the students health insurance (50% in
2013, 47.8% in 2015).
Collaboration and Advocacy.School
nurses often partner with community
organizations outside of the school to
meet the needs of students and their
families. Nearly three-fourths (73.0%) of

respondents had partnered with a health

department within the past 2 school
years, and 41.2% had partnered with a
community clinic. Half of the
respondents (50.2%) had partnered
during the past 2 school years with a
Lions Club, who often provide assistance
with vision needs. The Lions Club was
the organization most recognized (under
other at 1.9%) as another funder of
NASN membership dues.
An important aspect of school nursing
is advocating for student health within
schools and with key decision makers.
Nearly three-fourths (72.1%) of
respondents indicated they engaged in
advocacy by reporting data to local,
state, or national officials at least once a
year, and 36.7% of the respondents had
written letters to local, state, or national
decision makers.
Educational Needs
School nurses indicated, in both the
2013 and 2015 surveys, areas where they
would like to receive continuing
education and their preferences to how
they would like to receive the education.
In 2015, the list was divided into top skills
school nurses would like more education
about and topics where more knowledge
was needed. Table 7 outlines the 2015
survey respondents top six continuing
nursing education skills needs and
continuing education topic needs. The
topic needs identified in the 2015 survey
were similar to the continuing education
topic needs most commonly identified in
the 2013 survey, with assessment of
rashes, behavioral health, 504 care plans,
and legal issues identified as topic needs
in both surveys. Comparing answers by
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region showed no major differences in

skills or topics identified.
School nurses in 2015 preferred
one-day local offerings (89.7%) as the
type of educational program but
indicated self-pace self study worked
best with their schedule. . . . (69.2%).
One-day local offerings were also most
likely to be preferred by respondents to
the 2013 survey as a type of educational
offering, and respondents to the 2013
survey preferred self-paced web-based
educational programs as an educational
offering that worked with their schedule
and learning style as well.
NASN and Other Resources. NASN offers
its members a variety of benefits to assist
their school nursing practice. One of the
top reasons members joined NASN was
access to education programming
specific for school nurses. Respondents
to the 2015 survey identified the top
three benefits offered to NASN members
that were most valuable: access to the
practice-related issues in the NASN School
Nurse (57.4%), access to school nursing
research in The Journal of School Nursing
(38.8%), and professional/practice-related
news and informational emails (33.6%).
Limitations
Gender and race/ethnicity were not
asked on the 2015 survey because they
were asked on a survey regarding
medications that was administered a few
months later. As in the past, results
indicate the majority of school nurses are
female (98%) and White/Caucasian (95%)
(Maughan & McCarthy, 2015). These
demographic numbers are slightly higher
than in 2013. The lack of diversity in
school nursing is a continued concern
November 2015 | NASN School Nurse
333

Table 7. 2015 Educational Needs Identified by School Nurses, 2015

Top 6 Skills Needed

Top 6 Topics Needed

1.Health care plans development (504, IEPs, IHPs, emergency

plans) (45.5%)

1. Assessment of rashes, skin conditions (56.7%)

2.Infectious disease information (outbreak management, pertussis,

MRSA, herpes) (39.2%)

2. Behavioral health (ADHD, etc.) (36.9%)

3. Medically fragile skills (trach, catheters, tube feedings) (30.6%)

3.Role of school nurse in 504 process (advocate for

accommodations, etc.) (35.4%)

4. Physical assessment skills (30.0%)

4. Legal issues (35.2%)

5. Technology (iPads, tablets, apps) (28.2%)

5.Mental health (assessment and evidence-based management for

depression or other health conditions) (33.3%)

6. Decreasing absenteeism (26.4%)

6. Staff and student wellness (30.8%)

for NASN as the students school nurses

serve are increasingly diverse. National
efforts are in process to increase the
diversity of nursing to better reflect the
national demographics.

Discussion
Much of the results of the two surveys
were remarkably similar, particularly the
questions related to demographics of the
respondents. Although many answers
were similar, there were some notable
aberrations.
One difference was the decrease in
nurses who assisted a parent or student
with enrollment in Medicaid or access to
free or low-cost health care. The change
in school nurses involvement may be
explained by the efforts in 2013 related
to the Affordable Care Act to assist all
students and families to secure
insurance. Evidence indicates the
number of children who lack health
insurance is at an all-time low (7%)
(Rudowitz, Artiga, & Arguello, 2014).
School nurses are natural leaders in
linking students and families to the
health care and access they need.
Another significant decrease was the
number of school nurses who knew if
reimbursed Medicaid funds were used
directly for school health services.
Practicing school nurses are often not
involved in money allocations, which
may explain the decrease in the

334NASN School Nurse|November 2015

percentage of respondents who know

how these funds are used. School
administrators may not realize
reimbursed funds may assist them in
supporting additional school nursing
personnel, which in turn may allow for
additional Medicaid-eligible services to
be billed and additional funds for the
district (that could again provide
additional school nurses). With the
recent announcement from the U.S.
Department of Health and Human
Services Centers for Medicare & Medicaid
Services (2015) clarifying services
without charge (known as the free care
rule), many schools may now be able to
bill for services provided to children on
Medicaid that they were not able to in
the past. NASN is collaborating with
Medicaid directors and school nurse
administrators to assist them in
understanding the implications of the
free care rule change and Medicaid
reimbursement in general. Over half of
the respondents do receive reimbursed
funds from Medicaid, but nearly half do
not. Several services by school nurses
may be reimbursable from various
sources and NASN wants to facilitate this
message (NASN, 2013).
Regional Differences
This is the first year NASN has been
able to compare different regions of the
country regarding models of practice,

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salary, and students served. Although

many of the demographics and
educational needs were the same, two
distinct differences were found. The
results indicate that school nurses
working in the western part of the
United States oversee more students than
school nurses in the rest of the country.
In addition, the salaries of school nurses
in the eastern and western are slightly
higher than the middle and southern
states. Surprisingly, some of the
respondents (23.3%) indicated they
worked in just one school. This leads to
questions regarding the safety and needs
of students in schools where there is not
a nurse in every school and differences
in student health and academic outcomes
related to this model. NASN, in
partnership with the National Association
of State School Nurse Consultants,
through the Step Up and Be Counted
Initiative, are collecting the data needed
to inform how school nurses can best
assist students to have positive health
and academic outcomes (Patrick et al.,
2014). Although there were few
geographic differences, more analysis
and regional considerations will be
assessed to help meet the varying needs
of school nurses.
Looking Ahead
It was not a surprise about the slight
increase in the respondents age and

years of experience. As many in the

current school nurse workforce begin to
retire, it is critical for NASN and others to
see that their collective wisdom is not
lost. In addition, orientation materials
and standards of practice that reflect
current school health needs were
requested in the narrative option of the
survey.
NASN is developing online practice
modules that provide an overview for
the developing, proficient, and
exemplary nurse related to key school
nursing skills. The care coordination
module is scheduled to be released later
this year. NASN recently developed a
template to be used for individual health
plans and were informed from this
survey that additional materials and
trainings are needed to address this skill
and others. Conducting needs assessment
and obtaining feedback from school
nurses across the country is important so
materials are relevant, timely, and
provide the support school nurses need
to help students be healthy, safe, and
ready to learn.

References
Maughan, E. D., & Mangena, A. S. (2014).
The 2013 NASN School Nurse Survey:
Advancing school nursing practice. NASN
School Nurse, 29(2), 76-83. doi:10.1177/19426
02X14523135
Maughan, E. D., & McCarthy, A. M. (2015).
Medication administration in the schools:
The good, the bad, the safety. Breakout
session at 2015 National Association of
School Nurses Annual Conference,
Philadelphia, PA.
NASN. (2013). Reimbursement for school nursing
healthcare services (position statement). Silver
Spring, MD: NASN.
Patrick, K., Mendonca, L. L., Maughan, E. D.,
Wolfe, L. C., Bergren, M. D., Johnson, K. H.,
. . . Cole, M. (2014). National standardized
data set for school health services: Step Up
and Be Counted! NASN School Nurse, 29(5),
236-240. doi:10.1177/1942602X14544448
Rudowitz, R., Artiga, S., & Arguello, R.
(2014).Childrens health coverage: Medicaid,
CHIP and the ACA. Retrieved from http://
kff.org/health-reform/issue-brief/childrenshealth-coverage-medicaid-chip-and-the-aca/
U.S. Department of Health and Human Services
Health Resources and Services Administration.
(n.d.). Office of regional operations.

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Retrieved from http://www.hrsa.gov/about/

organization/bureaus/oro/
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services.
(2015). Re: Medicaid payment for services
provided without charge (free care) (SMD#
14-006). Retrieved from http://www.medicaid
.gov/federal-policy-guidance/downloads/
smd-medicaid-payment-for-services-providedwithout-charge-free-care.pdf

Anantha Sameera Mangena, BGS, JD(c)

Intern
NASN
Silver Spring, MD
Anantha is currently attending law
school. She worked on this project
as an intern for NASN.
Erin Maughan, PhD, MS, RN, APHN-BC
Director of Research
NASN
Silver Spring, MD
Erin serves as the director of
research and oversees the annual
school nurse survey and other data
collection projects.

November 2015 | NASN School Nurse

335