Tonja Frank has been a nurse for 33 years. She has worked in a variety of specialties, including as a labor and delivery, clinic, long-term care, and public health nurse, and as a Parents as Teachers educator. Her first school nursing position was in a rural district with a total of about 650 children. Six years ago, Frank began working for Nebraska's largest school district, the Omaha Public Schools, an urban district with more than 53,000 students. She currently works as a nurse in one of the district's middle schools, caring for sixth, seventh, and eighth graders.
Frank spoke with AJN at the beginning of September, a few weeks after most students returned to in-person learning in her district, which had shifted between virtual and partial and full-time in-person learning during the past year due to the COVID-19 pandemic. What follows are highlights of this conversation.-Corinne McSpedon, senior editor
How has the return to school been so far?
It's always crazy in the beginning of the school year as a school nurse because you have to get all your practices and paperwork in place. But now, COVID has added a little bit extra.
Last year, I went from working in one school to being the co-lead contact tracer for our school district, so all I focused on was COVID. Our district has 70 buildings, so it meant working with all the people doing the boots-on-the-ground work. This year, I've gone back to what I did before, working in one building with my students.
Were you involved in return-to-school plans?
Our school district's nurse supervisor has a voice in these plans, but the staff nurses do not.
Nebraska doesn't mandate school nurses. The district right down the road from me doesn't have a school nurse. So, school nurses' involvement in back-to-school plans this year has really varied. In our schools, nurses are certified staff on the teacher's contract, but some schools don't even have a nurse to be involved in this planning.
What are your biggest challenges this year?
I think the biggest challenge for school nurses is negotiating how to assess for COVID without over assessing. I can't send every kid home who walks in and says they have a stomachache or a headache. But I also don't want to miss a kid who has a stomachache or a headache and has COVID. I feel like I'm walking this tightrope of keeping the kids safe and healthy at school and yet not alienating parents because I'm sending their kids home left and right.
If kids are sent home with COVID symptoms, they have three options: they can stay out of school for 10 days, they can return with a negative test and symptoms improving, or they can get an alternative diagnosis from a physician. My school this year is in a lower socioeconomic area, and these parents have to work. They can't leave work unless it's an emergency. But COVID isn't the type of emergency where I say, "You don't have any choices. Your kid needs you, and you need to be here now." Instead, it's, "We're trying to protect everybody else, so you have to be here now."
Have policies such as mask mandates been controversial in your school, and how does this affect your work?
The teachers came back for one day this year, and then our district held an emergency board meeting and instituted a mask mandate. I think the plan is to continue it through the semester and then reevaluate. I'm very happy about that. There's definitely been some resistance from parents, from what you see at the board meetings, but that's usually an administration issue. It doesn't filter into the school nurse a lot of times.
Some of the school districts around here have required masks in elementary schools and not in the senior highs. But, in the last week, a couple of them have had to mandate masks for everyone, because they've had outbreaks. I'm really glad our district mandated masks for everybody, so we don't have to worry about figuring out who's vaccinated, who isn't vaccinated, how old they are. . . . It's so hard.
Have you seen a psychological impact on students during the COVID pandemic?
Absolutely. There's been a psychological toll because we were virtual for so long, and the kids weren't getting all of their academic and social activities. Students lost their comfort with school, and some have lost their normal social and academic place in the classroom. Even for those coming back to a previously attended school, they are learning new procedures, and it feels like everything has changed with COVID.
But there are also other psychological impacts. I had a student today who was almost bullied. She had a cough and explained that everybody in her family had a cold and a family member had been tested for COVID and was negative. "I don't think I have COVID," she told me, "but the other students just keep yelling at me, telling me I have COVID. They won't leave me alone." Everybody is so hyperaware at this point. You notice it in the grocery store. Somebody coughs and everybody just turns their head and stares. But all the other causes of a cough that we had before COVID didn't disappear. I worked in labor and delivery for a long time, and patients would come in throwing up and saying, "I'm just sure I've got preeclampsia, my blood pressure is really high." I would tell them, "No, you've got the flu." Just because you're pregnant, doesn't mean all those other things stop, and everything isn't necessarily related to the pregnancy. It's kind of like that now. Just because we have COVID, it doesn't mean people don't have allergies or aren't going to get viral or bacterial pneumonia. We still have all the things we had before, we've just added COVID on top of that.
How do you navigate that in your daily work?
It's tough, but I try to prioritize. You have to do that in school nursing anyway. The kid who hit his hand on his desk is going to have to wait for me to work with the kids who might have COVID. Part of that is it just being a new school year and the students understanding how the health office works and getting to know me. Every year you have to kind of retrain the kids, because they all expect to go to the front of the line when they come to your office. It doesn't work that way. At this point, because we have to keep them separated if we suspect they might have COVID, those kids take priority.
Are you seeing any trends in COVID cases among students since school started?
I like to say, "I'm in with the trees, so I can't see the whole forest." I'm not at a district level anymore, so I can only say what I'm seeing at my school. Plus, there's no way of always knowing if a student has COVID. I went through attendance today, and although parents might say their child is sick, they don't necessarily say what's wrong.
It's so hard to tell if kids are getting COVID from other kids at school. What we found last year was they may know the kid in school, but they're going over to their house after school, or it's somebody they play with or give a ride to. A lot of the time it's coincidental that they're in the same school, because their contact is outside of school.
What have you learned through your work as a school nurse in the last year?
Kindness goes a long way. Patience. Remember that everybody's going through something. Not necessarily in the same way, but everybody's going through something when we're talking about COVID. You never know how someone has been touched by this. It's just a minefield.