School Nurses: We're Not OK

Karen Rufo, Director of Health Services for the Lexington Public School District in Lexington, Mass., has been a registered nurse for 42 years. She’s seen a lot in more than four decades working in the healthcare industry, but nothing could have prepared her for the pressures of a global pandemic.

When the stress seems unsurmountable, she reminds herself and her team that they’ve never faced a challenge like COVID-19 before and they’re doing the best they can with the knowledge that’s available.

“I promise you, I’ll do a better job my next pandemic,” she says wryly with a hint of a Boston accent.

Right now, she’s doing everything she can to keep students safe and to keep her fellow school nurses from buckling under the stress. Burnout is higher than ever and there’s already a shortage of nurses, which could get worse in the coming months.

Eighty-six percent of NEA members say they have seen more educators leaving the profession or retiring early since the start of the pandemic in 2020. A staggering 55 percent of educators are thinking about leaving the profession earlier than they had planned, according to a National Education Association (NEA) survey . This represents a significant increase from 37 percent in August.

The damaging effects of too few teachers have been widely reported, but too few school nurses can lead to non-trained staff helping with nursing responsibilities like medical emergencies or administering medicine.

School nurses are shouldering a heavy COVID workload identifying cases, testing, contact tracing, and alerting parents about infections while juggling the already demanding responsibilities of their regular nursing roles. At the same time, they’re trying to stay one step ahead of an ever-evolving virus that seems to change with every passing season.

“It’s like yesterday we thought it was coffee ice cream, but now it’s strawberry, so we pivot again,” Rufo says. “I tell my nursing team it’s a good thing we all have good knees!”

Along with the unknowns of a highly contagious and potentially life-threatening virus comes fear, anxiety, and their close cousin, anger. Sometimes those emotions are vented by frustrated families when school nurses are trying to do their jobs treating sick students.

Rufo reminds the tight-knit nursing team in her district that a lot of the behavior they face is fueled by fear and that empathy is always the best defense. Meeting anger with empathy lowers the stress for everyone, especially if it goes both ways.

Nurses are balancing on a tightrope trying to keep kids safe and healthy while not interfering with in-person instruction. Sometimes they have to make tough calls that rankle some families.

“We didn’t cause anyone’s child to get the virus, and we want it go away more than the average bear,” Rufo says. “Please, don’t shoot the messenger.”

‘I Always Feel Like I’m Missing Somebody’

One of the worst parts of school nursing through the pandemic is the constant, nagging feeling that something didn’t get done; that someone didn’t get what they needed, says Tonja Frank, a middle school nurse in Omaha, Nebraska.

“There is an overwhelming amount of tasks to be done and care to be given,” she says. “I always feel like I’m missing somebody. It makes you feel anxious.”

With COVID taking up huge portions of the day, there are never enough hours for other critical functions, Frank says. For example, she struggles to keep up with vision screenings and giving out certificates that help students get the glasses they need. She is always working to get access to more inhalers for the huge number of kids with asthma. She has two students who require anti-seizure medications, four who have diabetes, and still others who need medication for ADHD. And then there are the kids who just need help with a scrape or bruise. She can’t interact with students as much and it weighs on her.

“It’s a revolving door in the nurse’s office, and I know I do the best I can, but I feel a little bit of guilt, and I wonder, could I have done more?” she asks.

Policy makers could ask themselves the same question – could they have done more for a school nurse like Frank who has 800 students to keep safe in her school with no help?

Right now she’s hoping that the open nurse’s aide position will be filled, but health paraprofessional jobs are the lowest paid in the district.

“Yet we’re giving medications that if administered improperly can kill someone,” Frank says. “It doesn’t quite add up.”

There Aren’t Enough Hours in the Day

School nurse Liz Pray regularly gets 100 calls a day from parents and caregivers. As a nurse, she’s trained not to leave anything undone and it was hard not to respond right away to all of the voicemails clogging her inbox. Finally, she updated her message telling callers that it could be 48 to 72 hours before she’d be able to get back to them.

Pray is a high school nurse for Moses Lake Public Schools in Grant County, Washington.

"As the sole school nurse responsible for the health and well-being of roughly 2,750 students in six locations during a global pandemic my daily duties are not sustainable," she recently told the Washington state legislature. "Currently my day consists of overseeing our onsite COVID testing, contact tracing, keeping up with the changing guidelines and responding to my students’ physical and behavioral health needs."

Across the state nurses are leaving because of the unsustainable workload. Even new hires, who started out with a lot of excitement, resigned from their positions within a month because the workload was too heavy, Pray says.

“There was a time when school nurses could focus on prevention, but now we are always putting out fires and there aren’t enough hours in the day or days in the week,” Pray says. “It’s hard to leave things undone, it’s not in the nature of a nurse, but for self-preservation, we need to be able to unplug at the end of the day. The nurses who are still here know we need them, and we need them to take care of themselves.”

Make A Plan

“But please, don’t tell us we should go out for a walk,” says Karen Rufo in Massachusetts. “Those of us in the trenches, we don’t have the energy. We get home, have supper, then get back to work. We are dog tired.”

Going for a walk isn’t going to get them through the week, let alone get them to June, she says. Nurses always have a plan for the kid with the food allergy, or a plan for the student with Crohn’s so they make it to the bathroom in time. Rarely do they have a plan for themselves.

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Rufo advises her nursing team to make a plan to find a buddy within the team, someone to talk to about what they’re feeling, or to find something to look forward to, like spring break, a family wedding, or the next Red Sox season.

She advocated to get all of the nurses district-issued cell phones, which were invaluable for communicating during the pandemic, but also for keeping spirits up. She started a text chain to share positive messages, including something to smile or laugh about every Friday.

Part of the plan also means remembering what they are passionate about and what they enjoy in life and to go back to that when pressures mount.

“Focus on what brings you joy, and when you’re stressed with workload, or being berated by an anxious parent, remember that,” she tells her fellow school nurses.

Just as important to school nurses’ well-being is the care they receive from the communities they serve, says Liz Pray.

“Please. Take a moment to check in on your school nurses, because we’re not OK.”