Disclaimer: This toolkit is intended to provide resources for school nursing practice as it relates to the care of students in Oregon schools. This is not medical nor nurse practice advice and is not prescriptive as it relates to individual students or individual nursing practice or assessment. These resources do not override individual assessment and clinical judgement. Nurses are responsible for their own assessment and practice.

“Patient acuity is generally defined as a measurement of intensity of nursing care needed by a patient. For the proper development of a staffing plan for people receiving care, patient acuity is a particularly critical benchmark” (COCA, 2019).  Acuity includes the measure of a patient’s severity of illness or medical conditions, as well as the stability of physiological and psychological parameters of the condition, and the dependency needs and behaviors of the patient and the patient’s family (API Law Insider, 2023).

Acuity is a concept significantly related to patient safety under the premise that as acuity rises, more nursing resources are required to provide safe and effective care. This may include more intensive nursing time, continuous surveillance, or advanced nursing skills related tasks that cannot be delegated (Jennings, 2008; ANA 2017).  Because fields of nursing are so diverse, there is no one universal acuity tool for all settings. However there is an agreement in literature of the following concepts as it relates to acuity measurement:

  • Using a consistent model of measurement provides objective, consistent, and  sustainable data (American Nurses Association, 2018; Ingraham & Powell, 2018)
  • Acuity measurement should be quantifiable (American Nurses Association, 2020; Ingraham & Powell, 2018; Edelson et al, 2011)
  • Acuity Assessment must be completed by a RN (Washington Department of Health, 2006; Kidd et al, 2014; Juve-Udina et al., 2020)
  • Acuity should consider time and complexity of nursing, including nursing consideration of nursing care that is accomplished via delegation, teaching, or training  (Jennings, 2008; Juve-Udina et al., 2020; Barrow & Sharma, 2022)
  • All patient problems must be considered to appropriately assess acuity (Juvé-Udina et al, 2019; American Nurses Association 2020; Kim et al., 2020)
  • Social determinants of health impact complexity and acuity of an individual and their health outcomes (CSDH, 2008; Weir et al, 2020)
  • Insufficient nursing numbers are directly associated with patient safety and outcomes (Carlson, 2017)

While in an acute care setting the mechanism of acuity assessments occurs both in real time and retrospectively, in the school setting the data is typically collected over the course of the year to plan for subsequent academic years (ANA, 2017). 

The National Association of School Nurses suggests that student acuity data be revisited at minimum annually (Combe et al., 2015) and be used in combination with other staffing factors and community specific indicators to determine needed school nurse workload.

School Nurse Staffing

Most evidence indicates that there should be one nurse per school and that increased nurse staffing increases student attendance and academic success (American Academy of Pediatric [APA], 2016; NASN, 2015).  However, the regulatory requirements in place currently in Oregon  focus on student acuity data and ratios for school nursing staffing (Aiken, et al, 2017; APA, 2016) .  These ratios were developed in the 1970’s without robust evidence.  These ratios were developed to  support the presence of nurses in the school setting to protect the rights of students with chronic needs. Although there was little evidence to support the identified ratios, many states and the National Association of School Nurses recommended one school nurse to 750 students in the general student population; 1:225 for student populations requiring daily professional nursing services; 1:125 for student populations with complex healthcare needs; and 1:1 for individual students requiring daily continuous professional nursing services (American Nurses Association [ANA]/NASN, 2011; NASN, 2015). While a ratio of one school nurse to 750 students has been widely recommended and was even acknowledged in Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2014a) and by the American Academy of Pediatrics [AAP] (2008), it has been subsequently recognized that a one‐size‐fits‐all workload determination is inadequate to fill the increasingly complex health needs of students and school communities (AAP, 2008; ANA/NASN, 2011).  In addition to the laws that established rights for children with disabilities to attend school, medical advances have increased the number of students with special healthcare needs in schools significantly since the ratios were enacted.

Nurse-to-student ratios are currently  regarded as an outdated method of staffing school nurses and are not grounded in evidence (Jameson et al, 2020).  Further, while school nursing practice has changed dramatically over the past two decades, with more complexity in pediatric populations and increased technology in chronic disease management and the ability to sustain life in children who would have historically been demised, staffing ratios have not kept up with complexity (Willgerodt et al, 2018).

To that end the National Association of School Nurses (NASN) and American Academy of Pediatrics ( AAP) have formulated position statements on this matter.

NASN Position Statement School Nurse Workload: Staffing for Safe Care (excerpt)

School nurse workloads should be evaluated on at least an annual basis to meet the health and safety needs of school communities (Jameson et al., 2018).

American Academy of Pediatrics

Children with special health needs are living longer and attending school more than ever.  Use of ratios to define the number of nurses needed in schools far predated the complexity of disease management that currently exists in the school setting.  Case management has evolved significantly in school nursing, and chronic disease management trends and technologies have advanced significantly and continue to advance, intensifying the demands on school nurses for consistent professional development.  In addition, nurses are the single licensed staff in school health services settings that are responsible for population management in addition to case management.  This may include health screenings, immunizations oversight, communicable disease surveillance and mitigation, health policy, and outreach, among other things.  For these reasons and more the American Academy of Pediatrics joined the National Association of School Nurses in position statements that schools should, at minimum, employ one nurse per each building (AAP, 2016).

Policy Statement: Role of the School Nurse in Providing School Health Services (excerpt)


Despite the support of fully staffing schools with school nurses, ratios remain in place in Oregon Statute.

Oregon law (ORS 336.201) defines three levels of acuity related to required (school) nursing services:

  • Medically Complex: students who may have an unstable health condition and who may require daily professional nursing services.
  • Medically Fragile: students who may have a life-threatening health condition and who may require immediate professional nursing services.
  • Nursing-Dependent: students who have an unstable or life-threatening health condition and who require daily, direct, and continuous professional nursing services.

Many school districts additionally collect data on students with non-complex chronic conditions, which can be defined as conditions of prolonged duration that do not resolve on their own, that may be associated with illness, impairment or disability, and that are well-managed or stable enough that they pose minimal risk and require little or no intervention at school.

ORS 336.201 further states each school district shall ensure that the district has access to a sufficient level of nursing services to provide:

  • One registered nurse or school nurse for every 225 medically complex students.
  • One registered nurse or school nurse for every 125 medically fragile students.
  • One registered nurse or school nurse, or one licensed practical nurse under the supervision of a registered nurse or school nurse, for each nursing-dependent student.

In addition to the requirements of subsection (2) of this section, each school district is encouraged to have one registered nurse or school nurse for every 750 students in the school district.

American Nurses Association

When looking at acuity from a literary standpoint, it is important to consider broader evidence. In addition to school nurse specific content. From a nurse generalist perspective, multiple factors should be considered in the staffing of nurses, with patient acuity only reflecting a part of that rationale

According the the American Nurses Association (2012; 2020):

“Nurses have a professional duty to be knowledgeable about staffing– its processes and organizational functions, as part of their responsibility to patients. While nurse managers and other leaders may be accountable to their organization for nurse staffing, all nurses are accountable to their patients and profession.”

The process to effectively manage the nursing workforce is multifaceted, in order to match nursing resources to patient (student) needs, four phases are recommended by ANA:

(ANA, 2012, ANA, 2020)

To that end, acuity data should be one element of determining workforce needs (ANA, 2020).

Acuity Student Assessment

Assessing individual acuity is focused on determining the nursing intensity associated with  patient (student) problems and the relationship to nursing priority, clinical judgment, and nursing  time that these problems will take to address (Juve-Udina et al., 2019).  Assessment of acuity status is problem-focused and, while predictors may exist based on the main clinical problem, the full acuity is based on the appraisal of compiled individual acuity components to make up a complete acuity assessment.   As the components are found in the nursing process and clinical complexity,  it is necessary that a nurse be the one to perform the assessment  (Juve-Udina et al., 2019; Kidd et al., 2014 ).

(AQHR, 2020; Jennings, 2008; ANA 2017;American Nurses Association, 2020; Ingraham & Powell, 2018; Edelson et al, 2011;  Kidd et al, 2014; Juve-Udina et al., 2020; Juve-Udina et al., 2020; Kim et al., 2020; CSDH, 2008; Weir et al, 2020; Carlson, 2017; Welton, 2017, Mezzich & Solloum, 2008; Rinjbeek & Reps, 2021; Cordon et al, 2021; Bernell, 2016)

Acuity Population Assessment

In clinical and population health settings it is critical to consider all elements that may impact the workload of the RN beyond individual student care (Jameson et al, 2018).  Just as assessing all elements of individual acuity is necessary in providing predictive levels of nurse staffing needs, so too should all factors be included in assessing the overall community indicators in identifying potential nursing workload and demand (Juvé-Udina et al., 2019; NASN, 2016; Weir et al., 2020).  As health disparities and social determinants rise in a community, so too does the overall clinical complexity.  Community indicators can be used to identify the potential complexity of the the community as it relates to health and social services demands, these indicators are heavily Social Determinants of Health, such as:

(Adapted from Rural Health Information Hub [RHIH], 2023)

While the above indicators may not be used to conduct a formal community health assessment for the purposes of acuity, proportional awareness or anecdotal evidence of some of these factors, demography, rurality,  and other apparent disparities may frame the need for increased nursing workforce within the school setting (Jameson et al., 2018; NASN, 2020, RHIH, 2023).

Evidence Based Practice

Basic Information

Jennings BM. Patient Acuity. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 23. Available from:

Legal Practice Standards

At the forefront of nurse case management for school nurses, is the understanding of scope of practice as it relates to case management and delegation of  nursing tasks in a community setting:

Public Access Practice Resources

As well, the professional nurse in the school setting should understand the existing resources and framework for assessing acuity or school nurse staffing. 

American Academy of Pediatrics
National Association of School Nurses (NASN)  
Oregon Department of Education (ODE)
Rural Health Information Hub

Professional Development


The following templates are modifiable for use by school nurses as it relates to their practice and should be used consistently with Oregon State Board of Nursing, Delegation Laws and local school policy.


Author: Jan Olson
Contributors: Tami Pike, Ely Sanders, Wendy Niskanen, Corinna Brower
Peer Reviewer: Jamie Smith
Editorial Reviewer: Ann Occhi


American Academy of Pediatric ( 2016) Role of the school nurse in providing school health services. Pediatrics 137 (6) e20160852

American Nurses Association. (2012). ANA’s Principles for Nurse Staffing, 2nd ed. Silver Spring, MD: American Nurses Association.

American Nurses Association (ANA). (2014). Connection between nurse staffing and patient outcomes can be made in all hospital clinical areas with expanded measures. Retrieved from‐ PR/Connection‐between‐Nurse‐Staffing‐and‐Patient‐Outcomes.pdf

American Nurses Association. (2017). Principles for nurse staffing (3rd ed.).

American Nurses Association ( 2018). Use a tool for consistent, objective, and quantifiable patient assignments.

API Law Insider (2023) Patient acuity definition.,patient%20and%20the%20patient's%20family.

Barrow JM, Sharma S. Five Rights of Nursing Delegation. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

Carlson, K. (2017). Nurse-Patient Ratios and Safe Staffing: 10 Ways Nurses Can Lead The Change.

Combe LG, Bachman MB, Dolatowski R, Endsley PE, Hassey K, Maughan E, Minchella L, Shanks B, Trefry S, Zeno E. (2015) School Nurse Workload: Students Are More Than Just Numbers. NASN School Nurse.30(5):283-8. doi: 10.1177/1942602X15596582. Epub 2015 Jul 28. PMID: 26219906.

Centers for Disease Control and Prevention (2021). Social determinants of health: Know what determines health.

Clinician Outreach Communication Activity ( COCA) Patient Acuity Should Determine Staffing, Not Profits or Earnings.,is%20a%20particularly%20critical%20benchmark.

Commission on Social Determinants of Health (CSDH) .(2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health.  World Health Organization: Geneva.

Dolatowski R, Endsley P, Hiltz C, Johansen A, Maughan E, Minchella L, Trefry S. (2015). School Nurse Workload--Staffing for Safe Care: Position Statement. NASN School Nurse;30(5):290-3. doi: 10.1177/1942602X15594143. PMID: 26296829.

Duffield, C., Diers, D., O'Brien‐Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244‐255. doi:10.1016/j.apnr.2009.12.004

Ingram, A., Powell, J.,(2018) Patient acuity tool on a medical surgical unit. Nurseline.

Jameson, B. E., Engelke, M. K., Anderson, L. S., Endsley, P. & Maughan, E. D. (2018). Factors related to school nurse workload. The Journal of School Nursing, 34(3), 211-221. doi: 10.1177/1059840517718063

Jennings BM.(2008). Patient Acuity. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US);  Chapter 23. Available from:

Juvé-Udina, M. E., Adamuz, J., López-Jimenez, M. M., Tapia-Pérez, M., Fabrellas, N., Matud-Calvo, C., & González-Samartino, M. (2019). Predicting patient acuity according to their main problem. Journal of nursing management, 27(8), 1845–1858.

Kim, J., Kang, T., Seo, HJ. et al. Measuring patient acuity and nursing care needs in South Korea: application of a new patient classification system. BMC Nurse 21, 332 (2022).

Best NC, Nichols AO, Waller AE, Zomorodi M, Pierre-Louis B, Oppewal S, Travers D. Impact of School Nurse Ratios and Health Services on Selected Student Health and Education Outcomes: North Carolina, 2011-2016. J Sch Health. 2021 Jun;91(6):473-481. doi: 10.1111/josh.13025. Epub 2021 Apr 11. PMID: 33843082.

Penman-Aguilar A, Talih M, Huang D, Moonesinghe R, Bouye K, Beckles G. Measurement of Health Disparities, Health Inequities, and Social Determinants of Health to Support the Advancement of Health Equity. J Public Health Manag Pract. 2016 Jan-Feb;22 Suppl 1(Suppl 1):S33-42. doi: 10.1097/PHH.0000000000000373. PMID: 26599027; PMCID: PMC5845853.

Rural Health Information Hub [RHIH}

Stanton AL, Revenson TA, Tennen H. Health psychology: psychological adjustment to chronic disease. Annu Rev Psychol. 2007;58:565-92. doi: 10.1146/annurev.psych.58.110405.085615. PMID: 16930096.

Welton JM.(2017) Measuring Patient Acuity: Implications for Nurse Staffing and Assignment. J Nurs Adm;47(10):471. doi: 10.1097/NNA.0000000000000516. PMID: 28957863