Leading During a Pandemic: A School Nurse Administrator Roundtable

Abstract

The ongoing COVID-19 pandemic has been taxing to healthcare workers, no less for those serving on the front lines in schools. From initial school closures and online learning to gradual reopening with hybrid learning models, to full in-person learning, school nurse administrators provided guidance in collaboration with public health officials, based on evolving information. Infection control was at the forefront, while government and scientists partnered to quickly develop effective vaccines. Technology provided new virtual platforms for learning, conducting meetings, and socialization, while also being widely used to deliver information, misinformation, and disinformation. Challenges have been numerous, but school nurse administrators and school nurses in general, with a commitment to the health and safety of their populations, continue to adapt to the ever-changing demands. The journal’s Editorial Advisory Board interviewed five school nurse administrators, representative of diverse geographic locations, school population size, and employer models, to capture their reflections on school health leadership during the COVID-19 pandemic. History is deserving of their stories.

Keywords

school nurse administrator leadership COVID-19 pandemic mitigation strategies infection control school nurse staffing public health

In their article detailing pandemics throughout history, Piret and Boivin (2021) provide a table listing a timeline of pandemics. Our current pandemic, SARS-CoV-2, initially identified in Wuhan, China in December of 2019, thus commonly named COVID-19, was the fourth of this current century preceded by severe acute respiratory syndrome (SARS-CoV; 2002-2003), swine flu (H1N1; 2009-2010), and Middle East respiratory syndrome (MERS; 2015-ongoing). School nurses recall the H1N1 pandemic, and a past NASN School Nurse article highlights the crucial role of the school nurse, where early in the pandemic, Mary Pappas (2011) alerted health officials in New York City of an outbreak of symptoms occurring in her school. Carolyn Duff, past president of NASN, explains “the possibility of a pandemic is always on school nurses’ radar screens” (2020, p. 48), and she goes on to elaborate on a school nurse’s ability to be flexible with a pandemic response plan that is “reactive to new evidence and adaptive to new practice environments” (p. 48). Duff also reminds that enlistment of the Leadership principle from NASN’s Framework for 21st Century School Nursing™ (National Association of School Nurses, 2016) is central to school nurse pandemic response, as well as the Framework’s focus on the safety and health of students.

The Editorial Advisory Board (EAB) of the NASN School Nurse desired to capture and preserve for historical purposes, a description of the challenges and successes of school nurse leadership during the COVID-19 pandemic, hereafter referred to as COVID. More simply stated, we wanted to create a platform for school nurse administrators (SNAs) to tell their story. An invitation was placed on NASN’s SchoolNurseNet SNA discussion list in November 2021 specifying that participants must spend a minimum of 50% of their time in a managerial role and that they supervise a minimum of 10 school nurses. Over 40 SNAs responded to the invitation. Restrictions of article length required narrowing down the participants, and the EAB focused on diversity of geographical representation, student population size, and employment agency type. An online, supplemental file provides acknowledgements and photos of the SNA participants. Table 1 provides additional information, including the SNA name, job title, school name, demographics, and school health staffing.

Table 1.

School Demographics and Staffing (Largest to Smallest Student Population)

Name, title, employer	School district demographics	Health staffing
Karen Moran Fossile Health Services Director I Clark County School District Las Vegas, NV Clark County School District is the 5th largest school district in the nation servicing urban, suburban, and rural areas.	Clark County School District 310,000 students 226 Elem 1 K-8 school 3 K-12 school 59 MS 45 HS 30+ Alternative, special schools, distance education, etc.	Total ≈ 616 Note. Does not include agency staff 200 RN FTE (approximate) 22 LPN FTE 384 First Aid Safety Assistants FTE (includes 18 FTE Float) 1 Chief Nurse 7 Health Services Director I 1 Employee Health Director 1 Health Services Coordinator
Sara O’Toole Director, Nursing and Medical Services Pinellas County School Board Pinellas County, FL Florida establishes school districts by county. Pinellas County is the most densely populated county in Florida, covering the 280-square mile peninsula located between the Gulf of Mexico and Tampa Bay.	Pinellas County School Board 90,000+ students 76 Elem 2 K-8 schools 19 MS 17 HS 4 Exceptional education schools 7 Educational alternative schools	Total 157 FTE Funded by the school district: 21 RN FTE 103 LPN FTE 3 administrators FTE 3 clerical FTE Funded by the Department of Health Pinellas: 6 RN FTE 2 LPN FTE 15 Health support technicians FTE 3 Administrators FTE 1 Clerical FTE
Barbara Robertson Director of Health Services Conroe Independent School District Conroe, TX The school district covers 348 square miles, north of Houston, and includes the cities of The Woodlands, Shenandoah, Oak Ridge North, Conroe, and Grangerland, as well as several other smaller towns, communities, and unincorporated areas.	Conroe Independent School District 68,000 students 35 Elem (K-4) 10 Intermediate (Grades 5-6) 7 MS 3 Ninth-Grade Centers 6 HS 1 Academic alternative HS 1 Juvenile justice alternative education program 1 Juvenile detention center	Total 145 FTE 62 RN FTE 2 LVN FTE 65 Health aide FTE 7 Float RN FTE 5 Float LVN FTE 4 Float health aide FTE
Kim Ragan Assistant Director School Health Cabarrus Health Alliance (CHA) Kannapolis, NC CHA is the county public health authority in Cabarrus County. CHA employs the school health staff per a contractual agreement with Cabarrus County and Kannapolis City School Districts. Cabarrus County is a suburban-rural county covering 365 square miles in south-central North Carolina with a population of 226,000.	Kannapolis City Schools 5,766 students 1 PK6 Elem 1 MS 1 HS Cabarrus County Schools 34,339 students 20 Elem 8 MS 10 HS 5 Nontraditional (Opportunity MS/HS, Alternative HS, early College, Elem/MS School of the Arts, Virtual Academy)	Total 54 FTE Employed by Cabarrus Health Alliance School Health Administrative Team 1 RN director FTE (12 month) 2 RN assistant directors FTE (12 month) 3 RN supervisors FTE (12 month) Kannapolis City Schools 9 RN FTE (10 month) Cabarrus County Schools 39 RN FTE (10 month)
Sarah Marion School Nurse Supervisor Le Bonheur Children’s Hospital Community Outreach (LBCHCO) Tipton County Schools Covington, TN Tipton County is a rural county just north of Memphis. LBCHCO employs the school health staff per a contractual relationship with Tipton County Schools	Tipton County Schools 10,400 students 1 PK 6 Elem 1 K-8 school 3 MS 3 HS 1 Alternative learning center 1 Teen learning center	Total 15 FTE 6 RN FTEs 8 LPN FTE 1 RN supervisor FTE

Note. PK = preschool/early childhood; K = kindergarten; Elem = elementary school(s); MS = middle school(s)/junior high school(s); HS = high school(s); FTE = full-time equivalent; RN = registered nurse; LVN = licensed vocational nurse; LPN = licensed practical nurse.

In addition to demographic and school health staffing data, participants were asked five questions. Interestingly, the participants submitted their responses late 2021 through early 2022, coinciding with the third wave of the pandemic. The EAB is thankful for all of those who expressed an interest in sharing their stories, and we encourage SNAs to take time to answer these questions for your community, and in so doing capture the historical significance of school nursing during this remarkable time in history.

1. What was your typical workload like at the beginning of the 2020-2021 school year, and how did it change by midyear, end of the year, as well as the beginning of the 2021-2022 school year?

Karen Moran Fossile: At the beginning of the 2020-2021 school year, I was working 40 to 45 hours plus per week, depending on staffing issues. My administrative duties included oversight of

staff at schools including school nurses, specialized procedure nurses, and contracted agency nurses,

several committees (Policy and Procedure, School Nurse Advisory Board, Employee Engagement Committee) with in-person meetings once per month, and

First Aid Safety Assistant training and New School Nurse training.

In addition, I participated in nurse administration meetings every other week and assisted with interviews of school nurse candidates and agency nurses (three separate agencies). Some of the rural schools were reopened in a hybrid model (three elementary schools, one middle school, and one high school) in August of 2020, while the rest of our school district remained closed providing distance education. Parents of students at the three rural schools were asked to review health symptoms confirming their child was free of symptoms prior to the student entering the building each day. We began holding virtual meetings to determine who needed to be quarantined on confirmation of a COVID positive student or staff member. All of our committee meetings remained virtual.

In March 2021, all elementary schools reopened in a hybrid model, with half the students attending Mondays and Tuesdays, the other half attending Thursdays and Fridays, and Wednesdays reserved for cleaning. Parents and guardians also had the option to keep their child in distance education. In April 2021, all elementary schools converted to a typical 5-day model, and secondary schools reopened in the hybrid model in order to social distance due to space. Each school was required to have both a sick and well room, and all sick and well rooms were supplied with ionization filter systems. All nurses were Fit-tested for N95 masks following Occupational Safety and Health Administration guidelines, as well as the First Aid Safety Assistant at each school and at least two health office backups. We interviewed and hired many agency nurses placing them at schools to assist in the sick rooms. Following guidance from our local health department, we developed policies and procedures to guide the transition to full in-person learning. There were many facets of this process:

Additional hours were devoted to training, coordination of services, meetings, contact tracing, data collection, and staff education.

Staff education involved explaining the three points of service for delivery of first aid or medications.

° First point of service was the classroom—complete Basic First Aid in the classroom with consideration if medication can be given in the classroom or right outside in the hall.

° Second point of service was the well room or health office for completion of diabetes management.

° The third point of service was the sick room where students exhibiting signs and symptoms of COVID-19 were sent for evaluation.

We established a triage form for questions to consider when sending a student to the sick or well room. This included a phone call being placed to an established person who advised the teacher on which room to send the student.

The regular school year ended on May 26, 2021; however, on June 1, 2021, every school offered June acceleration programs using COVID-related Elementary and Secondary School Emergency Relief Funds. Most of our school nurses were not on contract. Thus, we needed to offer incentives to work the month of June. Further complicating the strain on our work force, our Extended School Year Program started on July 1, 2021, running through July 27, 2021. With new school nurses reporting on July 28, 2021, and the returning school nurses starting back on August 4, 2021, there was no break for planning or respite for the nursing administrators prior to students beginning classes on August 9, 2021.

We started the 2021-2022 school year with COVID and contact tracing as our major responsibilities. As administrators, we also covered Saturdays and Sundays for isolation and quarantine calls and were working 50 to 60 hours per week. We were not able to perform any other duties but COVID-related activities. Virtual meetings were set in 15-minute increments, and some days that is what you did almost the entire day. It was exhausting. Mandatory vison and hearing screening was halted at this time.

Sara O’Toole: The beginning of the 2020-2021 school year was very challenging. The State of Florida made the decision that all schools would be open for in-person learning for any family who wanted their student to attend in person; additionally, there was the option for districts to offer online learning. As an administrator, and the only health expert in the district, I was working long hours during the workweek and weekend as well. From the beginning, our district formed a centralized COVID team made up of nurses and Human Resources staff; I provided administrative oversight to the team. I was fortunate to be a part of our district’s medical advisory team, which was composed of the county health department director, the head of our local children’s hospital Infectious Disease Department, the medical director for our local Federally Qualified Health Center, local pediatricians, and school district leadership. This team met frequently to help shape our reopening. I also participated in public school board workshops and meetings and a Facebook Live event, where we discussed COVID health and safety protocols. Additionally, our health policies needed to be reviewed and/or created to encompass national and local COVID guidelines; the nursing staff needed training; we had staffing issues to solve; and my office fielded many phone calls and emails from concerned and nervous parents regarding the safety of in-person learning along with a host of other activities that take place during a “normal” opening of the school year.

Once school opened in August 2020, the pace seemed to level out until early November. In early November 2020, we noticed a steady increase in COVID positive cases in the district and community. This increase continued throughout the winter holidays and January 2021, which again meant working long hours on the contact tracing process with the health department. I oversaw the daily reports of positive cases in the district, which were reported to both district leadership and the public. Beginning in February 2021, the case count began to slowly decrease, and levelled out by early March. We saw a slight increase after spring break, but cases then declined until the end of the school year.

COVID cases were low over the summer, and we were hopeful going into the opening of the 2021-2022 school year—then Delta hit. With the arrival of the Delta variant, we once again experienced a huge spike in cases, and opened the school year much like the 2020-2021 school year, with almost the same challenges as previous, but all students now attended in person. August and September 2021 were challenging months, as the State of Florida enacted some rules that directly affected contact tracing and quarantine in schools.

I was fortunate to be a part of our district’s medical advisory team . . . comprised of the county health department director, the head of our local children’s hospital Infectious Disease Department, the medical director for our local Federally Qualified Health Center, local pediatricians, and school district leadership. (Sara O’Toole)

Barbara Robertson: My workload at the beginning of the 2020-2021 school year started with long days which were routinely 12+ hours, 7 days a week, to prepare for opening in-person learning in early September. From consulting with the local health department, meeting with district administration and nursing staff, and writing/implementing pandemic protocols, the hours were long, and the days stretched from weeks to months. By midyear, the long days continued as COVID case counts increased. We operated a contact tracing department to mitigate student and employee positive cases, as well as a COVID testing site for employees, while supporting campuses to implement effective mitigation measures. Collecting and reporting data on district case counts, ordering and managing PPE (personal protective equipment) inventory, facilitating vaccine opportunities for employees, and continued monitoring of COVID in our schools, communities and elsewhere, occupied much of my day. By the end of the 2020-2021 school year, the virus count in our area was greatly diminished which allowed me to return some focus to other important topics such as professional learning opportunities for my nursing staff.

As we returned to school fall of 2021, we were quickly inundated with the Delta variant. COVID fatigue, vaccine hesitancy, and optional mask usage contributed to unprecedented case counts and pushed our nurses to the brink of exhaustion. Between managing our COVID response with my departmental duties, my workload once again returned to 12+ hours per day. After a couple of very difficult months, by late November 2021 we began experiencing some of our lowest case counts in more than a year. With the reduction in COVID-related issues, we were able to refocus our energies on student screenings for vision, hearing, and spinal, provide professional learning opportunities for our nurses, as well as give nurses a chance to catch their breath and prepare for whatever may come their way the remainder of the 2021-2022 school year. I remain confident we will be ready.

Kim Ragan: At the beginning of the 2020-2021 school, I was working 40 to 50+ hours per week. The school year began with 100% remote learning. I attended a multitude of meetings focused on COVID planning and mitigation strategies; weekly meetings with school leaders (composed of superintendents, assistant superintendents, health services directors, human resources, and student health services from both districts and our Public Health COVID Team and School Health Administrative Team); weekly meetings with multidisciplinary teams from the school districts (transportation, school nutrition, curriculum, facilities, custodial supply, athletic directors, etc.); and frequent meetings with our School Health Administrative Team. Additionally, I participated in daily public health planning meetings with our COVID team, public health leaders, hospital, and county emergency management to discuss the COVID numbers, testing and vaccine clinics, mitigation strategies, and community responses. The entire School Health team assisted in community-based vaccine clinics, and we developed a rotating schedule to distribute the workload. The School Health Administrative Team worked with nurses to strategize how to connect with students and meet their health needs while in a remote learning environment.

By midyear, I was working more hours as the schools moved to A/B hybrid learning necessitating additional training and weekly virtual meetings to keep the school nurses current on all things COVID; to assist our administration team with interviewing, hiring, and orienting new school nurses; and to keep parent letters and educational materials updated to reflect the current public health guidance. I also had to help cover schools during a temporary nurse vacancy and leave. In addition, I fielded frequent questions from the nurses, parents, and school staff regarding COVID via phone and emails; worked large, community-based, drive-through COVID vaccine clinics at an area event center; and coordinated the pilot program for rapid antigen testing in select schools which included ordering and delivering testing supplies and developing and conducting training sessions for the nurses. I also aggregated school-based testing data to share during the weekly school leaders’ meetings. The administrative team was very busy with “all things COVID.” We were trying to stay abreast of current COVID guidance, keeping our school nurses updated on the changes, trying to acknowledge and validate their fears while promoting multilayered mitigation strategies to help keep them safe, and providing the nurses a safe space to express their frustrations and concerns as they were often caught between public opinion and enforcing the public health guidelines.

By the end of the 2020-2021 school year, the students were back to 100% in-person learning, community vaccine clinics were being held 2 to 3 times per week, the number of calls and emails increased, and the weekly meetings continued. We thought that if we could just make it through the school year our team would finally get a chance to rest and recover, and then we learned about the second chance summer school programs.

As administrators, we also covered Saturdays and Sundays for isolation and quarantine calls and were working 50-60 hours per week. We were not able to perform any other duties but COVID-related activities. Virtual meetings were set in 15-minute increments, and some days that is what you did almost the entire day. It was exhausting. (Karen Moran Fossile)

Sarah Marion: The beginning of the 2020-2021 school year was filled with much planning. I assisted in developing and maintaining the school system’s COVID safety plan. This included continuing research of best practices in reducing the risk of spread of COVID. I attended several webinars to stay current on the constantly evolving data and guidelines, then in meetings to discuss how to implement updates. I estimate averaging about 10 to 15 hours per week in webinars and zoom meetings. I assisted my nurses and their principals in setting up separate areas for sick and well visits. This proved challenging in several buildings where space is limited. I also developed a new procedure for sending students to the health rooms to reduce the risk of possible exposure. This required me to speak to the faculty and staff at each of our county’s 14 schools. I developed new data collection forms for the number of positive cases, close contacts, and symptomatic students we were seeing each day. Of course, our routine beginning-of-the-year duties also had to be completed such as CPR (cardiopulmonary resuscitation) certifications, skills assessments, and bloodborne pathogen and AED (automated external defibrillator) training.

By midyear, our processes were in place and my focus transitioned to data collection and staffing challenges. I spent around 8 hours a week organizing the data being sent in by the school nurses. We had several staffing challenges both COVID-related and unrelated. This led to direct patient care dominating my time for much of the winter months. By the end of the school year, COVID cases had dropped in our area. We were able to complete our end-of-year duties much like other “normal” school years.

The beginning of the 2021-2022 school year was similar to the beginning of the prior school year in that once again procedures were changing, and I was again researching, planning, and updating procedures to correspond to new data and guidelines.

Many times, it felt like we would put a practice in place and the next day guidelines would change, specifically regarding quarantine management. (Sarah Marion)

2. Were you able to hire new staff during the pandemic, and if yes, were you able to retain the new staff (or new positions) into the current 2021-2022 year?

Karen Moran Fossile: We were able to hire many new nurses during the pandemic and retain the majority of them during the 2020-2021 school year when we were working primarily from home. However, it proved difficult once we returned fully to in-person learning in August 2021. We lost many nurses as the newly hired school nurses had never experienced the workings of a health office, and COVID overwhelmed all the school nurses. With regard to health services administration, prior to the pandemic we had a Chief Nurse/Director III and six Health Services Directors 1. We have increased to now having seven Health Services Director 1, one Employee Health Director 1, and a Health Services School-Based and Provider Relations Coordinator.

Sara O’Toole: Yes, we have been able to hire new staff, although we have noticed a decrease in applicants over nonpandemic years. For the most part, we have been able to retain the new staff we have hired. To meet the gaps in our staffing, and in order to have a nurse in every school every day, the district contracted with nursing staffing agencies to fill the holes until we could (hopefully) hire permanent staff members.

Barbara Robertson: Our school district has always been committed to student health and safety. The majority of our campus clinics, based on campus enrollment, employed a full-time health aide in addition to the registered nurse prior to the pandemic. As we anticipated the increased workload of our school nurses, district administration elevated the remainder of the approximately 18 part-time health aides to full-time for the 2020-2021 school year. By mid-fall of the 2020-2021 school year, it was clear additional support was needed for contact tracing, COVID testing, and campus nurse support. The district hired a nurse specialist and an additional administrative assistant, seven float RN full-time equivalents (FTEs), three float LVN (licensed vocational nurse) FTEs, and three float health aide FTEs. These support positions were instrumental in providing the additional help needed to allow our district to remain open and provide a safe and healthy learning environment for all students and employees. The district’s support for these important positions continues in the current school year.

Kim Ragan: While our county has been committed to having a full-time RN in every traditional and year-round school for over 20 years, we had difficulty keeping positions filled and saw a decrease in applicants during the 2020-2021 school year. During the 2021-2022 school year, we added 2 additional school nurse supervisors,1 additional nurse to cover the virtual academy and alternative high school, a COVID testing coordinator, 1 LPN and 3 medical office assistants to support our nurses at the largest schools, as well as contracting with a temp agency to bring on 45 full-time unlicensed assistive personnel to support the school nurses primarily with contact tracing and COVID testing. The CHA also hired a full-time school liaison who worked in the COVID Public Health Command Center to be point of contact for questions and concerns from school nurses and school leaders and to provide support and guidance.

Sarah Marion: I was not able to hire new staff; however, I was able to restructure our staffing to have a nurse in each school. In previous years, one building had two nurses due to two entities being housed in that building (a preschool and an elementary school operating separately from each other). I was able to reorganize the nursing care so that one nurse could take care of both entities in the building which freed up the other nurse to staff my one school without a full-time nurse. I cannot imagine handling the added responsibilities brought on by COVID had I not been allowed to make that change. Fortunately, I was able to keep that change in place this school year so that I still have a nurse in each school.

3. How did your provision of staff development and departmental meetings, including new nurse orientation, change during the pandemic?

Karen Moran Fossile: Departmental meetings, staff development, and new nurse orientation were all virtual during the 2020-2021 school year. Even our opening nurses’ meeting, in August of 2021, was virtual. To date, we have not had any committee meetings due to the shortage of school nurses.

Sara O’Toole: Since the lockdown in March 2020, almost all department staff meetings have been held virtually. We have been able to bring very small groups together face-to-face and maintain social distancing, but with a large staff it is very difficult to find an appropriately sized space. In August 2021, we did have our back-to-school meeting in person, but we split the staff in half to be able to distance ourselves and shortened it to a half-day meeting. The staff have felt the loss of collaboration and comradery with other staff. While we have noticed a small increase in positive cases in the last few weeks with the advent of Omicron, we did hold our first annual holiday get-together at a park December of 2021 (living in Florida allows us that luxury!) New nurse orientation has continued to be face-to-face, either 1:1 between mentor and new nurse or in a small group setting. We adapted some of our onboarding training to be online, so new staff spent less time with their mentor in a classroom setting.

Barbara Robertson: Our district is geographically large, covering 348 square miles. Due to the size, Health Services utilized a virtual platform for many conferences, meetings, and professional learning opportunities prior to the pandemic, which made the transition to full time virtual usage for these activities much easier. Engaging staff virtually presented some challenges, but the professionalism of our entire nursing staff made it work. We conducted our department’s Back to School meeting, new nurse orientation, and vision and hearing screening certification training virtually at the beginning of the 2020-2021 school year. We found virtual options were not as conducive to learning for instruction on skills such as the screening training or when delivering a large amount of critical content. We quickly transitioned back to in-person learning as soon as we could for these important trainings using mitigation strategies to keep everyone safe. Not discounting the need to be together in person, our nursing staff continues to be eager to participate in virtual professional learning opportunities to strengthen our team, their practice, and provide the highest quality of nursing care to their population.

Kim Ragan: We had more frequent meetings, most of which were held virtually. Our school health administrative team led weekly virtual meetings to keep nurses up to date on the latest COVID guidelines, address concerns, and answer questions. We are fortunate to have a strong collaborative partnership between the CHA and our school districts and were able to utilize virtual meeting platforms to offer support and public health guidance to both districts, continuing weekly meetings with school and public health leaders. Orientation included COVID symptoms screening, quarantine and isolation guidance, rapid antigen testing, close contract identification and case investigation, how to conduct tracking through our collaborative platform shared between the school leaders and CHA, and multi-tiered school mitigation strategies. For the first time ever, we were forced to hold some of the “in-house” orientation sessions virtually.

Sarah Marion: Like so many other things, COVID changed my plans for staff development and continuing education. The nursing staff and I are employees of the local children’s hospital contracted by the school system. I had planned to have my staff attend a day-long training provided by the hospital; however, all in-person classes were cancelled. I assigned several online training modules to take the place of topics we would normally have covered in-person. Our monthly staff meetings were also done virtually. We are required to perform annual skills assessments which we typically do in small groups. The pandemic necessitated me going to each nurse individually to perform these during the 2020-2021 school year.

We found virtual options were not as conducive to learning for instruction on skills such as the screening training or when delivering a large amount of critical content. (Barbara Robertson)

4. What was your upmost challenge, and how did you resolve the challenge? Looking back is there something you would do differently? How did you conduct preventive health screenings such a hearing and vision screenings?

Karen Moran Fossile: On November 13, 2020, our chief nurse, Yvette Wintermute passed away unexpectedly. Another nursing administrator, Linda Kalekas, stepped in as interim chief nurse. As we entered the 2021-2022 school year, we had the additional challenge of COVID and contact tracing for our entire school district. Fortunately, by this time, a permanent chief nurse was in place, Sheri McPartlin. Our school nurses, as well as the nurse administrators, were involved in COVID cases constantly, every day. All mandatory vision, hearing, and scoliosis screenings were halted. We pleaded with our chief nurse to take the COVID contact tracing away from the site school nurses. In September 2021, COVID Central was opened. COVID Central services both employees and students and was initially staffed with a few experienced school nurses, 50 agency nurses, and 25 disease investigators working together to answer all the parent and employee calls related to COVID, contact tracing, and providing resources for free testing at our CLIA labs and vaccines pods. Currently, over 130 agency nurses and 25 disease investigators continue to manage the 350,000 student and employee COVID-related concerns. We have resumed vision and hearing screenings in our schools and are operating under an interim service delivery model to reduce burden on our schools and health services staff. Looking back, we should have centralized COVID operations before the start of the 2021-2022 school year to reduce the burden and stress on our schools.

Sara O’Toole: I think that the biggest challenge I have faced throughout this pandemic was finding my voice and using it to provide truth and facts even with other people who have different opinions. I have always preferred to fly under the radar and advance the department in small private ways. This pandemic made health services, and therefore me, front and center in the district. Several individuals in the district and community looked to me for guidance, support, reassurance, and answers. For many, I became a trusted source of knowledge and information; for others, I was seen as pushing an agenda they did not agree with. Over the past 20 months, I have had many people thank me for my opinion, tell me they “don’t know how I’m doing it,” and compliment me on my honesty or on the way I publicly delivered complex information in a way that was easy to understand. However, I have also been yelled at so many times I have lost count, had my job threatened, had my faith questioned in a public forum, and had my nursing license threatened. I have learned to be comfortable telling people that I do not have all the answers because this was a new and novel virus and we are literally watching science in action! I have much thicker skin now than prepandemic and am stronger in my convictions and ability to speak truthfully to others even if it’s not what they want to hear. All of these challenges have made me a better leader.

Looking back, we should have centralized Covid operations before the start of the 2021-2022 school year to reduce the burden and stress on our schools. (Karen Moran Fossile)

I think that the biggest challenge I have faced throughout this pandemic was finding my voice and using it to provide truth and facts even with other people who have different opinions. (Sara O’Toole)

Regarding health screenings, our district has been fortunate to have a screening team that has conducted our mandatory screenings. The 2020-2021 school year was challenging, as we had students learning in-person but also students learning virtually. Students were allowed to return to brick-and-mortar school at any time last year. As a team, we looked at the in-person enrollment numbers in every school and used the screening team where they would have the most impact—the schools with larger numbers of in-person students. We tweaked our screening procedures to ensure social distancing and safety. We spent more time at the larger schools so not to rush through the students and to prevent students congregating together for long periods of time. For smaller schools, who did not receive the screening team, the school nurses oversaw the screenings, completing them at their own pace and spreading the screenings out over the course of many months.

Barbara Robertson: My greatest challenge over the past 21 months is the professional struggle of “Am I doing enough?” The pandemic has magnified the feeling of responsibility over anything I have felt since first becoming a nurse. The Texas Board of Nursing charges each nurse with a duty to provide a safe environment for the client and others. As a nurse, and, especially a nurse administrator, I often ask myself, “Is this the safest course of action? Is it too much, too little, or just right?” When the nurse is wrong, bad things can happen so the pressure can be intense. Our school district has over 68,000 students and 8,500 employees. The challenge to keep them all safe, healthy, and in school or at work is huge.

Rather than a challenge to be solved, this professional duty requires ongoing flexibility, adaptability, and relevant knowledge to make the best decisions possible. While working closely with our local healthcare entities and health department, I also collaborate with my nurse advisory team and local nurse leader colleagues, stay abreast of ever-changing guidance, and use current resources provided by Texas School Nurses Organization (TSNO) and NASN. An outstanding team of administrators supports me, so I am never alone in my efforts to protect our students, employees, and communities.

If I could do anything different, it would probably be to make myself take more time for a break from trying to protect everyone. As nurses, we often give all we have to help our patients, which can leave nothing in reserve, mentally or physically, for ourselves. I am working on acknowledging this and taking steps to care for myself so I can continue to care for others.

During the 2020-2021 school year, we placed a priority on vision screenings for students in the required grades. After weathering the increased COVID cases in the fall semester, our nurses worked tirelessly to conduct screenings in a safe manner and identify students who needed referrals and/or assistance prior to the end of the school year. This current school year, 2021-2022, we are well on our way to meeting our goal of completing vision and hearing screenings for all required grades along with those who may have been missed last school year. Additionally, this school year, our district provided each nurse with a one-year membership to NASN, which will not only support their nursing practice but also make available the VSP Global Sight for Students gift certificates, so they can provide vision assistance for their students in need.

If I could do anything different, it would probably be to make myself take more time for a break from trying to protect everyone. (Barbara Robertson)

Kim Ragan: The biggest challenge for me was staying current on the ever-changing COVID guidance, state required and recommended school protocols, and helping to make sure that our school nurse team was updated as well. I resolved this challenge by leaning into the strength of our Public Health COVID Team and the strengths of our School Health Administrative Team to help clarify questions I had and by attending regular meetings with public health and school leaders. Another challenge was keeping staff morale up when they had their own concerns and fears and when the nurses were regularly having to listen to negative feedback from the parents.

Looking back, I would be more intentional about staying ahead of the curve on the constantly changing COVID guidance and providing a safe platform for each of my direct report nurses to vent and express their concerns without fear of judgement. Regarding preventive screenings, our nurses did not conduct mass screenings during the 2020-2021 school year. They conducted hearing and vision screenings for evaluations and as concerns were presented.

Sarah Marion: The biggest challenge I faced during the 2020-2021 school year was keeping up with the constantly updating guidelines. Many times, it felt like we would put a practice in place and the next day guidelines would change, specifically regarding quarantine management. To ensure I remained up to date, I bookmarked several pages on our state Department of Health’s website and checked them at least every other day. I would then send the new information to my staff via email.

Our state suspended mandatory health screenings for the 2020-2021 year, instead making them recommended. When COVID cases decreased toward the end of the second semester, I was able to take a few days to visit each school to assist with as many screenings as we could complete. While we did not have time to complete as many as previous years, we were still able to screen several grades during a year with so many other added responsibilities.

5. What are you most proud of looking back on the past 2 years?

Karen Moran Fossile: We are most proud of the establishment of COVID Central which now manages all COVID cases, including contact tracing, communication, and documentation into our electronic medical record. As a result, the school nurse’s burden of COVID-19 and contact tracing has been greatly reduced.

Sara O’Toole: I am most proud of my staff! I am fortunate to have two assistant managers who jumped right in and took over so many of my day-to-day duties when I was knee-deep in COVID. They are the ones who interviewed new staff, figured out scheduling and coverage issues, and helped the clinic nurses problem-solve issues. My secretary learned very quickly how to handle the volume of phone calls we were getting, how to answer some of the easy questions, and how to prioritize the calls. As for my nurses in the clinics, I can’t say good enough things about them! While many were nervous to return to in-person school, they rose to the challenge and adapted their ways of working to meet the needs of their schools. They took every change in stride, helped us figure out better ways to work, advocated for themselves and their students, and provided a calm voice of reason for so many of our families and staff.

Barbara Robertson: Telling people what to do is easy, leading people is harder. I want people to follow me because they believe in the journey, because they want to go where I am going, not because they feel obligated in some way. I am most proud of the trust that was built and relationships that were formed by hard work, a passion for student and staff health and safety, and providing honest information during very difficult times. Being a part of leading our district through the 2020-2021 school year has been a highlight of my nursing career. I was pleased to be a part of the collective efforts from every department in our district to support student health and success. Our district has shown that together we can do hard things well. I was humbled and honored when the TSNO recognized my hard work by selecting me as the TSNO School Nurse Administrator of the Year for 2020. It is truly my pleasure to be a part of this district and serve the students, employees, and communities that make up Conroe ISD. I am confident that together we can overcome any challenges that COVID has in store.

They took every change in stride, helped us figure out better ways to work, advocated for themselves and their students, and provided a calm voice of reason for so many of our families and staff. (Sara O’Toole)

. . . we were able to implement . . . protocols which prevented any major COVID outbreaks within the school system. We did not have to close down any schools during the 2020-2021 school year . . . (Sarah Marion)

I am most proud of how our School Nurse team stepped up to the COVID challenge and being part of hundreds of staff and volunteers working long hours, during all types of weather, to hold large scale vaccine clinics, having fun, with smiles on our faces, and working collaboratively with multidisciplinary teams, and developing new relationships with community partners. (Kim Ragan)

Telling people what to do is easy, leading people is harder. . . . Our district has shown that together we can do hard things well. (Barbara Robertson)

Kim Ragan: I am most proud of how our School Nurse team stepped up to the COVID challenge. I felt honored to serve alongside hundreds of staff and volunteers working long hours, during all types of weather, at large scale vaccine clinics, while having fun, with smiles on our faces, and working collaboratively with multidisciplinary teams, and developing new relationships with community partners. I am very proud to be a part of the outstanding, mutually respectful, working relationship between our local health department and local education associations, and of how we worked collaboratively to continually keep the health and safety of our students and community the focus of our work.

Sarah Marion: Thanks to the incredibly hard work and great resilience of my amazing staff and a great relationship between nursing and school administration, we were able to implement and adhere to protocols which prevented any major COVID outbreaks within the school system. We did not have to close down any schools during the 2020-2021 school year due to COVID (We did get a few snow days though!). I am ultimately most proud of how well my nursing staff handled each and every change presented to them throughout the year.

Conclusion

There is no doubt that the pandemic thrust school nursing into the spotlight. Initially, when schools were closed to slow the spread of disease, school nurses served as navigators between public health and education institutions to assist in establishing and implementing mitigating factors, magnifying both the role and workload of SNAs and school nurses. Additionally, SNAs and school nurses demonstrated an ability to quickly pivot as they responded to ongoing, evolving information, all the while assisting the school community in deciphering between factual and nonfactual information. Public health measures were at times met with resistance, more so as the pandemic lengthened in time from weeks to months, then to years. Thank you SNAs and school nurses for your commitment in promoting the health of our students, staff, and communities. We encourage all of you to take the time to tell your story. It is a story of challenges, collaboration, respect, resiliency, trust, and passion.■

Supplemental Material

sj-pdf-1-nas-10.1177_1942602X221084069 – Supplemental material for Leading During a Pandemic: A School Nurse Administrator Roundtable

Supplemental material, sj-pdf-1-nas-10.1177_1942602X221084069 for Leading During a Pandemic: A School Nurse Administrator Roundtable by Cynthia A. Galemore, Sarah Marion, Karen Moran Fossile, Sara O’Toole, Kim Ragan and Barbara Robertson in NASN School Nurse

Footnotes

ORCID iD

Cynthia A. Galemore

Supplemental Material

Supplemental material for this article is available online.

Cynthia served as the Director of Health Services for Olathe Public Schools from 1995 until her retirement in 2017. Cynthia is a former NASN Director and has served as the editor of the journal since 2010.

Sarah is a nurse supervisor for Le Bonheur Children’s Hospital Community Outreach, working in the Tipton County School system. Her first profession was teaching before she made the switch to nursing. She began her nursing career at the children’s hospital before transitioning to the hospital’s community division to merge her professions as a school nurse.

Karen has 17 years of school nursing experience in the Clark County School District in Las Vegas. Since 2013, she has been part of the Nursing Administration overseeing about 35 school nurses and 60 schools. Karen began her nursing career in Philadelphia working at St. Christopher’s Hospital for Children for 22 years in various roles from staff nurse to management.

Sara has worked at Pinellas County Schools for 11 years, first as a school nurse then in administration for the past 8 years. She is a member of the Florida Association of School Nurses and has collaborated with the State of Florida on various school nursing projects and initiatives.

Kim has 25 years of school nurse experience having worked in North Carolina, Minnesota, and Grand Cayman, British West Indies. For the past 17 years, she has worked in Cabarrus County as a member of the School Health Administrative team at the Cabarrus Health Alliance (CHA). CHA is the county public health authority providing school nurse services to 40,000+ students in the county’s two public school districts. She is currently a Master’s in Public Health Leadership candidate at the University of North Carolina at Chapel Hill. As a public health nurse Kim works as a liaison between the Local Education Agencies and the Public Health COVID department.

Barbara has worked in Conroe ISD for 17 years, 10 years as a school nurse, and the past 7 years in administration as Coordinator and now Director of Health Services. She is an active member of the Greater Houston Area School Nurse Leadership Group where she collaborates with area school nurse administrators on best practices for student health and safety.

References

Duff

(2020). School nursing—Always student-centered: Leading and innovating on the frontlines of the pandemic. American Nurse, 15(10), 48.

National Association of School Nurses. (2016). Framework for 21st Century School Nursing Practice. NASN School Nurse, 31(1), 45-53. https://doi.org/10.1177/1942602X15618644

Pappas

(2011). From local school nurse to national advocate. NASN School Nurse, 26(3), 180-182. https://doi.org/10.1177/1942602X11404559

Piret

Boivin

(2021). Pandemics throughout history. Frontiers in Microbiology, 11, 631736. https://doi.org/10.3389/fmicb.2020.631736

Supplementary Material

Please find the following supplemental material available below.

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