Impact Lives

Does One Size Fit All? State Mandated Nurse: Patient Ratios

If you ask any woman, that would be a flat “NO”. But seriously, there is no question that our current health care system is experiencing a gap between patient needs and nursing’s ability to meet those needs. Hence, the hubbub around state mandated nurse-patient ratios. The issue resurfaced when California rolled out their final phase of the legislation’s mandated minimum ratio in 2008 and continues to be a hot topic over the past decade.

However, California’s legislation only emphasizes nurse staffing needs in hospital-based settings. And though we understand the emphasis for specific ratios in hospital settings, what about setting nurse-patient ratios in other areas of nursing care? This past May, New York introduced H.R. 1857, the “Student-to-School Nurse Ratio Improvement Act of 2013.”1 This bill aims to reduce the student to school nurse ratio in public elementary and secondary schools.1 According to a 2007 study conducted by the National Association of School Nurses (NASN), the all school average ratio currently stands at 1:11512 while California’s mandate suggests 1:5 on general medical-surgical floors.3 I know this is not a true scientific comparison however it is still an eye opener.

I raise the issue of student-school nurse ratios because we are continually reminded that school achievement can be seriously impacted by both the child’s ability to manage a chronic physical or emotional health problem and the care and coordination of a registered nurse 4.98% of school children spend their day at school and of those, 16% of them have chronic physical, emotional or other health problems.2 If that is not frightening enough, there has been an increase by 60% of children in special education with health impairments due to chronic or acute health problems, along with a 40% increase in asthma in the past ten years, and 60% increase in incidence of diabetes.2 Are children expected to manage these chronic health conditions on their own during the school day? The answer appears to be yes according to one study where on average only 30% of schools has a school nurse who works part time in one or more schools.4 In addition, students were two times more likely to leave school early that did not have a registered nurse on campus.4 Why? Who is administering medications and treatments and monitoring these students when the school nurse is not present? Most likely these tasks fall on the shoulders of administrators, educators and unlicensed personnel who are not prepared to perform these tasks.2 This should not be an acceptable substitution. School nurses are needed to perform the necessary assessment and intervention skills to keep students in classrooms so that they can learn.2What I am trying to demonstrate here is that there is a significant gap. Not for lack of trying but it is unlikely that a school nurse with a ratio of 1:1151 could effectively meet the chronic and acute health needs of students while working part time in several schools.

A bill like H.R. 1857 is a great start, but we should be careful not to convince ourselves that it will independently solve all our problems in the school setting. The bottom line is that one size does not fit all. It will take more than just this bill for nurses to maintain the health and safety of children in schools. The NASN suggests a mandated state-wide maximum caseload with funding, such as nursing coverage based on student acuity. But I believe the proposed solution can only be successful depending on the persons involved, their accountability and flexibility. Direct care nurse’s involvement in determining a workable and effective staffing system is essential and should not be overlooked because they have the inside knowledge and perception necessary to know how changes would affect current practice. And this is where a MSN degree coupled with current school nursing experience would be quite valuable.

Benedictine University’s Advanced Knowledge of Health Care Systems course emphasizes the unique needs of health care settings and focuses on the operational and financial aspects of these healthcare systems. The Financial Management and Resource Allocation in Health Care Systems course also explore issues with funding sources and constraints, reimbursement and cost containment. These are all important aspects to focus on when dealing with staffing issues and patient acuity.


H.R. 1857--113th Congress: Student-to-School Nurse Ratio Improvement Act of 2013. (2013). Accessed May 16, 2013.

2 National Association of School Nurses. “School Nursing in the United States: A quantitative study”. (2007). Accessed May 16, 2013.

Furillo, J. and McEwen, D. “State-Mandated Nurse Staffing Levels Alleviate Workloads, Leading to Lower Patient Mortality and Higher Nurse Satisfaction.” Accessed May 16, 2013.

DuRant, B., Gibbons, L., Poole, C., Suessmann, M., &Wyckoff, L. “Caseload Assignments” Accessed May 16, 2013. ew/tabid/462/ArticleId/7/Caseload-Assignments-Revised-2010

About the Author

Dr. Jasmin Whitfield RN, MSN, MPH, DNP is an adjunct faculty member in the online MSN program at Benedictine University. Her extensive background includes progressive administrative roles in acute rehabilitation services and community health nursing. In addition, Dr. Whitfield is currently accountable for the oversight and organization of the Health Services Department at Sidwell Friends School’s D.C. campus including but not limited to health and wellness promotion and outreach and developing and managing occupational health and safety education, policies, and programming for students and employees. To learn more about Dr. Jasmin Whitfield please visit our online nursing degree faculty section.