School nursing services did not end when our brick-and-mortar buildings closed in March because of COVID-19.

School nurses continued to provide a full spectrum of care in the most innovative ways. We supported parents as they grappled with the enormity of the sudden pivot to remote learning and linked parents and students to community resources that school nurses know so well. We continued care coordination, working with our most vulnerable students and families; created pathways to provide virtual school nursing services; and provided health education. Certified school nurses became contact tracers, delivered meals to students and families, and explained the transition from in-person medical appointments to telehealth. And we continue to support our parents in scheduling much-needed physicals and immunization updates before school reopening.

The front line of our struggle with COVID will now be at school and school nurses will be the first responders. Students and staff with one or more COVID symptoms may be asked to isolate for a minimum of 10 days following department of health guidelines. There will be mass absenteeism of both staff and students, as close contacts for those who have tested positive will also have to quarantine for 14 days.

This information has not been communicated clearly and consistently on a statewide level to our school communities. Youth community spread of the virus is already here and we are in an ever-changing landscape in terms of COVID-19 containment—we are chasing this virus and the virus is chasing us.

Too few nurses in too many schools.

One important question to ask is, “Does your school have a school nurse?” According to the National Association of School Nurses (NASN), 25% of schools across the country do not and 35% have only a part-time school nurse. The remaining 40% of schools with a full-time school nurse may have thousands of students and multiple buildings. There are approximately 95,000 school nurses for almost 57,000,000 students. 

The gap between CDC guidelines and real-world implementation.

School nurses are being asked to set up isolation rooms without available PPE to care for students and staff who may be symptomatic for COVID. And without access to quick, reliable, point-of-care testing, we are guessing who is safe to be in our buildings.

The Centers for Disease Control and Prevention (CDC) guidelines are vague about isolation areas, mechanism of contact tracing in school, and managing anticipated classroom and/or school closures and reopening. They use language like “if feasible,” which may end up being interpreted as not possible if not feasible. When nonmedical decision-makers read statements like “if feasible,” they can easily discount the value of established, evidence-based public health strategies.

There is a big difference between theory and practice. School nurses will be implementing and evaluating the soundness of the plans as we work to reopen schools safely. But not all school nurses have been included in the planning process.

Unrealistic mitigation strategies?

One of the many related challenges we face is the need for community buy-in for mitigation strategies such as masks, social distancing, testing, isolating when ill, and quarantining after exposure. Contact tracing has been promoted by the departments of health and education without having any infrastructure in place with local and regional health departments and schools.

We are faced with implementing multiple public health mitigation strategies that may not be fully actionable given how school communities function. The reality is that testing and reporting of results to health departments are sorely lagging, thus impeding ongoing community mitigation strategies. And many schools have not even started testing.

The combination of lack of contact tracing infrastructure in schools, delay in test results, lack of community buy-in, and lack of the necessary PPE to protect our school nurses and staff could create a perfect storm of outbreaks among our school communities throughout this country.

The five W’s.

Right now, these are the ONLY tools we have in our toolbox to keep our students and staff safe at school. Remember the “5 W’s”:

  • Wear a mask
  • Wash your hands
  • Watch your distance
  • When you are sick, stay home
  • When the health department calls, answer the phone

Conflicting safety priorities.

I could add a 6th ‘W’ for windows—opening windows, and doors, for improved ventilation. (The irony is that we are instructed to lock our doors and windows in response to school shooters and now we need to open our windows and doors to improve ventilation. So which guidelines do we follow?)

School safety was precarious before COVID-19. It is now in disarray, propped up with a series of ever-changing guidelines from previously trusted sources like the CDC. School safety has become a political football in a country that cannot even agree that wearing masks should be part of a united national response to this deadly epidemic.

We need a clear road map.

School nurses are voicing their concerns about the safe reopening of schools and lack of public health guidance from the highest level of state government. The NASN’s vision is that “all students are safe, healthy, and ready to learn.” We are ready to support learning, but health and safety must be at the center of every decision made about school reopening.

The question that must be answered is, “How will we know when it is safe to reopen school buildings?” We need parameters, metrics, a road map. Anything less is a guessing game of hope and crossing our fingers and toes that we won’t have an exposure at school.

Robin Cogan, MEd, RN, NCSN, is a blogger, a school nurse in Camden, New Jersey, and a part-time lecturer at Rutgers-Camden School of Nursing.