Like other health care providers, school nurses are on the front lines of the pandemic, as they treat students who may be infected with the coronavirus and interact with public health officials to keep kids, staff and families safe and as healthy as possible.

To their already-busy work lives, COVID-19 has added another layer of concern, another potential situation to which nurses must respond. Their work has changed considerably since the public health emergency was declared in March, said Mona Hattenberger, now in her second year as lead nurse for Grand Forks Public Schools.

“It has been a very busy start of the school year,” said Hattenberger, who supervises seven, full-time school nurses who cover the district’s 18 schools. “We have had all of the normal things that we deal with in the regular start of the year, and then adding all the COVID stuff, and then helping to alleviate fears, helping to alleviate worries and just doing a lot of training with (paraprofessionals).

“That being said, we love being able to help and be busy -- so that’s not necessarily a bad thing. It’s just different than it has been," she said.

In school, students who display possible COVID symptoms are likely to be treated in a different room than someone who presents with a broken ankle, Hattenberger said. If they suspect COVID or influenza, she and her team members may conduct a more in-depth assessment of these students and recommend to parents that they might see their doctor.

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“If we’re seeing a lot of symptoms, we may highly encourage them to get a (coronavirus) test but, again, talk with their primary care provider,” she said. “We can’t make anyone take a test, but we do a lot of encouraging when we feel it’s appropriate.”

Students with COVID-related symptoms are kept in the school’s isolation room, to which a collaborating paraprofessional has been assigned, until the parent or guardian can pick them up, Hattenberger said. These paras -- one at each of the district’s 18 schools -- are new to the staff this year, hired as part of the district’s response to the pandemic.

“The protocol of when we send them home and when we keep them in school has changed a little bit,” she said.

Dealing with COVID issues “has been a challenge” for school nurses, “but, that being said, it’s a challenge that we’re up for,” she said. “We just kind of jumped in and rolled up our sleeves.”

Flexibility is key to their work, because “things change on a day-to-day basis,” she said of a CDC protocol that could be in place on a Monday but two days later is completely different. “We have to be willing to change and take what we have and do the best we can with what we have.

“We have a really good group of nurses and they really enjoy their job,” she said, “I don’t think they’d be here if they didn’t.”

Emotional, mental health

School nurses also must be attuned to the pandemic’s psychological impact on students’ health, Hattenberger said.

A stomach ache is often not just a stomach ache -- there’s often an underlying cause, according to Hattenberger, adding that a lack of food at home or a missed supper the night before needs to be considered.

People have a lot of stressors at home that they are keeping inside, she said.

"Sometimes it’s easier for kiddos to say that they have a physical health issue when they may or may not have mental health issues or anxiety issues, worried feelings, things like that," she said.

This year, especially, routines are interrupted at home -- parents may have lost jobs or are working from home, Hattenberger said,.

"They may have close friends or family that have been in isolation or in quarantine and the kiddos don’t understand why they can’t see Grandma for (months). So the little things typically build up into big things for them and, I think, with all the COVID stuff on the news and things, it’s very scary for them," she said.

The nurses work closely with school counselors and social workers to help students in need.

“We do a lot of things that the general public doesn’t necessarily realize,” said Hattenberger, adding that some may think the school nurse just hands out Band-Aids and medications. “That’s the old way of looking at school nursing .... I think it’s come a long way since the beginning of school nursing.”

Their work involves medically fragile students, including those who have a cancer or severe autoimmune diagnosis, and those with diabetes, physical disabilities and vision impairment, or in wheelchairs.

“Some kids have seizures and, without school nurses, they may not be able to come to school," she said.

Nurses also develop a lot of health care plans, according to Hattenberger.

“We make sure there’s a plan in place for when kids are in school so they’re safe and healthy, they’re at their peak and able to learn well, because if they’re not feeling good and they’re not healthy, they’re not able to learn," she said.

Flexibility is key

Nurses must adapt to changing situations.

“Everyone is really flexible, no two days are alike, but (nurses) are used to getting pulled in many different directions," she said.

Some have had experience that is particularly valuable at this time.

"(They) are used to being in the front lines … and most of us have been in settings with infectious disease,” she said. “I feel like COVID is just another one. We just know we need to have really good hygiene, handwashing, wear proper equipment and do the kinds of things that keep us healthy.”

And things are more settled than at the start of the year, she said.

“When we started planning for the school year, we had so many more questions than we had answers. As the school year has progressed, we have so many more answers and we’ve been able to find those answers and solutions," said Hattenberger, pointing to Grand Forks Public Health as an important resource. “We have a direct line to (them), we can call when we have questions. They are very much our right-hand people -- without them, we wouldn’t be able to do our jobs as well as we do now.”

Public health connection

Grand Forks Public Health officials work with school districts in the county by providing expertise in consultations and health screenings, while making sure students have the vaccinations necessary for entry to school. The department formed a team to liaise with schools about their opening plans, and the focus now is working with school nurses on COVID and communicable disease protocols.

“We have four or five people that have responded mostly to administrators of schools, both in the city and the county,” said Debbie Swanson, director of Grand Forks Public Health. “(They are) answering questions, helping them to interpret isolation and quarantine, when it's needed for either students or staff.”

Swanson said the health department has a long history of supporting school nursing programs in Grand Forks, and the ongoing coronavirus pandemic now presents opportunities to strengthen nursing programs in rural school districts in the county.

On Oct. 6, the Grand Forks County Commission approved supporting four school nurse positions in those rural districts. Commissioners set aside $178,000 for two school nurse positions for schools that don’t have them. Those nurses, when hired, will each split their time between two schools -- Manvel and Midway, and Emerado and Larimore.

The two remaining positions have been filled by districts in Thompson and Northwood. Those schools will receive $34,000 each to help offset the cost of the nurse positions, as well as other COVID-19 mitigation efforts.

Brittany Ness, the school nurse at Northwood Public School, is new to her job, but not new to public health policy. For nearly eight years she worked as a public health administrator in Steele County, which encompasses Finley, N.D. After that, she went to Mayville State University, where she worked to introduce students of all ages to careers in health care. In April, she became the university’s COVID coordinator, where she researched the history of the illness and the recommendations and guidelines related to it.

That knowledge helped her transition into her new role, which, she said, has become more important than ever. Each morning she consults the school’s list of absent students then calls the parents to ask what kind of symptoms their children are showing, and answers any questions they might have. She does this for teachers and school staff as well, on top of regular school nurse duties.

“It's really busy because we're caring for students and they're coming in with injuries from recess, and they're having their regular fall-time flu-like illnesses,” Ness said. “It’s a challenge to assess the difference and should they stay in school or should they go home.”

Parents have been doing a good job of monitoring symptoms, and when the time comes for a child to go home, the wait usually isn’t long, according to Ness. Most families have at least one parent nearby in Northwood, or even a grandparent, though assistance from grandparents is less than what it normally would be, as families try not to expose them to illness.

That shorter wait time for pickup means kids spend less time in the school’s quarantine room -- the “away team” locker room, not often in use now -- which ,for younger children especially, can be frightening. Ness tries to avoid using that room, but sometimes it’s inevitable.

“It's a scary thing when we say ‘you have COVID symptoms and are going to go to the quarantine room,’” she said.

And feeling scared isn’t limited to the students. Students and staff at the K-12 school are both showing symptoms of anxiety, fear and frustration. They are worried about getting sick, or if a family member might get sick. Students’ biggest fear, Ness said, is having to go back to distance learning, which happened Monday, Oct. 12. Grades 7-12 are now studying from home. The school will reassess the situation in a week.

Monitoring the mental health of students and staff, part of a school nurse’s job before the pandemic, has become a high priority. Ness makes sure she’s modeling the safe practices she teaches in the school. A calm demeanor while talking with students about what they can do to stay safe, helps ease their anxiety. It’s another pandemic-added added dimension to the job.

“Without COVID, you would never be put in that position to have to sit and comfort a child while you're waiting for their parents in an isolation room,” she said.

Ness said she copes with what seems like the “never-ending” pandemic by taking each day as it comes. Her closely-knit family -- she is married with three children and has two sisters and a brother -- gives her people to talk to and share things with.

When it comes to work, she said she is “absolutely” supported by the public health departments she works with. Ness needs to work with two departments, Grand Forks, for Northwood’s school, and Traill District Health, on behalf of the Hatton Eielson school. The two schools partner together for extracurricular activities.

“They're always there,” Ness said. “If they don't have the answer, then they have somebody to contact with at the state health department, so I think it's easy to get ahold of somebody and get your questions answered.”