(CNN) — As she held up her cell phone to take back-to-school selfies with the new school resource officers last week, the excitement of the first day swept through Liz Pray just as it had in previous years. But Pray, a school nurse, was nervous, too.

“I don’t know what the school year is going to bring,” she said.

With the highly transmissible Delta coronavirus variant circulating in the United States and tensions boiling over around masks and vaccine requirements, this school year will be like none she has experienced before.

For the past seven years, Pray cared for young students across four different elementary school buildings within Moses Lake School District in central Washington state. Now, she will care for older students at Moses Lake High School, more than 2,000 students total.

“It’s so fun to see those students coming back to me, and seeing how much they’ve changed over the last few years, and the young adults that they’re molding into,” Pray said. “I’m excited to see them all at the same time, but I’ll admit I’m nervous.”

Pray is one of about 96,000 full-time school nurses in the United States who are facing an uncertain school year ahead. Even before the pandemic expanded their workloads and altered their day-to-day tasks, the United States was grappling with a shortage of school nurses.

By the end of her first day back, Pray had taken on a stack of paperwork an inch thick, found time for a single restroom break and managed a late lunch around 3:15 p.m.

“If I had to sum up the day — check on your school nurse, because they are not OK,” Pray said.

Pandemic sheds new light on old problem

Pandemic aside, the US Centers for Disease Control and Prevention recommends that schools have one full-time nurse for every 750 students. Now, when students and schools may need nurses more than ever, it’s estimated that about a quarter of schools still have no nurse at all.

The latest data from a national school nurse workforce study, published in the Journal of School Nursing in 2018, found approximately 39% of schools employ full-time nurses and about 35% employ part-time school nurses, while 25% do not employ school nurses.

In Washington, where Pray is based, a working paper from the University of Washington’s Center for Education Data & Research in Seattle found last year that the statewide student-to-nurse ratio during the 2019-2020 school year was one nurse for every 1,173 students on average.

The country has had a shortage of school nurses for years, but the burden is clear now.

“I would love to see a school nurse in every school across our country,” said Linda Mendonca, president of the National Association of School Nurses.

“That would be my magic-wand dream, because every American schoolchild deserves a school with a full-time school nurse, not just to help them navigate through a pandemic, but to support students every day with their physical and mental health and making sure that they’re academically ready to learn,” Mendonca said.

Pray said she spent the summer as she normally would: checking records to verify which students are caught up on routine immunizations and organizing files for those with chronic illnesses, among other back-to-school tasks — but the workload was much greater than years’ past.

“When I moved to the high school this year, not only did my caseload almost triple making that move, because I’m the only nurse in the high school, but we haven’t seen a good majority of those kids in the building for 18 months,” said Pray, who also serves as president of the School Nurse Organization of Washington.

“So, we’re dealing with all of their chronic health conditions like diabetes, asthma, allergies, and then on top of that, toss in all of the mental health pieces. The anxiety about walking in the door that first time. Depression because they’ve been at home without any socialization with their peers,” Pray said.

“And then you’ve got Covid.”

‘You can definitely tell there’s a lot of tension’

Due to the pandemic, Pray has other responsibilities now added to her plate: planning Covid-19 testing strategies and pop-up vaccine clinics, analyzing ways to disinfect surfaces and improve air ventilation, preparing for potential Covid-19 outbreaks and disgruntled parents who may be against masks or vaccines.

“In our district, there was a protest down at our administrative office about the mask mandate,” Pray said. “You can definitely tell there’s a lot of tension in our state right now, regarding masks and vaccines.”

That tension also has been seen nationally. During a school mask meeting in Florida, scuffles broke out. Outside of a school board meeting in Tennessee, angry anti-mask protesters harassed a parent. In Louisiana, protesters forced the shutdown of a school board meeting after not complying with a statewide mask mandate.

The division over masks and vaccine requirements within communities tend to reflect the variability among US school districts when it comes to rules and policies.

“You can’t really say anything in general about the role of the school nurse during the epidemic, because of the variability from one district to another,” Linda McCauley, dean of the Nell Hodgson Woodruff School of Nursing at Emory University, told CNN.

Nationwide, some schools mandate that students and staff wear masks to reduce the spread of the virus that causes Covid-19. Others don’t.

Some schools require anyone exposed to the coronavirus to quarantine to reduce the risk of spreading the pathogen to others if they are infected. Others don’t.

Some schools require staff to be fully vaccinated against Covid-19 in order to protect young students who are not yet eligible to be vaccinated. Others don’t.

Because Covid-19 policies vary across school districts, the responsibilities of the school nurse can vary as well. And in some schools where mitigation measures to reduce spread of the coronavirus are not followed or enforced, that can increase a school nurse’s risk of exposure to the virus.

Rural schools more likely to have no nurse

Some of these differences in school policies, practices and behaviors can vary by geographic region.

For instance, in rural regions of the United States, Covid-19 vaccine uptake generally has been slow — and it’s also in these regions, where positive Covid-19 cases cripple health care systems, that the shortage of school nurses appears to be greater.

Schools in the rural regions of the United States appear to be “significantly more likely” than schools in urban areas to report having no nurse at all, according to the study published in the Journal of School Nursing in 2018. In that study, 23.5% of rural schools report having no nurse compared with 10.3% of urban schools.

“When you get into a rural setting, you’ve got school districts, pre-pandemic, that saw a nurse once a week or once a month depending on where they were, and they share nurses with multiple districts that could be an hour away from each other — and then you get in the middle of a pandemic, and the nurses are needed, and we’ve never been leaned on in that way,” said Pray, whose Moses Lake School District is considered to be in a rural area.

To address the nation’s school nursing shortage and also improve the number of school nurses in rural regions, funding is needed, Laura Searcy, a pediatric nurse practitioner who is a past president of the National Association of Pediatric Nurse Practitioners and a fellow of the American Association of Nurse Practitioners, wrote in an email to CNN.

“Funding is a key issue. There is an inconsistent mishmash of state and local funding that puts small rural school districts with inadequate tax bases at a disadvantage,” she said in the email. “And those areas also are likely to have a shortage of primary care pediatric health care providers as well.”

In those schools where no nurse is on staff, often teachers are trained and relied on to provide certain aspects of medical care that typically would be performed by a school nurse.

“We wouldn’t accept medication being given to a child from unlicensed support staff in a hospital, for example, so it’s always baffling to me that we accept this in the school setting for our medically fragile students,” Gloria Barrera, president of the Illinois Association of School Nurses, told CNN.

In Illinois, the Chicago Teachers Union went on strike in 2019 while calling for a full-time nurse in every school. Chicago Public Schools, according to its website, is still hiring nurses to meet that goal. Even before the strike in Chicago, the American Academy of Pediatrics in 2016 recommended that pediatricians can advocate for a minimum of one full-time professional school nurse in every school.

“As a school nurse, I know that I’m serving as a bridge between the health care and education systems and other sectors, as well as a link to broader community health issues through the students I serve. That continuity of care is why I became a school nurse,” Barrera said. “For any nurse that’s considering a career as a school nurse as a specialty, it really has historically played an important role in promoting public health within our schools and larger communities — and you are needed.”

School nursing jobs can be hard to fill

Nationwide, there is an overall shortage of nurses — not just school nurses. The American Nurses Association has even called for the US Department of Health and Human Services to declare the nurse staffing shortage a “national crisis.”

But there appear to be several factors driving the nation’s school nursing shortage specifically, including the funding needed to hire, no direct pipeline to connect nurses to schools and lower wages compared with other nursing roles in hospitals or other settings.

“I know very few nurses who right when they graduate go into school nursing. They find it along the way, and there’s a number of reasons for that,” said McCauley, dean of Emory University’s School of Nursing.

“Students who are passing their licensure exam and getting their first degree in nursing rarely have rotations in school nursing. It’s not impossible, but it’s rare,” she said. “Students may not have exposure to school nursing.”

Therefore, on one hand, younger nurses applying for school-based positions might not have that much experience within educational settings. Then on the other hand, more experienced nurses might not be satisfied with the pay offered in schools.

In May of last year, the median annual wage for registered nurses in US hospitals was $76,840 compared with $64,630 for registered nurses in educational services, according to the US Bureau of Labor Statistics.

The disparity in pay for school nurses compared with other nursing positions could be due to most school nurses not working year-round, McCauley said.

“You have to keep in mind that they work probably 10 months out of the year,” McCauley said. “So their salary looks lower than other registered nurses, but I can’t seem to tell whether that’s adjusted for a yearly salary.”

Overall, “there is a national nursing shortage, so school districts find themselves competing against health care facilities for the same pool of applicants,” said Searcy, a pediatric nurse practitioner.

“The compensation is not quite equitable, so that’s always been a concern,” said the National Association of School Nurses’ Mendonca.

“I have heard anecdotally too that for nurses who were close to retirement, or thinking about it, that the pandemic has maybe pushed them in that direction sooner than what they may have been planning on,” she said. “So that makes the shortage even a little more critical than what we’ve been dealing with.”

Lawmakers push for more school nurses

Some Democratic lawmakers want to help improve funding for school nurses through proposed legislation called the Nurses for Under-Resourced Schools Everywhere Act, introduced by Nevada Congresswoman Dina Titus and Montana Senator John Tester.

The NURSE Act would create a grant program at the US Department of Education to reduce the cost of hiring nurses in elementary and secondary public schools, according to Titus’s office. School districts could apply for the grants if at least 20% of their students are eligible for low-cost or free school lunches.

Titus on Wednesday urged Congressional leaders to include the legislation in the upcoming budget reconciliation package. The National Association of School Nurses also has announced support of the NURSE Act.

But for some school nurses like Liz Pray in the state of Washington, they wish the push to get more funding for school nursing happened sooner, before the pandemic.

Now, “there’s a nursing shortage everywhere across the nation,” Pray said.

“For school nursing, we thought for sure that after the wave of Covid went through this last year, you would see nurses wanting to leave the hospital and go to something that had a more firm schedule — Monday through Friday, potentially summers off — but we’re not seeing them making that transition over because there’s such a drop in pay,” Pray said.

“It’s not set up like the medical field. They’ve got to do some work to attract the nurses to come over, but at the same time, they’re needed in the hospitals too. There’s just a shortage all around.”

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