School nurses serve as case managers, bringing together healthcare providers, families, and schools to support student health and well-being. Schools are the primary locations for addressing student health issues, while school nurses are the healthcare providers that students see regularly (Dolatowski et al., 2015). School nurse performance and consequent health outcomes in a school depend on several factors. The focuses is on nurse workload as a contingent factor determining healthcare outcomes and academic achievement among students. It includes the amount of time, competency, patient care demands, physical exertion, and the complexity of care provided for a given caseload – the number of patients assigned to an individual (Jameson et al., 2018). The policy change analysis hopes to reduce school nurse workloads to enhance their ability to promote and deliver quality care where necessary.

Read more: SAMPLE PAPER: Policy, Politics, and Global Health Trends

A1. Public Policy Issue

The proposal encompasses the policy introduction facilitating nursing assignments to every school building. The goal is to prevent overburdening school nurses with heavy workloads that might limit their ability to perform at optimal or give students the necessary attention they require based on their relative needs. The National Association of School Nurses recommends one school nurse to 750 students in the healthy student population; 1:225 for students requiring daily professional nursing services; 1:125 for students with complex healthcare needs; 1:1 for students needing daily, continuous professional nursing services (Dolatowski et al., 2015). The more school buildings an individual school nurse takes on, the higher the probability of exceeding these recommended thresholds. 

A1a. Issue Selection 

There is an apparent lack of school nursing staffing in my assigned school district. The result has been school nursing providers receiving assignments for more than one school building. For example, the School Nurses of Washington (SNOW) usually assigns me three school buildings, but with the COVID-19 pandemic, these assignments have increased to four. Based on experience, assignments to multiple school buildings increase the caseload, and consequent workload responsibility, requiring school nurses to put in extra effort to achieve the same efficiency in delivering care to students. However, given that multiple assignments result in a higher nurse-to-student ratio, school nurses rarely have enough time to afford every student the attention they need to address their health issues sufficiently. It may result in adverse student health and well-being, with spillover impacts on their academic achievements. Ensuring that each school building has a school nurse will ensure efficient healthcare delivery on a more manageable student population, relieving school nurses’ workload burden.

A1b. Issue Relevance

The policy change issue should be a critical consideration because it will help reduce daily workloads and promote easier case management for students while maintaining high competence and quality care standards. From the school nurse’s point of view, too much work – resulting from a high nurse-to-student ratio and increased responsibility – requires significant investment in time and effort, which may cause the nurse some stress. These ultimately lead to burnout, reduced performance standard, and the possibility of turnover. According to Farid et al. (2020), there is a close association between high workload and low staffing with nurse burnout and low patient care. It can also reinforce the staff shortage problem. Besides students receiving low-quality healthcare and well-being services, they also face the risk of lacking overall access. Dolatowski et al. (2015) note that inadequate staffing can lead to service delivery gaps, resulting from conflicting commitments, inconsistent care, and the inability to allocate resources, especially in emergency cases. Appropriate school nurse staffing, involving a high degree of specialization to the various school buildings and units, will help reduce burnout from working multiple buildings and increase access and availability, ultimately contributing to better care provision.

A1c. Financial Impact

Most school districts experience a lack of funding, which influences staffing. Therefore, schools have to manage what the government can provide, including sharing resources, such as school nurses. Therefore, the emphasis on adding extra personnel to service each school building will come at a cost. Based on Willgerodt & Brock (2016), most school nurses (76.7%) receive funding through education dollars. Hence, the additional expense will source out of the taxpayer’s pocket to cover the new deficit. Other funding sources include health departments and hospital systems. There is a possibility that the expense incurred may also extend towards parents paying tuition as schools try to share the new expense burden through the imposition of higher school fees. Nonetheless, it is a sound investment, especially in immunization, mental health service, and the treatment of chronic conditions. Implementing the policy will have the school district saving on cost, depending on whether cost considerations include medication costs, lost work production, hospitalization, and treatment. The amount of time spent dealing with health-related issues within schools lacking a school nurse and its impact on academic achievement contribute to the overall cost. Every dollar spent on school nursing services will translate to overall savings in cost. 

A2. Personal Values

Perhaps the most critical value is dedication, especially given the demanding nature of the job and the demographic receiving care. Students comprise human beings in their early development stages, requiring significant care and attention to optimize developmental and learning outcomes. It is a daily routine, requiring significant dedication, especially where cases require specialized attention or services. It is here that a degree of selflessness and integrity play a role, requiring that the healthcare provider always prioritize health outcomes irrespective of the underlying circumstances that the event occurs. The school nurse’s responsibility is to provide care where it is needed and to all who need it. The level of dedication put into my work in providing care has helped me realize that there are hurdles that we professionals need to overcome or find ways around to ensure that health is a priority, especially with conflicting responsibilities. Ultimately, we are accountable for the students within our care.

A2a. Ethical Principle or Theory

The principle underlying the above perspective is that of social justice. The principle of justice holds that there should be an element of fairness in distributing social burdens and benefits in all medical decisions. The principle also holds that practitioners should ensure equal distribution of scarce resources and treatment (Fowler, 2015). Finally, all laws and legislation apply when making choices. Thus, it would be prudent to adopt a model that emphasizes equal access to quality healthcare, noting the significant challenge in staffing as a resource worth developing. It will ensure that students receive the best care while noting individual needs, individual effort, and merit considerations in the process. The solution to having a school nurse for each building aligns with these objectives, ensuring that school nurses, as a resource, operate at optimum and adequately meet students’ specific needs within a given locale or school unit.

The Top-Down Approach to Policy Advocacy

The top-down approach refers to the process of higher-level officials reaching independent conclusions that change or improve on current policies in place. Top-down theories began with the assumption that policy implementation begins with a central government’s decision (Pülzl & Treib, 2017). 

B1. Decision Maker

The primary decision-making body is the school district board, responsible for making all the policy decisions. It comprises Harlan Gallinger (legislative representative; Director District 3), Marnie Maraldo (Board President; Director District 2), and three other directors: Sydne Mullings (District 4), Anne Moore (District 1), and Suzanne Weaver (District 5). Although these directors are responsible for making decisions regarding policy change or improvement, it is the district superintendent – Ron Thiele – that presents policy change briefs to the board. Rob faces multilayered accountabilities to the community, the staff, and the various agencies involved in healthcare provision, and as such, the individual responsible for receiving the policy brief. 

B1a. Explanation

The school board-superintendent relationship is a crucial element in the process of public policy implementation. There is a substantial amount of literature characterizing this relationship’s critical role in enhancing change efforts’ sustainability (Spain, 2016). The reason is that the two stakeholders form a symbiosis that leads to the formulation of a leadership framework that facilitates the adoption of new policies. The superintendent makes suggestions for change based on observations made within the school district and recommending these changes to the board. The school board then considers the support necessary, including supportive frameworks and resource allocation. Leadership is one of the principles underlying the National Association of School Nurses (NASN) framework for the 21st Century School Nursing Practice. Encompassed within this principle are issues related to advocacy for policy development and implementation, funding, reimbursement, healthcare, and education reform. In any case, the school district board is responsible for conducting budgeting processes. Rationally, the proposed policy change issue’s critical nature will determine the emphasis and priority placed on supporting its reform. It is the reason why attention from the school board-superintendent to the public policy change issue is vital. 

B2. Challenges

Elimination of school nursing jobs or reduction of nursing hours has frequently been the response to budget cuts. When faced with budget cuts or insufficient funding, health boards and school administrators will want to cut costs, sometimes considering school nurses as a “luxury” that schools cannot afford (Lineberry et al., 2018). Therefore, there is bound to be some disapproval for implementing the policy. It might have to constrict the budget for other competing priorities or an overall overhaul of budgets to redirect funds towards the new policy. Assigning a single school nurse to every building means more personnel and more funding to sustain them. Furthermore, sustaining the current skill and competence level will require training to ensure that the new personnel must fulfill the quotas inferred by the policy change – additional cost.

It raises the second challenge: the lack of skilled nurses to fill the new staffing roles. Increasing nurse staffing and decreasing the nurse-to-student ratios may prove challenging due to the national and state nursing shortages. According to a report by Haddad et al. (2020), the nursing profession continues to face shortages due to the lack of potential educators, high turnover, and inequitable workforce distribution. Also, nurse burnout is a critical determinant factor influencing turnover and nursing shortages. The shortage of labor undermines the policy solution’s practicality unless the various health agencies have a ready solution to equip schools with skilled and competent staff to meet students’ diverse and ranging needs within the different school contexts. 

Finally, there is the issue of adoption by both the respective schools and students. For schools, a dedicated school nurse will mean both structural and cultural change within the institution. Integrating the school nurse role and responsibilities within the general curriculum could result in varied reactions: acceptance, rejection, or coping. For example, in a situation where school administrators delegate school personnel the health and well-being responsibility, the new school staff role may interrupt or cause a reshuffle in school responsibilities for such personnel. Also, there is the inconvenience factor, especially for children. Children may find it hard to adjust to a new nurse professional, especially if the topics discussed are sensitive. Creating rapport takes time, and they may not appreciate the change. Both circumstances may lead to adoption challenges by lower-level staff who may find the change intrusive and students who may not feel comfortable with the new assignees.

B3. Options and interventions

The first is to use a multifactorial health assessment that includes the acuity and care considerations and social determinants of health to determine sufficient school nurse workloads (Dolatowski et al., 2015). Other social determinants of health that nurses are also responsible for aside from the caseload level, impacting nurse staffing. These include the health factor determinants (health conditions, prevalence, immunization), health behaviors, health conditions, disease prevalence, immunization levels; socioeconomic status, employment, education levels; housing status, food security, transportation access; support systems, access to health care and social services; environmental factors; and language or communication barriers. These factors will help establish the amount of care needed for a specific unit or population and the appropriate student nurse staffing ratios. A multifactorial health assessment will help enhance efficiency and reduce resource wastage, such as making assignments where school nurses’ demand is low.

The second intervention involves developing evidence-based tools to evaluate factors influencing student health and safety to help develop staffing and workload models that support this evidence (Dolatowski et al., 2015). Understanding a cause-effect relationship between the multifactorial health factors impacting a given school, region, or state can help decision-makers understand – in a quantitative way – the impact that a certain degree of student nurses will have on a particular student population exhibiting certain characteristics. Doing so will also help establish the principle of justice, which ideally means specialized services based on a given population’s unique characteristics. Quantitative measures can help determine the healthcare demand scope and impact the workload model or staffing solutions will have on a student population, depending on the metrics used for analysis. 

The school district can hire specialists to conduct benchmarks on various healthcare provision models used in other districts (if present) to determine the best-practice model based on optimal health and academic outcomes (Dolatowski et al., 2015). These models can either be registered nurse (RN) alone, school health teams led by a registered nurse, or RNs certified in school nursing’s specialty practice. Benchmarking acts as a learning process. The school district board and the superintendent can learn about present implementation successes or failures, and if the proposed policy change and extrapolated outcomes are feasible. If so, then deliberations can occur relative to those outcomes, enhancing the policy outcomes through informed decision-making from the benchmark-generated insights. Ideally, this intervention acts as a point of reference, which also saves on time and cost. 

Finally, there is also the option for participative involvement of critical stakeholders. It encompasses productive deliberations that involve school administrators and school nurses, whose insights help the decision-making process for policies that impact student health (Dolatowski et al., 2015). Nurse involvement adds to the quality of insights generated by evidence-based research and relevant benchmarks. Involving nurses in the policy-making or improvement process helps integrate personal and professional experience in the final solution. The outcome is thus relevant and practical since it bases the strategy on knowledge from individuals who have been in similar settings and can validate the relevance of a model or framework developed in response to the public policy issue proposal. Furthermore, school nurses’ participation and involvement help consider key concerns, making them feel that the school board and respective health agencies care about their welfare, including the impact that workload may have on them.

 B3. Course of Action

Given that each school district has unique tastes and preferences on what they would want for a health policy change and the approaches used to implement the policy, it would be prudent to use active participation as the ideal method for enacting policy change (or not). Aside from the fact that evidence-based research and benchmarks would serve as excellent starting points for deliberation, the information presented to the board will still be appropriate to the regions or institutions to which the study or analysis occurred. Also, a multifactorial value assessment would be valuable to a policy issue of this magnitude. However, it would take longer to complete, especially if there are different metrics used to quantify the variables for comparison. A straightforward and relatively cheaper approach or intervention would be to conduct participative involvement for front-line school nurses, who are more accustomed to the fieldwork involved in school nursing care. These individuals would serve as the basis from where the board can derive information regarding institutional cultures, the workload, the challenges faced by school nurses, and factor determinants facilitating the new policy’s success, including whether it is feasible or not. The participative process would generate more insightful and relatively stable information regarding the school district, making it possible to make appropriate plans and budgeting. It promotes greater integration and acceptance by new staff, as the deliberative process’s recommendations will be relatable and collectively agreed upon by critical stakeholders. 

B3. Success of the Policy Brief

There are two critical success factors used to monitor and analyze the success of the policy brief. The first is in the promotion of the proposed public policy by the school district board. The targeted aspects to evaluate include growing levels of interest, new opportunity creation for school nursing staff, and evaluating efficacy and practicality. Some of the indicators or expected outputs from this increased interest include the number of meetings and presentations requested by the board. The impact of comments is vital since it can help establish the direction in which the board sways and improve the public policy issue arguments to enhance the chance of approval. The other measure of success is evaluating whether the board requests or gains an interest in whether there are sufficient nurse practitioners from the relevant health agencies like SNOW to fill the forecasted vacancies. The aspects to evaluate include whether public officials and other relevant actors have commenced training, and if the training context relates to school nursing or general child care. Individual interviews and practitioner self-evaluations are tools that one can use to develop insights that gauge whether the efforts aim to fulfill the policy change issue’s requirements. 

The Top-Down Approach to Policy Advocacy

The bottom-up approach views local bureaucrat as the main actors in policy delivery and conceives implementation as a negotiation process within networks of implementers (Pülzl & Treib, 2017). Essentially, decision-making and process implementation originate from lower levels and proceed upwards.

C1. Identified Organization or Community

The organization expressing interest in school nurse staffing and the challenges associated with high nurse-to-student ratios is the School Nurses of Washington.

C1a. Summary of Expressed Interest 

The School Nurse Organization of Washington (SNOW) supports school nurses in delivering healthcare services designed to improve students’ health and academic success. The organization has been vocal in rallying for an increase in staffing assignments and reducing nurse-to-student ratios, which is why it is pro-delegation. The organization supports the registered nurse’s need to delegate to other health workers or unlicensed school personnel when they feel shorthanded. It believes that overburdening nurses through assignments can undermine their effectiveness, making the public policy issue a significant topic for the organization.

C2. Community-Based Participatory Research

The three applicable community-based participatory research (CDPR) principles are; building on resources within the community, long-term commitment by all partners, and co-learning and empowerment, as derived from Smith et al. (2015).

C2a. Approach and Collaboration 

Approaching SNOW to collaborate will be relatively easy since the organization already has a vested interest in the public policy issue and the membership advantage. As a SNOW member, with knowledge regarding the values, principles, and objectives it pursues, it will be relatively easier to approach top management at the organization, pitch the idea, and rally up support for carrying on with policy advocacy. A contingent factor influencing rendered support is whether the policy proposal aligns with its policy advocacy version to have each school building equipped with its school nurse. Also prudent is acknowledging SNOW’s input and association with the policy brief and consequent influence on policy implementation – if successful. An acknowledgment will go a long way to increase the company’s reputation and image for potential employees and institutions that would like to pursue future collaborations with the organization.

C2b. Goal Alignment 

SNOW’s goal is to work towards objectives that support school nurses in delivering optimal student care. One of the goals it advocates for is reducing the nurse-to-student ratio to reduce burnout, poor performance, and even turnover. The public policy issue focuses on this goal, evidently aligned with the organization’s vision for effective and efficient healthcare delivery in schools, emphasizing specialized care for the demographic present within each school building and equal access.

C2c. Action Steps

There are a total of four steps needed to achieve the public policy issue goal. The first is forming a research group responsible for obtaining information current and reliable information regarding nurse-to-student ratios in the state for analysis and presentation. The second step is to attend open forums with field specialists and the public to understand better the issue and the data drawn from research. Open forums allow for open dialogue and unbiased debate regarding the issue at hand, if and what can make it better. Also crucial in the current digital age is to scale social media, finding information, comments, reports, or any other information accessible referring to school nursing programs and the experience students have with them. These will help draw up raw data from multiple stakeholders. When combined with information derived from the open forums and research group, the insights can make for a decent proposal and goal formulation. Finally, making a presentation to SNOW’s management can help fine-tune the goal and policy proposal to align with the organization’s overall goal.

C2d. Roles and Responsibilities

Top Leadership/Managers. Top leadership or management support is crucial as they provide the capacity (e.g., resources, such as funding, teams, venues, and others) to explore the public policy issue, conduct briefings, and also any related deliberations.

Educator and Trainers: An educator will help understand the data derived from the research group and information derived from the field team. The educator understands operational principles in the nursing profession and how different factors impact outcomes. They will also be responsible for insight into developing capacity, especially due to the nursing practitioners’ shortage.

Field Expert. Field experts are vital in that they advise on how to retrieve information from the field. It includes whom to observe or interview, what kind of questions are necessary, how to conduct and record the responses, and the ethical principles one should abide by in fieldwork. 

Lobbyists. The need for lobbyist agencies or actors in the policy advocacy process is to provide the organization with information regarding any similar policy change attempt efforts from the past that could inform and strengthen the current policy change proposal’s weight and validity. 

C2e. Key Elements of Evaluation Plan 

From a building on resources perspective, leveraging the company’s resources, such s finances and employees, will come in handy when developing and validating the need for a  public policy change in nurse staffing. Co-learning and empowering will involve sharing information and insights between skilled personnel in the organization and myself to compose a compelling and presentable policy brief. Participative decision-making involving various stakeholders, especially in open forums with school nurses, will help develop a more sustainable policy solution that enhances beneficial outcomes for many. The more individuals the policy benefits, the more acceptable it becomes, which extrapolates to long-term sustainability.

C2f. Community/Organization Plan 

Evaluating the success of the organizational plan will involve assessment of various metrics, including a shift in social norms regarding nurse staffing, interest in the proposal, increasing alignment of the core issue with core societal values, increasing knowledge on the issue, and an increase in the number of partners supporting the issue.

Evaluate the Effectiveness of the Two Different Approaches

D1. Strengths of Each Approach

The top-down approach is cost-effective because it realizes a focused use of resources from the individual managed application. It also saves time since it reduces the number of deliberations needed to decide on a policy change course. It is also easier for the school district board to establish goal alignment since they do not have to consult many actors. On the other hand, the bottom-top approach involves team creation and in-depth knowledge generation, contributing to reliable and informed decision-making. It also enhances the reliability of the policy change outcomes. Another crucial aspect is the bottom-top approach to promote greater acceptance due to the morale and motivation derived from active participation in decision-making.

D2. Challenges of Each Approach

The top-bottom approach provides limited coverage during the early phases. Most of the lower-level personnel, such as the school nurses affected by the new policy, may not accept the outcomes of the new policy change or decision regarding policy change direction. It may also be more expensive if the chosen solution does not help solve the problem or issue raised. The bottom-up approach involves many actors and takes up a lot of time and effort considering the individual opinions and considerations each has to enhance the public policy change proposal’s value. A lack of consensus will derail policy development.

Most Effective Approach 

 The bottom-up approach would be the most effective. It allows registered nurses to participate and voice their concerns, providing first-hand accounts of why increasing staffing to reduce the nurse-to-student ratio is important to improving student health outcomes and academic performance. The approach is most effective because it allows for greater stakeholder involvement and enhances implementation and adoption success. The results are informed and preferred since they emanate from those whom the policy will impact the most.


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Farid, M., Purdy, N., & Neumann, W. P. (2020). Using system dynamics modelling to show the effect of nurse workload on nurses’ health and quality of care. Ergonomics63(8), 952-964.

Fowler, M. M. D. M. (2015). Guide to the code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Association.

Haddad, L. M., Annamaraju, P., & Toney-Butler, T. J. (2020). Nursing shortage. In StatPearls [Internet]. StatPearls Publishing.

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Lineberry, M., Whitney, E., & Noland, M. (2018). The role of school nurses, challenges, and reactions to delegation legislation: A qualitative approach. The Journal of School Nursing34(3), 222-231.

Pülzl, H., & Treib, O. (2017). Implementing public policy. In Handbook of public policy analysis (pp. 115-134). Routledge.

Smith, S. A., Whitehead, M. S., Sheats, J. Q., Ansa, B. E., Coughlin, S. S., & Blumenthal, D. S. (2015). Community-based participatory research principles for the African American community. Journal of the Georgia Public Health Association5(1), 52.

Spain, A. K. (2016). Situating school district resource decision making in policy context. American Journal of Education122(2), 171-197.

Willgerodt, M., & Brock, D. (2016). NASN school nurse workforce study. Seattle, WA: University of Washington.