The pandemic is over, but Minnesota school nurses are still under pressure

The COVID-19 pandemic emergency is over, but school nurses across Minnesota say they are still in triage mode.

Student visits to their offices are still up, driven by an increase in mental health problems. Meanwhile, many districts struggle to recruit and retain their licensed school nurses, and the funding that paid for extra coordination and training during the pandemic is drying up this fall.

Tracy Princivalli is the district nurse for Pequot Lakes Public Schools, serving more than 1,850 students. She oversees students with diabetes, catheters, tube feeding, tracheotomy tubes for airway management and more. Since the pandemic, she says the job has only gotten more stressful.

She estimates that she sees nearly 20 students with mental health problems every day, managing a dozen or more anti-anxiety medications on top of increasing office visits. These problems span from panic attacks to self-mutilation or suicidal ideation.

"A mental health provider sees seven to eight people a day," she said. "I'm seeing 20 per day. What's wrong with that picture? I'm the school nurse."

Especially in rural areas like hers, school nurses are often the most accessible health resource for students and serve as a bridge to public health programs and the health care system. They put Band-Aids on scraped knees, yes, but they also maintain daily care for chronic diseases or life-threatening disorders.

Schools with a full-time licensed nurse also see improved attendance and reduced chronic absences, according to the 2022 Minnesota student survey on health and well-being.

But half of Minnesota school districts do not employ a licensed school nurse, according to a 2022 workforce survey, the most recent tally available. Those licensed school nurses have completed additional certifications in public health; some schools have nurses or health staff who haven't met those extra requirements.

The 2022 Minnesota Student Survey shows a steady increase in long-term mental health problems for students since the pandemic, with almost 44% of students in grades eight, nine and 11 in Minnesota expressing mental distress.

The rates are even higher for some student groups: LGBTQ students reported emotional distress at twice the rate of students who do not identify as part of this group. Sixty percent of students who faced housing or economic insecurity reported emotional distress.

Frequently, these mental health concerns are hard to spot, maybe presenting as a stomachache or headache every Monday at the beginning of school. When a nurse is consistently in the school building, they may be able to spot these symptoms and refer students to the district mental health team before they become more serious problems.

Unlike nurses in clinics and hospitals, school nurses like Princivalli are frequently the only health care staffer in the building, without colleagues who can provide a break or opportunities for collaboration.

According to the National Association of School Nurses and the American Academy of Pediatrics, "best practice" calls for a full-time nurse in every school building.

But Minnesota law only requires a licensed school nurse if a district has 1,000 or more students enrolled. That standard has not been updated in over 30 years.

An influx of federal COVID-19 relief funds paid for regional school nurse coordinator positions in different areas of the state. These roles gave other school nurses a network of collaborators to turn to for problem-solving, training and support.

"We finally started to make some headway," said Magen Borkenhagen, the regional nurse coordinator for the South Central Service Cooperative. In her region, she focuses largely on professional development, teaching best practices in areas like mental health and trauma recovery — valuable skills for helping students struggling with returning to the classroom after online learning.

"Just because the pandemic is over doesn't mean that the trauma from the pandemic is," she said.

"They can't just go back to life before COVID. It's not possible for any of us."

Nurse hiring and retention challenges

The regional coordinator roles are disappearing as the pandemic relief funds expire; the few who remain have found other grant money to keep going, sometimes for just another year. This may leave smaller districts without a licensed school nurse again, worrying many who fear students will lose access to routine medical care.

"They're not going to get the treatment and access to a health care professional that they deserve," Borkenhagen said.

Morgan Litzau, a coordinator for the southwest west-central region, whose job is continuing thanks to other state funding, said it's a struggle to recruit licensed school nurses. Even in an area with the funding to support another licensed nurse, it took almost a year to fill the position, she said.

A lot of it, she said, "is a money issue."

A hospital or clinic salary for a registered nurse can be almost double the range for a licensed school nurse, who are often paid on teacher contracts at $20-$35 an hour. That disparity can be even higher in smaller or rural districts.

"You can go work at Subway for almost the same amount of money that you can with a four-year degree in nursing and 30 years of experience," said Princivalli, whose predecessor in Pequot Lakes left before the pandemic due to low pay.

Princivalli said she has stayed, despite the pay, because her life is spent making kids feel better.

"I don't like to paint it as all gloom and doom," Princivalli said. "Being a school nurse is the most rewarding nursing career I have ever had."