When many people think of a school nurse, they imagine a person who hands out Band-Aids for boo-boos.
But school nurses do so much more. They are school leaders who address the physical, mental, and emotional health needs of students.
As the COVID-19 pandemic played out, many school nurses took on even greater responsibilities. These include monitoring and evaluating staff and students for COVID-19 exposure and symptoms, contact tracing, and educating students, staff and community partners on vaccine and prevention measures. School nurses are also developing initiatives to deal with the anticipated increase in mental health services that students, families and staff will need in the post-pandemic world.
School nursing is a specialized practice that operates in environments very different from an acute care hospital setting. School nurses work alone, practice independently and are typically the sole health care provider in the building.
As part of our public health system, they play a critical role in disease surveillance, disaster preparedness, wellness and chronic disease prevention interventions, immunizations, mental health screening and asthma education.
I know from personal experience. From 2009 to 2014, I was the sole school nurse responsible for the health and safety of over 900 public elementary school children. This included special education classrooms for preschoolers and students with nonverbal autism. I now research how school health policies and practices effect the work environment of school nurses, and the challenges and barriers they face.
Research shows how a positive work environment for school nurses increases job satisfaction, reduces turnover and improves academic outcomes for students. A study of school nurses in Massachusetts schools demonstrated that for every dollar invested in school nursing, society would gain US$2.20 as a result of kids’ better health and disease prevention.
No one-size-fits-all ratio
A school nurse’s workload depends on a number of significant variables. For example, how many students in the school have chronic illnesses and need medication administered? How many students attend the school? What ages are they? What is the average number of student visits to the health office each school day? Are students spread across multiple buildings? What level of experience and specialized skills does the school nurse have?
The number of students in a school who are dealing with poverty or other health equity issues – including access to quality education, safe housing and health care – also impacts and increases the workload for school nurses.
These evidence-based variables can be used to guide school administrators and school nurses on what constitutes safe staffing. Making sure school nurses have a safe, appropriate workload is critical to ensuring that students have their health needs met at school.
Parents who are concerned about their child’s health at school may want to find out how many students their child’s school nurse cares for. How many students does the school nurse see on a typical day? Is a school nurse in the building every day? Does the school nurse cover more than one building? What happens when there is an emergency, such as a child with a life-threatening allergic reaction? Where are the emergency care plans kept? Is there stock medication available such as epinephrine and albuterol for students with severe allergies or asthma?
I believe school nurses need more manageable workloads in order to provide the safe care needed for better student health and academic outcomes. This leads to better health not just in individuals but in communities that need it most.
Using that data, we found the average annual salaries, as reported by the BLS, for 19 medical and protective-service roles where saving lives is a part of the job. We ranked the above from lowest to highest average annual salaries and included employment figures as of May 2020, the most recent period for which data is available.
Lifeguards tend to make a relatively low annual salary, while firefighters and police officers are well compensated on average. Surgeons are very highly paid.
More than a year into the COVID-19 pandemic, some nurses who have worked tirelessly on the frontlines to help sick patients through uncertainty are considering a step away from the profession.
Some are struggling to cope mentally and many feel underappreciated and undervalued.
For Nikki Motta, a travel nurse who spent the past year working at hospitals along the east coast, the toll of caring for COVID-19 patients left her with stress that has led to hair loss.
Motta told Insider that the hospitals she worked at were badly understaffed and in many cases she would have a higher than normal patient load despite the demand for 1:1 care for some critically ill patients. Motta also had limited help, so tasks like turning patients over or generally taking care of them fell on her alone, which put a physical strain on her body.
“You’re physically turning and lifting people who are incapable of helping you because whether they’re in a medically induced coma or if they are just completely exhausted and de-conditioned so much so that they can’t help you. You are turning them on their sides to assess their skin, to make sure that they don’t get bedsores and you don’t always have another person to help you do that,” Motta said. “You don’t always have a machine to help you do that. So nurses are doing things that are putting wear and tear on their shoulders and their backs and their knees for multiple hours throughout the day for various different people of all body types and physical conditions.”
At least a quarter of travel nurses are looking for other jobs
A Trusted Health report released on Wednesday found that in a survey of over 1,000 travel nurses, 67% of respondents said the healthcare system did not prioritize their mental health and well-being. Additionally, almost half of the respondents said they were considering leaving the profession and 25% of them said they are actively looking for a job outside of nursing or planning to retire.
The percentage of young nurses, those under 40, were 22% more likely than average to report that their commitment to nursing had decreased.
“That’s a big deal because the pipeline of nurses is already small. We’ve had a shortage forever. There’s some statistics saying that there’s going to be 175,000 open roles every single year until 2029 and if we have nurses leaving the profession that early into their career and we can’t train enough then that can create a whole other healthcare crisis for our system,” Dan Weberg, Head of Clinical Innovation at Trusted Health, told Insider.
Liz Evans left her staff position as a cardiothoracic ICU nurse to work as a travel ICU nurse in COVID-19 hotspots.
Evans told Insider that hospitals in California were short-staffed on nurses during the pandemic and that meant she had to take care of five or six patients during a shift, which she described as “unheard of.”
“Usually, in an ICU, you have one patient, max two, and that’s because they’re so critical. You have to be there at all times because they literally could tank in five minutes and if nobody is watching, they could die,” Evans explained.
Limited resources means nurses are doing a lot more
Motta was also frustrated with various demands placed on her that fell outside of taking care of patients. She said she’d spend hours after her shift was technically over just charting patient information and also spent lots of time during her shift running around to get supplies.
After six years as a nurse, Motta said she’s looking to leave bedside care and go into advanced practice.
“I really started looking away from bedside over the last year because the weight was really heavy of what I was doing and I didn’t feel like I was doing the job that I initially signed up for, which is to help people and make people feel better,” she said. “I feel like there are even more and more expectations for nurses and nurses are the type of people who want to help and who want to do what is asked of them but I think that is being taken advantage of in a lot of ways.”
Evans also said that conditions forced her to learn other critical roles and do jobs she normally wouldn’t do as a nurse just to keep patients alive. But the role taxed her emotionally, mentally, and physically.
After only three years as a nurse, a traumatizing moment made Evans consider leaving the profession. She said there was a day where a patient coded, meaning they need life-saving treatment, and no one else responded to her calls for help because two other people on that same floor also coded.
“There were not enough resources and so I was in there doing chest compressions, trying to keep my patient alive while everyone was in a different code and as soon as that code was over they came over to mine, but it was already too late,” she said. “So I might be yelling at the door like: ‘Hey, like I need help. Like, I need someone in here and get a manager, get somebody, somebody should be here,’ and there was nobody there.”
She said that same night, another patient coded and again there weren’t enough people to help until eventually, a nurse manager came over to help her.
“But it was just the two of us. There was no doctor to be seen. There was no other person there,” she said.
Healthcare systems can take steps to keep nurses
While many nurses are considering leaving the industry, the decision isn’t very easy. Both Evans and Motta said they’re still unsure if they want to leave and are looking towards healthcare roles that are less focused on direct patient care. They also haven’t taken the decision lightly, but simply feel overwhelmed and burnt out by the current state of the healthcare system.
However, both said the healthcare system can take steps to ensure nurses feel supported, which could help with keeping them in the profession.
Motta said ensuring there’s an appropriate nurse to patient ratio so that nurses aren’t understaffed should be a priority. So is having experienced nurses around to help newer ones. She added that nurses should also be compensated appropriately for the mentally and physically taxing jobs that they do.
“I think that healthcare systems need to realize that nurses are valuable and that they’re an integral part of healthcare systems and they wouldn’t run without them. And I think that that also goes for the time spent away from the bedside. I think any job where you are emotionally, mentally, and physically taxed, you need to be able to step away from that job,” she said.
Shawna Blackmun-Myers grasped her patient’s hand, called the woman’s family, and held up the phone. As everyone said their goodbyes on the other end, the patient couldn’t respond: A tube down her throat was feeding oxygen from a ventilator into her lungs.
Blackmun-Myers, an ICU nurse at the Jacobs Medical Center in San Diego, told Insider that the woman was in her 50s and had been bubbly when she came in weeks earlier. Normally in the ICU, Blackmun-Myers said, “people are so sick that that energy and that light is dimmed, but even her being in that situation, she was still just such a bright light.”
“We were dancing and listening to music, and we were watching some soap opera drama stuff on TV and, you know, talking tea about everybody,” she added.
But the woman’s condition worsened quickly. Hospital staff readied a ventilator.
“She’s crying and telling me, you know, ‘I just don’t want to be alone. And I just know that once this tube goes in, I don’t think it’s coming out. I think this is going to be it,'” Blackmun-Myers said.
“I did my best to let her know, you know, obviously she’s not alone. I was there with her. I had her back,” she added.
Then the virus brought heart and kidney problems. The woman went on dialysis. Eventually, there was nothing more the hospital could do to restore her quality of life, and her family knew she wouldn’t want to live this way.
In January, Blackmun-Myers oversaw the woman’s death as hospital staff disconnected the ventilator. The sound of crying family members echoed through the phone.
It was the middle of winter in Southern California. Coronavirus cases were at an all-time high, and ICUs were above 90% capacity. Blackmun-Myers’s unit was losing multiple patients every day.
“I ugly-cry, and then I get angry, and I accept the fact that I did everything I could,” she said. “And just move on so I can take care of the next person and their family.”
Blackmun-Myers didn’t know it at the time, but a new coronavirus variant had been overtaking the region.
The CAL.20C variant was first identified in Los Angeles in July, then disappeared from the record until October. But by January, it accounted for 44% of Southern California coronavirus samples in one study, and more than half of California samples in another.
Several other factors contributed to Southern California’s winter surge – holiday travel, crowded housing, pandemic fatigue – but many researchers think the variant played a role.
Two studies that aren’t yet peer-reviewed suggest that the variant is more infectious than the original virus strain. The research also found it to be associated with a higher incidence of severe illness and partially resistant to antibodies developed in response to the original virus or vaccines.
Although California cases have dropped from a peak of about 40,700 per day in late December to about 4,000 now, experts warn that CAL.20C or other variants could still change the course of the pandemic.
“Now is not the time to relax the critical safeguards that we know can stop the spread of COVID-19 in our communities,” Dr. Rochelle Walensky, the CDC director, said at a White House briefing last week.
“Please hear me clearly,” she added. “At this level of cases, with variants spreading, we stand to completely lose the hard-earned ground we have gained.”
Blackmun-Myers and three other Southern California healthcare workers say what they saw this winter should serve as a strong warning.
Struggling to be heard
The ICU was loud. Given the influx of coronavirus patients, the Sharp hospital network in San Diego had to jerry-rig negative-pressure systems to prevent virus particles from wafting out of patients’ rooms. The makeshift tubing roared overhead, so nurse Kristine Chieh had to yell over it – and through several layers of PPE – for patients to hear her.
Chieh isn’t normally an ICU nurse, but in January, the COVID floors needed all the help they could get. Two days before her first ICU shift, Chieh’s friend, a man in his late 40s, died from COVID-19 after more than two weeks in the hospital.
“I walked through the ICU, looking at the windows, and I swear I see my friend over and over and over again in those beds,” she said.
Chieh recalled stopping to help a man video chat with his family. A mask covered his face, pumping oxygen from a BiPap machine. Chieh lifted the mask for short intervals so he could speak to his family. After a few seconds, he would run out of breath, and Chieh would put the mask back down. Family members would speak up to fill the silence.
“There’s all kinds of people on that iPad, like he must have a large family,” Chieh said. “They thought it was so awesome to be able to hear his voice, and I think he was really excited to use his voice.”
She spent about half an hour like that, lifting and lowering the mask.
“The other ICU nurse was in the process of intubating somebody at the same time that this is happening, so there’s no way she would have been able to do that for him,” Chieh said. “I clocked out for the day and I don’t know what ever happened to him, long term. Hopefully he made it out okay.”
‘It almost overtook my vocabulary and my mind’
Chieh works as a float nurse across three locations in the Sharp hospital network, going wherever she’s needed. Typically, she works in progressive care units – the level before intensive care. But during the winter, even the COVID-19 patients there were severely ill. Chieh would dash from room to room, changing in and out of protective gear to help patients who suddenly found themselves struggling to breathe.
“Throughout my shift, I’ll get patients who are off and on just being like, ‘I can’t breathe, I can’t breathe.’ And then I go in and I do breathing exercises with them. I adjust their oxygen. I have the respiratory therapist come in, do breathing treatments, whatever is needed,” Chieh said.
They would calm down and be fine for about an hour, she said, before it happened again.
Robert Bang, a floor nurse in Los Angeles, spent his winter days the same way. Alarms were constantly sounding through the computer system, he said, to alert him that a patient’s oxygen levels had dropped too low. He would rush to the patient’s room, sometimes to find that they didn’t even realize they were losing oxygen.
“If you’ve been short of breath for so long, you just start developing fatigue from breathing so hard. So it might be like your new normal,” Bang told Insider.
Even when he went home, Bang said, he would still hear the alarms in his head. Work followed Chieh home, too.
“My husband gave me this feedback: I talked about COVID too much at home. Talked about math too much, talked about every news article,” she said. “It almost overtook my vocabulary and my mind.”
That hasn’t fully subsided – Chieh said those winter days still haunt her.
“I feel like I can remember every single COVID patient,” she said. “I imagine what it must be like to have this astronaut person come into their room to work with them. They must be terrified.”
‘I’ve never seen something infect people so easily’
Many of Dr. Kenny Pettersen’s patients in Los Angeles live in crowded homes with a combination of parents, kids, grandparents, or cousins under one roof. That made it difficult to make quarantine plans for the COVID-19 patients who weren’t sick enough to stay at the hospital.
In spring and summer, he told Insider, “when someone in the household would have COVID, usually like half or less of the rest of the household would get COVID.”
But this winter, Pettersen, said “it was almost universally 100%.”
Pettersen is a primary-care physician at Olive View-UCLA Medical Center. The change in LA’s outbreak was so noticeable to him during the winter that he assumed the virus itself must have changed.
“I’ve never seen something infect people so easily,” he said. “I felt like I was almost wasting my time talking to patients about the prevention of household transmission.”
More research on CAL.20C is still needed to confirm his suspicions, though, since the initial studies of the variant haven’t been peer reviewed, and the spike-protein mutation that characterizes it has not been thoroughly investigated.
Relief and grief after the surge
Pettersen’s grandmother died of coronavirus in August. Many of his patients died, too, and some left behind young children. One family is losing their home after the coronavirus-related deaths of two family members.
“Practically every one of my patients, either they’ve been infected, or many of their family members have been infected, they know somebody very well who has died or gotten severely sick,” Pettersen said. “I think the cumulative toll that takes on my patients is just really profound.”
Still, he said, the mood among his coworkers is more upbeat now. There are even days at the hospital when nobody dies of COVID-19.
“I think that we can start to breathe with a little bit more confidence,” Pettersen said. He and his wife have both been vaccinated.
Bang and Chieh say they feel safer these days, too. The volume of COVID-19 patients is much lower. They’ve been vaccinated, and more people are getting shots each day. But the winter memories persist. Some healthcare workers are now nervous about other variants. And there’s a strong possibility they or their colleagues will develop PTSD.
But Pettersen, at least, said he was finally able to go to an outdoor restaurant for sushi with his wife recently.
“We can, you know, be optimistic for the first time in about a year,” he said.
In the survey of 9,200 registered nurses in the US in February, 81% said they had reused single-use personal protective equipment, such as masks and gowns. In the union’s survey of 23,000 nurses conducted last April and May, 87% reported reusing personal protective gear.
In the latest survey, 61% of hospital nurses said they had been tested for COVID-19, and nearly half said that staffing had recently gotten slightly or much worse.
One year later, a promising vaccine rollout could greatly reduce the threat of COVID-19. But the survey suggests that many frontline nurses are burning out from dealing with the same problems.
“We are a year into this deadly pandemic and hospitals are still failing to provide the vital resources needed to ensure safety for nurses, patients, and health care staff,” the NNU’s executive director, Bonnie Castillo, said in a release.
Why nurses are still reusing masks
A year ago, nurses painted a harrowing picture of unprepared hospitals bracing for COVID-19.
Hospital nurses, who spend more time at patients’ bedsides than other healthcare workers, said the PPE shortage would expose them and their families to the disease. NNU members protested in April outside the White House to demand more protective gear.
The PPE shortage stems in part from the Trump administration’s reluctance to coordinate and fund equipment-stockpiling efforts. Shikha Gupta, the executive director of the advocacy group Get Us PPE, recently told NPR that while the shortages were not as widespread as they were last year, supplies varied depending on the state.
As a result, nurses reused single-use N95 masks, which become contaminated with extended use, according to the Centers for Disease Control and Prevention.
Many nurses also said that hospitals were unprepared to meet the demand for equipment and that some nurses who had brought attention to the lack of resources were punished. HCA Healthcare, the country’s largest hospital system, told nurses and doctors last year that it could fire those who spoke publicly about policies surrounding equipment and patient care.
The pandemic could have long-term consequences for nurses
Nurses recently told Insider that the lack of support from the government and employers, as well as the exhaustion from working during the outbreak, could lead to an exodus from the profession.
“I have talked to a lot of doctors and nurses who have told me, ‘I’m going to quit,'” Kristen Choi, a psychiatric nurse in Los Angeles, previously told Insider.
The NNU survey pointed to stressors among registered nurses: 57% of hospital nurses surveyed reported feeling more anxious than before the pandemic, and 43% said they’d had more trouble sleeping this year.
A lack of hospital nurses can lead to worse patient care. A study published in the American Journal of Infection Control in December found that assigning nurses to care for too many patients at once led to a higher rate of mortality from sepsis. Research from Australia has suggested that having fewer patients per nurse could save lives and lead to less readmission.
Though there is no reliable data on how many nurses left the profession because of the COVID-19 outbreak, a recent report from Emory University found that one-third of nurses who left their jobs in 2017 said they did so because of burnout.
Castillo said that the NNU’s latest survey “shines light on how hospital administrators are continuing to jeopardize one of society’s most valuable workforces during Covid-19, registered nurses, by prioritizing profits over basic safety and infection control measures.”
Nonetheless, skepticism exists among healthcare workers and the American public at large.
Dr. Joseph Varon, a critical care doctor from Houston, has said that more than half of the nurses in his unit are objecting to getting inoculated for political reasons. “Most of the reasons why most of my people don’t want to get the vaccine are politically motivated,” Varon told NPR.
In Portland, Oregon, Dr. Stephen Noble, a cardiothoracic surgeon told AP: “I don’t think anyone wants to be a guinea pig. At the end of the day, as a man of science, I just want to see what the data show. And give me the full data.”
About a quarter (27%) of the American public is hesitant to get a vaccine, according to a study from the Kaiser Family Foundation. This rises to 29% of those who work in a health care setting, the study shows.
Gov. Mike DeWine has announced that he hopes to instill a “sense of urgency” in his state’s healthcare workers by offering a stark warning. He has told frontline staff they could miss out on getting a vaccine any time soon if they don’t act now, according to The Columbus Dispatch.
“Our message today is the train may not be coming back for a while,” DeWine said at a press conference.
In other states, there is also concern about the low take-up rates of vaccines by frontline workers.
In North Carolina, public health officials revealed that more than half of those working in nursing homes have so far refused to get a shot, according to AP.
A significant proportion of nursing staff in West Virginia is also refusing to get vaccinated. About 45% have said no to a COVID-19 jab, AP reported.
Martin Wright, who leads the West Virginia Health Care Association, blamed fast-spreading misinformation about vaccines: “It’s a race against social media,” he said.
Between 20 and 40% of frontline workers in Los Angeles have also refused a COVID-19 shot, public health officials the Los Angeles Times. In neighboring Riverside County, the paper says this rises to 50%.
In a bid to increase the vaccination rates among healthcare workers a number of administrators have resorted to offering raffle tickets and free breakfasts at Waffle House in exchange for a jab, AP reported.
The need to successfully roll out the vaccine has never been more apparent. In recent days, the US has broken records for both the highest daily rise in new COVID-19 cases and for the highest daily death toll.
On Friday, there were a record-breaking 307,579 new daily cases, according to Worldometer.
On Thursday, Worldometer shows that 4,245 people died from coronavirus-related complications,