...more than 1.5 billion students, or 91.3 % of global enrollments, were directly affected by school closures. We are living through such an unusual time. School nurses play a critical role as public health nurses, guiding school communities through a global pandemic unlike anything seen in the past 100 years. Due to the pandemic and worldwide shutdown, remote education became a necessity. The United Nations Educational, Scientific, and Cultural Organization (2021) reports that more than 1.5 billion students, or 91.3 % of global enrollments, were directly affected by school closures. School nurses have navigated uncharted territories as we traveled from the first few identified cases of COVID-19 in the United States (US) in March 2020 to current times. This public health emergency has demonstrated itself as fluid and forever changing, but nonetheless offers lessons and actionable steps that can inform the future.

Grounded in public health, school nurses have historically been involved in communicable disease surveillance and contact tracing.Who is better suited to lead the approximately 56.4 million students that were initially projected to attend elementary, middle, and high schools across the US (The National Center for Education Statistics, 2019) than school nurses? Grounded in public health, school nurses have historically been involved in communicable disease surveillance and contact tracing. With this foundation, school nurses are ideally situated to lead a coordinated pandemic response in partnership with the local health department.

In 1902, Lillian Wald appointed Lina Rogers as the first school nurse in New York City (NYC), overseeing 10,000 students in four schools. Ms. Rogers pivoted from a practice of exclusion to one of treatment, education, and return to the classroom, greatly reducing absenteeism (Filiaci, 2016). Ms. Rogers was a leader in the coordination of care; she developed practice standards, actively engaged in disease surveillance and mitigation, and utilized continuous quality improvement strategies. What began as a thirty-day trial period resulted in the beginning of school nursing as we know it today.

What began as a thirty-day trial period resulted in the beginning of school nursing as we know it today.The pandemic of 1918 resulted in the closure of many schools for up to four months (Battenfield, 2020). A few school systems, such as NYC, and Chicago, equipped with robust public health strategies that included school inspection programs and healthcare teams, determined that students were “better off in school” and committed to keeping them open throughout the pandemic (Stern, Reilly, Cetron, & Markel, 2010). In recent years, financial cutbacks have taken a detrimental toll on the public health infrastructure, including suspension of needed services and a depletion of school nurses (Stern et al., 2010). The current coronavirus pandemic has further highlighted the need for a robust public health system, one that can provide support during “normal times” as well as during times of public health emergencies.

...school nurses were sought for their expertise, problem solving skills, flexibility, and innovative practice. The World Health Organization (2019) has designated 2020-2021 as the International Year of the Nurse and Midwife, in honor of the 200th birth anniversary of Florence Nightingale. This designation held an extraordinary premonition for school nurses, spotlighting them as the only public health expert in the educational realm. Within this year, school nurses were sought for their expertise, problem solving skills, flexibility, and innovative practice. The National Association of School Nurses (NASN) Framework for 21st Century School Nursing Practice ^TM (NASN, 2015; 2016a) provides structure and focus with the five key principles and components of current, evidence-based school nursing practice. The Community/Public Health principle describes the existing components of school nursing practice that were amplified during the COVID-19 pandemic, facilitating a quick and timely response (see Figure).

Figure. Framework for 21st Century Nursing Practice

[View full size]

NASN, 2015. Used with permission.

In this article, three New Jersey school nurses share reflections about the COVID-19 pandemic. We illustrate the roles included in the framework above to describe school nurse contributions to address the COVID-19 community spread via contact tracing and care coordination. We describe school nurse advocacy through promotion of legislative inclusion in the state of New Jersey and efforts to mirror vaccine confidence. Our conclusion offers action steps to increase the presence of school nurses in key areas and build a more robust public health infrastructure.

School Nurse Reflections on the COVID-19 pandemic

Challenges included food insecurities, job loss, housing instability, lack of or poor internet access, and lack of computer devices to connect students to learning. The pandemic struck New Jersey and the metropolitan area with vigorous force, precipitating the closure of all New Jersey schools for in person instruction on March 18, 2020. School districts struggled to devise systems of remote education while grappling with the numerous social determinants of health that impacted local communities. Challenges included food insecurities, job loss, housing instability, lack of or poor internet access, and lack of computer devices to connect students to learning. In addition, families struggled with social isolation, childcare concerns, and behavioral health issues for children and caregivers as we strove to comprehend the complexities of staying safe during a pandemic.

The spring of 2020 turned into summer as the pandemic continued to ravage the country. Schools remained closed for the 2019-2020 school year. In August 2020, 52% of U.S. K-12 students were expected to start the year remotely, while 44% were expected to participate in some form of in-person instruction (Burbio, 2020). But this all changed in September 2020, when the number of estimated remote learners jumped to 62% out of an abundance of caution for school safety (Burbio, 2020). As of September 4, 2020, New Jersey school districts submitted 2020-2021 reopening plans to the Department of Education that included over 400 school districts planning to start the school year in a hybrid format, 242 planning all remote instruction, and 68 beginning with in-person learning (Attrino, Sebastian, & Slavit, 2020).

Virtual School Nursing
School nurses are still working throughout the nation to keep students safe, healthy, and engaged in learning through virtual health offices. School nurses are still working throughout the nation to keep students safe, healthy, and engaged in learning through virtual health offices. More than half of the nation’s brick and mortar buildings did not open for face-to-face learning in Fall 2020, but learning continued (Liesman, 2020). Virtual school nurses are actively working with individual school districts by collaborating, cooperating, and consulting with school staff, parents, and community partners to navigate this unprecedented pandemic. Many school nurses are also health educators and are using online learning platforms to connect with students, staff, and administration. During this public health emergency many feel like virtual pioneers as we create online classrooms to provide health education lessons about handwashing, proper mask wearing, and physical distancing. School nurses are staying connected through applications such as Zoom and other video conferencing events to hold virtual meetings so that education continues.

School nurses are working with local health departments, addressing rumors, calming anxiety, and offering credible health resources and information. This pandemic shines a spotlight on the work of school nurses as the public health experts in their school communities. School nurses are working with local health departments, addressing rumors, calming anxiety, and offering credible health resources and information. We survey communities for infectious diseases, initiate contact investigations for those with signs of illness or exposure to COVID-19, and refer those who are symptomatic for medical evaluation. Many school nurses are volunteering to test individuals for COVID-19, answer hotlines, and provide case management for those with signs of illness through local health departments (Johnson & Johnson Nursing, 2020). School nurses are encouraging vaccine confidence, working as vaccinators, and volunteering with their state Medical Reserve Corp during the COVID-19 vaccine rollout.

We may be “virtual school nurses,” but are connected and responsive to the needs of school communities across the country.School nurses are also addressing food insecurities by overseeing food distribution to those who need assistance. We coordinate home delivery by working with community partners, such as the Backpack Crew and local food banks for families most in need of additional goods and services. One example of this is the Little Free Pantry, where local Little Free Libraries have become small free pantries during the pandemic (Sreenivasan, Garner, & Kargbo, 2020). School nurses are flexible, one of the hallmarks of being a nurse. We are innovative in a crisis and have displayed professionalism and resilience in this yearlong public health emergency. We may be “virtual school nurses,” but are connected and responsive to the needs of school communities across the country.

(Intarasuwan, 2020)

Hybrid Learning and Extended School Year: One School Nurse’s Experience
In June 2020, New Jersey Governor Phil Murphy granted districts the option of holding in person summer school, allowing them the choice of offering instruction via an in-person, remote, or hybrid format beginning July 6, 2020 (Governor of New Jersey, 2020). Districts choosing to offer in-person instruction were advised to follow New Jersey COVID-19 Youth Summer Camp Standards (New Jersey Department of Health [NJ DOH], 2020) and submit attestation that we would adhere to all relevant health and safety standards (Governor of New Jerey, 2020). This declaration created multiple challenges as districts scrambled to develop reentry plans, recruit staff, procure personal protective equipment (PPE), and develop health and safety protocol within a few short weeks.

It was with some trepidation that we approached reentry to school during the summer extended school year program. It was with some trepidation that we approached reentry to school during the summer extended school year (ESY) program. The rate of transmission within our New Jersey community had decreased over the summer months and there was a renewed emphasis on returning students to in-person instruction, especially for our special needs population. With that consideration came the responsibility to ensure that all staff and students would have access to a safe, healthy, and equitable educational environment.

...school nurses were at the table during the reentry process, acting as leaders in public health... Our district was one of the few in our area to offer a summer cohort program. Staffing was a challenge as individuals expressed concern regarding the risks associated with participating in-person, for both themselves and their loved ones. School based reentry guidelines and protocols were developed that aligned with the NJ DOH (2020) Youth Summer Camp Standards through a collaborative process with district administration, the local health department, and staff. True to the Framework for 21st Century School Nursing Practice ^TM, school nurses were at the table during the reentry process, acting as leaders in public health while coordinating care, applying evidence-based practice, and continuously working toward quality improvement (NASN, 2015; 2016a).

In response to ESY school reentry, we attempted to accomplish in a few weeks what typically takes months to plan. We rushed to order supplies that would support a safe return to the building, such as signage for physical distancing and hygiene measures, hand sanitizer, thermometers, and face coverings. We researched and created school-based isolation rooms and protocol, and transformed designated space into isolation rooms for sick individuals. We spent hundreds of hours trying to procure PPE for nurses, related services, and other staff, while searching for N95 fit testing supplies. As the 2020-2021 school year began, we were still searching for PPE supplies, including the ever-elusive medical grade masks, N95s, gowns, and gloves. With the district decision to implement morning temperature screenings, we created a temperature screening process and trained staff on procedures. There was much to do in little time.

Anxiety was evident and as the school nurse, I sought to both soothe and reassure. In truth, I struggled with the decision to work in-person...Anxiety was evident and as the school nurse, I sought to both soothe and reassure. In truth, I struggled with the decision to work in-person, questioning the ability to keep those attending safe from illness. Would we have adequate supplies, receive the necessary PPE in time, and be able to keep our students and staff safe? This was unfamiliar territory; we were trying to find our way in uncharted waters and learning as we went along.

As the date of opening approached, meetings were held to discuss protocols and concerns. Parents were notified of school-based procedures, including physical distancing and the use of face coverings. Many students were unfamiliar with the use of face coverings. This required a variety of interventions to enforce use such as role modeling, reinforcement, and timers to gradually build both endurance and tolerance. These techniques did not work for everyone, but they were a starting point.

We developed a strong coordinated approach to contact tracing, but any evidence of illness or contact tracing within the school created anxiety in staff and families alike. This required both sensitivity and ongoing education. We learned several valuable lessons as we navigated the new classroom setting, including the importance of physical distancing. With small class sizes, our summer program was a success with only a few intermittent hiccups. However, we knew that these small class sizes would be harder to uphold as we advanced through our fall reentry process.

Contact tracing has been a daunting task, creating a heavy burden on the already extensive school nurse workload.Since then, we have provided a phased-in hybrid model of instruction. We have experienced a revolving door of remote and in-person instruction, both individual and building based, as we encounter both symptomatic and positive individuals, their close contacts, and family members. Similar to the 1918 pandemic, we have found that students continue to gather after school hours, allowing for transmission of illness between and among previously healthy children (Filiaci, 2016). Contact tracing has been a daunting task, creating a heavy burden on the already extensive school nurse workload.

School reentry has been a variable process with habitually changing local, state, and federal guidelines. As the school nurse role adapts to the challenges presented during this pandemic, we have had to adjust our expectations and role perceptions. As nurses, we aim to comfort and heal but this is not always possible as we strive to enforce a variety of ever-changing regulations and protocols regarding school reentry, quarantine, and isolation guidelines. Ongoing support within and amongst the school nurse community is essential as we navigate this rugged terrain.

COVID-19 Community Spread Through a Magnifying Glass

Contact Tracing
Prior to the pandemic school nurses were, and remain, uniquely positioned to assess the needs of their community; we work to improve community health outcomes through leadership, advocacy, and care coordination (NASN, 2018). This past year, many school nurses have collaborated with local health departments responsible for conducting COVID-19 case investigations and contact tracing. During the initial COVID-19 response, the number of contact tracers needed to adequately contain the spread of the virus greatly exceeded the number who were available (Kalyanariam & Fraser, 2021). Health department personnel found themselves quickly overwhelmed by the number of positive cases. This prompted collaborative partnerships with school nurses to bridge the gap while state public health officials scrambled to develop infrastructure and educational training for teams of contact tracers.

...many school nurses have collaborated with local health departments responsible for conducting COVID-19 case investigations and contact tracing. Public health case investigation and contact tracing befits to school nurses because we possess the appropriate skills. For example, school nurses are excellent communicators whom the public perceives as ethical, honest, and trustworthy (Saad, 2020). Typically, the public has not been cooperative with contact tracing investigation. School nurses work to bridge that divide while upholding privacy laws and assuring confidentiality.

Health departments have legal mandates to investigate cases of communicable disease and a duty to notify contacts that they have been exposed (CDC, 2020). Routinely, health departments are notified of laboratory-confirmed results by an electronic system that relies on the timely input of test results. Unfortunately, as cases of COVID-19 rose, the system was inundated and unable to keep up with the demand. Lags led to delays in implementing early mitigation strategies with positive individuals and their close contacts. It was here that school nurses stepped in to fill a critical role by expediting case investigation and recommending mitigation measures to families to contain the spread of the virus. These measures were promptly implemented at the time of the parent report to the nurse days, and even weeks, earlier than the local health department received notification of a positive result.

Care Coordination
...school nurses expanded their roles as care coordinators due to an increased need to connect students and families with community resources.The Agency for Healthcare Research and Quality (2014) describes care coordination as “a patient-and family-centered, team-based activity designed to assess and meet the needs of patients, while helping them navigate effectively and efficiently through the healthcare system” (para. 7). During the effort to manage the pandemic, school nurses expanded their roles as care coordinators due to an increased need to connect students and families with community resources. This included assistance to access resources such as health insurance, medical supplies, medications, testing, and healthcare providers (Fauteux, 2020; Johnson & Johnson Nursing, 2020; NASN, 2020; Sohn, 2020).

School nurses have a natural inclination to quickly build trust and rapport with individuals, and at the same time are cognizant of privacy laws. As such, we provided exceptional care coordination as case investigators and contact tracers. School nurses reviewed symptoms; educated individuals about isolation versus quarantine; and identified social determinants of health that impeded wellness. The brief example in the table below highlights how the actions of the school nurse coordinated community service to meet the needs of a family and prevent potential exposure to what could have been many community members.

Table. Example of School Action to Prevent Spread of COVID-19

Care coordination during the COVID-19 investigation in communities remains challenging as many residents continue to experience collective trauma. According to Substance Abuse and Mental Health Service Administration’s National Survey on Drug Use and Health, there were approximately 57.8 million Americans living with mental and/or substance use disorder prior to the pandemic (McCance-Katz, 2018). This past year has been associated with mental health challenges related to morbidity and mortality caused by the virus and the implementation of mitigation strategies, including the impact of physical distancing and stay-at-home orders.

Symptoms of anxiety and depressive disorders have increased considerably...Symptoms of anxiety and depressive disorders have increased considerably in the United States during April through June of 2020, compared with the same period in 2019. During late June 2020, more than 40% of adults reported struggling with mental health or substance use disorder. Greater than 30% of these adults reported at least one symptom of anxiety or depressive disorder, 26% had symptoms of a trauma- and stressor-related disorder (TSRD), and 13% admitted to starting or increasing the use of substances to cope with stress or emotions related to COVID-19 (Czeisle et al., 2020).

It is predicted that the impact of the current national COVID'19 pandemic will influence the need for urgent access to mental health services, including care for suicidality (Canady, 2020). School nurses play an integral role in the early identification of mental health needs and provide referrals to community resources, bridging the gap between school and home (Gilbert et al., 2015; Haddad, Butler, & Tylee, 2010). Through these therapeutic interactions, a sense of connectedness grows and supports holistic healing. The value of this role has been highlighted in stories shared by school nurse colleagues (Fauteux, 2020; Johnson & Johnson Nursing, 2020).

School Nurse Advocacy

The global pandemic has highlighted the importance of school nursing.The challenges of the COVID-19 pandemic are immeasurable but, amid the uncertainty, there have been shining moments. The global pandemic has highlighted the importance of school nursing. School nurses have stepped into the center of the chaos, canvassing local and state decision-makers to include their voices in plans for school reopening, and serving as role models to support the vaccination rollout.

Promoting Legislative Advocacy in New Jersey
Influencing public policy change can be difficult and complex, particularly for associations with limited recognized power and financial resources such as the volunteer-based New Jersey State School Nurses Association (NJSSNA). It took a global pandemic unlike anything in the past 100 years, for NJSSNA to be tapped for their expertise by the leadership of the New Jersey government. Since the virus has turned the world upside down, NJSSNA has been included in Legislative and Department of Education (DOE) committee meetings as they focused on the impact of COVID-19 and re-entry planning for schools. The Senate Education Recovery Task Force, led by Senator Teresa M. Ruiz, invited representatives from the NJSSNA Executive Board to actively contribute to a working group formed to address barriers created by COVID-19 for school districts across the state.

There are 44 states that have school nursing leadership positions at their respective DOE or Departments of Health (DOH). New Jersey was not one of them. For the past six years, school nurses have had no representation at the NJ DOE. With the onset of this pandemic, New Jersey could no longer afford a decentralized approach to school health. The NJSSNA was honored to fill the void in leadership. Leaders in the NJSSNA found themselves with an opportunity to present this information to state representatives, the decision makers and lawmakers with the ability to take action to resolve this gap in school health leadership.

This can be a model for other state school nurse associations to engage their respective legislators.The NJSSNA legislative team was invited to present the most pressing health concerns to the taskforce. The comprehensive presentation concluded with the need for a State School Nurse Consultant embedded in the NJDOE. Senator Ruiz not only took notice, but she also took action to fill a gap in school nurse leadership at the state level, stating:

One thing the school nurses stressed during our Education Recovery Taskforce meeting on health and safety was the need for a statewide school nurse consultant. Especially as we look towards reopening our schools and adjusting to the new normal, strong lines of communication between the Department of Education, the Department of Health and our school nurses will be crucial. Beyond the COVID-19 pandemic, the consultant will help to strengthen our health programs and ensure all districts are meeting high quality standards (Ruiz, 2020, para. 2).

Within a very brief period, Senator Ruiz crafted legislation to create the position of a State School Nurse Consultant at the NJDOE. The bill was supported in both the New Jersey State Senate and Assembly and passed with little opposition. Governor Phil Murphy signed the bill into law on September 14, 2020 (P.L.2020, c.85, 2020).

Even though this pandemic has wreaked havoc on our New Jersey communities, it has created opportunities for the NJSSNA legislative committee to be recognized as a voice for advocacy and to establish powerful legislative partnerships. NJSSNA will maintain working relationships with state policy makers as we strive to improve school nursing practice and advocate for New Jersey leadership to always provide safe and healthy schools. This can be a model for other state school nurse associations to engage their respective legislators.

Mirroring Vaccine Confidence
School nurses are key professionals who will build confidence in the use and acceptance of the COVID-19 vaccine as we look to build herd immunity at the community level. They are frontline healthcare workers in an education setting and have been included in the “1a” priority category for receiving the vaccine.

Historically vaccines have been the most effective public health interventions against the spread of infectious disease. Vaccines decrease morbidity and mortality related to communicable diseases (CDC, 2018). School nurses recognize the limited number of tools to mitigate the spread of COVID-19, so we eagerly awaited adding the vaccine to our toolkit to protect our school communities. Children are not part of the initial vaccination plan; however, our school communities include teachers, staff, administrators, and parents who rely on the trusting relationships with their school nurses for credible health information.

School nurses are role models to assure vaccine confidence...At the local level, school nurses volunteer with their state medical reserve corps and stand-by as boots on the ground vaccinators (Frenette, 2021; Sohn, 2021). The rollout of the vaccination plans includes the use of schools for administration sites. School nurses are role models to assure vaccine confidence through educating school communities about the importance of COVID-19 vaccination as the rollout continues to unfold.

Conclusion: Action Steps to Move Forward

As history has taught us, there will be more public health emergencies. Implementation of necessary actionable steps is in order before this occurs. First and foremost, there must be funding for and the collective will to have a school nurse in every building. This recommendation is supported by NASN (2016b) as well as the American Academy of Pediatrics (AAP, 2016). Although school nurses have access to 95% of our nation’s 56.4 million children, 25% of schools have no school nurse, while 35% of schools have a part-time school nurse (Maughan et al., 2017). COVID-19 has magnified the contribution of school nurses and the need for each school district to have a comprehensive health services program (Cogan, 2021).

...there must be funding for and the collective will to have a school nurse in every building. We need to revive the public health infrastructure, with dedicated funds to create robust collaborative partnerships, which have been and are sorely missing during the COVID-19 pandemic. Future planning must include a coordinated approach to testing and equitable vaccination rollout, supported by federal, state, and local governments. Public health messaging by credible, trusted community members must be amplified in a comprehensive, responsive, and accessible manner from the onset of any future national emergency. Messages must also reflect the human experience of the collective trauma that individuals, families, communities, and our nation face in order to cope and heal through crises.

School nurses, when included in school safety planning, have risen to the highest challenges that the pandemic has posed... When school nurses have a seat at the decision-making table, we bring unique knowledge for planning, mitigating, and responding to any public health emergency. They provide the consistent human connections necessary to keep school communities safe, learning, and flourishing in the most unpredictable of times. School nurses, when included in school safety planning, have risen to the highest challenges that the pandemic has posed and led their districts in the response to this national emergency. Another actionable step moving forward is to ensure a school nurse is present at the planning table in schools, in communities, and at the state and federal levels. If not, rest assured that we will create our own tables for the health and safety of school communities and their key stakeholders.

Author Note. We have no known conflict of interest to disclose. Please address correspondence about this article to: Robin Cogan, 610 Old Orchard Road, Cherry Hill, NJ 08003; send electronic communication to the email below; or call my cell at 856-912-2608.

Authors

Catherine A. Grano, MSN, RN, CSN-NJ
Email: cathyann@hotmail.com

Catherine A. Grano is a certified school nurse who has worked in the elementary setting for the past 11 years. Cathy is a contact tracing supervisor in the local health department and has offered numerous presentations and educational sessions regarding school reentry during the COVID-19 pandemic. Cathy is the Vice President of the Monmouth County School Nurses Associations, member of both the Education and Standards & Practice committees of the New Jersey State School Nurses Association, and a Johnson & Johnson School Health Leadership Fellow. As a matriculating student in the PhD in Nursing program at Seton Hall University, Cathy is currently exploring the experience of the school nurse in her research endeavors.

Eileen M. Gavin, MSN, FNP-BC, NCSN
Email: egavin2@icloud.com

Eileen M Gavin is a Nationally Certified School Nurse (NCSN) and is board certified through the American Nurses Credentialing Center (ANCC) as a Family Nurse Practitioner (FNP-BC). An alumnus of the Johnson & Johnson School Health Leadership Institute where she has served as a mentor, liaison, and community coach. Eileen has been appointed Co-Chair of the Legislative committee of the New Jersey State School Nurses Association. She has been recognized as an accomplished mentor and educator through multiple awards on the local, state, and national level. From the onset of the pandemic, she has worked with her local health department as a contact tracing supervisor. Eileen currently is a school nurse at the high school level where she continues to promote the health, safety, and wellness of all students and staff in Middletown New Jersey Schools.

Robin Cogan, MEd, RN, NCSN
Email: Robin.Cogan@Rutgers.edu

Robin Cogan is a Nationally Certified School Nurse (NCSN), currently in her 20th year as a New Jersey school nurse in the Camden City School District. Robin is the Legislative Co-chair for the New Jersey State School Nurses Association. She is proud to be a Johnson & Johnson School Health Leadership Fellow and past Program Mentor. Robin is the honored recipient of multiple awards for her work in school nursing and population health. Robin serves as faculty in the School Nurse Certificate Program at Rutgers University-Camden School of Nursing, where she teaches the next generation of school nurses.