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Why school nurses are critical to getting more kids vaccinated

By Ken Budd
Aug. 31, 2021
A school nurse standing at the front of a classroom speaking to a masked group of students about the Covid-19 vaccination.

Lack of confidence in the COVID-19 vaccines runs high for some parents, a recent survey from the Kaiser Family Foundation found. Almost a quarter of parents say they will “definitely not” get their children vaccinated, and 90% of those said they were very or somewhat concerned about long-term effects from the vaccine. Other top fears included side effects and potential damage to their children’s fertility.

Janet Farmer, RN, district head nurse for the 14,000-student Laramie County School District in Cheyenne, Wyoming, says she frequently hears concerns that the vaccines were rushed and not fully tested — though she’s hoping that FDA approval of the Pfizer-BioNTech vaccine on August 23 will increase their confidence.

Many school nurses argue they are uniquely positioned to counter misinformation about the vaccines, given their long-standing relationships with parents and students, and their prior experience inoculating kids against other infectious diseases.

Indeed, Farmer’s school district has already held several vaccine clinics for staff and students. Other schools have done the same: In May, days after the FDA issued emergency use authorization for the Pfizer-BioNTech COVID-19 vaccine for adolescents ages 12 to 15, nurses in the Mt. Lebanon School District in Pennsylvania administered vaccines to roughly 1,000 middle school students. In Washington, D.C., multiple schools hosted clinics in June to vaccinate students before the start of the school year.

This, on top of a multitude of other pandemic-related responsibilities — giving COVID-19 tests, conducting contract tracing, and screening for symptoms  — which is one reason the Biden administration announced that it would dedicate $500 million of the $7.4 billion American Rescue Plan Act of 2021 to help governments hire school nurses.  

“I don’t think I’ve worked so many 12-hour days in my life,” says Lorri Greenlee, RN, coordinator of health services for the Winfield Unified School District in Kansas, which ran six clinics for staff in the spring and three for students in May. “It’s all COVID all the time.”

School-located vaccine clinics (SLVCs) can play a major role in vaccinating young people, and the need is urgent. As of August 25, just 3.3 million U.S. residents ages 16-17 were fully vaccinated, the CDC reported. The numbers were higher for those ages 12-15 — 5.2 million — but that’s less than one-third of the approximately 17 million adolescents ages 12-15 in the United States. The White House is encouraging schools to host vaccination clinics, and about 45% of school nurses report that their schools are somewhat or very likely to do so in the 2021-22 school year, a June survey from the CDC Foundation found.

Even in places where vaccine confidence is low, school nurses can subtly encourage vaccination without overtly pushing it on kids and parents who are vehemently opposed.

“Because COVID vaccine hesitancy runs strong here, we understand this is a deeply personal decision,” says Farmer.

School nurses have credibility

SLVCs aren’t a new concept. New York City schools became vaccination sites for smallpox in 1875 and schools nationwide helped inoculate children against polio in the 1950s. And while SLVCs for COVID-19 have not been as broadly adopted, they’re ideal for vaccinating young people since they provide a “captive audience,” as Greenlee puts it, and convenience for parents. What’s more, school nurses are frequently highly trusted figures and credible sources of information on medical subjects — including vaccines — given their often long-term relationships with families.

“School nurses develop trust and relationships with families sometimes from kindergarten all the way up [to 12th grade],” says Linda Mendonca, DNP, RN, president of the National Association of School Nurses (NASN). “I always say, the school nurse is the heart of the school community. The nurse’s office is a safe place for students.”

School nurses also have a well-earned reputation for listening to parents. This means they not only hear anxieties about the vaccines, but learn families’ motivations for possibly getting vaccinated, whether it’s so their daughter can play soccer or the family can visit grandma.

“It’s about understanding their concerns and providing information,” says Mendonca, who is also an assistant professor at the Rhode Island College School of Nursing. “I think school nurses are good at that. They can provide vaccine education and debunk some of the misinformation.”

Greenlee has found that one-on-one conversations are often more persuasive than public information campaigns.

“Yesterday, as I was doing COVID testing on an employee, I simply asked, ‘Have you considered getting the vaccine?’” she says. “We are trying to be open to the group of parents who have been a bit hesitant and may be willing to have a good conversation. As contentious as this has become, we try and just be there.”

Experience with immunization efforts

In 2010, following the H1N1 outbreak, Maine’s Camden Hills Regional High School became a registered SLVC. So once students ages 16 and older became eligible for the Pfizer-BioNTech COVID-19 vaccine on May 6, Janis Hogan, RN, NCSN, an NASN board member and a school nurse at Camden Hills, immediately reached out to health care provider MaineHealth. The school held its first clinic on May 18.

About 165 students quickly signed up. MaineHealth provided a pharmacist, vaccinators, and, of course, the vaccines. Hogan managed the other logistics, including securing the location — a “mini-gym” at the school — promoting the clinic, reviewing enrollment forms, and recruiting volunteers who staffed an arrival station, post-vaccine station (to watch for allergic reactions), and checkout station.

Because Hogan and the school had run clinics in the past — Camden Hills also hosts annual clinics for flu vaccines — she had strong relationships with county health officials and local health care providers.

“I already knew people [at MaineHealth], so I emailed right away and said, ‘Hey, can we partner?’” says Hogan. “I let my superintendent know I was ready to hold a clinic at our school and as soon as we were given the go-ahead for students, we got it going.”

In Laramie County, Farmer has a similarly solid relationship with local health officials. As COVID-19 began to spread in March 2020, Farmer and her team began meeting with their county health department. Schools receive regular information (such as the latest COVID-19 numbers) and feedback on their protocols. The relationship is invaluable for running clinics.

“When we did our staff clinics last spring, they had it down to a science,” Farmer says of the local health department. “Station-wise, it was go here, go here, go here, stop here. They had signage, they had everything.”

When those relationships don’t exist, school nurses can take the initiative — sometimes to the surprise of county officials. In Saint Louis County, Missouri, a group of school nurses began thinking about establishing SLVCs in September 2020. They contacted the county health department, and as Katherine Park, MSN, RN, NCSN, told Stat, “It’s almost like they had never really considered they could utilize us.” The county is encouraging students to get vaccinated at one of three health department clinics through mid-September, though it is also working with school nurses to inoculate students.  

In Delaware, schools work with private vendors such as Walgreens and Rite Aid. Megan Fioravanti, BSN, RN, NCSN, a school nurse at North Star Elementary School in Hockessin, recently worked with a local high school that partnered with Albertsons. The pharmacy provided everything from the vaccines to staff and the school nurses ran the clinic.

Fioravanti wants to launch a COVID-19 vaccine clinic at North Star once the vaccines are approved for kids under 12. North Star provided H1N1 vaccines in 2009 and offers annual flu vaccines, so Fioravanti and her team have experience inoculating thousands of kids.

“I’m hoping we can get a lot of kids vaccinated quickly in a place where their parents feel comfortable,” she says. “They know us, they know we’re going to take care of their kids, and I hope that helps to increase our vaccinated numbers.”   

Incentives for injections

In Kansas, Greenlee’s school district is taking creative steps to boost vaccinations among students as it holds its first fall clinic on September 3. Kids can get a frame to use on Instagram showing they received the vaccine. A September 10 clinic will be held at a high school football game.

Some school districts are combining COVID-19 vaccines with other health activities. When athletes in Laramie County received concussion pretests in August, they could also receive a COVID-19 vaccine (junior high clinics offered Tdap, hepatitis A, HPV, and meningococcal shots as well). At one clinic, that led to about 40 COVID-19 vaccinations.

“Public health is not our area of expertise, but we’ve learned a lot in the last 18 months,” says the NASN’s Mendonca. “I think that we’re going to be ready whenever the vaccine becomes available for kids under 12.”

Advice for Running a Clinic

Launching a school-located vaccine clinic requires significant planning, partnerships, research, and energy. Resources include: