We conducted a descriptive cross-sectional survey of school nurses associated with the National Association of School Nurses and the Massachusetts School Nurse Organization. This study (STUDY00001610) was reviewed and approved by the UMass Chan Medical School Institutional Review Board as exempt on February 28, 2024, and participant consent was not required.

The survey was iteratively developed with input from school nurses who were identified through the research team’s professional connections. First the research team which includes a former school nurse and researchers with expertise in chronic disease prevention drafted the survey. Next the drafted survey was reviewed by one practicing Massachusetts school nurse for content completeness and clarity no changes were made after this review. Finally, the survey was pre-tested by three currently practicing Massachusetts school nurses. During this pre-test, feedback was collected on survey length, relevance of the content to school nurses, completeness of content, ease of answering, and suggestions for improvement. Following the pretest the survey was shortened, and questions were added to ask about the school population served and the presence of a school health center. The exact phrasing of survey items is shown in the result tables. The survey included questions about school nurses’ practices and beliefs related to blood pressure screening and identification and monitoring of elevated blood pressures or diagnosed hypertension, as well as school nurse demographics, and characteristics of the schools they serve. The primary survey items sought to uncover the current state of youth blood pressure related efforts by school nurses as well as opportunities to expand such efforts.

Currently practicing school nurses were recruited to participate in the survey through the Massachusetts School Nurse Organization (MSNO) and the National Association of School Nurses (NASN). A brief invitation to participate in the survey along with a link to participate was included in the MSNO monthly email newsletter (March and April 2024) which is sent to all their approximately 800 members. This brief invitation and link were also distributed via two emails sent three weeks apart in March and April 2024 to a random sample of 2,000 NASN members determined by NASN. When accessing the survey link participants were first directed to a page which assessed eligibility. School nurses were eligible to participate in the survey if they were willing and able to participate in an English language electronic survey and indicated that they were currently practicing as a school nurse (no restriction was placed on the level or type of school at which they practiced).

The survey was hosted on the UMass Chan Medical School REDCap platform. REDCap is a secure web platform for building and managing online databases and surveys which is widely recognized for its utility in research and has been used extensively by our team (Harris et al., 2009, 2019).

We used descriptive statistics in the form of means with standard deviations for continuous variables and proportions for categorical variables. Since not all items were completed by all participants the number of responding participants is given for each item in the result tables. Based on common guidance for privacy, all cell sizes with fewer than five responses are reported as “<5” (Manual for Preventing Disclosure: Rules for Researchers, 2023). All analyses were conducted with STATA 18.

The demographic characteristics of the school nurses who participated in the survey and the schools they serve are shown in Table 1. Most of the participants were female (98%), of white race (92%), and held a bachelor’s degree (58%). The majority of participating school nurses worked in schools that were public (91%), served both elementary and secondary levels (42%), and had 250–1,000 students. The number of schools served by participants ranged from 1 to 34 with a mean of 2.2 and standard deviation of 3.5 and 69% (n=126) reported serving a single school. Only nine participants reported having a school health center (in which primary care services are provided by advanced practicing primary care practitioners) and seven of those reported they work separately from the school health center. Overall, participants served schools within 37 states, and the geographic distribution of schools served is shown in Figure 1.

All of the 186 participants who completed the section on equipment reported that they had access to a blood pressure cuff in the school(s) they serve: access to manual cuffs (98%), automatic cuffs (57%), both manual and automatic (55%), and multiple sizes of blood pressure cuffs (89%) were reported. Three percent of participants also reported having access to ambulatory blood pressure measuring devices.

As shown in Table 2, when asked about the frequency at which they perform several general practices, most participants reported they often counsel children on healthy lifestyles (i.e. healthy eating and physical activity) (59%), and measure children’s vital signs (46%). Participants reported undertaking the practices of measuring height, weight, and calculating body mass index (BMI) less frequently with only 18%, 17%, and 15% respectively reporting they “often” undertake the practice of each of these measurements.

Table 2 also demonstrates the nurses’ report of the frequency at which they perform several practices specifically related to the identification and monitoring of high blood pressures and diagnosed pediatric hypertension. Of the participating school nurses, 53% reported that they “sometimes” measure children’s blood pressure and 20% reported they do so “often”. When asked about specific situations in which they measure blood pressure, most participating school nurses reported that blood pressure measurement was “never” or “seldom” for the purpose of regular screening (41% and 43%), nor for follow-up after a high blood pressure which occurred at school or the child’s primary care clinic (43% and 37%). Vital sign assessment was reported as the reason for blood pressure measurement “sometimes” by 41% and “often” by 32% of participating school nurses. Receipt of referrals from children’s primary care providers to measure children’s blood pressure was reported as occurring “seldom” by 41% and “sometimes” by 34% of participating school nurses. Most participating school nurses also reported that they “never” treat children for high blood pressure in reference to lifestyle counseling (50%) and to pharmacologic treatment (77%).

Reported frequency of practices related to communication are also displayed in Table 2. Of participating school nurses communicating about children’s health with the children’s primary care provider, it was reported as occurring at least “sometimes” by 63% of participants as well as at least “sometimes” with the children’s parents/caregivers 84%. Communication specifically regarding children’s blood pressure was reported by participating school nurses as occurring with the children’s primary care provider “sometimes” (11%) as well as with the children’s parents/caregivers “sometimes” (28%) and “often” (8%).

Participating school nurses’ level of agreement with statements about their role are shown in Table 3. The majority agreed or strongly agreed that school nurses should have a role in providing lifestyle counseling (94%), making referrals for healthy eating and physical activity (72%) as well as social needs (78%). Additionally, 78% of participants agreed or strongly agreed that their student population would benefit from care coordination. However, less than one fifth (19%) of participating school nurses disagreed with the statement “I do not have enough time to complete all the tasks I need to as a school nurse”.

As shown in Table 3, most participants strongly agreed or agreed to having interest in doing more to support cardiovascular health (24% and 58%), and high blood pressures/diagnosed hypertension (15% and 54%). Most participants also expressed agreement that school nurses have a role to play in diagnosing (73%) and managing hypertension (77%), as well as their own confidence measuring blood pressure (99%), their awareness of blood pressure guidelines (62%), their comfort interpreting blood pressures (80%), their familiarity with blood pressure percentiles (58%), and their confidence communicating with children’s primary care providers about blood pressure (89%). However, only about one third of participants reported they either “agree” (27%) or strongly agree (6%) that pediatric hypertension impacts their student population.

Our primary findings is that in this sample school nurses reported that, blood pressure measurement is occurring in schools, and they are generally confident with measuring and interpretating blood pressures. However, this practice is generally a part of vital sign assessment in response to acute symptoms, not specifically for the purpose of blood pressure screening nor identifying and monitoring elevated blood pressures or diagnosed hypertension.

Importantly our data demonstrate that in line with the AAP’s suggestion on the utility of school blood pressure screening “to identify children who require formal evaluation” and “in the monitoring of diagnosed HTN [hypertension]” about one of every six participating school nurses at least “sometimes” screen for hypertension and about one in every three participating school nurses sometimes monitors blood pressure based on primary care provider’s requests (Flynn et al., 2017). Qualitative work conducted by our team in 2022 similarly found in one large not- for- profit healthcare system in central Massachusetts, school nurses collaborate with pediatric providers to screen or monitor pediatric blood pressure during the hypertension diagnosis process. However, the majority of school nurses are not undertaking these practices. The US Preventive Services Task Force (US Preventive Services Task Force, 2020) does not recommend regular blood pressure screening in children and adolescents, and the AAP cites a lack of evidence and standardized protocols to support diagnosis of hypertension based on school measurements (Flynn et al., 2017). Such lack of consensus may explain why these practices are not more widespread and represents a missed opportunity to recognize school nurse’s potential in care coordination for at risk and affected children.

Currently, pediatric hypertension is an underrecognized condition (Falkner et al., n.d.). There is important work that must be done to raise awareness of the impact of hypertension in youth (Falkner et al., n.d.; Goulding et al., 2024). Our survey found that one third of participants did not believe that hypertension has an impact on their student population. This may be because many school nurse participants are not currently providing direct care or care coordination for students with diagnosed hypertension, nor regularly screening blood pressure. However, prior work has also identified low awareness of this condition in parents (Goulding et al., 2022), and lack of recognition by pediatric providers (Bello et al., 2017; Brady et al., 2010). The low belief of hypertension’s impact in the present sample is especially interesting because it is contradictory to the high number of participants who reported bring aware of evidence-based guidelines related to pediatric blood pressure and wanting to do more to support cardiovascular health and high blood pressures/diagnosed hypertension in their student population. School nurses may see the importances of cardiovascular health promotion in children but may be unaware of the rising prevalence of and long-term impacts of hypertension in this population. Alternatively, this response may reflect a focus on obesity prevention as the primary practice related to cardiovascular health promotion (Story et al., 2009). Importantly, cardiovascular health promotion focused on blood pressure may overcome some of the barriers encountered by prior obesity centered efforts (Ruggieri & Bass, 2015).

Even in cases where pediatric hypertension is diagnosed, the process of reaching a diagnosis can be long and delay the onset of proper management (Goulding et al., 2023). Raising the school nurse’s awareness of the impact of hypertension in youth may increase recognition of their potential role in identifying, and monitoring elevated blood pressures and diagnosed hypertension in students. Regular blood pressure screening by school nurses and their involvement in the diagnostic process through care coordination is in line with current school nurse practices (Willgerodt et al., 2024). The opportunity for care coordination is especially clear since school nurses in our survey reported frequently communicate with parents around their child’s episodic visits to the health office and also commonly communicate with primary care providers. Further research is needed to examine the effectiveness of such care coordination models that involve school nurses. Supporting and standardizing this role of school nurses in adjunct with primary care pediatricians could help to decrease the time to diagnose hypertension and in turn improve early identification and subsequent management of pediatric hypertension, especially in populations that face systemic barriers to returning to healthcare clinics. Therefore, further research should be conducted to establish evidence-based protocols for school nurse’s role related to blood pressure and associated care coordination.

Such efforts to expand the role of school nurses in relation to blood pressure will need to consider school nurse’s access to appropriate equipment and procedures for the conduction of blood pressure measurement in school settings. High quality blood pressure measurement relies on knowledge, skill, and appropriate equipment (Falkner et al., n.d.; Flynn et al., 2017). The vast majority of participants in the present survey indicated access to a blood pressure cuffs (either manual, automatic, or both; and of various sizes). Our survey however did not elicit responses about the calibration of the equipment, or the validation of the equipment for use in pediatric or adolescent populations. Further exploration of school nurses’ training in diagnostic protocols and application of AAP guidelines will be needed to support expansion efforts.

School nurses’ report of wanting to do more to support cardiovascular health and belief that they have a role to play in hypertension identification and management is contradictory to our finding that most school nurses feel they do not have enough time to complete the tasks they need to as a school nurse. This lack of sufficient time for school nurses is also seen in our low response rate even though we partnered with state and national organizations to send the survey. Prior research has also shown the overburdened nature of the school nurse role (Endsley, 2017; Willgerodt et al., 2024). The school nurse is usually the only healthcare provider in the school and an estimated 40% of school aged youth have at least one chronic health condition (Centers for Disease Control and Prevention [CDC], 2023). Unsurprisingly, workload and caseload issues as well as lack of access to resources are reported as barriers to school nurses implementing population health practices (Davis et al., 2021; Hughes et al., 2024; Willgerodt et al., 2018). This underscores the importance of investment in school nurses and policies to support school nurses and the work they do.

The recent National School Nurse Workforce Study 2.0 highlighted that many schools do not have school nurses and noted the importance of demonstrating and documenting the value of school nurse’s work (Willgerodt et al., 2024). In the present work we describe the role that school nurses are already playing in relation to hypertension in youth which has not yet been widely described. We also describe the potential for this role to expand and the value that this expansion may have for early identification and timely management of this impactful condition. Such descriptions are important for supporting and advocating for the critical role of school nurses in health promotion. School nurses have the skillset and tools available to measure blood pressure and are interested in doing more to support their student’s cardiovascular health. The potential for school nurses to identify elevated blood pressure, and manage hypertension through care coordination, and for schools to serve as a population-based venue for preceptive cardiovascular care is clear.

While it has important implications for school nurses, this study also has limitations that should be considered in interpretation of its findings. First, social desirability bias may be present in school nurses’ responses especially given the altruistic nature of nursing. Second and likely reflective of the lack of time that many school nurses reported, this survey suffered from a low response rate. As such, we present findings from a sample of school nurses that may not be generalizable to all school nurses in all settings. Although more participant demographic diversity could have helped our findings reflect a broader population of school nurses, the similarities between our sample’s demographic profile and that reported by a nationally representative samples of public school nurses supports the representation of US school nurses in our sample and generalizability of our findings (Willgerodt et al., 2018, 2024). The reach of our work is also supported by the fact that we had participants from 35 states. School nurse education is a particularly important demographic as it is related to school nurse care delivery models. The proportion of our sample which hold a bachelor’s degrees is similar to that found in a prior nationally representative sample (Willgerodt et al., 2018, 2024). However, in our sample of school nurses a higher proportion hold a master’s degree (Willgerodt et al., 2018, 2024). This may reflect our oversampling of school nurses from Massachusetts, where a master’s degree in a related field is required within 5 years of hire (603 CMR 7.00: Educator Licensure and Preparation Program Approval Regulations - Education Laws and Regulations, n.d.). Despite the limited diversity of our sample, this work remains critically important as there is a lack of contemporary data on school nurse practices related to blood pressure screening, and identification and monitoring of high blood pressures in youth.