On a recent day at West Towson Elementary School, there was one student with COVID symptoms waiting to be tested.
Two more students were coming from the gym with shortness of breath and needed their asthma inhalers. A diabetic child had dropping blood sugar.
“Those were just the urgent needs at that moment,” said Lisa Vanderwal, the school’s veteran nurse who says the coronavirus pandemic is causing her to make unprecedented choices about who gets priority among the hundreds of students in her care. “I’ve had days where I don’t know if I can keep doing it.”
Schools are in their initial weeks, a normally chaotic time for school nurses planning for students with special health needs, identifying those missing routine immunizations, and treating scrapes and headaches. But now there are new needs among the kids, many who have not been in a classroom in a year and a half and have additional medical and mental health conditions. And the threat of COVID-19 looms over it all.
Nurses and administrators say challenges this year can’t be overstated. The number of nursing vacancies and pandemic-related workloads differ among Baltimore-area school systems, but school nurses, nursing aides and health care coordinators already are burning out. Some nurses are minding more than one school because someone is out sick or the position is unfilled.
School administrators are working to provide backup, or at least offload some COVID-related duties to contractors or temporary workers funded with federal dollars.
“We have advised nurses to prioritize safety when time is limited,” said Charles Herndon, a spokesman for Baltimore County schools.
Each of the county’s 175 public schools has a full-time nurse except one, which is covered with backup staff, Herndon said, and they have conducted about 100 tests a day on students showing COVID symptoms.
The system also plans to test unvaccinated staff but will rely on a state vendor for that as well as regular COVID screening of students without symptoms if officials decide it’s warranted.
“More than anything else, our challenge has been just having enough time for nurses to conduct tests,” he said. “The testing program requires significant additional paperwork for each test, and there are plenty of competing priorities on school nurses’ plates right now, from tracking and enforcing immunization requirements to caring for students with special health needs to contact tracing.”
In Baltimore City, which may have the region’s most ambitious COVID testing program, there were some hiccups the first two weeks, acknowledged Alison Perkins-Cohen, the school system’s chief of staff.
The schools planned for a new corps of health care coordinators to conduct weekly “pool” tests of asymptomatic students and staff, which tests an entire class at once. Nurses or aides were supposed to follow up with individual tests when a pool test popped positive, in addition to testing those with symptoms. Couriers were hired to ferry test samples to labs.
But a handful of schools missed their first pool tests because of turnover in the staff hired at each school over the summer. Couriers also missed some pickups, delaying some results. Some parents still haven’t signed permission slips to have their children tested.
The city has 40 nurse supervisors who oversee school nurses, or more likely, aides at each of about 160 schools. Currently, six schools have no full-time health worker and officials are working on how to get them covered.
But Perkins-Cohen said she believes the testing plan is paying off, showing a lower positivity rate than the city as a whole and “showing our schools are safe.”
She also said the program will get in a rhythm and serve the schools as long as needed — until more students are able to be vaccinated and the pandemic subsides.
“I think we had a really successful start,” she said. “Anybody implementing a program of this size will need time to work out the kinks. ... We’re looking at creative solutions, but in the end the national nursing and labor shortage are problems.”
The union representing school nurses says help is needed now. They plan a rally at schools headquarters Monday to draw attention to the needs.
Wendy Smith, president of Local 558 of AFSCME Council 67, said school nurses aren’t able to do their routine jobs properly as they focus on the pandemic. And they worry about students suffering delays in testing or results that could put them either at risk of infection at school or unnecessarily sent home to quarantine.
The courier issue has prompted some staff to drive samples to drop-off points themselves, she said.
“I had one nurse put the sample in a grocery bag and get on an MTA bus to deliver it herself to a FedEx collection site,” Smith said.
The burdens on nurses, aides and contractors is apparent around the region and country, though Maryland appears better off. The vaccination rate among those age 12 and up is relatively high, all schools now follow a mask mandate, and though hundreds of students already are quarantining in the Baltimore area, the number is lower than most other states.
The nursing shortage is a national issue, felt in hospitals, nursing homes and other health care facilities. Gov. Larry Hogan took steps Thursday to expand the nursing workforce by, for example, allowing those with out-of-state licenses to practice in Maryland.
The 18-month pandemic has prompted some nurses to retire, leave the field or go to work for temp agencies that pay far better than schools, said Kate King, president-elect of the National Association of School Nurses.
The biggest problem nationwide is that many school systems never had school nurses and are trying to spread around limited staffs.
There are close to 95,800 full-time school nurses nationwide, according to a pre-pandemic study by the association. That’s enough for just under 40% of public schools to have a full-time nurse and an additional 35% to have a part-time nurse, the bulk in elementary schools. Private schools had far fewer nurses.
“The pandemic has really stretched nurses,” said King, who is also a school nurse in Columbus, Ohio. “There are so many cases already.”
She has pointed her own students to public libraries, where they can get an at-home test to be performed in front of a health official via the internet.
“It’s creating a real moral dilemma for nurses,” she said. “They do work that is taking all day, 10 hours a day and all weekend to make sure they identify all the kids sick or exposed and get everyone quarantined. In many cases they aren’t paid for it, and they aren’t even sure they are doing everything well.”
Increasingly, she said, “parents yell at nurses because they are angry or scared. ... In some cases it’s the last straw.”
In Maryland, the state has created federally funded programs aimed at supplementing the routine screening and symptomatic testing already being done in schools.
So far, 14 of the state’s 24 school systems say they plan to do regular screening of unvaccinated students or staff, according to the Maryland State Department of Education, which Monday extended the deadline to Oct. 10 to apply to the program.
Only three school systems had launched routine screening by this week, including Baltimore City, said Andy Owen, a department spokesman. An additional 16 jurisdictions are using the program for diagnostic testing where the state provides testing supplies and a contracted vendor processes the samples.
“Some school systems have reported staffing challenges, and we are exploring options to assist in this area as well,” Owen said. “School systems that coordinated and stood up their testing programs earlier have faced fewer of these challenges.”
Most Baltimore-area counties say they are looking to fill open positions and some are trying to hire extra workers or contractors to assist with testing, tracing or other pandemic-related duties. Most say the task has been difficult.
Harford County schools said they have sufficient staff to test students when needed, but Carroll County schools want to fill two vacant positions and hire eight to 10 more nurses to assist with contact tracing and calls to parents.
Anne Arundel County schools are looking for nine nurses to fill vacancies and supplement the staff, who conduct testing on symptomatic students and staff. The county hopes to use contractors to add COVID screening tests.
In Howard County, officials want to supplement staff so there is a nurse and health assistant in each school, rather than just one, to help with testing and tracing. That means four more full-time health workers and 15 contract nurses, hiring that has been difficult, said Jahantab Siddiqui, chief administrative officer for the schools.
“The pandemic has certainly created more challenges in health services where our nurses and health assistants have been on the front line, supporting screening and vaccination efforts and contact tracing while balancing their standard responsibilities of addressing students’ routine medical needs,” Siddiqui said.
Baltimore Sun reporter Rose Wagner contributed to this article.