Health Services Staffing

Editor's note: This article has been updated to reflect the 2020 National Association of School Nurses (NASN) staffing guidance.

School districts are required to provide a coordinated school health program for students, but a registered nurse (RN) is not required on each campus.

Many districts ask TASB HR Services if they can hire licensed vocational nurses (LVNs) in lieu of RNs. The general recommendation is to staff at least one RN to oversee the comprehensive student health program and provide supervision to district LVNs and any other unlicensed staff assigned health-related services.

Differences Between an RN and an LVN

The Texas Board of Nursing (BON) regulates the nursing profession and issues licenses, and the Texas Nursing Practice Act (NPA) defines the scope of practice for RNs and LVNs.

An RN must hold an RN licensure and have a diploma in nursing, an associate’s degree in nursing (ASN), or a bachelor’s degree in nursing (BSN). An LVN must complete an accredited vocational nursing program by an educational unit or through a hospital and hold an LVN licensure.

Services provided by an RN require substantial specialized judgment and skill based on knowledge and application of specified coursework. An RN is equipped with skills essential to nursing in a school setting.

In Texas, an LVN must be supervised by an RN, physician, physician assistant, podiatrist, or dentist (Tex Occ. Code § 301.353). Supervision is defined as the process of directing, guiding, and influencing the outcome of an individual’s performance of activity according to 22 Texas Administrative Code (TAC) § 217.11(2)). Direct or on-site supervision is not required, although it must be timely and readily available.

Aspects of care and activities may be assigned to an LVN and an LVN may provide health services to students as long as an appropriate health care professional monitors, coordinates, and evaluates the provision of health services required to meet student needs essential to learning.

Neither an RN or LVN scope of practice includes the act of medical diagnosis or the prescription of therapeutic or corrective measures. An RN may conduct a comprehensive assessment and use data collected to create a nursing plan of care. In contrast, an LVN may conduct a focused assessment of an individual and information collected may be used by an RN to create a nursing plan of care. An LVN may implement a plan of care and give input into its development but may not create the plan.

An RN may delegate emergency administration of medications or treatment to unlicensed personnel. This may include epi-pens, glucagon, diastat, oxygen, metered dose inhalers or nebulizer treatments for relief of acute respiratory symptoms, and the use of a hand-held magnet to activate a vagus nerve stimulator to prevent or control seizure activity. An RN should verify the unlicensed person’s training, competency to dispense medicine safely, and adequate supervision of the process. 

A synopsis of differences in scope of practice for licensed vocational, associate, diploma, and baccalaureate degree nurses is available from the Texas Board of Nursing.

Contracts and Pay

A school district is required to provide a nurse with a Chapter 21 contract. This is the only non-certified position that requires a Chapter 21 contract. Texas law is unclear regarding whether only RNs are entitled to Chapter 21 contracts or whether the term "nurse" in Chapter 21 also includes LVNs. TASB Legal Services recommends that the district consult with its school attorney when deciding whether to place an LVN who performs full-time health-care and nursing services on a Chapter 21 contract.

RNs must be paid at least the minimum salary schedule (MSS) for their creditable years of experience. For purposes of the MSS, a school nurse is defined as “… an educator employed to provide full-time nursing and health care services and who meets all the requirements to practice as a registered nurse (RN) pursuant to the Nursing Practice Act and rules and regulations relating to professional nurse education, licensure, and practice and has been issued a license to practice professional nursing in Texas” (19 TAC § 153.1022 (a)(1)(D)). Therefore, LVNs are not subject to the MSS and are paid according to the district’s compensation plan.

However, if a district employs an RN in an LVN position, the employee must be paid as an RN. In 2000, the commissioner of education opined that all RNs who are on ISD payrolls and who perform full-time nursing services for their districts must be placed on the state’s minimum salary schedule even if their job descriptions only call for LVNs or nurse’s aides (Watkins v. Longview Indep. Sch. Dist., Tex. Comm’r of Educ. Decision No. 083-R10-2000 (Sept. 6, 2001)).

Staffing Ratios

There are no specific requirements for school nurse-to-student ratios. The National Association of School Nurses (NASN) recommends assessing student acuity and school community indicators to determine appropriate staffing levels.

Factors that should be considered include:

• Number of students
• Safety, medical acuity, and health needs of students
• Characteristics and considerations of the student population including social needs
• Characteristics and considerations of the school nurse and other clinic team members
• Context and culture of the school and school district that influence nursing service demands
• Overall costs, effectiveness, and resources

Currently, Texas school districts average one nurse for every 839 students.

Local Decisions

Ultimately, how a district provides safe, appropriate, and specialized health services to its students is a district decision. Districts choosing to staff a campus with an LVN or other unlicensed personnel must take care to arrange for supervision by an appropriate health care professional.

School Health Services—Nursing Practice Resources, including links to the Texas Board of Nursing and the Texas Nurse Practice Act, are available on the Texas Health and Human Services website.