PHILADELPHIA — Before the school day begins, nurse Kathy McCutcheon makes a list of which students have completed their online COVID-19 health screening.
Most students have fallen into the routine since the school year began and complete the checklist. But those who haven't submitted a form indicating possible symptoms or exposure to the virus must be checked upon arrival at Haddon Township High School in Westmont before they can enter the building.
It has become a part of the school day for students and staff across the region, with nurses playing a key role during the pandemic, whether schools are open for in-person or hybrid instruction or fully remote. They do the job knowing the possible risk to them and their families.
"It's not boo-boos and Band-Aids," said Donna M. Pleus, president-elect of the New Jersey State School Nurses Association. "You're trying to do your best and prioritize and keep everybody in the building safe. That's a lot to ask."
School nurses have been on the front line since the pandemic closed schools last spring. Many have helped prepare reopening plans, taken temperatures, enforced social distancing and sanitation rules, ensured mask-wearing, distributed lunches, monitored outbreaks, conducted contact tracings, and consulted with local health departments.
Often spread thin, they also are assessing and addressing students' needs from afar — monitoring spikes in student hospitalizations, managing mental health needs, identifying children who lack food and vaccinations, and looking for signs of abuse.
"Never did we know how much we need them," said Marie Blistan, president of the New Jersey Education Association, the state's largest teachers' union, which also represents about 2,700 school nurses statewide. "They have a lot on their shoulders."
Not every school has a full-time nurse, Blistan said, and in some districts, nurses are assigned to more than one school, something she wants to change. New Jersey requires at least one certified nurse in every district. Pennsylvania mandates students have access to nursing services, and some schools there also have nurses only part time.
A study in August by the Education Law Center in Newark found about 300 schools that enroll about 106,000 students, mostly in low-income districts, don't have a nurse. Because of a shortage of nurses, some other schools have a student-to-nurse ratio above the national standard of 1 to 750, the study found.
The role of school nurses has become more critical during the recent surge in coronavirus cases that has sparked debate about whether schools should stay open. Some have shifted to fully remote learning models, while others have delayed their plans to reopen buildings.
Asked how school nurses are coping, Pleus, a school nurse in Bergen County, said: "The first word that comes to mind is overwhelmed." She recently had to do contact tracing for nearly 200 people after a teacher tested positive.
In Philadelphia, because the School District has been remote since March with no immediate plans to return children to buildings, Emily Seiter, the school nurse at McClure Elementary in Hunting Park, tries to manage her students' health and well-being from afar. The K-5 school has more than 600 students.
"I am usually the first person to pick up or be concerned about someone's asthma," Seiter said. "In this case, there's no way for me to do that — I can't be with a child, I can't assess them."
Instead, much of her time earlier in the year was devoted to making sure students' vaccinations were complete, which often meant helping families figure out where to get free shots. School nurses often are the first to detect issues like food insecurity or child abuse, made more difficult with distance learning.
There has been an upside to remote classes, Seiter said — children haven't been exposed to environmental triggers that exist inside many Philadelphia public schools. McClure, for instance, was closed for an extended period last school year because of damaged asbestos.
"I've had multiple parents tell me that their kids' asthma is better because they're not in school," she said.
Colleen Quinn, the school nurse at the Philadelphia High School for Creative and Performing Arts, is busy every day — due in part to a spike in young people being hospitalized with depression, anxiety, and other disorders triggered by changes in the world.
"With everything going on with the pandemic, it's been tough for kids," said Quinn. She serves as a point person between hospital staff and teachers who are helping students transition back to class when they're ready. During a normal year, her office is a haven where students who are feeling overwhelmed stop in to recharge. She does her best with phone calls, but worries about students who miss the personal contact.
At Haddon Township High, which enrolls about 600 students, McCutcheon converted space near the nurse's office into an isolation room where students or teachers showing possible virus symptoms can be kept temporarily. A cart outside the room has gowns, gloves, and protective equipment. McCutcheon has not used the room.
"You must plan for the worst-case scenario," said McCutcheon, a certified school nurse for 16 years. "You hope you never need it."
Overbrook High School in Pine Hill has had only a few positive cases and principal Adam Lee credits low student enrollment and safety protocols by school nurse Marybeth Jensen. Only about 80 of the school's 600 students report to the building on any given day; the remainder learn virtually.
"She's my most important stakeholder," Lee said.
Jensen, a registered nurse for 27 years and now in her third year as a school nurse, said remote learning makes it easier for students who are not feeling well to stay home and help curb transmission of the virus. Besides monitoring for possible symptoms, she also triages other student illnesses and injuries and manages chronic diseases such as diabetes.
"At times, it's going to raise your stress levels," said Jensen. "I've been medically trained to handle most everything."
Although Camden schools are virtual until at least February, school nurse Robin Cogan, who oversees a handful of preschools in East Camden, said she has been swamped checking immunization records. She teaches a virtual health class, has story time online, and fields calls from concerned parents.
Cogan, who runs a support group for nurses and writes a blog, The Relentless School Nurse, said many are feeling overwhelmed. They often worry about making the right decision in evaluating a student with possible virus symptoms, she said.
"They don't want to miss anything," said Cogan, a school nurse for 20 years. "God forbid you're the school nurse who doesn't send a kid home for what turns out to be COVID."
With adequate protective gear and safety measures, nurses say they feel safe in school, despite the risk of contracting the virus.
"If that call was made I would be very comfortable coming back in person," said Kami Hall, a nurse in the Waterford school system in Camden County. "I love working with children. I miss them terribly."