History & Evolution of School Nursing
This piece was written as part of an independent study completed during the spring semester of my sophomore year.
School Nursing: A History
For as long as most living today can remember, nurses have been a fixture in both the public and private school systems. Though the role of the school nurse has long been diluted by many – some still believe that this job primarily entails handing out bandaids and sending sick children home – it is true that this field of nursing is multifaceted, complex, and ever evolving with the times. School nurses act with much greater autonomy and independence than many of their counterparts in other disciplines. They manage both acute and chronic illness, respond to injuries of every kind, and, increasingly, find themselves on the front lines of the mental health crisis plaguing our youth today. Yet, at its core, school nursing is a public health profession. From its birth in early twentieth-century New York City, school nurses have sought to provide education to both students and their families, promoting their health and well-being in and out of the classroom.
Prior to the early twentieth century, most children who became ill at school were sent home with a letter from medical inspectors detailing why they could not attend classes. New York City officials, beginning in 1897, employed 150 doctors to identify students with infectious diseases and immediately exclude them from the classroom (Loschiavo, 2020). It was assumed that the student would be taken to a doctor and receive appropriate treatment, however, this was rarely the case. New York City during this time was a Petri dish of germs and illness. A surge of immigrants – over 19 million between 1880 and 1920 (Loschiavo, 2020) – had led to overcrowding, unsanitary conditions, and rapid spread of diseases, including diptheria and whooping cough (Passarelli, 1994). Moreover, it meant that an increasing number of families lived well under the poverty line, with most parents still learning English and often unable to read. Thus, the likelihood of a school-issued note reaching the caregivers of an ill child were slim, and, even if it did, the chances of seeing a doctor and obtaining treatment were next to none. Disease was rampant, and rates of absenteeism among students increasingly high (Vessey & McGowan, 2006). Even worse, most lacked a basic understanding of both knowledge to prevent disease and available resources. That was when Lillian Wald stepped in. As a wealthy social reformer and nurse, Wald had founded the Henry Street Settlement in 1893, a clinic staffed by nurses that provided health services, English lessons, and meals to immigrants on the Lower East Side of New York City (Loschiavo, 2020). She was also among the first to promote the importance of public health nursing, recognizing that not only did the illness itself need to be addressed and treated, but also the underlying poverty and unsanitary living conditions.
It was from the Henry Street Settlement, in 1902, that Wald instructed fellow nurse Lina Rogers to take her practice to schools. It was decided that, if Wald and Rogers could successfully limit the chronic absenteeism plaguing city classrooms, officials would financially support more nurses in schools. Rogers, with Wald’s help, wasted no time, developing protocols for each illness, differentiating between infectious and non-communicable illnesses, and providing treatment accordingly. She also visited the homes of children diagnosed with contagious diseases, educated families, and wrote treatment plans (Vessey & McGowan, 2006). In just six months, rates of absenteeism had dropped by an amazing 90% in Rogers’s four assigned schools, and the city hired 27 additional nurses to staff various schools throughout New York (Loschiavo, 2020). Rogers was promoted to Superintendent of School Nurses by the city’s Board of Health, and she subsequently worked to promote nutrition and hygiene, create school-based wellness programs (such as dental screenings), and work in partnership with families, teachers, and the Board of Education (Vessey & McGowan, 2006). Word of Wald’s pioneering experiment, with the leadership of Rogers, traveled around the country, and the specialty of school nursing grew exponentially throughout the subsequent decade. Yet though school nursing quickly became its own unique field, it continued to be a branch of public health nursing with an overarching goal of not only treating but also educating and empowering patients and the community.
Though New York City is often recognized as the birthplace of school nursing, it is worth noting that nurses first appeared in schools before the twentieth century even began. The earliest recorded documentation of a nurse employed by a school was in 1892 London (Loschiavo, 2020). However, this nurse’s only role was to evaluate pupils’ nutrition, and didn’t involve any sort of education or treatment. It was only after Wald’s famous experiment that school nursing became widespread and effective. By the 1930s, some states mandated a specialized curriculum for aspiring school nurses, and the Department of School Nurses was officially established in 1968, developing requirements for credentialing in each state and policies for school nurses around the country (Loschiavo, 2020). The DSN later became the National Association of School Nurses, which it remains today, and seeks to promote the importance of nurses in every school.
It is without a doubt that much has changed since the birth of school nursing. Though living conditions across the country have dramatically improved and public knowledge of basic hygiene and disease prevention is much stronger, there still remains a large and ever increasing need for nurses in schools. Many students lack access to healthcare, others live with chronic diseases, mental illness, and developmental delays that require constant attention. Moreover, emerging diseases, as highlighted by Covid-19 in 2020, necessitate “ongoing surveillance” and education (Vessey & McGowan, 2006). Finally, as students continue to engage in risky behaviors such as drug abuse from a younger and younger age, school nurses must collaborate with teachers and health educators to provide preventative measures and care. But despite these generational changes and the evolution of the profession, school nurses remain an integral part of public health, providing education and resources to the children they serve, as well as their families and communities.
Profile: Lillian Wald
Though nurses first appeared in schools in late 19th-century Europe, Lillian Wald, a New York City social reformer, pioneered the experiment that led to widespread school nursing across the country, as well as its recognition as a branch of public health. Born in 1867 to a wealthy Jewish family, Wald was educated as a nurse, but chose to work extensively in public health and social justice. The Henry Street Settlement, a clinic staffed by nurses that provided health services, English lessons, and meals to immigrants on the Lower East Side of New York City, is arguably her most notable accomplishment. At the age of 25, while teaching to immigrant women at the Women’s Medical College (where she was also a student), Wald was approached by an upset child asking for help. She was led to a tenement on the Lower East Side, into a tiny, filthy apartment shared among multiple families and “overflowing with feces” (Loschiavo, 2020). A woman was lying in a bed, surrounded by blood, having hemorrhaged while giving birth. The woman’s doctor had left after learning she couldn’t afford to pay him. The experience alarmed Wald into action. Henry Street was established a year later in that very Lower East Side neighborhood. Clients paid what they were able, yet assistance from the government was minimal, allowing the idea that poverty existed because of “moral failure” (Loschiavo, 2020) to prevail, a mentality that Wald worked tirelessly to change. Wald also pioneered the idea of “public health nursing,” where she sought to promote nurses working both in communities and the homes of those they served (Roux & Halstead, 2017). This specialty quickly became widespread, with the National Organization for Public Health Nursing founded in 1912. Throughout her life, Wald also became a prominent advocate, fighting for rights for women, immigrants, and children. She was very involved in the Red Cross, working to end the 1918 Spanish Flu epidemic. The New York Times named her as one of the 12 greatest American women in 1922, and she was also designated as an “Outstanding Citizen of New York,” receiving a Lincoln Medallion. Wald died in 1940.
