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H.R. 1857 (113th): Student-to-School Nurse Ratio Improvement Act of 2013

The text of the bill below is as of May 7, 2013 (Introduced). The bill was not enacted into law.



1st Session

H. R. 1857


May 7, 2013

introduced the following bill; which was referred to the Committee on Education and the Workforce, and in addition to the Committee on Energy and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned


To make demonstration grants to eligible local educational agencies for the purpose of reducing the student-to-school nurse ratio in public elementary schools and secondary schools.


Short title

This Act may be cited as the Student-to-School Nurse Ratio Improvement Act of 2013 .



The Congress finds the following:


The American Academy of Pediatrics emphasizes the crucial role of school nurses in the seamless provision of comprehensive health services to children and youth, as well as in the development of a coordinated school health program.


The school nurse functions as a leader and the coordinator of the school health services team, facilitating access to a medical home for each child and supporting academic achievement.


School nurses promote wellness and disease prevention to improve health outcomes for our Nation’s children. In addition, school nurses perform early intervention services such as periodic assessments for vision, hearing, and dental problems, in an effort to remove barriers to learning.


Recent national data indicates 45 percent of public schools have a school nurse all day, every day, while another 30 percent of schools have a school nurse who works part time in one or more schools.


The American Nurses Association has reported that when there is no registered nurse on the school premises, the responsibility to administer the necessary medications and treatments, and appropriate monitoring of the children falls on the shoulders of administrators, educators, and staff who are ill-prepared to perform these tasks.


Statistics from the National Center for Educational Statistics indicate that of the 52,000,000 students who currently spend their day in schools, 15 to 18 percent of children and adolescents have a chronic health condition.


A recent study indicated that from 2002 to 2008, the percentage of children in special education with health impairments, due to chronic or acute health problems, increased 60 percent. School nurses use their specialized knowledge, assessment skills, and judgment to manage children’s increasingly complex medical conditions and chronic health illnesses.


Among adolescents aged 12 to 19 years old, the prevalence of pre-diabetes and diabetes increased from 9 percent to 23 percent between 1999 and 2008. More than 30 percent of children aged 2 to 19 years old are obese or overweight (>85th percentile). In 2008, more than 10 million children in the United States had asthma. The prevalence of food allergies among children under the age of 18 increased 19 percent from 1997 to 2007.


According to the American Academy of Pediatrics, students today face increased social and emotional issues, which enhance the need for preventive services and interventions for acute and chronic health issues. School nurses are actively engaged members of school-based mental health teams and spend nearly 32 percent of their time providing mental health services, including universal and targeted interventions, screenings to identify early warning signs and referrals to medical providers, and crisis planning.


In 2011, the Bureau of the Census reported 9.7 percent of children under the age of 19, which equals 7.6 million children under the age of 19, were without health insurance. Data shows that uninsured children achieve lower educational outcomes than those with health coverage. Children who cannot afford to see a medical provider miss more days of school, experience increased severity of illness, and suffer from disparities in health.


More than 1.6 million children experience homelessness each year in the United States. Homeless children develop increased rates of acute and chronic health conditions, and the stress of their living situation can negatively affect their development and ability to learn. As a result, schools have become the primary access to health care for many children and adolescents. School nurses serve on the frontlines as a safety net for the Nation’s most vulnerable children.


Communicable and infectious diseases account for millions of school days lost each year. Data illustrate that when students have access to a registered nurse in school, immunization rates increase.


A 2011 study showed that a school nurse in the building saves principals, teachers, and clerical staff a considerable amount of time that they would have spent addressing health concerns of students, including saving principals almost an hour a day; saving teachers almost 20 minutes a day; and saving clerical staff more than 45 minutes a day. This would amount to a savings of about 13 hours per day in the aggregate for such school personnel.


Using a formula-based approach, taking into consideration the overall health acuity of the student body and the workload of school nurses, for determining a balanced student-to-school nurse ratio offers a reasonable means for achieving better student outcomes.


Reducing student-to-school nurse ratios


Demonstration grants


In general

The Secretary of Education, in consultation with the Secretary of Health and Human Services and the Director of the Centers for Disease Control and Prevention, may make demonstration grants to eligible local educational agencies for the purpose of reducing the student-to-school nurse ratio in public elementary schools and secondary schools.



To receive a grant under this section, an eligible local educational agency shall submit to the Secretary of Education an application at such time, in such manner, and containing such information as the Secretary may require, which shall include information with respect to the current ratios of students-to-school nurses, student health acuity levels, and workloads of school nurses in each of the public elementary schools and secondary schools served by the agency.



In awarding grants under this section, the Secretary of Education shall give priority to applications submitted by high-need local educational agencies that demonstrate the greatest need for new or additional nursing services among students in the public elementary secondary and secondary schools served by the agency.


Matching funds

The Secretary of Education may require recipients of grants under this section to provide matching funds from non-Federal sources, and shall permit the recipients to match funds in whole or in part with in-kind contributions.



Not later than 24 months after the date on which a grant is first made to a local educational agency under this section, the Secretary of Education shall submit to the Congress a report on the results of the demonstration grant program carried out under this section, including an evaluation—


of the effectiveness of the program in reducing the student-to-school nurse ratios described in subsection (a)(1); and


of the impact of any resulting enhanced health of students on learning, such as academic achievement, attendance, and classroom time.



For purposes of this section:


ESEA terms

The terms elementary school, local educational agency, poverty line, and secondary school have the meanings given to those terms in section 9101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 7801).



The term acuity, when used with respect to a level, means the level of a patient’s sickness, such as a chronic condition, which influences the need for nursing care.



The term workload, when used with respect to a nurse, means the amount of time the nurse takes to provide care and complete the other tasks for which the nurse may be responsible.


Eligible local educational agency

The term eligible local educational agency means a local educational agency in which the student-to-school nurse ratio in each public elementary and secondary school served by the agency is 750 or more students to 1 school nurse.


High-need local educational agency

The term high-need local educational agency means a local educational agency—


that serves not fewer than 10,000 children from families with incomes below the poverty line; or


for which not less than 20 percent of the children served by the agency are from families with incomes below the poverty line.



The term nurse means a licensed nurse, as defined under State law.


Authorization of appropriations

There are authorized to be appropriated such sums as may be necessary to carry out this section for each of the fiscal years 2014 through 2018.