PhD

thesisOnly 13 states are in compliance with the national recommendation of 1 school nurse for every 750 students. The purposes of this investigation were to (a) determine if/how state laws mandating school nurses or school health services/activities influence state school nurse ratios and (b) identify other social, political, and cultural factors that influence school nurse-to-student ratios. This study consisted of quantitative and qualitative components. First, an analysis of secondary data was conducted to identify the relationship between state school nurse ratios and various factors identified in the literature. Data were collected from established databases from the 50 states and the District of Columbia. Data were analyzed using correlation statistics (Kendall's tau). Second, 30 qualitative telephone interviews were conducted in 11 states throughout the country. The participating states included Alabama, California, Connecticut, Delaware, Iowa, Massachusetts, Missouri, Montana, New Hampshire, Tennessee, and Utah. Content analysis was performed to identify factors influencing school nurse-to-student ratios. Qualitative comparative analysis (QCA) was then conducted to identify the unique factors influencing school nurse-to-student ratios. No relationship was found among states with laws mandating school nursing or other health services and school nurse-to-student ratios. Results showed a statistically significant relationship between school nurse-to-student ratios and the amount of funds spent per pupil for education and the amount of funds spent for educational student services. Interviews identified several other influential factors, including the strategy used to identify the need for more school nurses; the value placed on school nurses; local support and buy-in by the community, education, and parents regarding school nurses; fear of litigation; and dynamic leadership. Barriers to school nursing include funding, misunderstanding of the role of the school nurse, and philosophical opposition to school nursing. Cultural and geographic influences were also noted. Ongoing investigation is needed to identify the degree to which other factors affect school nurse-to-student ratios. In addition, a systematic approach to data collection at the state and local levels needs to be implemented. This information will help school nurse advocates develop and prepare future political actions