Abstract
School closures in March 2020 due to the COVID-19 pandemic precipitated losses of critical student resources as physical, mental, emotional, and social needs escalated. Identifying the challenges, strategies, and changes in school nurse (SN) practice in Massachusetts during this pandemic is fundamental to understanding how to manage future anticipated pandemics while protecting children, communities, and SNs. The purpose of this mixed-methods descriptive study in the second year of the global pandemic was to (a) listen to SN voices through a novel online survey including the prompts of challenges, strategies, and practice changes and (b) describe the SN experience of COVID-19 response in Massachusetts schools, including identification of intent to leave school nursing. Responses were analyzed using descriptive qualitative analysis (n = 73). The prompts each elicited subthemes that coalesced to a cohesive theme: Finding one’s way required the support of others to pave untraversed roads.
Keywords
school nurses, school nurse voices, COVID-19, challenges, strategies, changes in practice, research network, attrition, mixedmethods research
Schools in Massachusetts abruptly closed their doors on March 17, 2020, due to the COVID-19 pandemic, causing many students to lose critical resources such as mental and behavioral health management, social and educational support, and chronic care. While community resources shuttered, school nurses (SNs) expressed concern regarding how to stay connected with children, including students with medical complexity or disabilities, students experiencing food and/or shelter insecurity, and those lacking in-home supervision due to parental employment needs (Hill et al., 2021). The Massachusetts School Nurses Organization (MSNO) endorsed that SNs remain responsible for supporting students, families, and school staff and assisting local boards of health with pandemic-related efforts during remote learning. SNs participated in contact tracing, viral testing, redeployment to inpatient units (Combe, 2020), data collection, and virtual visits (Maughan & Bergren, 2020). Schools reopened or partially reopened their doors in the 2020–2021 school year with hybrid modes of student attendance. As the partial and full school closures continued, students’ physical, mental, emotional, and social needs escalated and have not abated (Hill et al., 2021; Van Lancker & Parolin, 2020).
The purpose of this study was to listen to the voices of SNs during an ongoing worldwide pandemic, address the challenges, strategies, and changes to their school nursing practice, and describe the SNs’ experience of COVID-19 response in Massachusetts schools. Consistent with another study exploring nurses’ experiences during the COVID-19 pandemic, as well as a study of oncology nurses, an online survey method was employed (Banerjee et al., 2016; Halcomb et al., 2020). While still emerging, online platforms have been recognized as an opportunity to obtain qualitative data (Braun et al., 2021). A novel mixed-methods survey, Listening to School Nurses: Sharing Your Stories and Using Your Voices, provided insight by SNs reflecting on the school health experience at a time when most were experiencing a combination of in-person and virtual learning.
As SNs rapidly adapted to pandemic-associated priorities, it is still being determined how their traditional supportive, screening and health maintenance roles were affected, what care may have been missed, or what changes to school nursing practice occurred. The return of in-person education uncovered deficits in virtual elementary and secondary education and in the virtual SN management of students’ health care (Cohen et al., 2023; Macyko, 2022; McDonald, 2020). Identifying challenges and strategies that occurred across the continuum of the COVID-19 pandemic is needed to manage anticipated pandemics. COVID-19 provided an opportunity for policymakers to prepare for future school closures that include channels of communication and administration of health care (Cohen et al., 2023). Understanding the experience of SNs during a health crisis is fundamental in protecting children and communities and addressing the retention of the SN workforce (Berlin et al., 2022).
Multiple articles have described exemplary SNs during the initial year of the pandemic (Combe, 2020; McDonald, 2020; Rothstein & Olympia, 2020). The COVID-19 pandemic persisted, with variants emerging with returning to in-person school. As the pandemic evolved, a safe or supportive environment for SNs was not assured as the only healthcare provider in an academic setting (Bergren, 2021).
The COVID-19 pandemic continues to influence the school systems. Students returned full-time to the classroom, discontinued mask mandates, vaccinations with boosters encouraged but not required, and childhood mental health identified as a national emergency (Hill et al., 2021; Theberath et al., 2022; Van Lancker & Parolin, 2020). All these changes presented issues for SNs. Understanding and identifying the evolving role of SNs through these changes is imperative for the support and retention of SNs.
The effects of COVID-19 on front-line healthcare workers, primarily in acute and primary care settings, have been the topic of ongoing research. However, there is limited research regarding the impact of the global pandemic on SNs (Lopez et al., 2022). Three qualitative studies conducted with SNs from different countries explored the first year of the pandemic in Hong Kong, Sweden, and Korea, respectively (Lee et al., 2021; Martinsson et al., 2021; Um & Choi, 2022). The most recent qualitative study of SNs reflecting on COVID-19 explored their experiences in 2021/2022 (Dickson et al., 2023). The effects of the pandemic may have varied across time, space, and resources.
This mixed-methods study included both a qualitative component and a brief quantitative component. The qualitative section utilized a content descriptive design to illuminate the experience of SNs during a global pandemic. SNs wrote personal stories guided by three prompts about their school nursing practice during the COVID-19 pandemic. The three qualitative prompts were developed by Massachusetts School Nurse Research Network (MASNRN) members with multiple years of school nursing experience, including during the COVID-19 pandemic. Massachusetts SNs’ experiences were elicited at the close of the academic year, September 2020 to June 2021.
A qualitative descriptive design (Doyle et al., 2020; Graneheim & Lundman, 2004) was chosen to explore Massachusetts SNs’ experiences. An online survey format was chosen because the investigators were aware of the time constraints of SNs. The ongoing limitations with in-person and videoconferencing related to the pandemic offered no mutual time to interview SNs. The investigators planned to invite as many SNs who wished to express themselves. SNs had the opportunity to describe their experiences guided by prompts to voice their thoughts, experiences, and concerns about COVID-19 in their roles.
The three qualitative prompts included:
(1) What have been your challenges as a SN over the past year related to the COVID-19 pandemic?
(2) What are some strategies you have used to address these challenges?
(3) Recognizing the impact of the COVID-19 pandemic, how has your practice changed?
The quantitative component was comprised of close-ended questions related to the pandemic and SN demographics. Four close-ended COVID-19-related questions and responses included:
(1) Has there been enough personal protective equipment (PPE) for your school nursing practice? (yes/no)
(2) Does your district have a COVID-19 response team? (yes/no/unsure)
(3) How would you describe your working relationship with your local public health nurse (PHN)? (none/poor/fair/good/excellent)
(4) Do you intend to leave school nursing in 2021? (yes/no/unsure)
(a) If a respondent chose either yes or unsure, a follow-up prompt for open text response was cued: “What might cause you to leave school nursing?”
The chi-square test of independence examined any differences among SNs with intent to leave school nursing as the primary dependent variable. Demographic variables and remaining COVID-19-related closed-ended questions were independent variables.
Research Participants. The inclusion criteria required that participants be SNs, either active, retired, or resigned, employed as Massachusetts SNs providing direct care to students during the 2019–2020 and/or 2020–2021 school years. Approximately 740 Massachusetts SNs belonged to MSNO in May–June 2021 from public, private, and charter schools across rural, urban, and suburban areas.
Data Collection. Surveys were collected and managed using REDCap electronic data capture tools hosted at Boston College (Harris et al., 2009, 2019). An initial email containing informed consent and a link to the online REDCap survey was sent to SNs belonging to MSNO on May 1, 2021, with a single reminder email and closure at the end of June 2021. The survey was sent via the MSNO member listserv on behalf of the investigators. Snowball recruitment was added to the purposive sampling to reach as many SNs as possible, including those who may have left school nursing during the pandemic. MSNO nurses were asked to forward the email to any SNs who may have left the field/MSNO but had served a portion of the applicable academic years.
Qualitative Analysis. Qualitative analysis of all 73 respondents’ answers was conducted manually by the five experienced SN investigators. The qualitative analysis was separated into tasks as delineated below, with all study investigators reviewing the data and analysis. All 73 respondents’ answers to the main prompts were included in the data analysis. An additional analysis was conducted with the qualitative responses volunteered by 13 survey participants to the follow-up prompt: “What might cause you to leave school nursing?” This open text prompt was cued on the survey platform by skip logic to yes and maybe responses to the closeended question, “Do you intend to leave school nursing in 2021?” A deductive process was used due to the nature of the guided prompts.
An initial summative approach sought a common language or text written by participating SNs. Summative content analysis (Hsieh & Shannon, 2005) by two investigators (MLH and MJOB) was used to discover keywords or brief phrases in the written material. Subsequently, qualitative descriptive content analysis considered manifest and latent content (Graneheim & Lundman, 2004; Ravindran, 2019). Descriptive analysis using SNs’ written phrases was interpreted by the five investigators. Each prompt was considered separately for unique meaning units/codes. Three investigators coded meaning units for common phrases and thoughts expressed (MLH, LW, and MJOB). Subcategories analyzed within the focused prompts (Challenges, Strategies, Practice Changes, and Cause for Leaving) brought ideas of similar intent together. Subthemes and themes were assigned by an investigator (MLH) and verified by other investigators for agreement (MJOB, LW, CB, and JA). Separate themes, subsequently designated as subthemes, were interpreted for each main prompt (Challenges, Strategies, Practice Changes); however, an overarching theme gleaned from the three themes. Categories, subthemes, and themes derived from the latent content were interpreted and agreed upon by the consensus of all five investigators. Using the SNs’ quotes provided an opportunity to “hear” exemplar voices while interpreting categories and themes that unified these voices.
Quantitative Analysis. Conducted using IBM SPSS Statistics (Version 26). Frequencies and means were used to describe the sample, while the chi-square test of independence was utilized to identify differences among SN variables. Several variables were recoded. Intent to leave school nursing was recoded into yes/maybe and no. Relationship with PHN was recoded into two groups: excellent/good/fair and none. District COVID-19 response team was recoded into yes and no/unsure.
This study was reviewed by Boston College IRB (IRB Protocol Number: 21.264.01e). An email invitation was sent to potential participants, including a letter of informed consent stating the purpose of the study, as well as confidentiality and risk measures. A checkbox at the start of the survey indicated consent.
One hundred and thirty SNs consented to participate in the anonymous online survey, with 73 completing the survey. The response rate was approximately 9.81% of MSNO-affiliated SNs completing the survey.
The majority of participants identified as female. The largest SN groups were 51–60 years old, employed as SNs for 11–20 years, and Caucasian/White. Almost 90% of participating SN respondents hold a bachelor’s degree or higher in nursing. Complete details are found in Table 1. School demographics captured a wide range of schools consistent with total school demographics obtained from the Massachusetts Department of Education (MA DOE; Table 2). The majority of respondents served at public schools, of which charter schools are a unique subgroup overseen by an independent board of trustees rather than a school board. The percentage of free and reduced lunch participation >50% served as a proxy for community-level impoverished socioeconomic status. MA DOE changed this identifier to “economically disadvantaged” as a more inclusive term to denote economic status (MA DOE, 2015). Thirty-one percent of respondents served in schools with ≥ 50% student participation in the free and reduced meals program, consistent with Massachusetts state rates for economically disadvantaged. School location by respondents indicated a higher percentage of suburban participants, while 50% of schools are listed as “rural” by MA DOE. Whether the SNs reflected their school location by MA DOE identification or personal assessment is unknown.
Table 1. School Nurse Demographics. N %
A small number of closed-ended questions and responses specific to COVID-19 were asked of participants (Table 3). While all Massachusetts SNs reported having PPE, more than 40% of respondents indicated that there was either no or were unsure of a district COVID-19 response team. The SNs’ working relationship with PHNs was overwhelmingly positive, with 93% indicating it as either excellent, good, or fair. No SNs reported a poor relationship with PHNs, though 7% indicated they had no working relationship with any PHN. All SNs were asked if they intended to leave school nursing at the end of the 2020–2021 school year, with a follow-up question about the cause for leaving asked of “yes” and “maybe” respondents. Eighteen percent responded that they would or may leave school nursing. No statistically significant differences were found between the SNs who indicated intent or possible intent to leave versus no intent to leave.
A summative approach, seeking a common language or text written by participating SNs, identified singular words such as “guidance,” “information,” and “work.” However, the various contexts in which the words were employed limited consistent interpretation. Two investigators (MLH and LW) coded the separate prompts, revealing multiple codes/meaning units. Manifest content was determined by coding common phrases and thoughts. The codes/meaning units and their frequency of occurrence are listed in Table 4. Subcategories brought ideas of similar content together, while categories were assigned by investigators, who combined relevant subcategories and explored latent content. A depiction of the analytic process for a single prompt is presented in Table 5. Three subthemes, one for each of the prompts of open-ended questions (challenges, strategies, and practice change), were derived from the latent content of the categories. A cohesive, overarching theme emerged from the three subthemes,
Finding one’s way required the support of others to pave untraversed roads.
Each prompt was analyzed by content descriptive analysis separately for subcategories, categories, subthemes, and themes; however, related codes/meaning units were found in multiple prompt responses. For instance, SNs expressed “increased fear and frustration among our communities” among the challenges they faced, while “mental health issues” were identified as a practice change. The cohesive, overarching theme acknowledged the interplay between the three prompts and captured the scope of the second year of the COVID-19 pandemic on Massachusetts SNs and their practice.
Subtheme. Finding one’s way
Category A. Role revision—the role is known, but the specific knowledge and methods were new. SNs identified the most frequent challenge they faced was being the sole healthcare provider in school during a worldwide pandemic “Quickly taking on the role of local public health nurse as well as school nurse. Fielding constant questions from staff, parents, community members, students about COVID-19” (SN #101). The return to in-school learning presented its own unique challenges. Seventy-five percent of respondents were in a school with hybrid status, as the number of students attending in person varied daily. Just as the full closure of schools and businesses in March 2020 was entirely new in the United States, reopening schools in a hybrid format was also unknown. This presented a unique circumstance where SNs needed to create new protocols for in-person access to the health office, as well as the time-consuming tasks of COVID-19 assessment, testing, and contact tracing.
Dealing with the added responsibilities of assessing students and staff for COVID-19 symptoms, Binax testing, contact tracing, following students and staff through quarantine and isolation, providing DPH guidelines to parents and staff, and educating, all while carrying out the everyday responsibilities in the school nurse’s office. (SN #28)
Many SNs reported working well beyond school hours, including evenings and weekends, to follow up with families. They restructured their personal and professional lives as the work demanded while recognizing the unsustainability of this course.
Lengthy hours of work, low staffing asked to do much more work than usual. School nurse role during the pandemic became more intrusive on the lives of the community. We were responsible for the entire community, not just students in our schools. Ever changing dynamic caused a lot of stress and at times nearly broke all our backs from the amount of weight that was placed upon us. (SN #65)
Category B. Navigation—the navigation system changed course frequently (sometimes reversing direction), making one vulnerable to inconsistencies, delays, and questions.
Because of the nature of COVID-19 as a novel, highly transmissible viral infection, protocols and information changed frequently, causing dilemmas for those supporting these changes. This struck SNs on two levels, not only the frustration with the changes to protocols and procedures “navigating the ever-changing regulations that COVID had presented” (SN #68) but also having to face the ire of parents, teachers, and administration “The challenges are numerous—angry parents, anxious teachers, and staff, enforcing DPH and DESE guidelines. I became a nurse to care for people. The past year, I feel as if all I have done is argue about safety protocols” (SN #13).
Category C. Roadblocks—Exclusion from decisionmaking, lack of recognition of SNs’ clinical expertise; stress—personal, school level, and community-wide.
Despite the tremendous workload, the struggle with school administration was even more disquieting for the SNs. There was not only a lack of recognition of the extensive workload by the schools’ administration but also the cross-purposes of both professional groups. As simply put by one SN, “Administration not listening to nurses.” (SN #50). Others found that school administration would limit their access to the Department of Public Health as well as PHNs. SNs struggled with conflicting information being presented by themselves and the school administration, leading to the nurses feeling alone and unsupported in their enforcement of infectious disease protocols, “Sometimes it was very difficult to be taken seriously or treated as if you knew what you were talking about” (SN #119).
Subtheme. Supported by others in similar circumstances
Category A. Continuous education—sought information through a variety of means.
SNs identified multiple logistic methods to manage the health office as the pandemic progressed. Methods for communicating with families and staff were as important as keeping themselves educated about COVID-19 so they were knowledgeable and current when addressing concerns about the infectious disease status. To effectively communicate, SNs described continuous education on COVID-19 and infectious disease procedures: “I have researched as much information re COVID-19 as possible. I’ve attended workshops, webinars, and lectures so that I feel confident when speaking with families and staff” (SN #46). SNs reported a variety of techniques and the valued ongoing communication with families and staff,
Our nursing staff has learned Screencastify for making videos for families. We have studied testing and done that at the HS level; we have created Google Forms for parents to complete and have populated to spreadsheets in order to track cases of COVID among staff and students, those who traveled, and those who are quarantined as close contacts. We have learned how to do contact tracing and worked with our local boards of health in local tracing. Electronic communication in a kind and clear manner has become more important than ever, as in-person communication has been difficult. (SN #34)
Category B. Connections/collegiality—essential support of SN colleagues and PHNs
While communication methods helped SNs to inform and manage tasks, maintaining collegial connections was frequently reported as vital to remaining engaged. Collegial connections provided not only resources and recommendations but also may have provided the emotional support many SNs felt was lacking from their school’s administration.
The absolute best thing about all of this has been my nursing colleagues. I am in elementary and I could call any nurse in my district at any level at any time and they would be helpful and kind and supportive. We have really drawn on each other’s strength this year. We bounce things off each other all the time or just vent. Couldn’t have done it without them. And I have a really terrific nurse leader. Can’t say enough about her efforts this year. (SN #48)
Strategies familiar to nursing, such as delegation, advocacy, and organization, were heightened in this school environment and honed during this time.
I developed a system to work with the front office on attendance and absences for students in isolation and quarantine. Developed protocols for nonemergent issues to be handled initially by staff, then myself. I also made a point to get to know all of the teachers and help where needed. We developed a teamwork that has led to a successful year. (SN #70)
SNs identified improving skills out of necessity, their need for communication, and management of tenuous situations. Self-preservation emerged as a strategy as well, “Staying in the moment-meditation, getting through ‘just today’ and trying to stay in that mindset for months on end, it was exhausting. Trying to do more self-care, catching up on sleep as I could” (SN #125).
Subtheme. Paving untraversed roads.
Category A. Completely changed—less time with students, increased case management and public health.
While school nursing has public health and case management components, the COVID-19 pandemic changed these to the primary component. SNs acknowledged the loss of direct time with students, even the lack of physical contact due to social distancing, as well as prioritizing tasks and deferring routine screenings and assessments. “I have been unable to practice and do anything but COVID-related activities. It has been a disservice to students to not be able to provide any other help” (SN# 61).
Category B. Acquired routines—newly developed skills and techniques
The SNs acquired tremendous knowledge and skills regarding infectious disease monitoring, epidemiology, and communication techniques. They also recognized the unintended consequences of these changes, “seeing how our mitigation strategies of handwashing and mask-wearing cut down regular flu and other viral illnesses that we see in our offices.” They also recognized the enduring nature of the skills and knowledge garnered during this tumultuous time.
Category C. Emerging concerns—loss of preventive care; concern about child/staff mental health.
The changes brought by the pandemic disheartened many; SNs no longer strategized students’ return to the classroom but instead needed to assess students for COVID-like symptoms and send them home as appropriate. “I see the kids much less than I used to, and I have to fight to send kids home if they are symptomatic, rather than working to keep kids in school!” (SN #32).
They were saddened by the loss of interaction with students, that they provided much less direct and preventive care, and were becoming concerned about the mental health of students.
I think we will see more impact next year with a full return. The mental health piece keeps making the news, but I don’t think we will fully realize the impact the pandemic has had on kids and families till we get them fully back in our sites and we can assess where they are after a year or so of isolation. We talk about a return to normal, but normal is still a big leap from where we are. The kids are not ok. I am anticipating more mental health visits next year than I typically see. (SN #48)
A subgroup of SNs responded to a single open-text follow-up question.
Thirteen participants who answered “maybe” (n = 11) or “yes” (n = 2) to the closed-ended question, “Do you intend to leave school nursing in 2021?” all wrote voluntary, openended responses to the follow-up question, “What might cause you to leave school nursing?” All responses were considered in the analysis. The responses were coded for meaning units by a single investigator (MJOB) and verified by the entire team (MLH, LW, CB, and JA). Words such as “respect,” “administration,” “value,” and “burnout” were used most frequently, with “respect” as topmost. Following the same analytic process of coding, categories, and theme interpretation, a single theme emerged,
Worn out having to validate my profession and my value.
Having to substantiate their value, knowledge, and capability as an SN daily, particularly without administration support, made for an untenable work environment.
Three SNs identified retirement was available to them, one indicating COVID-19 may have impacted their decision. Among the remaining SNs, the tone and experiences were much rawer and more emotional. Two categories captured the experiences of SNs poised to leave their role:
Category A. Invalidated as a professional.
This subgroup of SNs reported experience with school administration, which ranged from micromanaging their every action to excluding them from discussions about a healthcare crisis. This, combined with a lack of support for the work they performed over the prior 2 years, left them overwrought. “The way administration handled this and disregarded nursing during this pandemic” (SN #122).
Category B. Exhausted by the struggle.
These SNs felt not only unsupported by their administration but locked in an ongoing struggle, “It has always been a struggle to work with administration that does not understand the role and value of a school nurse. This year has been particularly hard as it felt as though it was a constant battle.” (SN #119). The administration’s role in this pandemic was not the only factor voiced as the ramifications of COVID-19 were also implicated, “I have had parents literally screaming at me that I have ‘thrown their family into chaos’ by enforcing rules and regulations. I am so tired of fighting” (SN #13).
The SNs felt the brunt of being asked to manage a healthcare crisis within a nonhealthcare environment, rapidly changing protocols, and knowledge deficits of nonhealthcare administration, resulting in conflicts. As the second academic year of COVID-19 was closing, these SNs perceived the only option in this tumultuous work environment was to leave it.
The current study illuminates the experience of SNs in one state during the second year of the COVID-19 pandemic. The participants’ demographics closely mirrored a prior study with a similar population (Gormley et al., 2021). Close-ended questions provided a snapshot of Massachusetts SNs at the end of the 2020–2021 school year. While the respondents felt they had sufficient PPE and valued connections to local PHNs, there were noticeable gaps in their involvement in COVID-19-related school decision-making teams. Consistent with the entire nursing profession, many SNs are approaching retirement. However, only three respondents indicated retirement as a reason for leaving. The decision to leave school nursing was considered by 18% of respondents. There was no statistical difference between the SNs who indicated they may or would leave versus those who planned to remain in school nursing at the end of the 2020–2021 school year.
The majority of SNs (93%) identified having a fair to excellent relationship with their PHNs; however, almost 7% of nurses had no relationship with a PHN. Due to the public health role taken on by Massachusetts SNs (e.g., contact tracing), having no relationship with PHNs made a very new task more stressful with no experts available. While public health is inherent in the SN role, pandemic measures were unfamiliar. A case study of Massachusetts public health nursing and school nursing identified a deficit of PHNs during the pandemic (Flaherty, 2020). This partnership described between the Department of Public Health and SNs during the first year of the pandemic occurred when most MA students were still remote. The second year of the pandemic was the hybridization of school attendance, during which SNs continued contact tracing and monitoring COVID-19 infections in addition to direct care.
SNs anticipated active involvement in a healthcare crisis. However, many did not anticipate the misconnection between the administration and themselves. Forty-one percent of respondents were either unsure of or reported no COVID-19 response team in their school district. This finding suggests that SNs may have been left out of important conversations yet were expected to manage the consequences of decisions made by such groups. Some spoke directly of mixed messaging between themselves and the school administration, creating a very challenging work environment.
“Finding one’s way required the support of others to pave untraversed roads” emerged through analysis of the SNs’ responses to their challenges, strategies, and practice changes. Qualitative responses provided rich details about their experiences during this time. The second school year of the pandemic saw changes for SNs. In Massachusetts, as most schools were returning to a hybrid form of school attendance after remote instruction, COVID-19 testing and contact tracing became the “new norm” in schools, with SNs finding strategies to ensure a safe and healthy school population. The population served changed to extend well beyond the school and into the community. Most Massachusetts SN respondents found their way through the COVID-19 maze. They frequently cited their colleagues not only as information sources but also as their emotional support. “I could not have done it without them,” echoed in the manifest and latent content. SNs understood they needed to rewrite their handbook to develop technological, testing, and communication skills quickly.
As part of the well-established role of SNs, safeguarding student and staff health includes public health measures. Minimizing the spread of communicable diseases is paramount for SNs. However, the unknown COVID-19 virus emerged precipitously and rapidly worldwide. Lessons from experiences with influenza (Rebmann et al., 2012) and Hurricane Katrina (Broussard & Myers, 2010) highlighted the importance of preparedness and the need for SNs to be part of disaster response teams (Esposito & Principi, 2020).
The extent of the social environment in SNs’ experience is unclear. Countries, or provinces within countries, managed the COVID-19 outbreak differently. Hong Kong had already experienced the SARS outbreak in 2003, which may have provided some reassurance that this pandemic would resolve quickly when they were interviewed in May and June of 2020 (Lee et al., 2021). Notably, Hong Kong schools remained fully in-person, and SNs were directly responsible for creating and enforcing guidelines for schools regarding COVID-19 protocols (Lee et al., 2021). While a single Hong Kong nurse reported being left out of the discussions regarding guidelines (Lee et al., 2021), several Massachusetts SNs reported frustration being excluded from reopening school plans while expected to manage the consequences of these plans.
Twenty SNs in Korea were interviewed in July and August 2020 (Um & Choi 2022) regarding their experience with infectious diseases. Korea had also experienced SARS, Middle East respiratory syndrome, an H1N1 influenza, all of which added to their knowledge regarding pandemic infections at a greater level than the United States. Like Massachusetts SNs, the lack of SNs and additional support to address the pandemic created stress and burnout among Korean SNs.
Swedish schools closely followed the United States regarding student attendance with initial in-person closure and subsequent reopening of schools in the 2020–2021 academic year. Focus groups with 19 Swedish SNs in November 2020 through January 2021 uncovered a common thread of changes to a digital way of working, assessing families and students, maintaining relationships within their school, and the support needed by SNs, whether received or not (Martinsson et al., 2021). Massachusetts SNs also described new work routines, including technology such as Screencastify and Zoom. They also identified that even when the COVID-19 pandemic is resolved, some of these technologies would remain in their professional toolbox. However, other expectations placed on Massachusetts SNs seemed to outweigh the benefits of the innovations. Testing and contract tracing consumed considerable time for Massachusetts SNs, which influenced their experience. Thirty-four New Mexico SNs were interviewed during the third academic year affected by COVID-19, from fall 2021 through winter 2022 (Dickson et al., 2023). One theme that emerged was “Identification of Pandemic Stages,” which reflected some of the same confusion regarding changing information and guidelines, conflicts with administration and parents, and questions regarding their professional capabilities. The “Mental Health of School Nurses and Students” is captured in another theme, while the “Lessons Learned” theme presents a positive outlook on the SN’s role, involvement with the community, and maintaining composure under fire. While the findings in the current study support these findings, further exploration is warranted.
Unique to this study was the prompt to understand the decision to leave school nursing as considered by 18% of respondents. Issues of workload, compensation, and lack of support were highlighted as reasons to leave or retire from data retrieved from the 2022 National Nursing Workforce Survey (Martin et al., 2023). These same issues are recounted in the voluntary responses to the survey question “What might cause you to leave school nursing?” with the respondents citing disrespect, devaluation, burnout, fatigue, lack of administrator support, fighting, and timing of life events. A reported increase from 21% in 2020 to 28% in 2022 among nurses in all settings who are planning to retire within the next 5 years (Smiley et al., 2023). The SNs participating in this survey nearly reached that level of expected attrition.
In a study prior to COVID-19, Jameson and Bowen (2020) utilized two instruments to correlate work-related burnout among SNs with emotional exhaustion as an indicator. Heavy workloads and depersonalization were positively correlated with emotional exhaustion, while Personal Accomplishments may modulate the negative effects of workload and depersonalization. Massachusetts respondents indicated emotional and physical exhaustion over the 2020–2021 academic year. Depersonalization may have been imposed upon the SNs when they were excluded from conversations and decision-making. However, many reported strategies may be viewed as Personal Accomplishments.
Lessons about SN retention may be learned from those who indicated they may or will leave school nursing. Berlin et al. (2022) call on healthcare providers to research workforce planning and increase resource efficiency; utilize virtual learning more effectively; increase marketing; and increase support for all nurses, novices to experts; and refresh, reward, and retain. SNs would benefit from sharing these suggestions with the school administration.
Further research should investigate the long-lasting impact COVID-19 presents to SNs. As several SNs in this and other studies have indicated, the mental health effects on children by COVID-19 continue. Researchers need to investigate pandemic procedures, which include SNs from the beginning, as well as SN-driven innovations that others may utilize.
SNs are typically the sole healthcare providers in an academic setting where they support the safety and wellbeing of their school communities. During this pandemic, scientific knowledge and treatment emerged over time. SNs need to be present at each level of discussion regarding health crises. In addition, staffing needs to reflect the magnitude of the crisis. This pandemic continues to influence our daily world; however, events and procedures need detailed review to support the management of subsequent events.
The study has both strengths and limitations. The qualitative design provided the opportunity to hear SNs’ perspectives concerning the continuation of a worldwide pandemic. At the time of the study, schools were still in transition with a hybrid learning environment, which influenced the nursing care of school-age children and youth. An online survey gave the nurses the opportunity to express themselves fully but also limited the ability to ask clarifying questions or add more details to their responses. While snowball sampling was used, no retired SNs responded to the survey. Survey data was collected from a single state that confronted COVID-19 during the early pandemic and experienced two major surges by the time of this survey.
This study has provided the opportunity to hear from SNs as they experienced a second academic year impacted by COVID-19. While 82% of respondents reported they would remain working in school nursing, the remaining 18% considered leaving school nursing. The SNs struggled with the limited knowledge and guidance from the healthcare system but continued to seek this information via numerous routes. Simultaneously, they were often the single voice of infection standards, facing parents and administration to maintain a safe standard.
The second year of the COVID-19 pandemic saw the return to school in multiple configurations, which required the coordination of care by the SNs. As the single health professional for school settings, they oversaw testing, tracking, and enforcing standards of care. While SNs continue to need the support of public health advocates as well as educators, they must be included in discussions from the beginning to provide a safe environment.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
M. Laurette Hughes https://orcid.org/0000-0002-3553-4120
Laura White https://orcid.org/0000-0002-0983-9641
Mary Jane O’Brien https://orcid.org/0000-0002-9109-8810
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M. Laurette Hughes, PhD, RN, CPNP, Massachusetts School Nurse Research Network; Franciscan Children’s Hospital, Boston, MA, USA.
Laura White, PhD, RN, CPNP, Massachusetts School Nurse Research Network; Boston College, Chestnut Hill, MA, USA.
Mary Jane O’Brien, PhD, RN, CPNP, NCSN, Massachusetts School Nurse Research Network; Boston Public Schools, Boston, MA, USA.
Judy Aubin, RN, MSN, NCSN, MEd, Massachusetts School Nurse Research Network, Boston, MA, USA.
Carol Bradford, BSN, RN, NCSN, Massachusetts School Nurse Research Network; Sudbury School District, Sudbury, MA, USA.
1 Massachusetts School Nurse Research Network, Boston, MA, USA
2 Department of Medical-Rehabilitation Research, Franciscan Children’s Hospital, Boston, MA, USA
3 William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, USA
4 Department of Student & Community Impact, Boston Public Schools, Boston, MA, USA
5 Sudbury School District, Sudbury, MA, USA
Corresponding Author: M. Laurette Hughes, Franciscan Children’s, 30 Warren Street, Boston, MA 02135, USA. Email: lhughes@franciscanchildrens.org
