Public Health Nurses in Schools

Schools have closed their doors for the holidays following the remarkable experience of having come back to classes in September while doing their best to protect children and staff from a pandemic. Public health nurses have played a central role and the following article provides insight into their contribution. I am grateful to Heather Lokko, RN MPH CCHN(C) (Chief Nursing Officer & Healthy Start Director, Middlesex-London Health Unit, and OPHNL Chief Nursing Officer Network Liaison), Irmajean Bajnok, RN MScN PhD FCAN (Senior Policy Analyst, RNAO), and David Groulx, RN, BScN, MPH, CCHN(C) (President OPHNL, and Manager, Professional Practice and School Health, Public Health Sudbury & Districts) who authored the article.

In the summer of 2020, as the first wave of the COVID-19 pandemic was subsiding, the government of Ontario made the decision to begin planning for children to return to school following a six-month closure, citing the advice of child care and health experts, teachers and parents. While the decision to reopen schools was widely supported, the proposed protective measures announced for teachers and students were met with concern and pleas to do more. 

One of the highly praised supports for schools – announced by the Ontario government on July 30, 2020 – was the allocation of $50 million to hire 500 school-focused nurses to join colleagues across the province to keep students and staff safe during the pandemic. This funding was subsequently increased by the federal government to facilitate the hiring of an additional 125 nurses, bringing the total to 625.

This announcement was lauded as critical and very helpful to students, school administrators and educators, and families. The government decision to look to public health and to registered nurses (RN) to provide education, support and protection in schools is based on the strong track record of successful contributions of Public Health Nurses (PHNs) in Ontario schools, and the strong advocacy of the Registered Nurses’ Association of Ontario (RNAO) and the Ontario Association of Public Health Nursing Leaders (OPHNL). Amidst the ongoing negotiations for stricter protocols, smaller class sizes, and safety precautions in schools, RNAO and OPHNL collaborated to shape the parameters of the school nurse program that would ensure success.

The two organizations met to develop a strategy for advancing this initiative as rapidly as possible. A number of critical elements were on the table, including discussions about the best approach to advocacy. Each organization prepared its own letter (OPHNL letter and RNAO letter) outlining key recommendations related to: 1) the hiring of school nurses at the public health unit (PHU) level; 2) the role of PHNs being focused on COVID-19 in addition to broader school health, as well as the expectation for nurse qualifications to align with the requirements for PHNs in Ontario (i.e. nursing baccalaureate prepared); and 3) the immediate hiring to coincide with the early days of school reopening, recognizing the time required for onboarding and orientation. Each organization also used other opportunities, such as personal contact with government decision-makers, the web and social media to continue to reinforce recommendations related to these critical elements of the initiative. 

The ministry of health established a plan for the allocation of school-focused PHNs based on the number of schools and school enrollment data provided by the ministry of education. RNAO and OPHNL recognize the benefit of funding the school-focused PHNs as an additional resource for all PHUs, and spoke about the need to ensure these positions extend at least two years, with strong consideration for these PHNs to become a permanent resource.      

Thanks to this joint effort, and the commitment of the ministries of health and education to the safe reopening of schools, the PHNs in schools initiative was formalized, and all of the issues advocated for by both groups were addressed. While RNAO was delighted with the decision to hire 625 nurses to help in schools, there was still considerable concern about safety issues regarding class size, mandatory masks and school ventilation. 

In addition to supporting PHUs by providing a role description, job posting and interview question database, the OPHNL Chief Nursing Officers Network recognized the opportunity to develop a provincial orientation program to prepare new hires for their role in the school nurse program. Such preparation had to reflect a COVID-19 context, with children and families re-experiencing school again after a six-month closure.

To ensure rapid development of an orientation that was as comprehensive as possible, OPHNL established an Orientation Curriculum Task Force, which included representation from RNAO, the Public Health Chief Nursing Officers Network, the Association of Ontario Public Health Nurse Leaders, the Public Health School Health Manager's Network, and a consultant from Public Health Ontario. This 12-member group worked tirelessly over a three-week period to establish a fully online orientation resource for school health nurses, ready when hiring began.

The orientation resource includes a Program Overview, along with five modules: Intro to Public Health; Comprehensive School Health; COVID-19 and Infection Prevention and Control;  Social Determinants of Health (SDOH) and Health Equity; and Child and Adolescent Health. Each module presents learner outcomes, reflective questions specific to the module, key online resources for learning (categorized as priority, essential and additional), and an evaluation. There is an overall program evaluation at the conclusion.    

In late August and early September 2020, PHUs began hiring RNs into the public health school nurse positions through large-scale recruitment efforts that focused on those with PHN experience. Since then, a total of 625 school-focused RNs have been hired across the province.

The orientation program was accessed online by those new to the school PHN position and those new to public health. Experienced school nurses primarily accessed the COVID-19 module. Based on evaluations to date, the orientation program has been extremely well-received, with the overwhelming majority of nurses finding its learner objectives, online content and reflective questions “very informative and useful.” Many expressed their “great appreciation” to have such a critical set of resources readily available in one place. Members of OPHNL’s Orientation Curriculum Task Force will be reviewing the feedback and revising the curriculum to reflect the views of all users. 

Following orientation and onboarding, the new hires rapidly began engaging with school communities to support the safe reopening of schools. These PHNs are currently supporting schools in the development and implementation of COVID-19 prevention, health and safety plans. They have completed tens of thousands of consultations with schools, school boards and parents. They are conducting infection prevention and control (IPAC) assessments and practices, and other assessments. They have developed many resources and decision-making tools, and are providing educational presentations that help school communities understand and apply COVID-19 guidelines. They are actively connecting school communities to health and other community partners, and are working to identify and mitigate health inequities. Within their role, PHNs are facilitating rapid response to COVID-19 cases in schools, and engaging in case, contact and outbreak management. Depending on the local context, this support to school communities is being provided by telephone, virtual platforms, email and in-person.

The COVID-19 pandemic is a new experience for everyone, and there has been much learning. PHNs are finding it very rewarding to support school communities throughout this unique time, working to prevent COVID-19 cases and outbreaks, and mitigating impacts if they occur. 

School PHNs do not focus on addressing illness in individuals. Instead, they utilize a ‘healthy schools’ approach to address health issues that are broad, impact the school population, and promote health and prevent disease and injury within the school community. School PHNs also work to address structural inequities and implement targeted programs and services that aim to mitigate the negative impacts, and leverage the positive impacts, of the social determinants of health.

In spite of the additional 625 nurses working in schools, the intensity of demands related to COVID-19 has made it nearly impossible for PHNs to engage in their usual comprehensive school health work to address critical health and wellness challenges. The inability to focus on school health more broadly has been a challenge for PHNs.

The ministry of health has surveyed all PHUs to gather some initial, early evaluation data on this initiative. Data are currently being analyzed and results will be shared when available.

From the perspective of RNAO and OPHNL, the initiative has been a successful one. From the advocacy that initiated it, through to its implementation and PHU-based delivery, it has provided invaluable support to schools across the province. The recommendations to government for this initiative were clear and consistent from the start. RNAO and OPHNL used a collective approach in terms of the specific advocacy work related to the initiative. And as the program successfully progresses, both organizations will continue their collaboration to advocate for safe schools, and to ensure new hires in the PHN role have ongoing access to a robust orientation program that provides timely, evidence-based information.