School Nurses Promote Vaccine Confidence

By Laurie G. Combe, MN, RN, NCSN; Laurie Fleming, RN, MPH, NCSN; Lisa Patch, MSN, RN, NCSN

The Community/Public Health principle of  NASN’s Framework for 21st Century School Nursing PracticeTM identifies the school nurse’s role in access to care, disease prevention, health equity, health promotion, outreach, population based care, risk reduction and surveillance. Schools play a major role in the spread of Vaccine Preventable Disease [VPD] (Swallows & Roberts, 2016)  both within and without the walls of the schools. There are over 59 million public, charter, private and independent school K-12 students in the United States (National Center for Education Statistics, 2018a; 2018b; 2019). This data does not reflect Early Childhood and Pre-Kindergarten students who enroll because of complex health conditions, disabilities, poverty, and English language learners. For all students, access to school nursing services are essential. 

At a roundtable discussion about school located vaccine clinics, school nurses identified four desired impacts they would like to see.  These include increased vaccination rates among students and staff, improved population health outcomes such as decreased absenteeism and less preventable disease, a positive public perception of vaccines, and increased access to and equity surrounding vaccines. (AIM & NASN, 2022, p. 16S)

While the SARS-CoV-2 pandemic has amplified the work of school nurses as disease prevention managers, this has been and will always be the work of school nurses. Vaccines are one means of disease prevention and school nurses align with state vaccine mandates to manage compliance.  In addition to required vaccines, school nurses also work with families to increase their knowledge and acceptance of recommended vaccines. This is a labor intensive effort requiring parent notification, frequent follow-up, collaboration with community partners for vaccine access, vaccine safety and efficacy education, documentation, helping families track down immunization records not included in state registries, and managing vaccine exemptions. 

Note that vaccine exemptions vary by state and type (Britannica, 2020)

  • Medical Exemptions are allowed in all states and the District of Columbia (DC)
  • Religious Exemption are allowed by 45 states and DC
  • Philosophical Exemptions are allowed by 15 states and DC
  • 5 states allow Medical Exemptions only

School nurses have noted a rise in vaccine exemptions over time. Disinformation and misinformation during the COVID-19 pandemic causes concern for future refusal of a wide swath of vaccines. In researching candidates for an upcoming election, several candidates are publishing their anti-vaccine mandate stance. Families need access to accurate information about vaccine efficacy and safety.  “School nurses have regular contact with students, are trusted by parents to deliver accurate health information, and have access to state immunization registries (NASN, 2020)”. When schools employ school nurses, vaccine exemption rates are lower (Leidner et al., 2019).

A 2019 survey found that 18% of school nurses administer vaccines, 98% conduct immunization compliance activities, and 41%  collaborate with non-school partners to increase student access to required and recommended vaccines (Leidner, et al,. 2019).  Successful school vaccine compliance efforts rely on strong policy language that supports school nurse compliance efforts and details the progression of communication to parents about compliance with vaccine mandates. Communications must be tailored to various audiences, taking into account health literacy, language and culture. Multiple methods of communication assist in meeting the communication preferences of families –  US Postal Service delivery, student delivery, email, text, and multiple phone calls may be required to achieve compliance.

Not all school nurses have the necessary infrastructure to qualify as Vaccines for Children (VFC) providers; they work with community partners to ensure equitable access to life saving vaccines. In the northeast where immunization compliance is higher than many areas in the U.S, states have teamed up with local pharmacies to provide child immunizations.  This provides parents with easy access to vaccines without waiting when they are notified by the school nurse that the student is non-compliant.  Community health centers and Urgent Care facilities also offer basic immunizations at little to no cost.  School nurses work to provide parents with the information on which pharmacies provide the needed vaccines.   During COVID school nurses have deployed drive-through SLVC for their communities.

When there are VPD disease outbreaks, school nurses in the southwestern US partner with local health departments to deploy School Located Vaccine Clinics (SLVC). In fact, schools have been sponsoring SLVC since the 1850s. NASN recognizes that the prevention of vaccine preventable disease is central to the work of school nurses, and partnered with the Association of Immunization Managers to provide a NASN School Nurse Journal Supplement – School-Located Vaccination Clinics (SLVC) in the Era of COVID-10 (AIM & NASN, 2022). The toolkit provides resources from a variety of partners, providing checklists, form templates, operating procedures and more. This effort recognizes that school nurses:

  • Engage partners to make SLVC a reality, thereby removing access barriers
  • Work directly within school communities, providing the opportunity to build trusting relationships with students, families, and entire school communities.

Additional NASN Immunization Resources can be found here.

With 60% of schools having inequitable access to a school nurse, who is assisting those school communities in disease prevention, vaccine access, and quality school health care? The COVID-19 pandemic has made clear that access to a school nurse is a student and community health equity issue. Does your school community have a school nurse?

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