The Journal of School Nursing
2025, Vol. 41(2) 195–196
© The Author(s) 2025
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DOI: 10.1177/10598405251316132
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Abstract
The coronavirus disease 2019 pandemic drastically shifted the public health burden onto the school health system. We, therefore, explored the school nurses’ experiences and needs for confronting the pandemic in school settings across Korea. This qualitative investigation enrolled 30 participants after their written consent. A written interview conducted through email and focus group interviews using an online meeting application verified participants’ opinions and experiences. Collected data were subjected to text-mining and content analysis. The school nurse was found to be responsible for many tasks, including education on preventive measures with unclear quarantine guidelines. Content analysis identified three key themes: “aggravated difficulties owing to lack of support resulted in burnout,” “reflection on supportive resources; direct provisions were helpful,” and “needs and suggestions to safeguard students’ health in the event of another pandemic.” Recommendations should all be considered to keep schools and students safe from future pandemics.
Keywordsschool health service, COVID-19, qualitative research, infectious diseases, school nurses, public health
Many health problems and political, economic, and social changes have arisen with the advent of coronavirus disease 2019 (COVID-19). As the burden of infectious diseases increases, the necessity to reinforce a preemptive and comprehensive health response system for students increases as well (Choe et al., 2021). Even before the emergence of COVID-19, various new infectious diseases such as the H1N1 influenza A and Middle East respiratory syndromerelated coronavirus (MERS-CoV) pandemics were experienced (World Health Organization, 2009, 2022). The risk of widespread transmission must be considered for new infectious diseases without historical epidemiological data. Schools are areas where infectious diseases can easily spread. Therefore, schools must quickly implement correct preventive measures (Lewis, 2021; Odone et al., 2021). As students are vulnerable to infectious diseases, devising detailed strategies to reduce the risk of infection in schools (Esposito et al., 2021) have been emphasized.
In the recent pandemic situation, new and diverse health policies were adopted in Korea (Ministry of Education, 2022), and these need to be improved through on-site evaluations. Extreme strategies, such as school closures (Ministry of Education, 2022) are linked to problems like learning losses and declining socio-emotional wellbeing (UNESCO, 2022; United Nations, 2020a, 2020b) and clinical depression (AlAzzam et al., 2021). In Korea, the number of students suffering from mental difficulties such as depression and stress as well as from new infectious diseases are rising rapidly (Korea Disease Control and Prevention Agency, 2022).
Since the effects of the pandemic will continue for a long time and new infectious diseases will appear repeatedly in the future, it is crucial to reduce transmission with rapid community response and appropriate treatment (Corless et al., 2018). Public health demand for an effective and rapid response to the COVID-19 pandemic reiterated the need to prevent infectious diseases in schools to ensure consistent and sustained educational services (UNESCO, 2022).
The perception and voice of the school nurse are significantly important. In Korea, school nurses are all registered nurses and are in charge of health education and healthcare for students in need of medical services (School Health Act, 2021). They respond medically in emergencies, as well as manage the healthcare, health education, and safety of students, teachers, and employees (School Health Act, 2021). However, the principal of the institution, a nonmedical person, is responsible for all the policies of the school, and the same is true for infection control. Therefore, the scope of work of school nurses can vary from school to school at the discretion of the principal. In 2021, the School Health Act was partially revised, allowing more than two school nurses to be assigned depending on the size of the school, although most schools have only one school nurse.
School nurses responded to the novel infectious disease with despite its difficulty and a sense of duty (Lee et al., 2015). However, it has been observed that school nurses have been quitting their jobs (Shin et al., 2010). After MERS, a national crisis response manual has been distributed to schools in Korea (Ministry of Education, 2016a), but the difficulty of the work of school nurses was aggravated by the prolonged COVID-19 pandemic (Kim & Cho, 2022). Exploring the COVID-19 experiences and needs of school nurses in Korea, as well as identifying specific details, will assist in devising measures to overcome their difficulties and improve job performance.
Thus, this qualitative study aims to explore the experiences of school nurses in responding to the COVID-19 pandemic in schools, including both the challenges they faced and the support they need for the future.
This study employed qualitative research methods such as content analysis and online Zoom focus group interviews to identify the experiences and needs of school nurses during the COVID-19 pandemic. Focus group interviews were analyzed using the conventional content analysis method, and the written interview contents were analyzed using text-mining, a form of summary content analysis (Hsieh & Shannon, 2005; Vaismoradi et al., 2016).
In Korea, school nurses are those who have completed additional teaching courses in the nursing school, obtained a nurse license after graduation, and received a teacher certificate from the government after an exam (Elementary And Secondary Education Act, 2021; Enforcement Rules of the Teacher Qualification Examination Decree, 2022). Among school nurses working in elementary, middle, and high schools across the country, those who could participate in the interview were recruited using a snowball sampling method. Thirty school nurses, who understood the aim of the study, participated in this study and provided their personal information and written consent.
Participants were affiliated with the following school settings: 18 elementary schools, 7 middle schools, 4 high schools including 1 boarding school, and 1 special school for disabled students, including developmental disabilities. Schools in Seoul and Gyeonggi Province had the most participants. The nurses worked at schools located in a variety of cities and suburbs. Most of the participants encountered students from multicultural families, but no one worked in international schools or schools only for students from multicultural families. The average age of the participants was 50.6 years, and the average years of employment was 21.5 years. Among the respondents, 29 were female, and 1 was male. Their educational backgrounds included 10 with bachelor’s degrees,12withmaster’s degrees, and 4 with doctoral degrees or completed doctoral courses (Table 1).
This study was conducted as a legally mandated public health investigation under the authority of the Infectious Diseases Control and Prevention Act (No. 12,444 and No. 13,392). It was exempted by the Institutional Board Review of Korea University Anam Hospital from oversight (IRB No. 2022AN0244).
The consent form for participation, which included explanations of the purpose of the study and the interview process using Zoom recordings, was provided to each participant via an email attachment to obtain the participant’s signature. Before the interview, a brief explanation of the purpose of the study and assurances of anonymity and confidentiality were given. A predetermined honorarium for the participants was provided after the interview.
The opinions of the participants were obtained from their responses to a written interview. The questions included in the written interview were: (1) “What do you think should be included or most important in the infectious disease prevention and response system?”, (2)“What do you think are the criteria for deciding between face-to-face and remote classes?”, (3) “What are the most participatory and least participatory parts of the infectious disease prevention and response system?”, (4) “What are some difficult problems to decide at school or situations that need the help of outside experts?”, (5)“What resources and connections are most helpful to the community and beyond on the current school site?”, (6)“What do you think will be needed in the future to better respond to infectious diseases?”,(7)“What do you think students have lost in terms of health while responding to infectious diseases on-site?”, (8) “Who are the vulnerable groups in the current infectious disease response system?”, (9) “What do you think is the overall evaluation and improvement of the infectious disease response manual, response system, and support?”, and (10) “Among the current infectious disease-related laws (School Health Act, Infectious Disease Prevention Act), which parts do not reflect reality or need revision?”’
Based on this, focus group interviews were planned, and four interview sessions were conducted using a web-based application for video conferencing (Zoom, Zoom Video Communications, Inc., San Jose, CA, USA) from April 25 to May 4, 2022.
Preparation. Interview participants were divided into four groups and informed about the date and time of the meeting and instructions on how to join the meeting, via email. Interview questions were provided, and participants were instructed to respond to a brief questionnaire to obtain their personal information.
Semistructured Interview Questionnaires. Semistructured, open-ended questionnaires were prepared per the Infectious Disease Prevention and Crisis Response Manual for Students (2nd ed) (Ministry of Education, 2016a), Comprehensive Measures for Student Infectious Disease Prevention (Ministry of Education, 2016b), and Guidelines for COVID-19 Infection Prevention Management in Preschool, Elementary, Secondary, and Special Schools (Ministry of Education, 2022) issued by the Ministry of Education.
The research questions were “What is the experience of school nurses in the field of preventing and responding to student infectious diseases?” and “What are the demands of the field for the current student infectious disease prevention and response system?”.
Interview Procedure. The focus group questions and guides were distributed in advance. The interview was conducted via a video conferencing tool by a researcher who had experience in conducting qualitative research, including focus groups. Participants were divided into four groups, with six to ten people in one group considered the appropriate sample size (Hennink et al., 2019). Each interview took 90 to 120 min and was recorded with the consent of the participants. The interviews continued until all relevant data had been collected from the participants, and ended after confirming that each participant had no new statements (Gill, 2020).
Another designated interviewer wrote field notes during the interview and gave debriefings. Postinterview, the participants reviewed and agreed to the interview content through the debriefing process.
Text-Mining Analysis From Written Interviews. The data collected through written interviews were analyzed via textmining to structure unstructured text through parsing and filtering. Frequency analysis visualized through the “word cloud” technique was employed to identify core word expressions. The results showed that the “school nurses” of “schools” were in charge of many “tasks” during the “infectious disease” situation and were experiencing certain difficulties. From these results, interview questions for focus group questions were constructed:
“What tasks are you in charge of regarding infectious diseases?”
“What does it mean to lack experts?”
“What was your experience regarding guidelines, official documents, and infectious disease prevention policies?”
“Specifically, what were the most helpful and the least helpful guidelines?”
“What are the demands in the field?”
Content Analysis. Content analysis was performed according to codes and categories (Saldana, 2016). The entire recorded interview was transcribed by a trained assistant, and a random number was assigned without identifying the participant. The transcribed interview contents were subjected to a meticulous process of sentence-by-sentence reading, wherein meaningful sentences were extracted and organized as codes. These codes were further condensed based on their similarity and categorized into subcategories. Subsequently, the data were abstracted and grouped into categories, representing themes related to participants’ experiences and needs.
To enhance the reliability of the data analysis and to exclude preconceived notions and prejudices, two independent researchers conducted individual analysis, and multiple meetings were held to ensure consensus on the analysis results. Additionally, feedback from a researcher with expertise in focus groups and qualitative research was sought, leading to the reclassification of certain categories and codes, along with the addition of a new theme.
The final analysis results were crosschecked against the original data.
As a result of content analysis, thirty major codes were extracted through the initial precoding, and ten categories and three themes were derived. The themes were “aggravated difficulties owing to lack of support resulted in burnout,” “reflection on supportive resources; direct provisions were helpful,” and “needs and suggestions to safeguard students’ health in the event of another pandemic” (Table 2).
Participants experienced aggravated difficulties owing to a lack of administrative support and cooperation. Moreover, the Guidelines for COVID-19 Infection Prevention Management in Preschool, Elementary, Secondary, and Special Schools (Ministry of Education, 2022) were not suitable for the situation and were difficult to follow. Therefore, participants experienced physical and mental burnout.
Lack of Cooperation and Help. Participants had to undertake all administrative work involved in the disease prevention practice, including recruitment of manpower and managing people with symptoms. Moreover, the school nurse had to handle all related complaints and tasks, even on weekends, because of the prolonged nature of the COVID-19 pandemic. Excessive and unnecessary official documents and ineffective guidelines added to difficulties at work. These difficulties were aggravated by continuously performing work alone without division of labor. School nurses found difficulty in receiving help owing to the lack of awareness from managers and other school colleagues. Conflicts arose when they asked for a proper division of duties. Therefore, the participants endured the workload on their own. Further, no person was put in charge of interpreting the work manual and dealing with each situation. It was difficult to contact the local public health center or the education office. Moreover, there were no health experts or medical personnel in the school’s COVID-19 response team. Therefore, they could not get adequate help.
“I had to respond to a huge number of inquiries most of the time except during sleep.” “There is no expert to ask or consult, no cooperation.”
Difficulty in Following Guidelines. Many quarantine guidelines did not reflect the school situation, and consequently, were difficult to apply. School nurses encountered challenges when confronted with conflicts between the National Quarantine Protocol and the guidelines provided by the Ministry of Education. Furthermore, the disclosure of policies to the media prior to their implementation at the site led to an escalation in parental complaints.
“Since there were no detailed guidelines issued specifically for each school field case, the schools had no choice but to interpret issued guidelines on their own and create additional guidelines.”
“Parents complained why the community health centers allowed their kids to go to school, but then the school isolated them.”
Physical and Mental Burnout. School nurses had a responsibility to protect the school community, with student safety as a priority. This became a psychological burden they carried as they were the only qualified medical personnel in the school. In the context of the prolonged pandemic, school nurses were exhausted physically and mentally as work increased tremendously; fatigue and stress accumulated, resulting in physical illness and accidents. They disclosed that there was insufficient compensation for excessive work and felt that people were unaware of the importance of school nurses. There was a lot of stress and fear; school nurses took sick leaves or planned to quit.
“I feel like I was thrown, without any weapons, into the midst of a disastrous war.”
“We are the only medical professionals in school, and we felt the pressure to control and take responsibility for the situation.”
“Going on three years without taking care of one’s health, there may be an accident.”
Participants evaluated support resources on the prevention of and response to infectious diseases.
Effective and Supportive Direct Provisions. School nurses felt that the direct provision of support instructors and quarantine supplies was an effective and helpful resource. They also believed that educational information and materials were useful. The selfscreening app was a mobile application provided by the Ministry of Education (2020), allowing students to conduct a daily self-assessment of their health status. It was useful in identifying symptomatic patients and increasing compliance rates to personal hygiene guidelines, including hand-washing.
“It was helpful that the local education office purchased and distributed quarantine items.”
“It was helpful when additional medical personnel was assigned to the school.”
Some Room for Improvement. School nurses complained that COVID-19 self-home-test kits were provided as a bundle, division, and repackaging had to be done individually for each school. It was not beneficial owing to inadequate manpower, it was time-consuming, and the participation rate was low. Temporary observation rooms had to be upgraded, and adequate manpower for school-based student COVID-19 screening had to be provided. They also remarked that simulated situation training for infectious diseases would have worked if all members of the school, including school administrators, had participated.
“Simulated training was not helpful since the school managers and other teachers did not participate, and there was no awareness of their roles in emergencies.”
Gained Resources in Hard Times. The participants opined that the most helpful resource they have gained was the group of fellow school nurses. School nurses endured hard times and exchanged opinions via online chats to solve problems in real time, thereby supporting each other. They believe their capabilities and confidence were strengthened as they had to innovate with inadequate resources available to them to tackle the situations that arose.
“I think I was able to endure it by relying on the group chat among the school nurses.”
The needs and strategies suggested by the school nurses to establish a safe school environment during any future pandemic were categorized as follows.
Precise Guidelines for Managing Different School Situations and Vulnerable Groups. In the infectious disease response system, children in kindergarten, students with disabilities in special or general schools, students in dormitories or athletic groups, and students with multicultural parents are considered vulnerable groups. Participants suggested that a support system for vulnerable groups, including after-school care of children and accompaniment to hospitals, is necessary. They requested more detailed guidelines for each school, based on size and situation, for measures to deal with various quarantine situations, with considerable leeway for schools to decide if a particularly difficult situation arises. Moreover, before implementing the policies or guidelines, school health experts should check the feasibility of the guidelines and the availability of adequate resources for implementation. Participants also remarked that it would be helpful to respond to complaints if accurate evidence or references had been included in the guidelines. Furthermore, it is necessary to present very detailed and clear information about the division of work for each school member in an updated manual.
“Distancing in schools is hard to maintain with children in real life situations.”
“Evidence or opinions of experts for each guideline should be provided to persuade others.”
Control Tower and Communication Channels. Participants said that a centralized comprehensive support center was needed to quickly respond to infectious diseases and prepare systematic crisis management measures. A task force including school nurses and medical experts needs to be constituted. For effective control of infectious diseases in schools, hotlines for communication between the school and community health offices or infectious disease crisis response departments were proposed.
“I hope the local education office has a response team consisting of school health experts only for schools.”
Revision of Regulations to Accurately Reflect the Work of School Nurses. Participants wanted legal protection regulations and authority to lead in the prevention of and response to infectious diseases in schools. School nurses, being the sole professional medical personnel in the school, should be given the power to make decisions and take responsibility. Paperwork and environmental hygiene tasks, on the other hand, should be allocated to nonmedical individuals. This allocation would enable school nurses to focus only on the practice of infection control. Moreover, job-related duties should be revised and redefined.
“With regard to the size of the responsibility, authority should be given to us, but we do not have the power to take legal action in a problematic situation while working.”
“We are the only medical people in the school; however other people do not consider us as medical professionals.”
Strengthen Student Health Education. During an infectious disease outbreak, the need for education to maintain health for all school members increases. Student health education should be further strengthened as a part of the regular school curriculum to keep schools safe from infectious diseases in the long run.
“Students are very good at hand washing, disinfection, and adequate ventilation because of health education. Consequently, preventing the spread of infectious diseases in schools and reducing the incidence of other diseases are possible.”
This study revealed that school nurses lacked adequate administrative support and struggled with increased administrative duties during the COVID-19 infectious disease outbreak.
During the pandemic, school nurses were burdened with administrative duties as well as health environment management. Not only school nurses but all teachers’ administrative work was affected due to school size or interaction with external environments during the COVID-19 pandemic (Kwon, 2021). It is necessary to confirm the administrator’s perception of the school nurse’s role to properly assign tasks and perform work efficiently (Green & Reffel, 2009). Moreover, the constant burden of teachers’ work requires the addition of appropriate administrative personnel.
In previous studies, Korean school nurses complained of a lack of support (Lim & Kim, 2021; Seo & Ha, 2022). Further, as the only medical personnel in schools, they have a great responsibility, without commensurate authority, to properly manage school infectious disease control strategies. In a pandemic environment, the increased burden thrust upon school nurses causes psychological stress (Yip et al., 2020). Stress and burnout lead to rapid turnover and retirement of school nurses, creating greater problems in managing infectious disease outbreaks in schools (Kim, 2015).
In Korea, school nurses are not in the same salary grade as curriculum-based teachers, so they do not receive the same amount of support and benefits from the school that curriculum teachers do. Health-related work is not subject to the criteria or standards typically applied in the context of merit pay (Yeo et al., 2011). Therefore, unless the principal orders support for school nurses during the pandemic, support is not forthcoming. The Ministry of Education has provided assistive manpower for school nurses during the pandemic (Ministry of Education, 2022). Despite being limited and insufficient, the school nurses confirmed that it was helpful. Therefore, additional manpower should be provided as essential in the future. School nurses expect to be recognized as medical personnel and be properly utilized as field experts who can focus on health education and nursing care for students (Willgerodt et al., 2018; McIntosh et al., 2022). For this to happen, current systems and regulations in Korea related to school nurses’ work need to be revised. School nurses suggested that changes in the perception of work division between colleagues and school managers and further strengthening their leadership are necessary. School nurses are valuable resources for future outbreaks of infectious diseases in schools. Therefore they should be afforded sufficient rest and compensation to better enable them to safeguard students’ health.
For school nurses, the direct provision of resources, including instructor assignments, was most useful for them. The rise in their workload without adequate manpower supply and the additional burden of performing complex administrative tasks must be rectified (Lee et al., 2015; Shin et al., 2010). The newly provided self-screening app that checks students’ symptoms before heading to school helped identify patients and was extensively used.
School nurses had to contend with vague, unclear COVID-19 guidelines that had to be interpreted and applied in the field. In the case of Korea, although the government created and distributed quarantine guidelines, the Ministry of Education delivered quarantine guidelines for schools separately, adding to the confusion. In the absence of medical experts inside the Ministry of Education, school nurses could not get adequate assistance even if they contacted the department that issued the guidelines. Furthermore, policies suitable for the field and specific strategies for infectious diseases in vulnerable groups were required. Previous studies mentioned the need for additional programs for school support (Cho, 2021) and for students who are in quarantine from school. This study’s participants cited additional vulnerable groups, such as students in special schools who cannot wear masks, boarding school students who require after-school quarantine, and children from multicultural families who cannot understand the guidelines or provide hospital companions as their parents are not familiar with the Korean language.
In the future, detailed guidelines based on current medical evidence, precise application models, and role allocations for the school as a whole, especially for vulnerable groups, are required. Plans that are appropriately validated and screened by school health experts for implementing guidelines should be provided, especially regarding the implementation of quarantine protocols. A centralized comprehensive control center with authority over all contagious diseases affecting students is needed. The teachers require a dedicated team of medical specialists with whom they can communicate and seek assistance during any future national infectious disease crisis.
School nurses have articulated that continuous infectious disease prevention education should be the most important policy (Jun & Lee, 2018). Most guidelines on infectious disease response are centered on managing symptoms or subjects, yet some previous studies pointed out the importance of strengthening health education for infectious disease prevention (Kim et al., 2012). Health education should not be restricted only to theoretical education but must include practical training that can be implemented daily. In addition, it is necessary to provide the learning objectives of health education for students in each grade level.
The strength of this study lies in its identification of the majority of problems faced by school nurses in schools through direct interaction with them, thus accurately reflecting realities on the ground. This study presents a significant contribution to the literature, as most guidelines on infectious disease response are centered on managing symptoms or subjects. However, few studies have emphasized the importance of strengthening health education and supporting the school nurses who manage infectious disease prevention. A major limitation of this study is that it did not include all the groups of school nurses, particularly those in preschools and colleges.
Using qualitative methods, this study explored the experiences faced by school nurses in the prevention and response to the COVID-19 pandemic and infectious diseases in Korea. The recommendations provided by these participants have the potential to enhance existing systems and effectively address practical field challenges. According to the study findings, ineffective work instructions, lack of cooperation, absence of a control tower, and the inability to address specific circumstances of the school led to increased workloads and complaints. As the lone medical professionals in schools, school nurses struggled to safeguard students from infectious diseases. These struggles caused these nurses to become physically and mentally exhausted with thoughts of leaving. School nurses require leadership from managers, school-centered quarantine policies, support from medical and school health experts, additional guidelines for vulnerable groups, and strengthened practical health education for preventing infectious diseases. They also call for rest, additional manpower, and revision of regulations related to their duties to safeguard student health in future pandemics.
In the future, studies on detailed policies on the level of infection control to be applied to schools and the standard indicators that determine isolation for each school grade are needed. Studies related to additional resources and policies to prevent students with disabilities or in special schools from deprivation of their right to learn are proposed. Finally, multidisciplinary studies for improving student health that encompass the community and improve the quality of life for school nurses are proposed. To comprehensively tackle infectious diseases in schools, education should extend beyond students and include faculty members and parents. By reflecting on the current crisis and the strategies employed to overcome it, valuable insights can be gained, paving the way for better preparedness to face future crises.
The authors would like to thank all participants for their responses. The results of this study were partially extracted from the policy report of the Seoul Metropolitan Office of Education.
CYJ and SK were involved in conceptualization; SK and KS in data curation, formal analysis, validation, and visualization; CYJ in funding acquisition; SK, KS, and MJ in investigation; CYJ, SK, KS, and MJ in methodology and writing—review & editing; and CYJ, SK, and KS in writing—original draft.
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 research was funded by the Seoul Metropolitan Office of Education (Seoul, Korea) in collaboration with the Ministry of Education (Sejong, Korea).
Kyoungsan Seo https://orcid.org/0000-0002-7343-5203
Se-an Kim https://orcid.org/0000-0001-9590-2426
Jihyun Moon https://orcid.org/0000-0002-0791-4054
The original contributions presented in the study are included in the article/supplementary material; further inquiries can be directed to the corresponding author.
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Kyoungsan Seo, RN, PhD, is an associate professor at College of Nursing, Chungnam National University.
Se-an Kim, RN, PhD, is an assistant professor at College of Nursing, Gachon University.
Young June Choe, MD, PhD is a pediatrician at Korea University Anam Hospital.
Jihyun Moon, RN, MPH, MSc, is a researcher and owner at Common Good Partners.
1 College of Nursing, Chungnam National University, Daejeon, Korea
2 College of Nursing, Gachon University, Incheon, Korea
3 Department of Pediatrics, Korea University Anam Hospital, Seoul, Korea
4 Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
Corresponding Author:Se-an Kim, RN, PhD, College of Nursing, Gachon University, 191 Hambakmoero, Yeonsu-gu, 21936, Incheon, Korea.Email: seiankim@gachon.ac.kr
