The Journal of School Nursing2023, Vol. 39(2) 143–149© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211054805journals.sagepub.com/home/jsn
The COVID-19 pandemic has caused major disruptions to U.S. school systems since March 2020. To facilitate our understanding of how school nurses participated in school reopening and what support school nurses needed beginning the 2020–2021 school year during the COVID-19 pandemic, we conducted a national survey in late summer 2020. A sample of 747 school nurses from 43 states responded to an online survey about roles, practices, and concerns. Over one-third (36.9%) reported not being included in school reopening planning. Mitigation practices reported by respondents primarily included measuring temperatures of students before school (21.3%), mask wearing by students (79.9%), and 6 feet social distancing (76.7%). The respondents’ greatest concerns were the educational impact on students with individualized education plans, parents sending children to school with COVID-19 symptoms, and the economic impact on families. Our results point to opportunities for greater school nurse involvement, improvements in practices, and measures to address school nurses’ concerns.
Keywords
school nurse, roles, practices, concerns, COVID-19, pandemic, school reopening
The COVID-19 pandemic has caused major disruptions to almost all aspects of life in the United States, including the functioning of school systems beginning in March 2020. Educators transitioned to remote instruction as 38 states required school closures and another seven recommended school closures for the remainder of the 2019–2020 schools year (Map, 2020). During this time, school nurses began teaching their school communities about COVID-19, sharing guidelines from federal, state, and local health departments about how to prevent infection spread (NASN, n.d.). They also joined efforts to provide food and educational materials to families and started collaborating with local boards of health for COVID-19 contact tracing (Flaherty, 2020). As schools were closing in the spring of 2020, school nurses sought out information and expressed concern for reopening school buildings safely, anticipating a return to in-person learning (Hoke et al., 2021; Pattison et al., 2021). Uncertainties about how best to reduce spread of COVID-19 in schools persisted in the summer 2020, while the Center for Disease Control and Prevention (CDC) was changing its guidelines, e.g., for universal temperature screening and social distancing (Hennes, 2020; Strauss, 2020). School nurses were actively seeking updated facts and protocols to help school administrators prepare for the safe reopening of school buildings to in-person instruction for the 2020–2021 school year. The National Association of School Nurses (NASN) provided information and resources to school nurses so that they could provide reopening guidance to school communities and advocate to be involved in reopening planning decisions (NASN, 2020a).
To date, results of two surveys are published that address concerns about returning to school during the COVID-19 pandemic. One survey conducted in May 2020 included 350 school nurses from Pennsylvania with the goal of understanding nurses’ perspectives about risk, concerns, roles, and practices (Hoke et al., 2021). Another survey of school employees, which sought to share identified areas of concerns and resources with the American School Health Association membership and school personnel, was conducted May 19 – June 3, 2020 and included 220 school nurses out of a total of 375 respondents from 45 states (Pattison et al., 2021). Although the two studies provide insights on perspectives during the spring of 2020, little is known about school nurses’ roles as schools were reopening in the late summer of 2020, what practices school nurses and staff were engaging in to reduce COVID-19 transmission, and what concerns school nurses had for the health of the school community, including themselves.
The purpose of this survey was to facilitate our understanding of how school nurses participated in school reopening and what support school nurses needed by describing their roles, practices, and concerns at the start of the 2020–2021 school year during the COVID-19 pandemic. The findings of the survey will inform stakeholders in the school community about how to engage and support school nurses as they lead and implement measures to reduce the spread of COVID-19 as well as other communicable diseases in schools in the future.
This quantitative study used a cross-sectional design with a convenience sample of school nurses reporting demographics, roles, practices, and concerns through an investigator-developed web-based survey in late summer 2020. With approval of the Northeastern University Institutional Review Board, an email invitation of the survey was distributed by the Massachusetts School Nurse Organization, Northeastern University School Health Academy (NEUSHA), and School Health Corporation via their electronic newsletters to their members or account holders, with an estimated 30,000 nurses working in PreK-12 schools. The invitation for the survey was sent out from August 23 to September 8, 2020, to coincide with the anticipated time frame of students returning to learning. Participation in the survey was voluntary and confidential. Participants were informed that it was estimated to take 15 minutes to complete the survey. Upon completion, if the participant was invited to participate in a random drawing for three online learning packages from NEUSHA, they were to click on a link to a separate survey to provide their name and contact information.
This anonymous online survey consisted of a total of 60 multiple-choice questions identified by two school nurse educators and an academic nurse researcher in consultation with an expert in survey design and parent participating in a public school district reopening committee. The survey was designed to be completed in 15 minutes. Questions addressed three major categories: (a) current school nurses’ roles in reopening, (b) practices by school nurses and schools to reduce risk of COVID-19 transmission, and (c) concerns related to student health, their own health, and the health of their families. Nurses’ roles and practices were examined using 11 dichotomous (yes/no) or single-choice questions, three multiple-choice questions, one open-ended question and one Likert scale question. Three Likert scale questions were used to examine nurses’ concerns about reopening school (with 0 being no concerns at all and 4 being extremely concerned) and concerns and level of anxiety about returning to in-person learning (with 0 being no concerns at all or not at all anxious to 3 being extremely concerned or very anxious). Nurses’ concerns about having enough personal protective equipment (PPE) and having it arrive prior to re-opening were captured by two dichotomous questions. The sample characteristics and nurses’ reports on reopening roles, practices, and concerns were described using summary statistics with means, standard deviations, or proportions, as appropriate. Chi-square analysis was performed to determine if there was a significant difference between those identifying as administrators and those not identifying as administrators in involvement in reopening planning.
Approximately 7,660 nurses in total opened the organizations’ email newsletters and 857 individuals clicked on the link to the survey included in the email. A total of 747 school nurses in the U.S. participated and completed the survey, yielding a response rate of 9.8%. The final sample of 747 nurses worked in Pre-K–12 schools in 43 United States with a regional distribution of Northeast (62.9%), South (16.6%), Midwest (10.7%), and West (9.8%) as indicated in Table 1. The majority of the sample consisted of non-Hispanic (94.9%) White (91.2%) female (97.7%) nurses. The largest age category represented was 56–65 year old (44.8%). The majority had a Bachelor’s degree (49.8%) or Master’s degree (32.8%). Many respondents (64.6%) reported 11 or more years of school nursing experience. Almost all (91.4%) were working in a public school system, and approximately half identified their school as suburban (52.6%) and reported working in multiple grade levels (44.7%).
School Nurses’ roles during the pandemic at the start of the 2020–2021 school year are reported in Table 2. Most of the respondents (71.8%) reported working as a school nurse assigned to one school during the pandemic. A small number (6.6%) identified as having only an administrator role and 2.4% were not assigned as a nurse to a school. While the majority of participants (76.5%) had been asked to train staff in COVID-19 related tasks (i.e., disinfecting and cleaning, hygiene, recognizing symptoms), over one-third (36.9%) reported that they were not included as part of their school and/or district’s reopening planning. The majority of the school nurses who had an administrative role participated in reopening planning compared to those who did not have an administrative role (93.3% vs. 57.3%, p < 0.001).
Practices used by school nurses and schools to reduce COVID-19 transmission in schools are reported in Table 3. Although most participants (68.5%) indicated their schools were requiring daily temperature checks to be performed by parents prior to school (47.2%) or by staff before entering school (21.3%), few participants (20.6%) rated this as a moderately (17.6%) or extremely useful (3.0%) practice. School nurses reported a range of temperature (99.0–101.0°F) that was established by the school as representative of a fever with 100.0°F followed by 100.4°F as the most identified thresholds for fever. In terms of mask requirements, almost all (98.9%) reported that staff would be required to wear masks and a majority (79.9%) reported that students, unless medically exempt, would be required to wear masks. More than three-quarters (76.7%) indicated that schools were using 6 feet for social distancing of students in class. Only one quarter (25.4%) reported that their school had an isolation space suitable and ready for a student with COVID-19 symptoms waiting to leave school. Although many school nurses (70.4%) were expected to report suspected and/or known COVID-19 cases to the board of health, more than a quarter (26.9%) did not know the district’s plan for communicating a known COVID-19 case to the school community.
School nurses’ concerns are summarized in Table 4, ranked by the average level of each concern rated on the Likert scale. The top three concerns with reopening schools articulated in the survey were: (a) the educational impact on students with individualized education plans (IEPs) or special needs during remote learning, (b) parents sending children to school with COVID-19 symptoms, and (c) the economic impact on families due to remote learning. Of the seven concerns with an average above 3.0 (moderately concerned on the 5 point Likert scale) or above 2.0 (moderately concerned on the 4 point Likert scale), only one was related to school nurses concerned for their own welfare, i.e., the possibility of increased workload on school nurses. The majority (60.5%) reported that they were concerned about having enough masks, face shields, and other PPE and having equipment arrive before the start of the school year (58.3%). While less than a third (29.9%) were extremely concerned about their health with return to in-person learning in the fall, more than a third (37.1%) were extremely concerned about exposing their family and/or household members to COVID-19 with the return to in-person learning.
The results of this survey provide valuable insights into school nurses’ roles, practices, and concerns at the start of the 2020–2021 school year, which was a critical time as the COVID-19 pandemic continued to create challenges for school communities planning for reopening schools and returning to in-person learning. We found that school nurses played a significant role in teaching school communities about measures to decrease virus transmission. However, when school nurses were not involved in planning for reopening schools, schools missed an opportunity to include the expertise of nurses who would be implementing many of the measures to reduce COVID-19 infection, including illness assessment and communication. We also found that while many nurses reported schools were following CDC recommendations for masks and protocols, practices for temperature assessment were inconsistent and most schools were not ready with an isolation medical waiting room or with a plan for communicating COVID cases to the school community. School nurses’ concerns were greater for students’ physical and emotional health, learning, and financial welfare than they were for the health and safety of themselves and their families.
Prior investigations did not report if school nurse respondents were part of reopening planning. When asked about practices during COVID-19, Hoke et al. (2021) reported that school nurses were changing the mode and frequency of communication with parents and Pattison et al. (2021) did not report on school nursing practices during the pandemic. Both studies highlighted concerns reported by school nurses. Pattison et al. (2021) found that 93.6% of nurses in their sample reported concerns about the availability of health supplies when they were surveyed in May/June 2020 as opposed to findings from this study that 60.5% reported concerns about having enough masks, face shields, and other PPE in August/September 2020. At the start of the pandemic in spring 2020, many school nurses had given their own PPE to local emergency services, clinics, and hospitals, with how and when to replenish their stocks still months away from being determined (Amir, 2020; Cogan, 2020). By August, the CDC and state agencies had identified lists of PPE needed in schools, federal funds were available for schools to purchase PPE, and many school districts had likely already ordered PPE. Hoke et al. (2021) found that 15.7% of their sample of 350 Pennsylvania school nurses were “extremely concerned” about their own safety in returning to the school setting without a COVID-19 vaccine. While our study questions did not refer to the COVID-19 vaccine, we found a higher percentage (29.9%) were extremely concerned about their health with return to in-person learning and in September 2020, a COVID-19 vaccine was not yet available.
Our results have significant implications for school nurses, school nurse educators, school administrators, and other school community stakeholders seeking to strengthen the roles and practices of the school nurse in supporting a healthy and safe community during the pandemic and beyond. Addressing school nurses’ concerns can also foster a healthy workforce more able to meet the health needs of the community.
School nurses are often the only health care professionals in schools, providing health services to students and tracking immunization status and disease outbreaks. As “essential members on pandemic preparedness, reopening and reentry planning team” (Dardas et al., 2020, p. 438), they should be included in all school/district decisions that involve the health and safety of the school population to ensure that evidence-based interventions are successful for reducing COVID-19 spread in schools. School nurses use skills within components of the leadership and community/public health principles of the NASN 21st Century School Nurse PracticeTM to advocate effectively for changes to practice, e.g., use of an isolation waiting room and PPE (NASN, 2020b).
Based on our finding that nurses with administrative responsibilities were significantly more likely to be involved with reopening planning than nurses without these responsibilities, we recommend that school communities establish school nurse administrators or lead nurses. If direct service school nurses are actively participating in reopening planning meetings during the school day, responsible staff members must be available to respond to student health needs (Bobo et al., 2019; Lineberry et al., 2018). One study suggests that a nurse administrator, who is not assigned to a school and understands public health, nursing, and education, is a cost-effective asset to society along with at least one full-time school nurse in all schools (Wang et al., 2014). However, we do not have sufficient evidence on what nurse supervision models result in better student and school community outcomes. The 2021–2022 NASN Research Priorities support studies that measure the impact of school health services infrastructure on health and education. In the meantime, without a nurse supervisor, we recommend that school nurses in a district collaborate on how to best support the administration and to identify one spokesperson to interface with administrators.
Recommendations from the CDC for practices to prevent COVID-19 transmission, including masking, social distancing, and temperature screening, have changed during the pandemic. Most school nurses in our study reported mask and distancing requirements for staff and students that were consistent with medical experts and early summer 2020 CDC guidance (Armstrong & Tan, 2020; Hallas, 2020; Strauss, 2020). Initial CDC guidelines for universal temperature screening were updated as science and practice demonstrated that many individuals were testing positive for COVID-19 and did not have elevated temperatures. Nevertheless, at the start of the 2020–2021 school year, some school districts required temperatures to be taken either by school staff or by parents/guardians before school, even as this survey shows that most school nurses questioned the usefulness of this effort to reduce COVID-19 transmission in schools. The continued practice of universal temperature surveillance for COVID-19 in schools may have resulted in unnecessary use of staff time and school resources and provided a false sense of security to the school community. The study revealed a wide range of temperatures identified as a fever threshold and indicates that clinical practice guidelines for temperature assessment should be established for the school setting.
School nurses’ concerns were greatly concerned for the educational, physical, emotional, social, and economic impact of remote learning on students and families. Yet school nurses did report concerns about exposing family members to COVID-19 and their own health, as well as increased workload, which could put them at risk for work-related burnout as the pandemic persists and additional responsibilities for reducing COVID-19 transmission continue (Jameson & Bowen, 2020). Additionally, evidence-based interventions for school nurse distress should be launched by state and national associations. For example, school nursing associations and academic institutions can promote evidence-based measures to prevent burnout, such as recognition of nurse contributions, inclusion of nurses in planning, positive collaboration among colleagues, conflict training and resiliency workshops and retreats (Brown, 2018; Cunningham & Çayir, 2021).
The survey was developed and reviewed by school nurse leaders during the summer of 2020 and was not piloted by nurses currently working in PreK-12 schools. Although we made the effort to reach out nationally and school nurses from 43 states participated in this survey, our sample is not a nationally representative sample and may be biased as the majority were from the Northeastern United States. Although our sample had a similar percentage of female participants as a recent workforce study of school nurses in the U.S. by Willgerodt et al. (2018), our study had a higher percentage of those identifying as White and older than 46 years of age. In addition, more participants in our study had a Master’s degree and were assigned to work in only one school than the Willgerodt et al. (2018) study. Also, we did not ask if there was a nurse on the reopening planning team or if respondents were able to attend reopening planning meetings. In schools where there are two or more nurses, another nurse in the school might be part of reopening planning meetings. When critical reopening planning meetings were occurring in summer 2020, school nurses with 10-month contracts may not have participated even if invited due to other responsibilities or were not offered compensation. We did not ask about contracts, compensation, family responsibilities, or other reasons for not being part of reopening planning. Questions related to the status of school opening and perceptions related to a future COVID-19 vaccine for the school community would have provided a more complete understanding of the school nurses’ situation and anticipated involvement with a critical tool to reduce COVID-19 illness.
This survey of school nurses’ roles, practices, and concerns during the COVID-19 pandemic at the start of the 2020–2021 school year provides a greater understanding of how school nurses participated in school reopening and what support school nurses needed by describing their roles, practices, and concerns at the start of the 2020–2021 school year during the COVID-19 pandemic. Our results point to opportunities for greater school nurse involvement in school reopening planning teams, improvements in implementation of evidence-based practices for reducing COVID-19 infection, and measures to address school nurses’ concerns during this pandemic. For the mental, physical, and economic health of our society, we need school nurses to be functioning to their full capacity to reduce risk of COVID-19 transmission in schools now and to improve the health and safety of our youth beyond the pandemic.
Two authors (Gormley, Hassey) have received partial financial support from Exergen Corporation (EC) to write the study results for publication. EC employees/consultants were not involved in the survey development, implementation, analysis, or writing of this manuscript for publication.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Exergen Corporation (grant number n/a).
Jenny M. Gormley https://orcid.org/0000-0002-3515-1111
Supplemental material for this article is available online.
Amir, V. (2020, August 8). As new academic year looms, public school nurses call for more funding to battle the coronavirus. CNN. https://www.cnn.com/2020/08/08/us/school-nursescoronavirus-funding/index.html.
Armstrong, A., & Tan, T. (2020, July 16). How Can We safely reopen schools in the fall? [slide presentation]. National Parent Teacher Association Virtual Town Hall. https://www.pta.org/docs/default-source/files/advocacy/2020/reopening-eventslides-7-16-20.pdf.
Bobo, N., Maughan, E. D., Carr, D., & Tillman, A. (2019). School nurse–Led care coordination: Proceedings from the national strategy to action roundtable. NASN School Nurse., 34(4), 229–234. https://doi.org/10.1177/1942602X19825617
Brown, S. (2018). The impact of resiliency on nurse burnout: An integrative literature review. MedSurg Nursing, 27(6), 349–378. ISSN:1092-0811MEDLINE Info: NLM UID: 9300545 Entry Date: 20181222 Revision Date: 20210824 Accession Number: 133645959
Cogan, R. (2020, August 20). The Relentless School Nurse: COVID Has Come to School & Our Cupboards are Bare. The Relentless School Nurse. https://relentlessschoolnurse.com/2020/08/20/the-relentless-school-nurse-covid-has-come-to-schoolour-cupboards-are-bare/.
Cunningham, T., & Çayir, E. (2021). Nurse leaders employ contemplative practices to promote healthcare professional well-being and decrease anxiety. JONA: The Journal of Nursing Administration, 51(3), 156–161. https://doi.org/10.1097/NNA.0000000000000987
Dardas, L. A., Khalaf, I., Nabolsi, M., Nassar, O., & Halasa, S. (2020). Developing an understanding of Adolescents’ knowledge, attitudes, and practices toward COVID-19. The Journal of School Nursing, 36(6), 430–441. https://doi.org/10.1177/1059840520957069
Flaherty, E. A. (2020). School nursing and public health: The case for school nurse investigators and contact tracing monitors of COVID-19 patients in Massachusetts. NASN School Nurse, 35(6), 327–331. https://doi.org/10.1177/1942602X20950670
Hallas, D. (2020). Safe return to school: A call to action PART 1. Contemporary Pediatrics, 37(8), 16–21. ISSN: 8750-0507MEDLINE Info: NLM UID: 8702030 Entry Date: 20200826 Revision Date: 20200826 Accession Number: 145176971.
Hennes, R. (2020, July 28). CDC updates school safety guidelines, strongly advocates for reopening campuses in the fall. CHRON. https://www.chron.com/coronavirus/article/CDC-updates-guidelinesfor-reopening-schools-15439413.php.
Hoke, A. M., Keller, C. M., Calo, W. A., Sekhar, D. L., Lehman, E. B., & Kraschnewski, J. L. (2021). School nurse perspectives on COVID-19. The Journal of School Nursing, 37(4), 292–297. https://doi.org/10.1177/1059840521992054
Jameson, B. E., & Bowen, F. (2020). Use of the worklife and levels of burnout surveys to assess the school nurse work environment. The Journal of School Nursing, 36(4), 272–282. https://doi.org/10.1177/1059840518813697
Lineberry, M., Whitney, E., & Noland, M. (2018). The role of school nurses, challenges, and reactions to delegation legislation: A qualitative approach. The Journal of School Nursing, 34(3), 222–231. https://doi.org/10.1177/1059840517741526
Map: Coronavirus and School Closures (2020, March 6). Education Week. https://www.edweek.org/leadership/map-coronavirus-andschool-closures-in-2019-2020/2020/03.
National Association of School Nurses (NASN) (2020a). Interim Guidance: Role of the School Nurse in Return to School. https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72dfff9-4ed7-833f-215de278d256/UploadedImages/PDFs/COVID-19_Interim_Guidance_Role_of_the_School_Nurse_in_Return_to_School_Planning.pdf.
National Association of School Nurses (NASN) (n.d.). The Valuable Roles of School Nurses during COVID-19. https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/School-Nurse-Activities-during-COVID-19.pdf.
National Association of School Nurses (NASN) (2020b). Framework for 21st century school nursing PracticeTM : Clarifications and updated definitions. NASN School Nurse, 35(4), 225–233. https://doi.org/10.1177/1942602X20928372
Pattison, K. L., Hoke, A. M., Schaefer, E. W., Alter, J., & Sekhar, D. L. (2021). National survey of school employees: COVID-19, school reopening, and student wellness. Journal of School Health, 91(5), 376–383. https://doi.org/10.1111/josh.13010
Strauss, V. (2020, July 25). Confused by CDC’s changing guidance on school reopening? Here are recommendations from experts not pressured by the White House. The Washington Post. https://www.washingtonpost.com/education/2020/07/25/confused-by-cdcs-changing-guidance-school-reopeninghere-are-recommendations-experts-not-pressured-by-whitehouse/.
Wang, L. Y., Vernon-Smiley, M., Gapinski, M. A., Desisto, M., Maughan, E., & Sheetz, A. (2014). Cost-benefit study of school nursing services. JAMA pediatrics, 168(7), 642–648. https://doi.org/10.1001/jamapediatrics.2013.5441
Willgerodt, M. A., Brock, P. D. M., & Maughan, E. D. (2018). Public school nursing practice in the United States. Journal of School Nursing, 34(3), 232–244. https://doi.org/10.1177%2F1059840517752456
Northeastern University School of Nursing, Boston, Massachusetts, USA
Corresponding Author:Northeastern University School of Nursing, Bouve College of Health Sciences, 360, Boston 02115, Massachusetts, USA.Email: j.gormley@northeastern.edu