This paper reports results from a nationwide survey of a systematic random sample of school districts. Information obtained from 482 participating districts was used to contrast roles of nurses and health assistants in school health programs throughout the country. Most districts relied heavily on nursing personnel for technically involved clinical services, but often employed health assistants to administer medications and basic first aid. Litigation was somewhat more frequently filed regarding care provided by health assistants than care by nurses or classroom personnel. But in general, health assistants were performing satisfactorily, particularly in districts where registered nurses coordinated the services and activities of health program personnel. While use of health assistants increased the past three years, school nurses were not being displaced. Just 9% of districts had downsized their nursing staff during that period. Despite the modest expansion of nursing resources, nurses reportedly were underused in health education programs of most schools.

The practice of school nursing must change with the times. School nurses must develop new leadership and collaborative skills to work within the interdisciplinary school and community teams that will be required to put changes in place. This article defines current trends and their implications for the search for the most efficient and appropriate school health services. It explores preparation and competencies for school nurses, legal and ethical concerns, and financing needed to provide adequate school health services. Many support systems exist today, and new ones are being developed to expand the range of health services provided in schools. The National Association of School Nurses encourages strategic planning for the new school health environment, and the Office of School Health at the University of Colorado provides extensive resources to help school nurses develop and put their plans in place.

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