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Correspondence: Daniel Crawford, DNP, ARNP, CPNP-PC, CNE, The University of Iowa College of Nursing, 334 College of Nursing Bldg., 50 Newton Rd., Iowa City, IA 52242-1121
Daniel Crawford, Associate Professor (Clinical) & Director, Pediatric Primary Care Nurse Practitioner Program, The University of Iowa College of Nursing, Iowa City, IA
Anne K. Nielsen, Pediatric Nurse Practitioner, General Pediatrics/Child Protection Program, The University of Iowa Stead Family Children's Hospital, Iowa City, IA
The coronavirus disease 2019 (COVID-19) pandemic has significantly affected children and families. The study purpose was to better understand the perceptions of pediatric-focused advanced practice registered nurses (P-APRNs) on the impact of COVID-19 on patients and practice.
Method
A 25-item electronic survey including Likert scales, multiple choice , and open-ended questions was sent by e-mail to electronic mailing list of the National Association of Pediatric Nurse Practitioners.
Results
Responses (N = 109) reflect the magnitude of challenges affecting child physical health, mental health, parental stress, and social determinants of health. P-APRNs expect greater refusal of the COVID-19 vaccine compared with other vaccines. Telehealth use continues at an increased rate and greater resources are needed to support clinical practice.
Discussion
The COVID-19 pandemic has transformed the lives of children, families, and P-APRN practice. These findings reflect challenges and opportunities moving forward. P-APRNs are well-prepared to lead change to support better and more equitable outcomes for all.
Significant changes have occurred globally because of the coronavirus disease 2019 (COVID-19) pandemic. People have experienced dramatic shifts in the way that they work, carry out everyday activities, and interact with others. For children, changes have occurred in the way that school and peer interactions occur and in the way they access health care. Pediatric-focused advanced practice registered nurses (P-APRNs) play a significant role in the provision of health care services for children across a variety of settings and have seen diverse changes in the health status of the children and families they care for (
). P-APRNs have been forced to adapt because of the pandemic to provide health care services in this globally transformed context for well-child care, common acute issues including children with COVID-19, mental health disorders, and the care of a variety of chronic health conditions.
During the COVID-19 pandemic, there have been social restrictions and infection mitigation efforts that have altered the typical way health care is delivered. Significant changes have been reported related to when children (1) are seen for well-child care (
Provision of pediatric immunization services during the COVID-19 pandemic: An assessment of capacity among pediatric immunization providers participating in the vaccines for children program—United States, May 2020.
MMWR. Morbidity and Mortality Weekly Report.2020; 69: 859-863
). These changes and the broader social and health implications related to the pandemic are expected to create lasting challenges with children's health, but the scope and duration of these challenges cannot be fully predicted (
The pandemic and associated changes to normal life patterns have caused a significant amount of increased stress and worry among children and their parents or caregivers (
). These dramatic changes in the everyday lives of children have led to increased stress, loneliness, mental health concerns, depression, and anxiety in the pediatric population (
). These changes in mental and physical health factors increase the risk for poorer quality of life, obesity, and a variety of other mental and physical health concerns.
Practice changes have occurred owing to the pandemic. Telehealth has been adopted in many practices in an attempt to better meet patient needs amid the pandemic (
). Offices have implemented protocols to test for COVID-19 and to administer the COVID-19 vaccine. Separate physical spaces have been designated for well versus ill children in many practices. Many practices are trying to meet the mental and physical health needs of patients but are met with inadequate support services.
Further investigation into the effects that the pandemic has had on children and families as well as any changes in health patterns or practices is important to supporting high-quality health outcomes. A gap exists in the literature related to the clinical practice experiences and additional resources needed by P-APRNs caring for children during the COVID-19 pandemic. Therefore, the purpose of this study was to describe the perceptions of P-APRNs on the impact of COVID-19 on their patient population and practice. This study addressed the following questions:
(1)
What effects have P-APRNs seen in their practice related to children's physical health, mental health, social determinants of health, and parent or caregiver stress?
What patient and family perceptions toward vaccination (COVID-19 and routine immunizations) have P-APRNs seen in their practice?
(1)
To what extent have P-APRNs adopted telehealth in their current practice setting?
(2)
What additional resources do P-APRNs need to best care for their patient population?
METHODS
Sample and Setting
A descriptive survey design with a convenience sample was used. The survey was distributed electronically to members of the National Association of Pediatric Nurse Practitioners (NAPNAP) by e-mail through their membership electronic mailing list. At the time of writing, NAPNAP reported having greater than 8,200 members. All members are included in the NAPNAP member electronic mailing list database unless explicitly opting out of e-mail communication from the organization. Individuals eligible for inclusion were board certified nurse practitioners who spend at least 50% of their clinical time caring for children. Exclusion criteria included non-nurse practitioner health care providers, those not actively practicing in a clinical setting, or those caring for children less than 50% of their allocated clinical time. The total number of eligible participants was unknown.
Instrument
A 25-item electronic survey was developed by a team of experts in pediatric advanced practice nursing, including four P-APRNs and a pediatric nurse scientist. The survey questions addressed the research questions and included demographic questions and items specific to the P-APRN's perceptions of the impact of COVID-19 on the physical health, mental health, and social determinants of health of the children cared for by P-APRNs, family perceptions toward vaccination, and the use of telehealth as well as changes in and needs for P-APRN practice. Items included in the final survey included a mixture of Likert scales, multiple choice questions, and open-ended questions. The items asking if changes had been noted in the pediatric nurse practitioners (PNPs) practice related to physical health, mental health, social determinants of health, and caregiver stress all began with “Since the onset of the COVID pandemic, what changes have you seen in the following in your practice?” Responses were on a 7-point Likert scale with 1 equal to a significant decrease; 2, a moderate decrease; 3, a slight decrease; 4, no change; 5, a slight increase; 6, a moderate increase; and 7, a significant increase. For example, the item on mental health impact asked participants, “Since the onset of the COVID pandemic, what changes have you seen with the following mental health concerns in your practice?” Eleven mental health concerns were listed, such as anxiety, somatic complaints, and self-harm. The survey was hosted on Research Electronic Data Capture (
This study was reviewed by the institutional review board at The University of Iowa. The study was subsequently reviewed and approved by the NAPNAP Research Committee. On receipt of the required approvals, an e-mail was sent by NAPNAP staff members to NAPNAP members through the electronic mailing list. The e-mail sent to members included an invitation to participate, details about the study and consent, and a link to the Research Electronic Data Capture survey. Recipients were notified that completion of the survey implied consent and that the survey could be exited at any time. Within the survey, the initial questions determined inclusion/exclusion criteria status using branching logic. The study details and invitation to participate were sent once to membership in June 2021 and were open for 2 weeks. Although the authors planned to resend the survey 2 weeks after the initial distribution, NAPNAP policy limited it to single distribution of the survey.
). Summary statistics and descriptive statistics were calculated for respondent characteristics (mean and standard deviation, frequencies, and percentages). Descriptive statistics were used (frequencies and percentages) for COVID-19 impact on physical health; mental health; social determinants of health; and caregiver stress, perception toward vaccinations, and resources needed during COVID-19. Data from incomplete surveys that included at least some responses beyond demographic items were included in analysis (n = 11).
RESULTS
Characteristics of the responding P-APRNs are provided in Table 1. A total of 109 individuals completed the survey with different numbers of P-APRNs replying to each question. The percentages for each category were based on the number of valid replies to the question. The P-APRNs had an average of more than 16 years of experience (mean = 16.7, standard deviation = 11.9, range 1–48 years). The most common academic degree for these P-APRNs was a master's degree in nursing for 72.7%, and most (81.7%) were certified as pediatric nurse practitioner–primary care. The practice area for these P-APRNs varied with most (67%) in primary care. Most practiced in the outpatient setting (90.8%).
Note. N = 109. DNP, Doctor of Nursing Practice; FNP, family nurse practitioner; MSN, Master of Science in Nursing; PMHNP, psychiatric-mental health nurse practitioner; PMHS, pediatric primary care mental health specialist; PNP-AC, pediatric nurse practitioner–acute care; PNP-PC, pediatric nurse practitioner–primary care.
a Percentages do not sum to 100% owing to rounding.
The impact of COVID-19 on children's physical, mental, and social health is seen in Table 2. These P-APRNs noted a significant or moderate decrease in children receiving routine well-child care (mean of 2.6 ± 1.1 on the 7-point Likert scale), standard recommended (non-COVID-19) immunizations (2.5 ± 1.0), and identification of developmental delays (3.3 ± 1.2). In addition, they noted a moderate or significant increase in inadequate physical activity (5.9 ± 1.4), obesity (5.5 ± 1.3), poor nutrition (5.5 ± 1.2), and difficulty accessing specialty care (5.0 ± 1.5) among the children in their practices. There was also a moderate or significant increase among the children they cared for in anxiety (6.2 ± 1.0), depression (6.1 ± 1.0), academic concerns (6.0 ± 1.1), and behavioral concerns (5.6 ± 1.0), resulting in an increase in referrals for mental health support (6.2 ± 1.2) but also difficulty in accessing specialty care (5.5 ± 1.3). Along with an increase in physical and mental health concerns during COVID-19, these P-APRNs noted an increase in a number of social issues, particularly in multiple caregiver stressors such as remote learning (6.6 ± 0.8), increased screen time (6.5 ± 0.9), increased media use (6.4 ± 1.0), child socialization/isolation (6.3 ± 0.8), child supervision (6.0 ± 1.0), and parent or guardian job loss (5.6 ± 0.9).
TABLE 2Coronavirus disease (COVID) impact on physical health, mental health, social determinants of health, and caregiver stress
Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes have you seen with the following physical health concerns in the children or adolescents in your practice?”
Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes have you seen with the following mental health concerns in the children or adolescents in your practice?”
Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes have you seen with the following social concerns in the children or adolescents in your practice?”
Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes in parent stress have you seen related to the following stressors in your practice?”
Note. Responses were on a 7-point Likert scale with 1 = a significant decrease and 7 = a significant increase.
a Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes have you seen with the following physical health concerns in the children or adolescents in your practice?”
b Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes have you seen with the following mental health concerns in the children or adolescents in your practice?”
c Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes have you seen with the following social concerns in the children or adolescents in your practice?”
d Each item began with asking subjects, “Since the onset of the COVID pandemic, what changes in parent stress have you seen related to the following stressors in your practice?”
Table 3 summarizes the P-APRNs’ perceptions of parental responses to routine childhood immunizations and the potential use of a COVID-19 vaccine for children and adolescents. Although 77.9% of the responding P-APRNs stated that fewer than 10% of their patients refuse the recommended childhood immunizations, the responses changed when asked about a COVID-19 vaccine. Only 9.6% reported that fewer than 10% of the parents in their practice would refuse the COVID-19 vaccine, with more than 38.3% anticipating that more than 30% of the parents in their practice would refuse the COVID-19 vaccine for children and adolescents. The greatest barriers to COVID-19 vaccination among these families were thought to be misinformation about vaccines from social media (50.5% identified as a significant concern), fear of side effects (50.5%) mistrust of government (36.7%), and fear of vaccine ingredients (34%).
TABLE 3Perceptions toward vaccinations
Variable
0%–5%
6%–10%
11%–15%
16%–20%
21%–25%
26%–30%
> 30%
n
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
n (%)
What percentage of your patient population refuses standard recommended immunizations?
95
48 (50.5)
26 (27.4)
10 (10.5)
5 (5.3)
3 (3.2)
1 (1.1)
2 (2.1)
What percentage of your population do youanticipate will refuse the COVID vaccine?
Subjects were asked, “What do you anticipate to be the greatest barriers to COVID vaccination in your population once the vaccine is approved by the FDA for use in children?”
Misinformation about vaccine obtained fromsocial media sources
97
0 (0.0)
11 (11.3)
37 (38.1)
49 (50.5)
Fear of side effects
97
0 (0.0)
4 (4.1)
44 (45.4)
49 (50.5)
Fear of vaccine ingredients
97
3 (3.1)
23 (23.7)
38 (39.2)
33 (34.0)
Concerns about vaccine mechanism of action
98
9 (9.2)
25 (25.5)
39 (39.8)
25 (25.5)
Mistrust of government
98
2 (2.0)
23 (23.5)
37 (37.8)
36 (36.7)
History of refusal of other immunizations
97
9 (9.3)
32 (33.0)
38 (39.2)
18 (18.6)
Belief that children are lower risk for serious illness
96
8 (8.3)
20 (20.8)
44 (45.8)
24 (25.0)
Lack of access to vaccine
98
50 (51.0)
29 (29.6)
16 (16.3)
3 (3.1)
Other
96
1 (1.0)
0 (0.0)
0 (0.0)
1 (1.0)
Note. Percentages may not sum to 100% owing to rounding.
a Subjects were asked, “What do you anticipate to be the greatest barriers to COVID vaccination in your population once the vaccine is approved by the FDA for use in children?”
The survey included questions about the extent to which these P-APRNs adopted telehealth in their practice owing to COVID-19. Before COVID-19, only 8 of 88 advanced practice registered nurses (9.1%) who responded to this question were using telehealth in their practice. However, 88 of 101 (87.1%) reported using telehealth in their current practice. The Figure 1 shows the percentage of patients seen by telehealth owing to COVID-19 during 2020.
FIGURE 1Use of telehealth during the coronavirus disease 2019 pandemic.
a Surveys completed during June 2021. b Subjects were asked, “What percentage of patients did you see via telehealth as a result of changes related to the COVID pandemic?” for each date interval. c Percentages may not sum to 100% owing to rounding. COVID, coronavirus disease.
The final section of the survey asked if there had been times during COVID-19 when the P-APRNs felt they did not have the necessary resources to provide the desired level of care for their patients and, if yes, what additional resources they needed. Approximately 65% reported a lack of necessary resources (Table 4). The most frequently identified provider-focused resource needed was “resources for addressing social concerns” (76.8%), and the most common patient-focused resource needed was “mental health education materials” (84.9%).
TABLE 4Resources needed during coronavirus disease (COVID) pandemic
Subjects were asked, “Since the onset of the COVID pandemic, have there been times where you felt you did not have the necessary resources to provide the desired level of care for your patients?”
(N = 99)
64
64.7
What provider-focused resources would be helpful/needed?
Educational materials about children's physical health during the pandemic (N = 99)
57
57.6
Resources about supporting healthy families (N = 99)
54
54.6
Other (N = 99)
1
1.0
a Subjects were asked, “Since the onset of the COVID pandemic, have there been times where you felt you did not have the necessary resources to provide the desired level of care for your patients?”
The findings of this study are consistent with recently published studies in the literature that examined the effects of COVID-19 on children and families (
). A unique contribution of this study is that it collectively examined the multifaceted, inter-related effects of the pandemic on the health and well-being of children and families through the lens of care provided by P-APRNs. It is clear that the COVID-19 pandemic has transformed the lives of children, families, and P-APRN practice alike. The scope of these findings reflects both challenges and opportunities moving forward.
The data collected in this study reflect a specific point during the pandemic for children, families and P-APRNs, but these findings present long-lasting implications for children's health. The COVID-19 pandemic has highlighted weaknesses already present in the health system (
). Barriers with access to care and the impact of social determinants of health on children's health outcomes are ongoing concerns but greater today than in the prepandemic health system. The increases in limited access to care and the impact of the pandemic on social determinants of health (food and housing insecurity, parent or guardian job loss, lack of transportation, and loss of insurance coverage) demonstrated in this survey present unique challenges to both care delivery and health outcomes.
The survey respondents reported a decrease in the number of children receiving routine well-child care and immunizations according to the recommended schedule—both mainstays of pediatric primary care. Children not receiving routine primary care are at risk for delay in the recognition of developmental, physical, and mental health concerns. These children also face an increased risk for contracting communicable disease because of the delay in immunization administration. Respondents overwhelmingly reported that the pandemic has had a negative impact on physical activity engagement and proper nutrition for children. These factors may lead to increased rates of chronic conditions including obesity, diabetes, and hypertension. Early identification of these risk factors and/or disease symptoms is valuable in supporting high-quality health outcomes. The negative long-term effects that have been a result of the pandemic are likely to extend beyond those directly related to the severe acute respiratory syndrome coronavirus 2 pathogen.
Most P-APRNs who responded to this survey indicated a significant increase in behavioral concerns, anxiety, depression, and academic concerns directly associated with the COVID-19 pandemic. Although not reflected in most responses, increases in abuse, neglect, suicidal ideation, and risk-taking behavior pose eminent threats to children's health and well-being. These clinical findings have resulted in an increase in referrals for mental health support only to be met with difficulty accessing specialty care services. The respondents also reported that families are experiencing remarkable increases in stress owing to the pandemic in the areas of remote learning/education, social interaction, child supervision, and family relationships. The pandemic has also magnified stress levels related to emerging concerns including screen time and social media use.
The identification of the effects of the pandemic on the mental health and well-being of children and families has been recently identified as a national emergency by the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association (
). Recognition by these organizations of the barriers to access to care, shortages of mental health providers, and increasing numbers of children and teens affected by the pandemic highlights the need for policy and practice changes in the health care system. To improve access to care, P-APRNs must begin to promote and implement models of integrated mental health in primary care settings. P-APRNs are well suited and prepared to provide this integrated care (
). Now, maybe more than ever, there is tremendous opportunity for the dual preparation of PNPs and family nurse practitioners in psychiatric mental health nurse practitioner programs (
). PNPs and family nurse practitioners may also pursue added certification as pediatric mental-health specialists to influence system-level changes that support expanded access to care.
It is widely believed that the development and deployment of the COVID-19 vaccine is a central element in the pandemic response (
). Despite this, the survey respondents indicated an anticipation of greater levels of vaccine hesitancy with the COVID-19 vaccine than that seen in their practices with other traditional immunizations. This finding is congruent with increased parent-reported vaccine hesitancy related to the COVID-19 vaccine when compared with other vaccines (
). Reasons for this P-APRN–anticipated increased hesitancy are perceived to be rooted in misinformation, fear of ingredients or side effects, and mistrust of government. P-APRNs must possess a depth of knowledge related to the COVID-19 vaccine for children to provide families with scientifically based vaccine information and be able to address these perceived objections.
One strategy for improving access to care during the COVID-19 pandemic has been the adoption of telehealth services (
). Although telehealth has been discussed as a future-oriented solution for some barriers with accessing care, this technology-based solution was not widely adopted before the pandemic. The onset of the COVID-19 pandemic presented the impetus for advancing the use of this service (
). Survey responses revealed a sharp increase in the percentage of visits completed using telehealth at the onset of the pandemic with a sustained increase in telehealth use during the time period measured. P-APRNs are uniquely positioned to both continue providing telehealth care and advocating for advances and improvements in telehealth service delivery. Advocacy within organizations for these purposes and within the policy domain for equitable reimbursement and regulations conducive to telehealth care present opportunities for P-APRNs to lead change and support expanded access to care.
There is a significant need for additional resources with nearly two thirds of respondents reporting inadequate resources. The areas of greatest need for provider-focused resources included resources addressing social concerns, strategies for supporting healthy families, clinical practice guidelines, and continuing education about pandemic-related topics. The greatest need for patient-focused resources included mental health education, community resources, and written or electronic resources. The need for these resources presents an opportunity for P-APRNs to fill this void through the creation of necessary resources and to design professional and patient education. P-APRNs must conduct research, measure outcomes, and employ quality improvement measures in practice to generate the data needed to guide best practices in caring for children and families through the remainder of the pandemic and into the postpandemic future. The ability of P-APRNs to create and innovate in the face of unprecedented challenges will benefit children, families, and the profession now and in the future.
The survey data collectively reflect the depth of challenges faced by children, families, and P-APRNs. However, these also begin to outline opportunities for P-APRN–led changes that target both professional and system barriers. The P-APRN professional identity and theoretical underpinnings serve as a foundation for addressing emerging issues in children's health. Relationally focused care provided by P-APRNs can illuminate opportunities for interventions to address pandemic-related challenges. P-APRNs should continue to advocate for policies that support patient access to advanced practice registered nurses–led care and address existing policies that create barriers to P-APRN care.
Limitations
This study attempted to survey a large percentage of the NAPNAP membership, but only a small percentage of members participated. Those who participated were experienced in their field and were from diverse geographic areas. Questions aligned more closely with outpatient practice settings. Experiences of those practicing in acute care settings may differ. Although the authors planned to resend the survey invitation 2 weeks after the initial distribution, NAPNAP policy at the time of distribution limited it to single distribution of the survey thus limiting responses. Furthermore, this survey represented P-APRNs’ perceptions at a defined point in an ongoing pandemic. The survey was distributed at a time in which simultaneous social unrest and natural disasters were also occurring, thus potentially limiting response rates. In the terms of survey contents, the perceptions of P-APRNs were measured rather than measurable practices or outcomes. The authors acknowledge there is potential for confirmation bias in measuring the perceptions of respondents amid persistent media coverage and social dialogue related to the pandemic.
Conclusions
This study collectively reflects the depth of challenges faced by children, families, and P-APRNs owing to the COVID-19 pandemic. The data presented the scope of these challenges through the lens of care provided by P-APRNs. These challenges present unique opportunities for P-APRNs to contribute to improved outcomes for patients, families, and systems. P-APRNs are well prepared to lead change in clinical care, research and translational science, innovation, and advocacy to support better and more equitable outcomes for all.
The authors would like to thank National Association of Pediatric Nurse Practitioners for sending this survey through their electronic mailing list and the National Association of Pediatric Nurse Practitioners membership for providing the data for this study.
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Psychiatric and general health effects of COVID-19 pandemic on children with chronic lung disease and parents’ coping styles.
Provision of pediatric immunization services during the COVID-19 pandemic: An assessment of capacity among pediatric immunization providers participating in the vaccines for children program—United States, May 2020.
MMWR. Morbidity and Mortality Weekly Report.2020; 69: 859-863
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