The Journal of School Nursing2021, Vol. 37(4) 292–297© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840521992054journals.sagepub.com/home/jsn
Pennsylvania responded to the COVID-19 pandemic by closing schools and moving to online instruction in March 2020. We surveyed Pennsylvania school nurses (N = 350) in May 2020 to assess the impact of COVID-19 on nurses’ concerns about returning to school and impact on practice. Data were analyzed using χ2 tests and regression analyses. Urban school nurses were more concerned about returning to the school building without a COVID-19 vaccine than rural nurses (OR = 1.58, 95% CI [1.05, 2.38]). Nurses in urban locales were more likely to report being asked for guidance on COVID-19 (OR = 1.69, 95% CI [1.06, 2.68]), modify communication practices (OR = 2.33, 95% CI [1.42, 3.82]), and be “very/extremely concerned” about their safety (OR = 2.16, 95% CI [1.35, 3.44]). Locale and student density are important factors to consider when resuming in-person instruction; however, schools should recognize school nurses for their vital role in health communication to assist in pandemic preparedness and response.
communicable diseases, health education, school nurse education, environmental health/safety, school nurse knowledge/perceptions/self-efficacy
The COVID-19 pandemic has plunged national, state, and local governments into a state of crisis as they work to mitigate virus transmission (Gates, 2020). Pennsylvania rapidly enacted several changes to flatten the curve, including statewide school closure in March 2020 (Commonwealth of Pennsylvania, 2020). This approach differs from the 2009 H1N1 pandemic response, where schools sparingly applied short-term school closure as a mitigation technique, retaining local decision-making control (Marchbanks et al., 2011; Uscher-Pines et al., 2018).
The American Academy of Pediatrics (2020) is concerned about the adverse health consequences (e.g., abuse, depression, suicidal ideation) students face due to school closures and advocated for in-person classes in fall 2020. COVID-19 data have shown “that children and adolescents are overall less severely affected by COVID-19 than adults,” suggesting that the benefits of returning to school may outweigh the risks (Götzinger et al., 2020). However, returning to school means increased risk of exposing faculty, staff, and family members, who may be more severely impacted by COVID-19.
We conducted a survey of Pennsylvania school nurses to understand the impacts of the COVID-19 pandemic on nurses’ perceived risk, concern for returning to school, role in their communities, and resulting changes to nursing practices. Specifically, we were interested in understanding how the COVID-19 pandemic is being perceived and impacting rural versus urban schools.
This cross-sectional, anonymous, internet-based survey of Pennsylvania school nurses was conducted in May 2020 and surveyed perspectives about returning to school during the COVID-19 pandemic. Participants were recruited through the Pennsylvania Association of School Nurses and Practitioners listserv and PENN*LINK, the official electronic mail service for the Pennsylvania Department of Education. Respondents (N = 414) completed a screener to determine eligibility. Eligible participants (N = 406) were 18 years of age or older, fluent in English, and were part-time or fulltime school nurses in Pennsylvania. Participants were invited to complete the survey and compensated with a $15 e-gift card for survey completion. The survey was limited to the first 350 participants due to available funds. The Penn State College of Medicine Institutional Review Board approved this study, and all participants implied their consent by survey completion.
Study data were collected and managed using Research Electronic Data Capture, a secure, web-based software platform designed to support data capture for research studies (Harris et al., 2009, 2019). The self-reported survey collected demographic information and included questions evaluating school nurse perspectives about the impact of the COVID-19 pandemic on personal and professional practices including the involvement in their school community. Questions also explored risk perceptions for returning to the school building using a 5-point Likert-type scale (Center for Drug Use and HIV Research, n.d.). Rurality was determined using school district and county by the National Center for Education Statistics’ Common Core of Data Public school data for 2018–2019 (Institute of Education Science, 2019).
Statistical analysis. All analyses were conducted in June 2020 using SAS Version 9.4 (SAS Institute, Cary, NC). Statistical significance was set at p < .05. Frequencies and percentages were calculated for all study measures. χ2 test were used to identify differences in nurse responses based on demographics. Significant items on χ2 testing were subsequently analyzed by binomial and ordinal logistic regression to quantify the strength of the association. The odds ratios were calculated with a reduced N of 337 due to missing values for locale.
A sample of 350 school nurses representing 55 of Pennsylvania’s 67 counties (82.1%) completed the survey (Table 1). Respondents represented 176 of the 500 public school districts, and an additional 48 schools were classified as either private, charter, or other. Sixty-five percent of respondents were from urban school locales, and this is representative of Pennsylvania schools as 68% of schools are classified as urban (Pennsylvania Department of Education, 2020a). Half of the nurses reported handling parent and/or student requests for guidance regarding COVID-19 (49.4%). Nurses reported a high likelihood of receiving a COVID-19 vaccine if/when available (84.9%); however, the majority (63.7%) were in support of students returning to school in the absence of a vaccine (Table 2). Locale was the only significant predictor of responses based on χ2 (data not shown). In regression analyses, nurses in urban locales were more likely to be asked for guidance on COVID-19 (OR = 1.69, 95% CI [1.06, 2.68]), change their communication practices (i.e., switch to only electronic communication; OR = 2.33, 95% CI [1.42, 3.82]), and be “very/extremely concerned” about their safety (OR = 2.16, 95% CI [1.35, 3.44]). Urban nurses were also more willing to get a COVID-19 vaccine when available (OR = 2.21, 95% CI [1.41, 3.46]) and concerned about returning to school without a vaccine (OR = 1.58, 95% CI [1.05, 2.38]).
School district locale played an important role in nurses’ concerns about COVID-19 and planned uptake of a COVID-19 vaccine. In Pennsylvania, the early part of the COVID-19 pandemic was concentrated to urban areas of the state, and case rates continue to be higher in urban settings, largely due to greater population density (Orgera et al., 2020). The disparity in infection rates likely accounts for the significant association between urban locale and nurse concerns. Guidance released by the Centers for Disease Control and Prevention indicates schools who plan to hold in-person instruction during the pandemic should adhere to key social distancing practices including ensuring students remain in small groups throughout the day, remain 6 ft apart, and do not share objects (Centers for Disease Control and Prevention, 2020a, 2020b; Pennsylvania Department of Education, 2020b). In addition, Pennsylvania-specific guidance indicates that schools may only provide in-person instruction if they have a health and safety plan that has been approved by their governing body and is available through their website (Pennsylvania Department of Education, 2020c). Despite this guidance, the realities of implementing academic activities and traditional nursing practices may present different opportunities and challenges based on each school’s structure and available resources, potentially contributing to the higher levels of concern for both safety regarding COVID-19 and returning to the school setting without a COVID-19 vaccine reported among urban school nurses. As school leaders consider plans for conducting inperson learning during a pandemic they should prioritize discussions with school nurses, focusing on concerns and implications on practice, particularly given the greater population density in urban schools compared to rural schools.
The role of the school nurse is undoubtedly evolving as a war against the COVID-19 pandemic wages on. School nurses are in a unique position to serve as content experts and, as described by the National Association of School Nurses (2018), “advocate for policy, system, and environmental change to facilitate a healthier community.” Similarly, a recent qualitative study by Faherty et al. (2019) described perspectives of school and preparedness stakeholders, including the importance of education and community engagement to improve social distancing practices during influenza pandemics. Nurses in our study described not only the impact of the COVID-19 pandemic on the traditional mechanisms for communication but also their ability to rapidly adapt to acute needs such as providing information to their school community. Their willingness to adhere to public health interventions, like receiving a COVID-19 vaccine, suggests an opportunity to role model these practices for students and families.
The ability to rapidly adjust to changing environments and the pivotal connection a school nurse has between health care and the school community suggests they are a critical link in supporting community public health during a pandemic (McDonald, 2020; Rebmann et al., 2012). Our findings support that school nurses need to be involved in school disaster preparedness planning and activities since they are the ones who are “responsible for implementing policies and programs to prevent infection transmission in schools” (Rebmann et al., 2012). However, capacity for this critical role may only be available with thoughtful planning and appropriate training to prepare school nurses for responding to a pandemic (Rebmann et al., 2012; Robinson, 2002; Willgerodt et al., 2018). Additional research is required to support the role that nurses play in the health, and by proxy, education, of students across the country.
Limitations to this study include selection bias, as responses may represent individuals with stronger feelings about COVID-19 and its impact on schools, particularly those representing urban schools due to increased COVID-19 prevalence when this survey was conducted. Additionally, the results represent perspectives from Pennsylvania school nurses and may not be generalizable to other states. However, the demographic characteristics of our sample were similar to a nationally representative sample of nurses who completed a recent survey described by Willgerodt and colleagues (2018).
In Pennsylvania schools, the decision to resume or maintain in-person instruction is made locally and may be influenced by proximity to urban and rural communities. The role of the school nurse is changing due to the pandemic, including the evolution of the nurse to serve a greater role in community health and disaster preparedness and infection control. This is in addition to adjusting their communication strategies and care provision to provide their normal standard of care to students. The voice of the school nurse is important in planning for current and ongoing school health and safety protocols, and school communities may be ready to listen now more than ever in order to make evidence-based decisions to protect student and school employee safety. However, understanding the capacity limitations of an already overburdened school nursing staff is critical, and a keen understanding of needed supports and resources will be important for school nurses to successfully adopt new roles.
We would like to acknowledge the Pennsylvania Association of School Nurses and Practitioners (PASNAP) for their support in distributing the survey to their listserv.
A. M. Hoke and C.M. Keller shared first authorship. The content is solely the responsibility of the authors and does not necessarily represent the views of the funders. The data set used during the current study is available from the corresponding author on reasonable request.
Alicia M. Hoke contributed to conception or design; contributed to acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Chelsea M. Keller contributed to conception or design; contributed to acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. William A. Calo contributed to conception or design; contributed to acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Deepa L. Sekhar contributed to acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Erik B. Lehman contributed to acquisition, analysis, or interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Jennifer L. Kraschnewski contributed to conception or design, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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 Merck Investigator Studies Program (MISP#57345) and the National Center for Advancing Translational Sciences, National Institutes of Health (UL1 TR002014, UL1 TR00045).
Alicia M. Hoke, MPH, CHES https://orcid.org/0000-0001-9061-6738
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Alicia M. Hoke, MPH, CHES, is a Research Project Manager at Penn State College of Medicine, Hershey, PA.
Chelsea M. Keller, MPH, CHES, is a Research Project Manager at Penn State College of Medicine, Hershey, PA.
William A. Calo, PhD, JD, MPH, is an Assistant Professor of Public Health Sciences & Family and Community Medicine at Penn State College of Medicine, Hershey, PA.
Deepa L. Sekhar, MD, MSc, is the Executive Director of Penn State PRO Wellness and an Associate Professor of Pediatrics at Penn State College of Medicine, Hershey, PA.
Erik B. Lehman, is a Biostatistician at Penn State College of Medicine, Hershey, PA.
Jennifer L. Kraschnewski, MD, MPH, is a Professor of Medicine, Public Health Sciences, & Pediatrics and Vice Chair of Clinical Research in the Department of Medicine at Penn State College of Medicine, Hershey, PA.
1 Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
2 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
3 Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA, USA
4 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA
Corresponding Author:Alicia M. Hoke, MPH, CHES, Penn State College of Medicine, 90 Hope Drive, Mail Code A145, Hershey, PA 17033, USA.Email: ahoke@psu.edu; ahoke1@pennstatehealth.psu.edu
