WIMBERLEY, Texas – Jacob's Well Elementary School nurse Annie Wood bends slightly to take the temperature of a fourth grade student. And then another. And then another.
Wood performs temperature checks with touchless thermometers of all students once a week, part of a new campus effort to keep the coronavirus away.
The Wimberley district is one of the few in Central Texas to have launched in-person classes for the fall semester, and so far, officials have reported no cases.
As school districts across the country reopen their doors to students for the first time since the pandemic abruptly shuttered schools last spring, school nurses will be critical in the fight against the spread of the virus among students and teachers. They helped craft school pandemic actions and will evaluate whether students should be pulled out of school because of coronavirus-like symptoms.
But the country faces a shortage of school nurses. About a third of all schools employ a nurse only part time, and 1 in 4 have no school nurse, according to the National Association of School Nurses.
"It's going to be school nurses who on the front lines and that's a place where we have systematically underinvested for a really, really long time," said Sara Johnson, an associate professor of pediatrics at the Johns Hopkins University School of Medicine. "How we support school nursing and school-based health services in general is really an important next step because this is going to be with us for a while. It's not going to go away this winter."
Texas does not require school districts to staff campuses with registered nurses. However, absent a nurse on campus, districts are required to train employees to provide medical care for students. Amid the coronavirus, that means office staff or other personnel with no medical background may be the ones to examine a child and determine whether the student is sent home.
School nursing is more than affixing Band-Aids to skinned knees and doling out cough drops. The profession, often filled by nurses who previously worked in hospitals, has grown more complex over the years, as campus nurses see more medically fragile students. In any given day, a school nurse may perform a urinary catheterization, help a diabetic student inject insulin or attend to a child who is having a seizure. For some children, particularly students from low income families, it is the only source of health care they may receive, and many high poverty schools don't employ them. COVID-19 now adds another layer of complexity to the job.
"People don't realize that real health care goes on in a school," said Laurie Combe, president of the National Association of School Nurses. "School nurses are delivering health care in schools that sustains students' ability to learn. Without that care there are many children who could not come to school."
"In this period of COVID, we really have been leading pandemic planning in so many schools," Combe said. "When school administrators recognize the public health and infection control expertise that school nurses bring to the table, then they are working as collaborative teams to develop their return-to-school plans, the messaging and all of the decision trees that need to be made along the way."
The Austin school district eliminated registered nurses from campuses about 25 years ago to save money. The district has since contracted health care services with Seton Family of Hospitals, which decides how to provide those services with a limited budget. This year, the district will spend about $7.4 million for 76 nurses to be shared among nearly 130 campuses, as well as mental health services. The contract leaves multiple schools to share nurses and others to be staffed by 48 clinical assistants, who receive some training by the Seton but are not licensed medical health professionals.
Putting a nurse on every Austin campus would cost about $10 million, and district leaders have said they don't have the additional money.
"Their pandemic plan and contact tracing plan is excellent and really puts the health and safety of staff and kids at the forefront," said Kelly Tarun, who for three years has been calling on the district to place more nurses in schools. "On the other hand, I'm not 100% confident that they can implement it with the shortage of nursing hours
"The pandemic only highlights the importance of having licensed professional nurses and health care staff in our buildings," she said.
Other urban and neighboring districts, including Round Rock, Leander and Hays, staff a nurse at every school.
School nurses have worked much of the summer on reopening plans and safety protocols, combing through CDC, state and local guidelines, all of which have been fluid. Now, as they prepare to reopen schools, the nurses and other staff members are distributing personal protective equipment to campuses. The Texas Education Agency provided schools some personal protective equipment, but district officials and campus nurses have had difficulty securing their own supplies amid a nationwide shortage. They also are helping train staff who will assist in monitoring campus isolation rooms, where students exhibiting coronavirus-like symptoms, will be placed until a parent or guardian can pick them up from school.
Ellie Ryden, the school nurse at Fern Bluff Elementary in the Round Rock district, said she wants to be back on campus, and wants kids back in school, but wants to reopen schools safely.
"I feel ready to take on the challenge," said Ryden, who has spent the majority of her 13-year nursing career as a cardiac nurse. " I want everybody to stay well and do whatever I can that's best for the greater good."
Texas Education Agency guidance says students and staff should prescreen for symptoms prior to students arriving to school every day, but does not recommend taking the temperature of asymptomatic students, as the Wimberley district is doing.
If there is a confirmed case of COVID-19 on campus, the infected student or employee must stay home through the infection period, returning only after 10 days, when symptoms dissipate or the person is cleared by a doctor. The guidance does not require individuals who have come in contact with the infected person to be sent home and schools are not required to close.
Beginning Sept. 8, Texas districts will be required each Monday to report to the state any confirmed COVID-19 cases, of employees and students, in a joint data collection effort with the Texas Department of State Health Services. Part of the reporting requires notifying the state if a campus had to close as result of the infection.
The data will be sorted by district and made public, making it easier for families and school employees to track the virus spread in their communities. School districts must continue to report cases to local health agencies, which is required by law for any infectious disease, such as pertussis, but the new coronavirus reporting goes beyond what is required for other infectious diseases. Campuses must also notify parents and staff if there is a confirmed case.
Individual districts also are creating their own protocols.
Darelle Jordan, a nurse at Wimberley High School, has spent 40 years in nursing, 22 in public schools. During that time, she said she has played a support role to education. "But this year I really need for them to walk beside me and have the top priority be keeping well. That's a real change in the way we look at what we're doing in school this year."
"Bringing lots of kids together in the midst of (a pandemic) is something we haven't done before," Jordan said. "I'm going to try really hard to make sure we do it safely. That's the job."
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