2024/01/01 by Kailee Steger · 1 voice
Health Professions · #School Health and Nursing Education #Child and Adolescent Health
paper · doi:10.5325/nursinghistory.32.0093
openalex publication_date 2024/01/01 · openalex created_date 2025/10/10 · openalex updated_date 2025/12/22
The history of school nursing lies in a hidden place, not unlike Robin Cogan’s description of the current state of school nursing presented at the Future of Nursing 2020–2030 Philadelphia Town Hall. Cogan, a school nurse, quickly moved into a national leadership position after she described COVID-19 policies toward schools and nursing during a New York Times interview. In that interview, Cogan declared the policies to be “playing Russian Roulette with our children,” and described school nurses as working within “a hidden healthcare system.”1 Hidden from the history of nursing and present-day public awareness of their existence, school nurses navigate the complex system of healthcare within schools—while they receive little attention from historians, sociologists, and even other nurses.COVID-19 school health policies have brought attention to the fact that school nurses, while commonly overlooked, are in fact at the center of public discourse surrounding public health, education, and politics. By examining the role of school nurses throughout American history we will better understand their work and how they navigated the space between education and healthcare. This examination will also help us appreciate the ways in which current conceptions of school nurses evolved from political action and labor movements.American school nursing history began in the Progressive Era (1898–1917) with Lillian Wald and Lina Rogers. Recognizing the increasing health needs of children within urban schools, the New York City Board of Health and Board of Education contacted Wald in 1902 in search of a balance between the quarantine of disease and absenteeism.2 School polices mandating a child’s exclusion from school for illness in order to contain the spread of contagious diseases resulted in nearly 20 percent of school children being sent home daily.3 The same policies, however, did not include adequate treatment and follow-up care for the children, and many stayed out of school long after the required period of quarantine. Others were left unsupervised at home while their parents worked.Aware of the success of school nursing in England, Wald was conscious of the fact that to have nurses, rather than only physicians, in the schools would cause a radical shift in the development of school health. In her attempt to prove the nurses’ worth, Wald enlisted Lina Rogers, a resident of the Henry Street Settlement, to act as a school nurse for one month, free of charge.4Working under the supervision of a physician, Rogers aimed to guard students against disease and the subsequent requisite absenteeism through early detection and preventative care. Her success was remarkable. Rogers reduced the number of absent students from 24,538 to 400.5 In the wake of her success, the board of health allocated 30,000 for an additional six months of salary for school nurses.6 Within weeks, a corps of eleven nurses, sponsored by the board of health and assisted by the board of education, began work in New York City schools.7The work of Lina Rogers and Lillian Wald is well documented by Lina Rogers’s own accounts and by their contemporary, Lavinia Dock. But the history of school nurses is hardly limited to these two. For example, in the works on the history of childhood, education, and nursing, prominent scholars such as Richard Meckel have analyzed the development of public school health policies and how those policies have served in the discussion of the state and the public school’s responsibility to promote the physical and mental health of children. In his seminal work, Classrooms and Clinics: Urban Schools and the Protection and Promotion of Child Health, 1870–1930, Meckel discusses how school health policies were designed and implemented by stakeholders (including parents, educators, policy makers, and professionals), but pays very little attention to school nurses.8 The question remains, how did school nurses view themselves within the category of professionals? Alongside physicians and teachers, nurses not only navigated but created school health policies. Moreover, their actions were not free from the influences of politics and power.Works from Judith Sealander and Cynthia Connolly closely analyze domestic policy as it relates to children. In her book, The Failed Century of the Child: Governing America’s Young in the Twentieth Century, Sealander traces the development of child health policies from their philanthropic beginnings, when they were based on science, to the politics of creating health legislation, and concludes with the unintended consequences of these policies.9 In Children and Drug Safety: Balancing Risk and Protection in Twentieth-Century America, Connolly uses the intersection of children’s health and policy in the United States as a window to explore how government regulation, professional authority, and shifting conceptions of childhood directly impacted domestic policy initiatives.10 In Connolly’s discussion of postwar pediatric nursing in the context of drug development and administration, she pays little attention to school nurses. Whether it is a missing piece of the historiography or an accurate depiction of a lack of nursing authority in school health, the role of school nurses needs to be made visible in this hidden place in the history of school health, childhood, and nursing.Significant primary sources on school nursing remain to be investigated. One promising source of archival material, the Tri-County Visiting Nurses Association collection (1894–1991), is located at the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania.11 This particular collection is meaningful to the history of school nurses because of the organization’s growth and development of child health services and, most notably, its commitment to school health.In 1911, the Nursing Bureau in New Jersey reorganized itself and changed its name to the Visiting Nurses Association (VNA) of Plainfield and North Plainfield. That same year, between three and five nurses conducted over 30,000 school inspections and made 436 home visits to school children.12 School inspections rose to over 100,000 in 1917. By 1921, the VNA served six school districts and completed over 150,000 school inspections with seven to nine nurses.13 As for the employment of school nurses, the VNA reported that some were directly employed by the board of education while a larger number were employed by the VNA or a combination of the two. What remained consistent throughout the annual reports during this decade was how time-consuming school nursing was and the large costs associated with its services. From 1921–1923, the VNA nurses spent 32 percent of their total time within the schools. That percent continued to rise in the coming decades.14 The VNA’s connection to schools went beyond the time nurses spent in schools. The VNA’s published receipts demonstrated that the board of education was the largest cost expenditure for the organization. Through both time and money, VNA nurses had a considerable connection to the schools in their areas.The actual work of school nurses, as described in the VNA’s annual reports, consisted of directing “Keep Well Clubs” for anemic children, conducting orthopedic, dental, and physical inspections, preventing the spread of infectious diseases, and beginning mental hygiene care. The rapid growth of school health programs, along with their increased costs, necessitated the VNA to appoint a medical advisory committee in 1927 and request funding from the board of health and the township committees.15 What was not promoted by the VNA in their school health services was the inclusion of primary care services.The rising demands that the VNA faced in providing health care to school-age children were consistent with the national movements to address children’s health in the years following World War I. Notably, the National Education Association published the Cardinal Principles of Secondary Education, which established health as one of the seven main objectives of education.16 The role of the National Education Association demands attention. As the only labor union in the United States with a federal charter, received in 1906, the National Education Association exerted incredible political authority over the education system. Importantly, they later would play a key role in the eventual creation of the U.S. Department of Education in 1979.The political authority exerted by the National Education Association meant that their reports and commissions were viewed more like government mandates than mere suggestions by a labor union. In 1911, the National Education Association partnered with the American Medical Association and over the next fifty years became one of the most influential groups in school health through their Joint Committee on Health Problems in Education. The committee published reports that included, “The Minimum Health Requirements for Rural Schools,” “The Health Supervision and Medical Inspection of Schools,” and a 1955 report titled, “The Nurse in the School.” School health became a central focus for a number of agencies between the 1930s and 1960s, but what became increasingly evident was the question of whose responsibility it was to organize and maintain school health, or perhaps more importantly, whose responsibility it was not.In the 1955 report, “The Nurse in the School,” the local control of school health became a key theme. Addressed in the section titled “Amount and Type of Nursing Service,” the report suggested that local planning groups were responsible for deciding what type of service best suited the community. The authors also highlighted the fact that “the responsibility of all health personnel should be defined so that their services may be related in a realistic way to the overall objectives of the school and community programs for the health of children.”17 While this work clearly defines the duties of the school nurse as delivering first aid, controlling communicable disease, and providing emergency care, the authors allowed local groups to decide what the community needed. This sense of local control is present throughout the history of education. The local primacy of school health fits within this proposed narrative.The VNA’s commitment to school health services, as well as their close association with the board of education, is reflective of the twentieth-century national trend to address school health needs on a local level. Within the VNA’s records it is clear that they not only provided nursing services but also decided when services were needed and how to distribute them among the schools. By 1953, VNA nurses spent 47 percent of their time in schools.18 However, boards of education began to employ their own nurses that were not associated with the VNA. As a result, the VNA no longer provided nurses to schools on a full-time basis. Despite this fact, the VNA nurses spent more time in schools than they did in any other single type of service.19 Unfortunately, reports from nurses themselves are not included in their records. Such reports might better explain how extensive their work was in schools and the reasoning behind it.Based on a collection of annual reports from other visiting nurses’ associations from across the country, school health services were not reported as frequently or with equal amounts of time devoted to school health as those reported in the annual reports of the Tri-County Visiting Nurses Association. Many of the visiting nurses’ associations limited school health to preschool visits or orthopedic inspection, but they did not always specifically list school health services in their annual reports.20 This collection is not an exhaustive list of visiting nurse associations, but it does address the local authority of child health services. Because individual communities were left to determine what services were most appropriate for their population, it would follow that each visiting nurses’ association annual report would differ. Additionally, those annual reports from other visiting nurses’ associations do not include the fact that the boards of education or the boards of health may have employed nurses directly, making it unnecessary for an association to employ them.From this preliminary archival research into the history of school nurses it is evident that the story is likely a local one. The Tri-County Visiting Nurse Association reports also state clearly that school health was central to childhood health during the early and mid-twentieth century. While hidden in education, the health of children in schools remained central to nursing, medicine, public health, and education. Policy initiatives such as the 1948 School Health Bill prove some consensus around the importance of school health, but what is less clear is under whose authority that care belonged. Greater exploration into the National Education Association, visiting nurse associations’ collections in archives throughout the country, and the American Medical Association Joint Committee’s report, “Health Problems in Education,” will likely offer more insight into how education and medicine positioned school nurses within school health initiatives.Studies that move beyond the early twentieth century will be crucial to understand how school nursing developed as a profession within the field of education and how nurses became political actors and labor organizers. From 1960–1980, the federal government began to expand its reach into schools with the creation of the U.S. Department of Education in 1979, but schools also experienced a period of limited government regulation when President Nixon vetoed the Comprehensive Child Development Act in 1971. During the second half of the twentieth century, school nurses organized to create the Department of School Nurses within the National Education Association. Within this time frame we can begin to explore how school nurses organized themselves and decided under whose authority they would work. How did nursing interact with democracy, politics, and authority after the 1954 Brown v. Board of Education decision and the Elementary and Secondary Education Act of 1965? We can gain insight into these questions by exploring how school nurses positioned themselves during this period of desegregation, the White flight to the suburbs, and expansive funding. The picture of the hidden healthcare system introduced earlier is challenged by the fact that school health was in fact very much at the forefront of education in the late twentieth century. So, then, if it is hidden, the question becomes hidden from whom? Future work on the history of school nursing should aim to explore these questions and in doing so move school nursing from its “assigned seat” in the shadows of nursing history to a place at the front of the class.An earlier version of this article was presented as part of a panel at the Agnes Dillon Randolph International Nursing History Conference hosted online by the University of Virginia’s Eleanor Crowder Bjoring Center for Nursing Historical Inquiry on March 19, 2022. I thank Cynthia Connolly and Patricia D’Antonio for their continued support and detailed feedback. Additionally, I thank the archivists at the George Washington University Special Collections Research Center and the Barbara Bates Center for the Study of the History of Nursing at the University of Pennsylvania School of Nursing for their guidance and expertise.