The Approach to Maintaining Student Health and Wellness During COVID-19 School Closures

DOI: 10.1177/1942602X20935612
For reprints and permission queries visit SAGE’s Web site,
© 2020 The Author(s) September 2020 | NASN School Nurse 269

Ask the E.R. Pediatrician

In response to the novel coronavirus
disease 2019 (COVID-19) pandemic,
most states in the United States enacted
statewide school closures, ranging
in duration from 1 month to the
remainder of the academic year. The
extended durations of these closures
present unique challenges, as many
families rely on the school as a source
of physical activity, mental health
services, psychosocial support, child
care, and food security. While the school
doors may be closed, the school nurse
can still play a vital role in emergency
management. This article discusses
challenges and proposes solutions to
maintaining student health and wellness
during extended school closures due to
the COVID-19 pandemic. Furthermore,
it is inevitable that until a vaccine for
coronavirus is developed and readily
available, many schools will continue
to see future closures, though likely for
shorter periods of time, as they respond to
local outbreaks.

Keywords: coronavirus; COVID-19;
pandemic; social distancing; school

Who Is the ER Pediatrician?

Dr. Robert Olympia, MD, is a pediatric
emergency medicine physician with
more than 20 years of experience,
currently working in an emergency
department in the “sweetest place” on
Earth (Hershey, PA). He is a professor in
the Departments of Emergency Medicine
and Pediatrics at the Penn State
University College of Medicine. His
research interests include emergency and
disaster preparedness for children in the
setting of schools and school-based
athletics, as well as in sports-related
illnesses and injuries. He has presented
his research both regionally and
nationally and has lectured on a variety
of topics pertaining to pediatric
emergency medicine, such as fever and
infectious diseases, trauma, sports-related
injuries, and disaster preparedness.

Who Is Dr. Olympia’s Coauthor?

Rachel Rothstein is a fourth-year
medical student at the Penn State
University College of Medicine and a
recent graduate of Tufts University School
of Medicine Master of Public Health

Program. Her interests include pediatrics,
pediatric surgery, and public health.

What Is the Purpose of the
“School Nurses on the Front
Lines of Healthcare” Series?

The “School Nurses on the Front Lines
of Healthcare” series will present cases
reflecting emergencies commonly
encountered in the school setting,
focusing on an evidence-based approach
to the initial management, stabilization,
and disposition of the ill or injured child.

Special features unique to each article
are Extra Credit Points and Report Cards.
Extra Credit Points are trivia questions or
clinical pearls scattered throughout the
article related to the topic at hand.
Report Cards are concise tables
summarizing key points in each article
that you can photocopy and laminate or
photograph and keep on your smart
device for easy access.


During an otherwise normal afternoon
in early March, your superintendent
urgently assembles the school nurses,

935612NASXXX10.1177/1942602X20935612NASN School NurseNASN School Nurse

School Nurses on the Front
Lines of Healthcare
The Approach to Maintaining Student Health and Wellness
During COVID-19 School Closures

Rachel Rothstein, BS, MPH

Robert P. Olympia, MD

270 NASN School Nurse | September 2020

principals, and other key faculty
members, as well as local public health
officials, to discuss the growing threat of
COVID-19. Your team ultimately decides
to close the schools for the next 2 weeks,
effective immediately. Shortly thereafter,
your state governor declares a state of
emergency and announces statewide
closure of schools for a minimum of 6

Parents in the community begin
contacting your team with concerns.
Many parents are essential workers and
cannot obtain child care. Others are
concerned about food security, in the
absence of school meal programs. The
list of student health and wellness
concerns continues. Your school district
is fortunate to have an emergency
procedure in place for infectious disease
outbreaks, and the school closure
provides you and the school staff time to
review and update your emergency and
disaster plan, addressing many aspects of
wellness for your students and their

School Closures During
Historical Infectious Disease

While the term social distancing is
likely new to many, the concept of
school closures as a tool for reducing
spread of infectious diseases originated
long before the COVID-19 pandemic.
During the 2009-2010 influenza H1N1
pandemic, over 720 schools, housing
nearly 368,300 students, closed across
the United States (Klaiman et al., 2011).
While the current durations of school
closures exceed those of other infectious
disease outbreaks in recent history,
consistent are the challenges to
maintaining student health and wellness
in light of closures.

The Role of the School Nurse
During School Closures

The National Association of School
Nurses (NASN) recognizes the school
nurse as a “vital member of the school
team, who collaborates with community
agencies to develop comprehensive
emergency response procedures” (NASN,

2019, para. 1). Likewise, the school nurse
provides expertise in school health as a
“leader and integral partner with school
staff and outside agencies in developing
comprehensive school plans/procedures”
(NASN, 2019, para. 3). NASN is
continually providing up-to-date resources
on COVID-19 for school nurses, which
incorporate emerging information from
the Centers for Disease Control and
Prevention (CDC) and other groups (CDC,
2020b; NASN, 2020). Furthermore, the
uncertainty surrounding future “peaks” of
COVID-19 or other infectious disease
outbreaks emphasizes the importance of
emergency and disaster planning.

As school districts enter this unfamiliar
phase of emergency management, the
school nurse plays a critical role in
addressing student health and wellness
during school closures. The document,
“Considerations for School Nurses When
Providing Virtual Care,” highlights the
role of virtual care in addressing student
needs, continuing case management,
providing resources to families, and
mitigating health disparities (NASN,
2020). NASN also provides, “Guidance
for School Nurses to Safely Send and
Receive Resources Between School and
Home During COVID-19,” to ensure safe
transfer of both student and school
property, including backpacks, student
medication, school supplies, electronic
devices, and ongoing food services to
socially and medically disadvantaged
families (NASN, 2020). Finally, “Ideas for
School Nurse Activities during the
COVID-19 Pandemic” provides a list of
activities that school nurses can complete
in light of closures (NASN, 2020).

Regarding school reopenings, NASN
provides template letters, addressing state
leaders, local leaders, and school
superintendents, advocating for the
inclusion of school nurses in planning
processes (NASN, 2020). In the article,
“Interim Guidance: Role of the School
Nurse in Return to School Planning,” NASN
outlines school nurse roles according to
the five major principles of the Framework
for 21st Century School Nursing Practice™
(Care Coordination, Community/Public
Health, Leadership, Quality Improvement,
and Standards of Practice). For school

nurses practicing in schools that are open,
NASN offers “Considerations for School
Nurses Regarding Care of Student and Staff
that Become Ill at School or Arrive Sick”
and “Facemask Considerations for
Healthcare Professionals in Schools”
(NASN, 2020).

Challenges to Obtaining Child
Care Coverage

Currently, 16 sectors of the workforce
qualify as “critical infrastructures” and
are essential to the country’s continued
functioning, potentially leaving 45.9
million children, who otherwise would
be in school, without adequate
supervision (Bayham et al., 2020). While
there is no definitive age at which it is
appropriate to leave a child home alone,
many resources are available to guide
parents in this decision. Leaving
children home alone may present risks
to both physical health and mental

On the national level, the Families
First Coronavirus Response Act includes
a provision that expands protection for
employees that during a public health
emergency are unable to work due to a
need for leave to care for their child
because the school or day care has
been closed or the child care provider is
unavailable (Moss et al., 2020). Similarly,
the Coronavirus Aid, Relief and
Economic Security Act includes a $3.5
billion expansion in funding of the
Child Care and Development Block
Grant, to help states establish child care
assistance for essential workers
( Johnson-Staub, 2020). Examples of
such interventions include temporary
pandemic child care centers in Ohio
and regional enrichment centers in New
York City. To assist your community’s
essential workers in obtaining child care
coverage, view your state’s emergency
child care provisions and actions in
response to COVID-19 on the Hunt
Institute website in Table 1. Also, the
Khan Academy websites listed in Table
1 offer free online video classes,
including music, games, crafts, and
educational materials, for children to
follow along while parents work or
accomplish tasks in the home.

September 2020 | NASN School Nurse 271

Table 1. Report Card: Resources to Aid Families in Your Community in Maintaining Health and Wellness

Child care Hunt Institute Information on your state’s emergency child care
provisions to help essential workers obtain
child care coverage



Khan Academy Virtual classes (e.g., music, games, crafts,
educational) to engage children while parents
complete work or tasks in the home

Wide Open School

Physical activity Healthy Children List of individual and family-oriented outdoor
physical activities that follow social distancing

Online PE

Grade-specific physical activities for the home;
weekly and monthly schedules to make
exercise a part of children’s routines

GoNoodle Online physical activity and meditation videos for
children to follow

Food security
and healthy

No Kid Hungry,

Resources on the state and district levels to
assist families in maintaining food security
during the pandemic


List of local food banks in your community, as
well as information on their responses to the

Nutrition Strategies to make nutrition a priority during the

CDC General tips on promoting healthy eating in the

Eat Right Healthy recipes that children enjoy
Safe opportunities to engage children in the



Mental health
and well-

Child Mind

Strategies to improve sleep hygiene

National Hotline Advocates, available to provide support and
access to community resources for victims of
domestic violence


Call 1-800-799-7233 or Text “LOVEIS” to 22522

NASN Guidance for parents on how to help children
cope with COVID-19

Child Mind

Guidance for parents on how to discuss
COVID-19 with children

CDC Activity and coloring workbooks to help facilitate
COVID-19 discussions between parents and
young children

Crisis Text Line Crisis counsellors, available to discuss COVID-19
and other related concerns with children
Text “HOME” to 741741

Daily routine Khan Academy Comprehensive daily schedules and academic
materials by grade level

Note. PE = physical education; USDA = U.S. Department of Agriculture; CDC = Centers for Disease Control and Prevention.

State Child Care Actions COVID 19

State Child Care Actions COVID 19

Wide Open School

Encouraging Good Sleep Habits

Encouraging Good Sleep Habits


Talking to Kids About the Coronavirus Crisis

Talking to Kids About the Coronavirus Crisis

272 NASN School Nurse | September 2020

Extra Credit Point: How Many
Hours of Physical Activity Should
Children Get Each Day?

The CDC recommend that all children
aged 5 to 17 years participate in 1 hour
of moderate to vigorous physical
activity each day, with an emphasis on
aerobic activities such as walking,
running, or biking, and that all children
3 to 5 years old participate in 3 hours of
physical activity daily, through activities
spread over the course of the day (CDC,

Challenges to Maintaining
Physical Activity

In addition to maintaining a healthy
body weight and fostering
musculoskeletal, cardiovascular, and
mental health, physical activity in
children is crucial to “self-expression,
building self-confidence, social
interaction and integration” (World
Health Organization, 2015, para. 13).
Schools help children incorporate
physical activity into their daily routines
through participation in physical
education (PE), recess, sports, and other
extracurricular activities.

As a result of school closures, children
lose access to these structured and
supervised sources of physical activity.
The extended duration of school
closures resembles summer recess, a
period during which physical activity
levels decline and sedentary time and
body mass index rise (Brazendale et al.,
2017); Unlike summer recess, the
pandemic limits children’s access to
alternative sources of physical activity in
the community, due to closures of
public spaces such as parks, sports
fields, tracks, and gyms. Many families
lack resources and equipment in the
home for children to continue their
usual activities. Finally, social distancing
limits the social interaction and bonding
that physical activity often affords

Prior to the COVID-19 pandemic,
nearly 32% of children in the United
States were overweight or obese, and
children spent an average of 7.5 hours in
front of a screen per day (Brazendale

et al., 2017; CDC, 2018). Both statistics
are likely to rise in light of the pandemic.
Families now have a critical opportunity
to adopt new attitudes and strategies to
make physical activity a priority. To
provide families in your community with
outdoor physical activities that follow
social distancing guidelines, visit the
Healthy Children website in Table 1. The
Online PE Network website in Table 1
provides a list of grade-specific physical
activities for the home, as well as
monthly and weekly calendars to make
these activities a part of children’s daily
routines. Finally, in place of traditional
screen time, the GoNoodle website in
Table 1 provides free online physical
activity and mindfulness videos for
young children to follow.

Challenges to Maintaining Food
Security and Healthy Eating

Approximately 29.7 million children in
the United States participate in the
National School Lunch Program, which
provides discounted or free school
lunches to children of low-income
households (U.S. Department of
Agriculture [USDA], 2019). Similarly, the
School Breakfast Program provides
school breakfast to nearly 14.6 million
children in the United States. (USDA,
2019). Food insecurity disproportionately
affects children residing in rural and
large urban areas, as well as single-
parent, Black and Hispanic households
(No Kid Hungry, 2020). Childhood
hunger can contribute to malnutrition,
difficulty concentrating, impaired
academic performance, stress, poor
social skills, and other adverse physical
and mental health outcomes (No Kid
Hungry, 2020). As a result of school
closures, children lose access to these
routine daily sources of meals. As of May
1, 2020, children in these programs have
missed a collective one billion school
meals (No Kid Hungry, 2020). To locate
resources to help families in your
community maintain food security, visit
the No Kid Hungry and USDA websites
in Table 1.

Even children residing in food secure
households may encounter difficulty in
maintaining healthy eating during school

closures. For many children, school
lunches provide the most nutritious
meals of the day, by ensuring inclusion
of fruits, vegetables, and milk. During
school closures for summer recess,
children typically consume fewer fruits,
vegetables, and milk and more added
sugars, saturated fats, and sodium
(Brazendale et al., 2017). Unlike summer
recess, the pandemic presents unique
barriers to obtaining healthy foods, due
to grocery store closures, delivery delays,
and item shortages, while access to “fast
foods,” which typically contain more
saturated fat, sugar, salt, and calories,
remain readily available. In efforts to
expand reach during the pandemic, food
banks are creating drive-through food
distribution centers, preparing and
distributing meals to children,
prematurely opening summer meal
programs, and keeping existing after-
school meal programs accessible. To
locate a food bank in your community
and to learn more about your local food
bank’s response to COVID-19, visit the
Feeding America website in Table 1.

To provide your community with
strategies to make nutrition a priority
during the pandemic, visit the Nutrition
website in Table 1. To provide families
with healthy eating tips, visit the CDC’s
website in Table 1. For a list of healthy
recipes that children enjoy, visit the
Academy of Nutrition and Dietetics’ Eat
Right website in Table 1. The Eat Right
campaign also helps parents find safe
opportunities to engage their children in
meal planning and preparation, which
may help children become more curious
about trying new foods.

Challenges to Addressing
Mental Health and Psychosocial
Implications of Pandemic

Schools represent the largest providers
of mental health services for children. Of
the 16% of children in the United States
receiving mental health services, over
70% do so in school, specifically through
school counselors, nurses, psychologists,
and social workers (Centers for Health
and Health Care in Schools, 2012). In
addition to counselling, schools provide
crucial behavior management and crisis

September 2020 | NASN School Nurse 273

intervention services. As a result of
school closures, children lose access to
these critical resources. This is
particularly concerning for children of
racial and ethnic minority groups, who
historically face greater difficulty in
accessing mental health services. School
closures also disrupt the structured daily
routines that are critical for all children,
especially those with underlying mental
health and behavioral disorders. Finally,
in social distancing from peers, children
lose access to a critical social support
network. Social isolation can further
negatively affect mental health outcomes.
School nurses searching for new
strategies to address student mental
health during the pandemic may
schedule a zoom meeting with the Crisis
Management Institute (2020).

The pandemic also presents unique
psychosocial stressors, which may
negatively affect the well-being of
children and exacerbate underlying
mental health disorders. Children may

experience additional home stressors, as
parents face unemployment, economic
hardship, and difficulty balancing work
with their caregiver responsibilities.
Essential workers may experience greater
stress in the workplace and spend less
time with their children, which can
negatively affect both the child’s
well-being and the parent–child
relationship. Physical activity, healthy
eating, mindfulness, and sleep hygiene
may all reduce psychosocial distress and
improve well-being in children. To assist
families in improving sleep hygiene, visit
the Child Mind Institute website in Table
1. In addition to physical activity videos,
the GoNoodle website in Table 1 also
provides online meditation and
mindfulness videos for young children to

Over seven million cases of child abuse
and neglect are reported in the United
States each year, four children of which
die each day (Safe Horizon, 2020).
Professionals expect these numbers to

increase in light of the pandemic, as
household stress is a significant predictor
of child abuse and neglect. In addition,
victims have limited ability to seek
refuge, due to closure of shelters,
religious venues, and other community
resources, as well as fear of contracting
COVID-19 in the emergency department.
Victims may connect with an advocate
by visiting the National Hotline website
in Table 1, by calling 1-800-799-7233 or
by texting LOVEIS to 22522.

Children may experience the illness,
hospitalization, and death of a loved one
from COVID-19. These hardships may be
difficult to understand based on
developmental age and can have
long-term psychiatric consequences. To
provide families in your community with
guidance on how to help children cope
with COVID-19, visit the NASN website
in Table 1. To engage young children in
these discussions, age-appropriate
COVID-19 activity workbooks and
coloring books are available on the CDC
websites in Table 1. Children may also
discuss COVID-19 concerns with a crisis
counsellor by visiting the Crisis Text Line
website in Table 1 or by texting HOME
to 741741.

Creating a Daily Routine

School closures significantly disrupt
children’s daily routines. Literature on
the structured day hypothesis
demonstrates that healthy behaviors are
“beneficially regulated when children
are exposed to a structured day (i.e.,
school weekday)” versus weekends and
summer recess, through, “compulsory
physical activity opportunities,
restricting caloric intake, reducing
screen time occasions, and regulating
sleep schedules” (Brazendale et al.,
2017, p. 1). Several nationally
recognized organizations emphasize the
importance of adhering to a structured
schedule despite school closures. As an
example, Table 2 displays a potential
schedule for a late elementary school
student, which incorporates resources
mentioned in Table 1. The Khan
Academy website listed in Table 1
provides more comprehensive daily
schedules for students in preschool to

Table 2. Report Card: Sample Daily Routine for Student Grades 3 to 5

Grades 3 to 5


8:00 to 9:00 Wake up, get dressed, wash up, eat breakfast

9:00 to 9:30 Start assigned schoolwork

9:30 to 10:00 Play outside or complete an Online PE Network physical
activity (Table 1)

10:00 to 10:30 Continue assigned schoolwork

10:30 to 11:00 Reading time

11:00 to 11:30 Play outside or complete an Online PE Network physical
activity (Table 1)

11:30 to noon Continue assigned schoolwork


Noon to 1:00 Eat lunch

1:00 to 2:00 Continue assigned schoolwork

2:00 to 8:00 Relax, play outside, family time, help cook, eat dinner

8:00 to 9:00 Bedtime

Note. Adapted from Khan Academy (2020).

274 NASN School Nurse | September 2020

second grade, third to fifth grades, sixth
to ninth grades, and 10th to 12th grades,
as well as academic lessons/assignments
by subject for students who are not
receiving ongoing remote education
during school closures (Khan Academy,
2020). Finally, Gasol Foundation
suggests creating themes for each
weekday, to reinforce healthy behaviors
and foster family time. Examples on this
website include “Workout Wednesdays,”
when family members participate in a
family workout together, or “Feelings
Friday,” when family members gather to
discuss their emotions surrounding
COVID-19 (Gasol Foundation, 2020).
Families can utilize these resources to
create a schedule that optimizes health
and wellness during the pandemic.

For Schools That Have
Reopened or Are Deciding
to Reopen

The return to school introduces new
challenges to maintaining student health
and wellness. Several resources are
available on the CDC’s, “Child Care,
Schools and Youth Programs—Plan,
Prepare, and Respond,” to assist schools,
youth programs, camps sports and child
care programs with the process of safely
reopening or with maintaining safety for
those that have already reopened (CDC,

Case Resolution

You visit the Hunt Institute website
(Table 1) to learn more about your
state’s emergency child care provisions
in response to COVID-19. Likewise, you
visit the No Kid Hungry and Feeding
America websites (Table 1) to locate
resources to assist your community in
maintaining food security. You
disseminate Tables 1 and 2, as well as
these state- and community-specific
resources, to parents in your
community. You receive feedback from
several families that these tools assisted
them in adopting a new and healthy
routine, despite school closures.
Families in your community feel better
equipped should the governor extend
the duration of school closures.

Moreover, you feel better prepared,
should your school district encounter
intermittent “peaks” of COVID-19 until
a vaccine is developed and readily
available, or an entirely new infectious
disease outbreak occurs in the near

Contact Dr. Olympia

If you have a clinical question, send
your question to Dr. Olympia ([email protected] Questions will be selected
and discussed as part of the “School …

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