Checking student temperatures. Distributing masks. Ensuring students and staff are following sanitation and social distancing guidelines. These are just a few of the new pressures on today’s school nurses as many school districts across the country begin their return to in-person instruction. But for many districts that have decided to remain remote until the end of 2020 or beyond, pressures on their school nurses have taken a new form: monitoring student health and wellbeing from a distance—and from behind a screen.

Even before COVID-19, being a school nurse was a challenging role, with many schools having just one nurse for hundreds or thousands of students. School nurses are often the first responders to many youth issues revealed in school, including mental health challenges, food insecurity and even child abuse. And because of their deep experience in delivering care to so many, and often with limited resources, they are uniquely positioned to advise on school safety amid COVID-19.

The Johnson & Johnson Notes on Nursing team spoke with six school nurses to hear their concerns for their students and colleagues, as well as how they are innovating in real time to adapt to their schools’ fall plans:

· Robin Cogan, MEd, RN, NCSN, School Nurse for the Camden City School District in New Jersey and Founder, "The Relentless School Nurse," 20 years as a school nurse

· Holly Giovi, RN, School Nurse for the Deer Park School District in New York, seven years as a school nurse

· Donnis Harris, MSN, RN, NCSN, School Nurse for the Quitman School District in Mississippi, 20 years as a school nurse

· Liz Pray, MSN-Ed, RN, NCSN, School Nurse for the Moses Lake School District in Washington State and President of the School Nurse Organization of Washington, seven years as a school nurse

· Carmen Rosenberg, MA, BSN, RN, PHN, District School Nurse for the Oxnard Union High School District in California and Co-chair of Government Relation for the California School Nurses Association – Central Coast Section, 25 years as a school nurse

· Rachel VanDenBrink, MSN, RN, Center Programs Nurse Coordinator in the Kent Intermediate School District in Grand Rapids, Michigan and President-Elect of the Michigan Association of School Nurses, 19 years as a school nurse

J&J: What are some of the challenges your students and staff have faced in this pandemic?

Liz: March 16 was the last time we saw our kids at school, and I’ll never forget it because it was my birthday. It was incredibly hard. As a nurse, all I could think about was how I was going to keep track of these kids. I oversee two elementary schools with more than 500 students each, and one of the schools that I take care of experiences significant rates of poverty. Many homes don’t even have internet. Who’s going to make sure these kids get fed? Calls to Child Protective Services have dropped over these past few months, and that’s because school nurses and staff play critical roles in looking out for signs of abuse. And as we’re planning to return to in-person schooling over the next few weeks, I’m thinking about new challenges around the bend, such as routine immunizations, discerning COVID-19 symptoms, navigating mask trading and even recess. We hoped to provide outdoor recess and mask breaks, but with the outbreak of forest fires in our state, we’ve been presented with even more new challenges.

Robin: Camden is an amazing, resilient city, and yet it is often said that when New Jersey gets a cold, Camden gets the flu. A lot of that has to do with access to resources. Many of our families live in crisis mode every day, and this pandemic has completely upended their lives. I’m currently a preschool nurse overseeing multiple buildings across the city. Everything about my role changed. I tried to make myself available to anything that the parents and children needed, from providing diapers and formula to helping coordinate COVID-19 tests. And as a nurse, I felt compelled to try to alleviate some of the misinformation about this virus. Many families were gathering without masks, didn’t necessarily trust or understand telehealth, and were told to stay six feet apart—a confusing guideline for those who are more familiar with the metric system. We’ve learned a lot of lessons and we’re still learning them. I think we’re going to study for a long time how poorly this health crisis was managed and communicated.

J&J: What are some of the challenges you’ve faced and are continuing to face as your school stays remote?

Carmen: When we found out that our district would be remote for the rest of the year, it was as if a rug was pulled from under us. I’m the only nurse in my high school of more than 2,200 students. A large part of my role is completing Individualized Education Program (IEP) reports and case management for our special needs students, and I remember thinking to myself, “What’s going to happen to them?” I deeply worry about the mental health toll this is taking on students who struggle to advocate for themselves. Before the pandemic, students would come to my office if they wanted to talk, but now students aren’t reaching out as I hoped they would. Many of the parents in my community speak Spanish and even though I’ve shared that I’m bilingual, not many parents are reaching out either. As a nurse you want to save the world, but sometimes you have to do the best you can with the tools you’re given.

Rachel: One of our biggest obstacles was figuring out how to best support our teachers in providing virtual education. School nursing is very hands-on, so brainstorming ways to provide “distance” school nursing was a challenge! To mitigate these challenges, we connected with other school nurses at the state and national levels to come up with ideas on how best to connect with families, support district initiatives to provide meals and provide mental health support and chronic disease education. As we transition back to in-person learning, two of our biggest challenges will be calming some of the fear and anxiety over COVID-19 with facts and providing good education about wearing PPE. I’ll be proud to present the teaching tools that my nursing team created for staff and students!

J&J: How have you and your fellow school nurses been innovating to help overcome the challenges presented by COVID-19?

Holly: Everything about COVID-19 has forced us to innovate, but I believe every nurse has an innate ability to adapt. And now more than ever, I feel the spirit of “we are all in this together.” Over the past few months, we’ve had to work together as a team to plan for a hybrid model and understand the ever-changing guidelines. My office needed to be reworked from one room to three to become a triage, a treatment room and an isolation room. As part of our COVID-19 Coordinator Team, I helped create forms to assist with employee and student screenings and quarantine spreadsheets to help monitor those with symptoms or positive results. We created several worksheets to help breakdown our state’s guidelines and specific COVID-19 symptoms. We also created a “cheat sheet” to help administrators navigate scenarios and answer questions. Nurses are sharing best practices, policies, training materials, flowcharts, videos and presentations. I believe we are stronger together for it and our voices are louder because of it.

Liz: The job of a school nurse is to make sure our students and staff are safe, so we got very vocal. Many school districts planning for the return of in-person learning have completely forgotten the school nurse. I started my role as the President of the School Nurse Organization of Washington this August, so I was glad to have a seat at the table and advocate for school nurses. We implemented a state-wide call for school nurses, to give them a safe place to discuss back-to-school logistics—and we’ve now opened the call to everyone. In my own district, I tried to make myself available by joining teacher Zoom meetings, popping into virtual classrooms and hosting virtual lunches where students were invited on little local adventures. I even created a video for a parent to teach them how to administer their child’s seizure medication. Even though our school is offering hybrid and in-person models this fall, we’re still going to make ourselves available digitally. In a way, I’m excited to see our kids again, but I’m also scared. School nurses are used to constantly adapting, but we’ve never had to deal with such frequent changes. What’s in our corner is the profound trust both parents and students have for their school nurses.

J&J: Have you been involved in any local or state efforts around the “return to school”?

Robin: I was fortunate to be involved at both the district and state levels, each with its own challenges and triumphs. At the district level, I was supported by a group of colleagues who devoted a large part of their summer to working on school reopening plans. We were the public health experts charged with crafting return-to-school plans in the midst of a pandemic, with ever-changing guidelines. We were integrated into cross-sector subcommittees, but our role was to focus on wellness, whether we were discussing remote learning or several hybrid models. As the legislative co-chair for the New Jersey State School Nurse Association (NJSSNA), I was asked to be a part of the Senate Education Recovery Taskforce. Senator Teresa Ruiz invited representatives from many state organizations to present concerns and solutions to the taskforce. The NJSSNA was able to express our immediate needs regarding the lack of PPE, building HVAC systems, proper ventilation and most notably, the lack of school nursing representation at the NJ Department of Education (DOE). Through our advocacy, Governor Phil Murphy will be signing a bill endorsing the position of a State School Nurse Consultant at the DOE. Forty-four States have a state school nurse consultant, and now New Jersey will as well.

Carmen: I’ve been involved in a lot of meetings at both the local and state levels as part of the California School Nurses Organization (CSNO). My administrator asked for a couple of volunteers to write up a plan to safely assess people entering the school site. We are now a taskforce of five nurses working on this project. As we think about returning to in-person schooling, we’re also thinking about potential problems we might face, such as teenagers wanting to congregate or thinking that wearing a mask isn’t cool, or students living in multifamily homes and possibly afraid to mention that someone in their family has COVID-19. Our taskforce has been brainstorming innovative and budget-conscious ideas to overcome potential issues, such as an app that can conduct passive screenings and a protocol for screening questions that can help with contact tracing. As school nurses, we all want to be on the same page, but how do you standardize a pandemic? Different districts have different needs. The good news is that nurses are great at collaborating and problem-solving.

Rachel: We are fortunate to have a State School Nurse Consultant who was able to provide a collective school nursing voice at the Michigan Department of Education and Michigan Department of Health & Human Services. I worked on a team of school nurses to support her voice in those departments. At the county level, I was fortunate to work on a team with our local health department and major hospital system to give schools tools to educate staff and students on safe COVID-19 practices such as mask wearing, hand washing, physical distancing and even contact tracing. Public health nursing is similar to school nursing—so combining the two has been a powerful change agent for our school districts.

Donnis: I’ve been very fortunate to have been included from the very beginning in preparing plans with our administrators. I’m a school nurse for a rural district with less than 2,000 students. Throughout the spring and summer, we worked to put together education materials and guidelines on implementing a hybrid model, mask wearing, hand washing and more. I was also asked to provide weekly in-person health updates from our state health department in a socially distant setting. At first I was hesitant, but now I realize how valuable it is for me to personally share current information and answer questions for our staff. I’m also grateful that our state’s health officer has embraced our school nurse perspectives and implemented weekly webinars so we can voice our concerns and recommendations. COVID-19 has been a scary and sad time for many, so recently I made a list of some of the good things that have come out of this pandemic. We now have a dedicated section of our district website for school nurses to share information with the community. And more people are listening to school nurses than ever before.

J&J: What’s something about school nurses that you would like people to know?

Carmen: School nurses often don’t grab the attention of those in administration because we’re not teachers, but we do so much more than distribute bandages and ice packs. Now more than ever, when people find out that I am a nurse, they come up and thank me. COVID-19 has really shown people that we are a significant part of the medical community. We’re on the frontline. We’re case managers. We help alleviate student stress and anxiety. We’re educated. We have compassion. We understand the cultures within our communities. We are the medical voices in our schools. We’re leaders.

Rachel: School nurses do so much more than bandages and pills! We are the bridge for our students between safe education and management of chronic conditions. We are the voice to promote and work toward safe and healthy learning environments so teachers can do what they do best—teach!—without having to worry about how to manage student insulin pumps, inhalers, EpiPens and the like. We assess, diagnose, plan, intervene and evaluate our school students and environments in our daily professional practice. And that’s why our voices should be heard in this health crisis—we understand the school setting and the needs of our education peers, yet we have the medical knowledge and perspective to bridge the two areas into the safest learning environment possible.

Holly: Without the licensed medical expert’s perspective on health and safety, how can you possibly expect to put forth a plan to educate a student, let alone protect the welfare of students and staff? The complexities of students’ lives today are ever-changing, and now with the added pressures of a pandemic, the school nurse’s role will broaden once again to include even more hats to wear. I would like society to know that school nurses take a completely holistic approach to everything we do concerning our students, their families and the staff. School nurses are so dynamic—we just figure it out, all with the focus of helping our students be well enough to be educated.

Robin: School nurses have always gone above and beyond, but we don’t always talk about it. The ratios of children to nurses in most schools are unbelievable—in fact, some schools don’t even have a nurse. There is a new focus on school nurse shortages and a new value in our perspectives as more school nurses take a stand, raise their voices and highlight their work. People are starting to understand that in order to keep our children happy and safe, as well as move our profession forward, school nurses need to be present. School nurses have always been innovating, doing what we need to do with what we’ve been given. But the next level of innovation will come when nurses demand to be part of the conversation.

J&J: Do you have any words of encouragement for fellow school nurses across the country?

Donnis: Our job as school nurses is doing the right thing to ensure the safety of our children—even when it isn’t popular. We’ve quarantined our high school football team twice to err on the side of caution because it’s such a close-contact sport. That’s a big deal in our Mississippi town. As nurses, we must pick and choose our battles. Do what you think is best and what you know to be the right thing. I may not have decorated my office the way I do each year, but I do have an isolation room set up in each school and we haven’t had any positive cases. I can rest easy at night knowing we’re doing the best we can.

Liz: As nurses, we always worry about everyone else. If I could offer any words for nurses feeling overwhelmed, I would encourage them to allow themselves and others a little grace. Everyone is struggling. Not being able to connect with peers is taking a significant mental health toll on our children. School hours were when a lot of our parents with special needs children would sleep. Tempers are short, people are on edge and it’s been very difficult for students, parents and team members to adjust to these changes. Remember to take a step back, take a deep breath and take care of yourself.

Editor's Note:
On September 22, 2020, Robin Cogan MEd, RN, NCSN, participated as an expert guest on Season 2, episode 7 of the “Road to a Vaccine” show hosted by Lisa Ling. The week’s episode was entitled, “Is It Really Safe for Schools to Be Open Right Now?” Here is the full clip:

Disclaimer: The responses above reflect the opinions of the individuals interviewed and do not necessarily represent the views of Johnson & Johnson.

Featured in school nurse collage photo:
(Top row, left to right)
Robin Cogan, MEd, RN, NCSN, Holly Giovi, RN and Donnis Harris, MSN, RN, NCSN
(Bottom row, left to right)
Liz Pray, MSN-Ed, RN, NCSN, Carmen Rosenberg, MA, BSN, RN, PHN and Rachel VanDenBrink, MSN, RN