Why school nurses are vital to ending the school-to-prison pipeline

As schools struggle to safely open and stay open during the COVID-19 pandemic, the vital role of school nurses has taken center stage. While school nurses are rarely in the limelight, they long have been on the front lines, promoting the health of school-age children and their communities. At the same time, the past year also brought new attention to the struggle for racial justice and new efforts to confront systemic racism — considered a public health crisis by the American Public Health Association. Here, too, school nurses have a crucial role to play in addressing a serious health equity issue affecting children and adolescents: the school-to-prison-pipeline.

The school-to-prison pipeline refers to zero-tolerance disciplinary approaches and exclusionary practices (such as suspension and expulsion) that put children, especially Black and Brown children and children with disabilities, at higher risk of institutionalization and incarceration. Not only are children with pre-existing disabilities or mental health issues more likely to get caught up in the school-to-prison pipeline, expulsion and subsequent criminal justice involvement have serious health impacts as well — mass incarceration has shortened U.S. life expectancy by five years. Exclusionary discipline also negatively affects the health and learning of other children at the school, even if they are not suspended or expelled. 

In a new article, my colleagues and I reviewed research about the physical and mental health consequences of the school-to-prison pipeline and identified ways that school nurses can intervene.

The foundations of school nursing are built upon public and community health. Pioneering school nurses in the early 1900s such as Lina Rogers and Charity Collins cared for students with non-contagious conditions in order to keep them in school, and helped protect other students and their communities from the spread of disease by making sure children with infectious illness were supported in their recovery at home. They identified issues such as hunger that can impede student success. Today, school nurses are critical to efforts to contain the spread of COVID-19. Systemic racism and the school-to-prison pipeline are also serious public and community health issues and should be treated as such.

Up to 85 percent of students in juvenile detention centers have a disability, but fewer than 40 percent received any sort of additional support before they were expelled from school. School nurses provide vital care coordination for students with chronic illnesses and disabilities, which involves creating individualized health plans (IHPs). According to the National Association of School Nurses, “school nurses create an IHP for select students with health care needs that, if not addressed, may negatively affect, or have the potential to affect, attendance and/or academic performance.” These plans should actively address the increased risk of expulsion for children with disabilities and include an emergency care plan should a situation arise in which suspension or expulsion is under consideration. 

Just as school nurses would fight for a child with a seizure disorder to have access to the care they need to safely remain in school, they should build plans to support children with diagnoses such as ADHD or learning disabilities who are at risk for disciplinary action. Given that children of color with disabilities are at even higher risk of expulsion, systemic racism must be addressed in these plans as well. Situations leading to disciplinary action should be viewed through a health lens: Did something related to a student’s mental or physical health lead to the incident? Is racism impacting the choice of disciplinary action? 

School nurses are in a unique position to help dismantle the school-to-prison pipeline, but they can’t do it without proper institutional support and funding. Unfortunately, only 40 percent of U.S. schools employ a full-time school nurse, and a quarter of schools do not have a nurse on staff at all. This lack of school nursing can lead to preventable student deaths and is also a missed opportunity to promote student and community health. Thankfully, Sen. Chris Murphy (D-Conn.) and Rep. Ayanna Pressley (D-Mass.) have co-sponsored the Counseling not Criminalization in Schools Act, which would ban the use of federal dollars to expand the presence of law enforcement in schools and allot $2.5 billion to support nurses, therapists and counselors. 

This bill has support from organizations including The American Federation of Teachers, the NAACP, and American Counselors Association. We must ensure that efforts to strengthen the school nursing and public health workforces also focus on diversifying them: School nurses are overwhelmingly white, with only 4.8 percent identifying as Black. School nursing jobs are not compensated nearly as well as hospital-based bedside nursing positions are, which makes them a less realistic option for many nurses. 

The school-to-prison pipeline is coming under increasing scrutiny as many question the country’s reliance on law enforcement to address issues related to mental health, substance use and poverty. School nurses — so key to keeping schools open during the pandemic — are equally key in changing the harmful disciplinary practices that close off life and learning opportunities for many of our students.

Shoshana V. Aronowitz, Ph.D., FNP-BC, is an associate fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a National Clinician Scholars Program postdoctoral fellow. Follow her on Twitter @shoshiaronowitz.