A School Nurse Ratio Can Be a Floor, a Ceiling, or Nothing at All

School Nurse Rules is a three-part Nurse.org analysis of the laws governing school nursing in all 50 states and the District of Columbia. It grew out of Jana Price’s investigation into the firing of a Pennsylvania school nurse who refused an assignment she believed fell outside her license.

Pennsylvania has one of the few enforceable school nurse staffing limits in the country. State law says the number of pupils under the care of each school nurse “shall not exceed one thousand five hundred,” a hard ceiling the statute records as last amended in 1965.

Moriah Benjamin was still expected to cover two buildings alone. The cap governs how many students one nurse is responsible for. It says nothing about how many buildings she is covering, or whether a supervising nurse is in any of them. That gap between a number and what it actually requires runs through nearly every school nurse ratio in the country, and it is why “one nurse per X students” tells you far less than it appears to.

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Pennsylvania and Louisiana Both Use 1:1,500. One Is a Limit on Students, the Other on Nurses.

Pennsylvania’s Public School Code provides that “every child of school age shall be provided with school nurse services,” then adds the limit: the number of pupils under the care of each school nurse “shall not exceed one thousand five hundred.” It is a ceiling on caseload. Go above it and the district is out of compliance.

Louisiana law uses the same number in a single sentence that runs the other way. Each city and parish school system “shall employ at least one school nurse certified by the State Board of Elementary and Secondary Education but shall not exceed a statewide average of one certified school nurse for each one thousand five hundred students.”

Two things are happening in that sentence, and they pull against each other. The first half sets a floor: every system must employ at least one certified school nurse. The second half sets a ceiling, and it is worth reading slowly, because it runs opposite to the way these numbers usually work. What may not be exceeded is a ratio of nurses to students. Going over the line means employing more nurses, not fewer. The state will not support better than one certified nurse for every 1,500 students.

The ceiling is written as a statewide average, which matters. It does not bind any individual district. A parish could staff at one nurse per 800 students, which is well above the line, so long as thinner staffing elsewhere keeps the statewide average within it. What the provision constrains is the total number of state-supported positions, not what any one district does.

So Pennsylvania caps how many students a nurse may be responsible for. Louisiana caps how many nurses the state will pay for, measured across the whole state. One is a workload protection for the nurse. The other is a budget limit. Louisiana’s has stood unamended since 1995.

Anyone comparing the two on a chart of “1:1,500” would conclude they have the same policy.

We reviewed the staffing provisions in all 50 states and the District of Columbia. “One nurse per X students” turned out to do at least fourteen different legal jobs. The categories below are ours, not any state’s, and some of them overlap. Two are not really ratios at all. But the differences between them are not small: some are enforceable, some cap spending rather than workload, and one can be satisfied without hiring a nurse.

Source: Nurse.org, School Nurse Rules, a review of school nurse staffing provisions in all 50 states and the District of Columbia.

Several of the figures we reviewed are decades old. Pennsylvania’s statute records its last amendment in 1965 and Louisiana’s in 1995, and Virginia’s target was written for a phase-in that was meant to finish in 1999.

Two states carry two of these at once, doing different legal work. Tennessee’s 1:3,000 sets how many nurses the state will fund, while its 1:750 only decides when a district has to file a report. Oregon requires a nurse for each nursing-dependent student, and separately encourages 1:750 across the wider student body.

Here is what nearly all of these have in common, and it is the thing that mattered in Millville.

A caseload cap counts students. It does not count buildings. A nurse responsible for 1,400 students across three schools is inside Pennsylvania’s limit. So is a nurse responsible for 1,400 students in one school. The law treats those situations identically.

Only two jurisdictions in our review clearly attach a staffing requirement to a building at all, and one of those comes with a caveat. Delaware requires a school nurse for each public school facility, though the duty is written as a funding backstop rather than a flat obligation. DC assigns a registered nurse to each school for those twenty hours a week. Everywhere else, the number floats free of the floor plan.

Pennsylvania sits awkwardly between the two. Its caseload cap counts students, but a separate health regulation says a child “shall be provided with school nurse services in the school which the child attends,” and state guidance tells districts that a supplemental LPN brought in to assist a certified school nurse “may not be assigned a student case load” of her own. Those provisions point toward the building. The number does not, and the number is what gets quoted.

Guidance issued by the state’s Division of School Health in 2019 told districts there is no set number of hours a certified school nurse must be physically present in her assigned buildings, only that she rotate through them regularly.

Federal survey data shows how common that arrangement is. In the Education Department’s National Teacher and Principal Survey, 60.2 percent of public schools reported a full-time nurse and 24.0 percent reported only a part-time one. In thirteen states, a larger share of schools reported a part-time nurse than a full-time one. The gap was widest in Utah, where 16.7 percent of schools reported a full-time nurse and 58.6 percent reported part-time. A part-time school nurse is usually a nurse whose week is split between buildings, which is the arrangement a caseload cap does not describe.

Pennsylvania’s own numbers show what that produces. In its 2022 School Health Update, the state health department counted 2,224 certified school nurses across 3,897 school buildings. Fewer certified nurses than buildings, in a state with an enforceable caseload limit. Both facts are true at once, because they measure different things.

There is a practical problem underneath all of this, and it is the reason the numbers matter beyond a legal survey.

Almost every measure we looked at points the same way: schools need more nurses than they have. In Pennsylvania, as noted above, there are fewer certified school nurses than school buildings. New Mexico’s health department reported that in 2023-24 more than a quarter of districts had no school nurse at all and a third had only one. North Carolina’s legislative program evaluation division examined the state’s own 1:750 goal and found it had never been met.

The same federal survey found that 18.1 percent of public schools had no nurse at all, full-time or part-time. These figures come from the 2020-21 school year, so pandemic staffing may have affected them, and NCES has not yet published a comparable state-level table for a later year.

Writing a better ratio into law does not create the nurse to fill it. Someone has to want the job, and school nursing competes for the same licensed people as every other setting.

That competition is not close. As the second part of this series found, licensed practical nurses in elementary and secondary schools earn a median of $25.93 an hour, the lowest of any setting we examined and about $5 below the national median for LPNs. Skilled nursing facilities pay nearly $8 more. In half the states we reviewed, we found nothing in the law saying whether a school nurse is professional staff or support staff, which is usually what decides paid leave, health coverage and whether the job runs ten months or twelve.

So the shortage and the ratio problem are the same problem seen from two ends. A state can write 1:750 into its code and never get near it. The ratio describes what the state wants. The pay, the benefits and the prospect of being the only nurse in two buildings describe what the job is actually like. A nurse deciding where to work is looking at the second one.

The reason this matters is practical. A nurse comparing job offers in two states, or a parent asking whether their district is adequately staffed, will find a ratio and reasonably assume it means something consistent.

It does not. Before a ratio tells you anything, you need to know four things about it: whether it is mandatory or aspirational, whether it counts students or hours or something else, which students it counts, and whether it says anything at all about where the nurse has to be.

Most of the time, the answer to that last question is no. That is the gap Moriah Benjamin was in the night she sent her text.

Pennsylvania is one of the few states with an enforceable limit on the books, and the statute records no change to it since 1965. But the limit counts students, and the question she was facing was about buildings. Her state’s ratio simply did not address it.

So she went by her license instead. In Pennsylvania a licensed practical nurse cannot practice on her own. She works under the direction of a registered nurse or another authorized provider, and a 2022 state guidance memo tells districts that a supplemental LPN “may not be assigned a student case load.” The district’s certified school nurse was out that day, and Benjamin was not aware of any supervising nurse being arranged in her place. She believed that covering two buildings under those conditions would make her the nurse in charge rather than the nurse assisting, which is not what her license allows. At 10:23 that night she texted her supervisor and said so.

The ratio in her state had nothing to say about that. Almost none of them do.

Related Reading

The investigation this analysis grew out of

School Nurse Rules

More on school nursing

🤔Does your state have a school nurse ratio, and does anything about your actual workload reflect it? Tell us in the comments below.

About This Analysis

School Nurse Rules is a Nurse.org review of the rules governing school nursing in all 50 states and the District of Columbia, covering who is permitted to serve as a school nurse, whether districts are required to provide nursing services at all, staffing ratios, credentials and pay.

In a small number of states, a current statute and the agency guidance describing it point in different directions, or we could not confirm that a provision remains in force. Where that happened we have said so rather than choosing between the two, and any provision we could not verify as current is left out.

The Division of School Health statement on certified school nurse presence is drawn from the Pennsylvania Department of Health’s December 2019 School Health Update, reproduced by the Pennsylvania Association of Pupil Services Administrators. The Pennsylvania Department of Education guidance quoted here was distributed to local education agencies by Penn*Link on August 30, 2022 and is reproduced in full by the Pennsylvania Association of Pupil Services Administrators. The per-school service provision appears at 28 Pa. Code § 23.51.

Benjamin’s text message comes from Jana Price’s investigation of the Millville hearing.

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