The pandemic, it turns out, is highlighting the important and complex job that school nurses do and showing their ability to adapt to difficult circumstances in order to care for students and communities.
There are things school nurses have always done and continue to do for student health, including physical and mental health and care coordination, according to Laurie G. Combe, MN, RN, NCSN, President of the National Association of School Nurses (NASN) and a school nurse since 1993.
“We have always had a public health role, looking for trends in disease or symptom presentation and collaborating with our local health departments,” Combe said.
One of the biggest changes for school nurses in the past year has been the amount of time they spend consulting with and educating families by phone instead of the traditional hands-on time taking care of children. Some of their time is spent finding out which students are absent because of symptoms, which have been tested, who is in quarantine because of close contact, and more, said Emily Poland, MPH, RN, school nurse consultant, Maine Department of Education.
The pandemic added contact tracing and COVID-19 testing, as well, to school nurses’ repertoires. And when the time comes, school nurses also will be helping to make sure there are systems within schools to deliver COVID-19 vaccines.
School nurses and other healthcare personnel played an important role in reopening schools and keeping them open during the COVID-19 pandemic, according to the CDC, which offers resources to help school nurses in these often complicated endeavors.
The reality, however, has been that school nurses had been struggling even before the pandemic to get the funding they need to keep and do their jobs effectively.
Like many states in the U.S., Maine’s schools were a mixed bag of in-class and online learning in early 2021. But school nurses in Maine were lucky in one respect. Everyone stayed on the job since the pandemic began. Many school districts in the state have even hired school nurses, according to Poland.
Combe said it has been interesting witnessing the different ways communities have worked with school nurses since the pandemic began in 2020. Some communities leaned heavily on school nurses’ expertise and kept them employed throughout the shutdown.
“School nurses began delivering virtual school nursing care, which was an innovation for us,” she said. “We are used to the in-person care that we deliver to students, but school nurses really stepped up, providing health education for their school community about staying safe.”
NASN surveyed its members in April 2020, and 61% of the 4,700 respondents indicated they were included in district discussions about COVID-19. Forty-three percent of those said they were involved in updating or developing policies for a response to COVID-19.
“That was encouraging news,” Combe said.
Other school districts did not understand the value that school nurses would provide beyond school walls and furloughed them, according to Combe.
Recommendations for how to optimally staff schools and school districts with healthcare providers exist, but not all schools abide by those. For example, the American Academy of Pediatrics recommends a minimum of one full-time professional school nurse in every school with medical oversight from a school physician in every school district as optimal staffing for students’ health and safety.
U.S. schools are far from optimal. Slightly less than 40% of U.S. schools employ full-time school nurses and about 35% employ part-time school nurses. But more than a quarter of U.S. schools do not employ a school nurse at all, according to the latest NASN data from 2017.
“In Maine, the only requirement by law is that each school district have at least one registered nurse,” Poland said. “It does not mean that registered nurse has to be full time, and it does not say how many students they can cover. There are some school districts that have a nurse in every single school building, and there are some school districts that have a nurse covering multiple schools, and that has become more difficult in the pandemic.”
School nurses are frustrated, according to Poland. Some of the frustration stems from what school nurses see as a lack of administrative or community support for those in the role of the school nurse. For example, when parents decide to have a party on the weekend and do not take precautions, that comes into school the following week in the form of cases, she said.
“Then there is just fatigue of doing this seven days a week for months,” Poland continued. “This isn’t how school nurses generally work. They don’t generally work seven days a week.”
If a school nurse in Maine finds out about a COVID-19 cases on Friday afternoon, for example, that nurse will often spend part of the weekend calling close contacts. The contact tracing, alone, has been a big job. There were 20 COVID-19 cases reported in Maine schools in September. In December, there were more than 800.
There are a lot of unknowns about how school openings will go in the fall. Much of that hinges on vaccine distribution, according to Poland.
But Poland thinks the pandemic might be helping to elevate the profession.
“I really see this specialty, because it really is a specialty, becoming more respected,” Poland said. “I think in the past it has not been as respected as it should be.”
The pandemic seems to have resulted in a greater recognition of the expertise required by the role of the school nurse and what they bring to the table in infection control and public health practice, according to Combe.
“More school nurses were at the table for this pandemic than we have seen at the table in the past,” she said. “We hope that will continue.”
Poland said she hopes leaders will respond with more funding for school nurses. But whether that will happen is unclear. Combe said that funding for school nurses could suffer if state revenues decline and school budgets are cut. Based on historical data, educators keep educators in the harder financial times but are less likely to keep healthcare personnel.
NASN and partners in the Safer Return to School Coalition have asked for $208 billion to support the personnel, materials, and facility resources to open schools safely.
“We await Congress’s action,” Combe said.
Nurses in other settings might not understand the scope of school nurses’ practice, Combe said.
“If I could frame it this way: The child that you took care of in the hospital may be newly diagnosed with diabetes, or a child who has a severe asthma exacerbation or severe food allergy is coming to my school upon discharge,” Combe explained. “That means that I have to have all the skills that you have, and in some cases, even more because I am the sole healthcare provider in the school. There is no one else I can rely on in an emergency.
“I have to make sure that child with diabetes and their parents continues to receive education, whether it’s connecting them with a diabetes educator in the community or it’s with me reinforcing that education and making sure that child’s care is translated safely into the education setting of the classroom because I can’t be with them all the time. Those pieces don’t change.”
The role of the school nurse is not for nurses right out of college, Poland said.
“You need some experience,” she said. “You are on your own. You have to be confident in your assessment skills. You have to be confident in what you know and what you don’t.”
Nurses considering a school nursing career should know it is not an easy job and can be intense at times. But it is immensely rewarding because school nurses work with students and families over time. These nurses can build strong relationships with students and families, and these nurses have the opportunity to make a positive impact on their long-term health, Combe said.