The Journal of School Nursing
2025, Vol. 41(2) 201–212
© The Author(s) 2023
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DOI: 10.1177/10598405231218532
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Abstract
As state and local government implemented school closures in response to the COVID-19 pandemic, school health services delivery experienced a fundamental change. School nurses were confronted with significant challenges to care for their students, while responding to the avalanche of public health responsibilities thrust upon them without training or resources. This qualitative study, conducted by a community-based participatory research partnership explored school nurses’ experiences and perspectives in urban and rural communities across New Mexico. Thirty-four school nurses participated in semi-structured qualitative interviews identifying 3 distinct pandemic stages and the following themes: 1) change/confusion of school nurse identity; 2) mental health challenges and stressors; and 3) lessons learned. These study results provide contextual depth to challenges that both urban and rural school nurses in New Mexico experienced during the pandemic and outline the important role school nurses have during public health emergencies in school settings.
KeywordsCOVID pandemic, qualitative research, school nurse, policy, community
The spring of 2020 left an indelible mark on our collective memories as the time when the COVID-19 pandemic began. While the COVID-19 virus circled the globe, federal and local governments closed institutions, businesses, and schools, suspending in-person exchange across communities for an unforeseeable future. For those working with and in school environments in the U.S, school closures brought an abrupt close to end-of-year activities. Smaller pandemics like the 2009-2010 H1N1 influenza pandemic provided a reference of what might happen in school settings (Klaiman et al., 2014; Marchbanks et al., 2011; Pappas, 2011; Wong et al., 2010). However, the COVID pandemic was new, unparalleled, a phenomenon that left public health leaders treading in unknown waters. We now know several years later, that nurses and health care providers in clinical settings managed constant alterations in clinical guidelines, lacked personal protective equipment, struggled with national, state, and organizational policy changes, and experienced significant mental health challenges (Catania et al., 2021). School nurses were among them.
Schools and school districts that employed a school nurse were in a potentially unique situation: they had an in-house, health expert with intimate knowledge of their student population, many with public health training ready to implement evidenced-based practices and recommendations from public health scientists (McDonald, 2020). The twenty-first Century School Nursing Practice Framework (National Association of School Nurses, 2016) outlines critically important components of school nursing practice to guide any public health emergency: ongoing provision and coordination of health services, surveillance, screening, referral for services, health education, development and implementation of isolation/quarantine practices, interpreting surveillance data and public health guidelines, planning for care of vulnerable student populations, and leadership advising district and school-level policy. Given this context, there was tremendous capacity for school nurses to lead planning and implementation of evidence-based, public health practice to the changing COVID crisis in schools (Barbee-Lee et al., 2021; Combe, 2020a, 2020b; Kunz et al., 2021; Marrapese et al., 2021; Maughan & Bergren, 2020).
While some school nurses were tapped to help lead this response in their school settings, many were not (Burch & Stoeckel, 2021; Gormley et al., 2023). There were continual changes in pandemic-related guidelines for schools and torrential political winds from national and state level COVID policies wreaked havoc in school settings. School nurses struggled to implement public health orders they received while state governments juggled the economic impact of the pandemic, and debates raged between citizen health/well-being, the common good, versus individual freedoms (Romano, 2020). Ethically bound by their professional obligations (American Nurses Association, n.d.) and ready to facilitate a return to in-person learning, some school nurses quickly recognized how COVID policies required compromise to meet staff and administration demands (Lee et al., 2021) and often at the cost their own health and safety (Hoke et al., 2021).
Students’ needs continued to be prioritized even though school service delivery sharply decreased (Kranz et al., 2022). Remote online learning for students and teachers was difficult and inequitable, especially where infrastructure and internet were not dependable (Becker & Maughan, 2017) and students grew more disengaged (Jones, 2022; Verlenden et al., 2021; Viner et al., 2022). Rural school nurses possessed a unique understanding of the impact COVID was causing in rural families. For states like New Mexico (NM), one-third of residents reside in rural areas, 98% of counties have healthcare provider shortages, and over 60% of residents identify as a person of color or Native American (New Mexico Department of Health (NMDOH), 2019; USDA ERS, 2023). While just over 500 school nurses serve over 320,000 students, 20 percent of NM school districts lack full-time school nurses, and 10 percent are without any school nurse. While some studies recounted the role of school nurses earlier in the pandemic (Cook et al., 2023; Kim & Bae, 2023; Lee et al., 2021; Martinsson et al., 2021), there is limited understanding of the unique experiences of rural school nurses during the COVID pandemic, inclusive of challenges later in the pandemic (Sammut et al., 2023).
A community-based participatory research (CBPR) partnership representing the University of New Mexico (UNM) and the NM School Nursing Association weighed the challenges of NM school nurses: How did school nurses, especially those in more rural communities, navigate COVID for their students and schools? How did changing public health orders impact school health services provision? Funded by the National Association of School Nurses, this study aimed to 1) explore and detail the experiences and perspectives of NM school nurses during the COVID-19 pandemic and 2) describe barriers and facilitators for planning and implementing school health services for students during COVID-19. The UNM Health Sciences Center (UNM HSC) Human Research Review Committee approved this study (study protocol #21-236).
For this study, we employed a pragmatic, descriptive qualitative design (Doyle et al., 2020; Sandelowski, 2010) using a community-based participatory research (CBPR) framework (Wallerstein & Duran, 2010). Additionally, we operationalized the twenty-first Century School Nurse Framework (National Association of School Nurses, 2016) when designing interview questions, data analysis and coding structure, and interpretation of findings to various school settings. We recruited and collected data from school nurses across NM, and data collection and analysis took place parallel to the changes experienced by the participants through the 2021/2022 academic year. We wanted to explore and better understand how school nursing was impacted by the changing pandemic phenomena.
A convenience sample for this study was recruited via emails sent to the state school nursing association membership list, school health and public health professional network list servs, presentations to school nurse meetings, recruitment information posted on social media sites and sharing of study information within social networks. We screened potential participants for the study inclusion criteria: 18 years of age or older, currently working as a school nurse in NM, and had worked as a school nurse in NM since March 2020 when the pandemic began. Recruitment continued through data collection and analysis stages, until we reached data saturation (Patton, 2015).
Data were collected through virtual, individual interviews conducted over a secure Zoom meeting platform following best practices for secure online meetings. The research team collectively decided that the academic PI would conduct all interviews. However, during the data collection period, the interviewer (PI) regularly discussed and reflected on the interviews with the school nurse research team members to ensure reflexivity of the PI, who was not currently working as a school nurse. The research team collectively developed the interview questions based on a comprehensive review of the nursing and school health literature that focused on school-based pandemic challenges, and the lived experiences of the school nurse research team members. Two additional NM school nurses reviewed the research questions for content validity and relevance.
Prior to the interview, participants provided verbal consent for participation and completed an anonymous demographic questionnaire asking their age, gender identity, race, ethnicity, years of experience in school nurse, type of school where they worked (primary/secondary), number of schools they covered as a school nurse, and geographic rurality (USDA ERS, 2023); participants were encouraged to select all categories of race that described them. The de-identified, demographic data was collected in REDCap, a secure, encrypted online data-entry platform (Harris et al., 2009). Each participant was then asked to describe their experience since COVID-related changes had been initiated in schools, what type of role they had in their respective school districts COVID response, and what had changed for their school nurse practice at their school or district since the beginning of the pandemic. Additionally, participants were asked to describe what they experienced or observed that helped and hindered addressing student needs during school closure and re-entry, what school nurses needed to address student health needs, and their most important lessons learned. Anticipating that some participants may experience discomfort discussing their pandemic experiences, the interviewer offered each participant a list of local mental health resources to contact if needed. Interviews were audio recorded, transcribed by a professional transcription company, reviewed for accuracy, and de-identified. Each participant received a $50 electronic merchandise card in gratitude for their time and expertise they contributed to the study.
Data analysis began and continued through the data collection period to provide consistent assessment of the amount and type of information shared from participants. We analyzed the de-identified transcripts using a participatory, team-based, iterative analysis process, involving all members of the research team (academic and school nursing). After uploading transcripts into NVivo qualitative analysis software (Lumivero, 2023), we created a preliminary a priori, coding structure using the 5 domains of practice from the twenty-first Century School Nursing Framework (standards of practice, care coordination, leadership, quality improvement, and community/public health), the day-to-day understanding of school nurse experiences to date during the pandemic, and a comprehensive review of the current literature to date. We entered this initial coding structure into NVivo software, then team members coded one transcript, and compared the results for accuracy. Team members then coded each interview transcript, meeting frequently to collectively discuss the analysis process, refer to field notes and memos, adding additional codes as necessary, until consensus was reached for codes within each transcript. We maintained an audit trail of discussions, reflections, and analysis decisions, finalizing data collection when the team collectively determined saturation of thematic findings. Five study participants were randomly selected and contacted by phone to member check and share preliminary findings for reflection (Saldana, 2021). Their review and feedback supported the interpretations of the study findings. In addition to individual member checks, we shared the study findings to the larger NM school nurse conference attendees in June 2023, their first, in-person gathering since before the pandemic. The study design and findings were presented to the larger group of conference attendees, with smaller, group discussions facilitated by the research team using a “World Café” design (The World Cafe, 2015). This process of collective reflection and co-interpretation of the study findings resulted in a deeper understanding of the data, adding rigor to the data analysis process.
We conducted thirty-four (34) interviews with participants from the fall of 2021 through winter 2022. Table 1 describes the sample of participants including age (mean = 48.9 years), gender (94% female), race (70% non-Hispanic/Latinx), ethnicity (85% White), years of school nursing experience (44% had 5 years or less), geographic rurality (41% in rural/frontier), type of school where they worked (65% worked in primary schools), and the number of schools covered (62% worked in 2 schools). Of note, none identified as working in just one school. The data analysis resulted in the following thematic findings: 1) identification of three pandemic stages, 2) change and confusion of school nurse identity, 3) mental health challenges and stressors, and 4) lessons learned. Each of these themes and their respective sub themes are described below.
The data analysis identified three distinct stages of the pandemic experienced by school nurses. Stage 1 began in March 2020 through the initial summer of 2020. Similar to the rest of the U.S., the NM state government closed schools and businesses and directed schools to move to online instruction. During this time, many participants described feeling unsure, not knowing what to expect. One rural school nurse described a lack of direction or sense that anyone was in charge: “It’s not like (the state government) has provided us a path or even any direction about what’s the best route. It’s ‘figure it out on your own.’ Do this and then figure it out on your own” and “it’s like crickets from the (health department) as far as direction and guidance.” During this stage, participants expressed confusion at not being consulted by their schools or school districts for planning and preparation for the upcoming school year, described by one rural school nurse: “I feel like they really didn’t take the nurses into consideration. Our professional background, our experience, our knowledge, they didn’t ask. They just didn’t ask.”
Stage 2 encompassed the fall through the winter of 2021 when schools went completely online. Some participants returned in person to their school sites, others worked remotely from home, most described this stage with anxiety, disconnect, and loss of contact with students, families, school staff. This was summed up by one rural school nurse participant:
All that flashes to my head is COVID and worry about other things I felt I should be doing or I felt disconnected, not only from my students, but colleagues, family. Just kind of felt freefloating out there, a sort of feeling of disconnectedness. Because I’ve been a school nurse for a lot of years, and this was all unanticipated, kind of was like exploring uncharted territory. It was uncomfortable for me because it was not something I ever anticipated, and I felt pretty much out of control.
At this time when public health leaders were trying to discern the best course of action, multiple versions of the state government guidelines “COVID-19 Response Toolkits” were issued. One rural school nurse described: “The (public health) guidance constantly changes or they don’t give it to us at all. Then they release it a week before school starts.” Participants found they were able to apply their public health expertise to address the “continual barrage of COVID 19” edicts that were directing their day-to-day practice. They described feeling like both the hero and public health expert in the schools.
Stage 3 started in the spring of 2021 when public schools re-opened, marking one year since the pandemic began, and the end of the lockdown when students and staff returned to in-person instruction. Despite relief at the possibility of returning to school, confusion grew as school nurses tried to interpret vague, frequently changing COVID policies, often without support. Angry confrontations escalated during this stage as school administration, students, staff, families and the larger communities where they worked questioned the policies school nurses were responsible for implementing. One urban school nurse described, “We all know that this whole public health crisis took a turn that none of us ever expected to see, being politicized and people having very deep emotional reactions to a lot of things.”
As their knowledge and nursing expertise was called into question, many participants felt support for their expertise erode. Instead of being credited as the reason students stayed in school, school nurses were now perceived as the reason students left. They were the “COVID-nurse,” screening students, often sending them home. Trust from students, families, and school staff faded for many school nurses as they “turned from the hero to villain.” One rural school nurse described the dramatic change: “It generated a lot of distrust, especially in our community and the lack of understanding. They just don’t understand because they’re not trusting in what’s happening. They don’t trust anybody anymore.” Another rural school nurse described the loss of being able to use their experience and nursing expertise: “Heightened vigilance to the point of really stifling the ability to do anything. Our critical thinking wasn’t really something that they wanted.” Another rural school nurse described the frustration of this stage: “I cannot finish one thing. I mean, when I’m doing something, they keep coming and calling. It’s easy to lose what I’m doing, because so many things happening and I’m the only one taking care of everything.”
Participants described their identity as a school nurse changing through the pandemic. Many nurses define who they are by what they do, there was confusion defining who they were given how their workload changed based on the pandemic stages. Their workload grew to include surveillance tracking, contact tracing, reporting, designing and managing isolation/quarantine procedures, and changing COVID vaccination recommendations. Many participants reported working 12 + hours most days, taking calls from school staff, parents, community members into the evening and weekend. As one rural school nurse participant shared, “It’s all COVID care, my whole job is COVID-COVID-COVID,” another described: “I have felt less like a school nurse, and more like the COVID police.” One urban school nurse participant compared their school nursing care before and how it had changed: “I’m just doing COVID care and I’m not doing the nursing care that I was doing before. Sometimes I feel like, I’m sorry I don’t have time to talk to this particular student because I get a call from a teacher saying, ‘There’s a kid in my class and he’s got COVID-like symptoms.’”
Many participants reported rarely being invited into the spaces where the pandemic response policy was discussed and created. However, they were most often the person given the responsibility to institute the school COVID policies, left responsible for translating and explaining them to fellow school health staff, students, families, and administrators. One urban school nurse described how difficult many of the policies they were asked to enforce, “You can’t have kids 6 feet apart when you have 23 kids in a small classroom.”
As COVID became increasing politicized, many school nurses fought against disinformation to support public health recommendations. For school nurses working in more rural communities where small-town relationships are a treasured foundation, participants described tremendous strain on relationships with individuals who did not agree with the mitigation measures in the school setting. By practice, school nurses are responsible for keeping their school and students healthy and safe, using evidence-based practice to guide their decisions. Now, school nurses had to be the enforcer of new COVID policy, deciding when students and staff were sent home, and when they could return. One rural school nurse participant described this tension:
As school nurses we’ve (had to be) the enforcer of the rules, the protocols are fracturing relationships. I think that one of the things I love the most about school nursing is the relationships that we make with our community, with our kids, with our parents, the teachers. It feels like people are so angry. And then when we’re asking kids to stay home and test, when we’re having to say you can’t come back to school because you’re a close contact or because you’re positive, the anger and the emotional response is– it was unexpected to me and really, really hard to handle, that anger coming at us.
Prior to the pandemic, school nurses were lauded for being a key variable to increasing school attendance, supporting students to stay in school to learn and be successful. However, a reverse dynamic was created during the pandemic. New policies required COVID positive cases to be sent home until they tested negative, often for 10 days or more. This change increased student absence described by one rural school nurse: “Now nurses in my district are being seen as a barrier to education, and that has never been true before.” Another rural school nurse participant described the shift exemplified by students not wanting to come to see them: “Students used to want to come. They’re afraid to come (to SN office) because they don’t want to get sent home.” For many school nurses, this role reversal of creating more student absence contributed to additional role confusion.
Participants experienced an increase in mental health challenges and stressors related to the overwhelming burden they felt created by the pandemic. This burden included the many changes managing COVID protocols in their school, maintaining contact with students and staff during closures, managing parental anxiety and anger, dealing with interactions with administration, parents, and students that were laced with political undertones, and their own personal emotional/mental stress. One rural school nurse described managing the overwhelming work load: “At one point I was doing anywhere from 10 to 19 (student quarantines) a day. So, it got really, really crazy. Really, really crazy. I don’t know if this is what I want to be doing. I know it’s valid. But it was really sucking the life out of me.”
Participants shared they felt they were the “dumping ground” for all things COVID, including the challenges schools were having during COVID. An urban school nurse participant shared they kept trying to manage all of the work, but felt like it was never enough: “They just keep adding on to what we have to do and guess we’ll figure it out.” A rural school nurse participant described the dread of what would happen if they left their office: “I couldn’t leave my office for more than about 15 min because I’d come back and there’d be all kinds of kids with issues. The kids were coughing in class. Teacher would panic, send them to the nurse.”
Participants also shared the trauma they endured from angry families and students, including verbal and emotional abuse, physical threats, and threats of lawsuits. This type of reaction was more commonly reported when the school nurse sent students home needing to be tested and/or quarantined, and would not permit them to return to school, or barred them from taking part in school activities or sports. An urban school nurse shared her confusion: “I’m in tears because I’m so angry sometimes, because I don’t understand what they want us to do. I don’t know, I guess that’s one of the hardest things right now is feeling like we’re in the middle.” A rural school nurse described how disinformation and disbelief about COVID has questioned their judgement as a nurse: “Even today, I’m sure someone will ask me if I still think it’s real. I get asked that almost every day. ‘Oh, is this even real?’ They still think it’s a conspiracy, they still think it’s fake.” The anxiety experienced by participants was summarized by one urban school nurse: “It was just too much for everyone. And there were incredibly unrealistic expectations of us. Myself personally, once we went into the next school year, just the fear and the anger and the paranoia was overwhelming.”
Some participants reflected on how other school nurses helped them manage the stress and anxiety, joining a weekly, virtual call to share information, and support one another:
I think my fellow nurses, we’ve made ourselves more available to help each other out when we have questions, which is different than pre-COVID. I kind of felt like I was by myself, although there were these other nurses. I just didn’t talk to them very often. I felt like I didn’t really need to. I could get by on my own. Now I think we all have a million questions, and we all need refreshers. I think having a good support system and work environment, other nurses to depend on, I think those make a big difference.
Concern Regarding Student Well-Being. The relationships that school nurses make and nurture with students, like many school professionals, is at the heart of why they do what they do. However, being separated from students during school closures and quarantine periods contributed to school nurses’ stress. In rural communities, lack of dependable internet service, geographic distance to check on students or for families to access healthcare, and difficulty accessing COVID tests and masks required for re-entry to school settings added to the challenge. Many participants had growing concern for students living in settings without emotional and/or financial support, or where students were left at home to take care of themselves and their siblings. One school nurse described their worry: “What happened at home during the shutdown? Then now they are quarantined at home online, watching TV, their parents aren’t home, and they’ve been trying to take care of themselves at home.”
Some participants described distress and ethical challenges as students were kept out of school (Baker et al., 2023; Gebreheat & Teame, 2021). Balancing COVID protocols with student needs for social/emotional development and academic continuity, participants also were anxious that students might be sent home to unsafe home situations. One urban school nurse described their concern for a student whose parent struggled with mental health issues:
We had one little girl that we were really worried about that mom has mental health issues and the child had not been seen at all, wasn’t showing up for her online classes. It was my job to go over to her house. I could hear them inside, but they would never open the door. I was so worried about her. We were able to finally get hold of grandma, they were alive and okay, but mom was not allowing her to leave the house, that was part of her mental illness. That was a thing. Mental health issues got worse, are still getting worse.
Student Behavioral Health Needs. After returning in-person, school nurses observed some student’s regression in academic and developmental milestones and exhibiting more extreme emotional behaviors, fighting, and suicide attempts. Many students were trying to manage their own mental health, described by an urban school nurse: “(There’s) not enough mental health support for the students…there were a lot of barriers, but the biggest barrier is the mental health. And now that’s manifesting not just in suicide, but violence.”
Participants identified the ongoing barriers to accessing scarce mental and behavioral health services, and the need for more mental and behavioral health services for students. A rural school nurse described a need in their school and community: “Somebody in the school to help them cope and help them strategize what to do in situations, that staff was not available. There just was not anyone to fill that position before and now it’s worse.” An urban school nurse described the increased needs since returning in-person: “There’s a lot of emotional problems. We are having record numbers of kids needing therapy, having a hard time socializing. They can’t get in to see therapists. There just aren’t enough.”
The fourth and final theme that emerged from participants were the lessons learned from the pandemic, a theme that weaved throughout data. The types of personal and professional lessons participants shared include grace, the importance of school nurses, flexibility, and community.
Grace. The phrase giving grace, offering kindness where it might not otherwise be expected, was shared repeatedly from participants. Grace was something expressed that participants offered themselves and something they extended to others, in the middle of a stressful situation or the unfamiliar situations the pandemic forced on everyone. Two rural nurses described this as: “We just need to give grace to everyone – everyone is stressed, scared, unsure, angry”; “Give grace for yourself, you are doing the best that you can. And some days are harder than others. And just reminding ourselves, ‘I’m not okay today, I’m going to need to take a minute.’”
An urban school nurse articulated how giving grace was a way to try and understand the collective, traumatic experience everyone was experiencing, and how they tried to comprehend why the extreme responses they had witnessed from others were so different from what they would have expected during a non-pandemic time:
Giving people grace and being able to give grace to others and to myself. Recognizing it’s very stressful, and people might lash out, but it’s not me, it’s not them. It doesn’t make them a bad parent or a bad person. They are just overwhelmed. And it’s like we’ve all been through this traumatic event together. We’re still in the throes of it. And we’re all having PTSD of a sort. We are all trying to cope and still be in the midst of the pandemic. And so just recognizing that we are all struggling and that we’re human beings. Sometimes we lash out. Sometimes we get frustrated, sometimes we all deal with it differently.
Importance of Their School Nurse Role. For many participants, the COVID pandemic confirmed the critically important function that school nurses performed in schools and school districts every day and especially during the COVID pandemic. After reflecting on their experiences during the interview, an urban school nurse shared the importance of their role: “School nurses at the school level working in the schools every day, they need to be part of the conversation, because we’re the front line, and we know what’s really happening and what is needed.” Another rural school nurse stated: “God, I just think school nurses are so important now. I always thought I kind of was. But now, I’m justlike,weare THE resource. And we should be. I don’t mindthatrole. I take it on. But I need more help to help me be a better resource.”
Flexibility and Community. Participants described how their experiences helped them put their work into perspective of a larger future. A rural school nurse reflected on the importance of being flexible: “I think flexibility has had to be the absolute– endurance and flexibility, the two terms that have to be at the top of any school nurse’s vocabulary right now.” Flexibility was also important to an urban school nurse who stated:
Flexibility, with a capital F. The ability to let a lot of stuff slide and roll off my shoulders, but balance that with being able to dig my heels in when it’s crucial and in the best interest of the students, the faculty, and the staff.
Participants recognized the importance of keeping the larger school community together during the pandemic, for both students and staff. One rural school nurse shared:
We need to remember, it comes down to functioning as a community and having support from parents as well as support from the district. I just wish I knew a way to unify everybody so that we could all work together and not send kids to school when they’re sick and not have a fight when your kid has to go home.
Reflecting how important the school community was for students, a participant stated: “I’ve learned that people, kids, they need each other. We all need people and people need people and kids need to be around other kids and other adults that aren’t just their parents.”
Through this study, we sought to explore and detail the unique experiences and perspectives of NM school nurses through the COVID pandemic. The data from participants presented a unique lens into the challenges these school nurses faced as they strived to provide school health services to their students during the pandemic. The study sample demographics mirrored the NM school nurse population (Ramos et al., 2024) and the national school nursing profession (Willgerodt et al., 2023). Participant narratives have similarities to data from other school nurses since the beginning of the pandemic (Baker et al., 2023; Gormley et al., 2023; Kim & Bae, 2023; Lee et al., 2021; Martinsson et al., 2021; Merkle et al., 2023) and the additional opportunity for reflection on the data by NM school nurse conference attendees in June 2023 further confirmed the nature of their experiences.
These data also expand previous descriptions of school nursing pandemic experiences. They include identification of the pandemic stages in schools, the deepening challenges as school nursing workload changed, and the challenges rural school nurse experienced. The pandemic stages reflected how shifting policies and the increasingly politicization of their work left school nurses having their evidenced-based, practice challenged daily (Hale et al., 2023). This shift from the initial stages of the pandemic lockdown to implementing increasingly unpopular COVID mitigation measures transitioned many school nurses from hero to villain. (Kim & Bae, 2023). While we were able to describe the unique experience of rural school nurses, they were similar to their urban school nurse counterparts. Rural school nurses did describe more strain in community relationships and less structural support.
Unlike some narratives from the beginning of the pandemic, more participants reported not being included in key decision making, planning, and policy creation than those who did (Rasmussen et al., 2022). Rather they were the recipient of policy and protocol created by others who were often unaware of their respective school settings, and were left to translate and defend these policies to students, school staff, and families. As experts in pediatric health care, community health care, and public health, school nurses (Rosen & Goodson, 2014) can be inhibited by the structural systems they work within. For example, districts that do not staff school nurses can be deprived of the school nurse’s expertise in policy making or implementation decision-making, leaving district and school leadership to make decisions without consulting them. When deciding on COVID school health policies, many participants reported that decision makers often did not understand or appreciate the many factors influencing how a school nurse will interpret policies through evidence-based practice.
Being responsible for implementing school health policies they did not contribute to creating is not a new phenomenon for school nurses. Previous evidence has demonstrated that school nurses often have to interpret vague school health policies, relying on their scope of practice, skills, experience, and strong advocacy to clarify vague policy language and determine the best course of action (Dickson & Brindis, 2021). However, the politicization of pandemic mitigation measures clearly exacerbated the situations in schools: even still, school nurses relied on their clinical expertise in evidence-based, public health-grounded practice only to find those practices unwelcomed (Baker et al., 2023; Taylor et al., 2022).
As the pandemic progressed and additional COVID workload stretched them thin, school nurses had to manage often abusive altercations (Baker et al., 2023; Kim & Bae, 2023), a reality that lingers for many school nurses. School nurses are a historically trusted source of preventative health information and practice. Yet they found themselves arguing to maintain social distancing requirements, defending quarantine measure when pressured to allow students to return (often athletes to play sports), and fighting for vaccinations to protect the most vulnerable students and school staff to return to school (Anthes, 2021). During a national nursing shortage that is projected to worsen in the coming years (Smiley et al., 2023), this treatment is unacceptable when students and schools need school nurses more than ever.
The sharp increase in student’s mental and behavioral health needs since the beginning of the COVID pandemic has been well documented. Participants’ observations of changes in students’ mental and behavioral health status (Bell et al., 2023; Samji et al., 2022; Viner et al., 2022) resulted in changes to their school nursing practice (Banzon et al., 2023; Hoskote et al., 2025). For NM school nurses, this change was heightened by the inequitable access to health services especially for rural communities (Burch & Stoeckel, 2021; New Mexico Department of Health (NMDOH), 2019; Ramos et al., 2014). This equated to additional time for school nurses to try and address students’ mental/behavioral health needs without additional resources or time to do so (Benton et al., 2022).
The personal mental health challenges participants shared are also familiar (Anthes, 2021; Brody, 2021; Chen et al., 2023). Merkle et al. (2023) surveyed a national sample of school nurses in spring of 2022 (N = 7971) and documented substantial mental health concerns in U.S. school nurses similar to the results of this study: 45% reported posttraumatic stress disorder, depression, anxiety, and suicidal ideation; 48% reported being bullied, threatened, or harassed. These experiences were ubiquitous to many school health and public health workers throughout the pandemic (International Council of Nurses, n.d.; Taylor et al., 2022; Will, 2023). The unacceptable working conditions and high levels of stress and burnout comes at a cost not only for those school nurses who decide to quit their jobs, elect for early retirement, and leave the profession they love, but also at a tremendous loss for students and the larger school community.
Overall these study findings support recent evidence of school nursing experiences during the pandemic and provide a unique perspective of NM school nurses, rural school nursing, and the changing pandemic context in schools.
The results of this study did not represent all NM school nurses’ experiences and participants self-selected to this study. The pandemic context in school changed after data collection and those experiences of school nurses were not included. NM school nurse experiences may be limited in how or if they transfer to other school settings or geographic areas. Despite these limitations, there were multiple study strengths. The participatory design of this study provided a school nursing perspective in the design of the study, recruitment methods, interview questions, and analysis of the interview data. The interviewer was not a school nurse, so did not have preconceptions about participants’ experiences. The study sample was representative demographically of the school nursing population in NM.
The perspectives and experiences of NM school nurses described in this study reflect similar experiences nationally and globally. They also describe the changes school nurses faced as school context shifted as the general public responded to COVID policy changes and pandemic mitigation measures became increasingly politicized. These data are important lessons for future public health emergencies, planning for school health delivery response, clarifying expectations and workload for school nurses to avoid potential confusion of their role, prioritizing the mental health support for school nurses, and the management of student health needs. These findings can inform future research exploring emergency preparedness for school health services delivery, and support policy advocacy efforts to increase funding for school nursing and other school health services that would fortify and strengthen school health delivery structures, particularly in rural communities (Brody, 2021; Willgerodt et al., 2023). Future research should include analysis of various school health service funding models that can impact the presence or absence of school nurses, especially those more rural settings where there currently are none. This research could identify gaps supporting valuable school nursing services and expertise that will be needed to prepare for the next public health emergency or pandemic.
As Lopez et al. (2022) addresses the impact of nurses’ pandemic experience, they soberly offer that “acts of selfsacrifice are not without their consequences,” words that all school policy leaders must consider. The greater nursing shortage that will grow due to attrition and retirement (Smiley et al., 2023) and this will impact the school nursing profession. This is a warning call to school districts, state and federal education agencies, and nursing education programs to learn from the experiences described in this and other studies as an opportunity to strengthen the school nursing profession. School nurses are clearly prepared by education, experience, passion, and ethics as ideal engineers to help lead multidisciplinary efforts for thorough, evidence-based pandemic response in school settings. Now is the time to center their voice, to prioritize the needs of students and staff within the school setting, and demand that school nurses be the instruments of change in the delivery of health care and public health in school settings.
We gratefully acknowledge the contribution of the school nurses of New Mexico and schools that support them who were affiliated with this study. We appreciate the study participants who generously gave of their time to share their experiences during the pandemic.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Association of School Nurses.
Elizabeth Dickson https://orcid.org/0000-0003-1248-368X
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Elizabeth Dickson is an assistant professor with the UNM College of Population Health and Center for Participatory Research, public health nurse, and school health advocate.
Lisa Crawford is the Director and Coordinator of School Nursing Services for the Gadsen Independent School District in Anthony, NM and Past-President of the New Mexico School Nurses Association.
Rhonda Sparks is a retired Director of School Health Service in Clovis School District in Clovis, NM and member of the Executive Board of the New Mexico School Nurses Association.
Anna Ciblis is a recent BSN graduate from the UNM College of Nursing and works on the inpatient unit at the UNM Hospital in Albuquerque, NM and is a school nursing advocate.
1 College of Population Health, University of New Mexico, Albuquerque, NM, USA
2 New Mexico School Nurses Association, Coordinator of School Nursing Services, Gadsden Independent School District, Gadsden, NM, USA
3 Clovis School District, Clovis, NM, USA
4 UNM Hospital, Albuquerque, NM, USA
Corresponding Author:Elizabeth Dickson, PhD, RN, University of New Mexico, College of Population Health, MSC07 4380 Box 9, 1 University of New Mexico, Albuquerque, NM 87131, USA.Email: edickson@salud.unm.edu
