Transcript MPS Title I School Nurse Program Evaluation

School Nurses’ Roles in
Promoting Population Level
Health in an Urban School
District
TSNO Annual Conference
November, 2012
M. Kathleen Murphy, DNP, RN, FNP-BC
Mary Jo Baisch, PhD, RN
Teresa DuChateau, DNP, RN, PNP-BC
History of
School Nursing
Roots of school nursing in community/public health nursing
• 1900-1930:
– Communicable disease management
– Home visits
• 1940-1960:
– Polio prevention and vaccination
– Vision and hearing screening
– Communication disease management
• 1970-2010
– Communicable disease management
– Medically fragile students, Complex health conditions
– School nurse focus on reducing and eliminating health related
behaviors to learning
1900s School Nurse
• One month demonstration with first US
School Nurse Lina Rogers
• Outcomes
• 9/1902 – 10,567 exclusions
• 9/1903 – 1101 exclusions (89.6%
reduction)
• Most exclusions for minor
illnesses: pediculosis, ringworm,
scabies
Source: Kalisch & Kalisch. (1978). The
Advance of American Nursing
1920 School Nurse—Lice Check!
1930
The School
Nurse as
Superhero
1940
Lice Check and Castor Oil
1950
Mary Dempsey
School Nurse
and
Attendance
Supervisor
Recent
Challenges
•
•
•
•
Value added to educational setting often not
understood
Funding
Wide variability in school nurse to student ratios
across the country
No common language for intervention documentation
Problem
Statement
• The school nurse role has evolved over time
• Variability in understanding the school nurse
role among the education community
• No common and consistent language and
documentation methodology to articulate
school nurse impact
Academic Success
Requires Health
• Children can’t succeed academically if
they are not healthy
• School age children come to school with
many health issues
– Most are generally healthy
• Episodic illness
• Family/emotional issues
– Others come with chronic illnesses
Background
Conceptual Frameworks for SN
Basic assumptions
– Primary goal of schools is education
– Education and health are linked
– School can be a part of health care delivery
systems for children
• CSHP
• Public health nursing
Coordinated School
Health Program
GOALS
• Increase health knowledge,
attitudes, and skills.
• Increase positive health
behaviors and health
outcomes.
• Improve education outcomes.
• Improve social outcomes.
(Washington Office of Public Instruction, 2011)
Wheel of
Public Health
Interventions
(Minnesota Department of Health, 2001)
Coordinated School
Health and the Wheel
FAMILY AND
COMMUNITY
INVOLVEMENT
HEALTH SERVICES
COUNSELING AND
SUPPORT SERVICES
(Minnesota Department of Health, 2001)
Wheel of Public
Health Interventions
• Introduced in 1998 as evidence based
model defining public health nursing as a
population based practice
• Articulates public health nurse practice at
the individual, community and system level
• Broad range of interventions (17)
• Specific categories allow for clearer
articulation of the public health nursing
role
Demonstrating the Value of School Nursing
MPS Title I School Nurse
Program Evaluation
Team members
Mary Jo Baisch, PhD, RN, Sally P. Lundeen, PhD, RN,
Lynn K. Carey, PhD, RN, Frank Stetzer, PhD, Sheryl
Kelber, MS, Betsy Holmes, BA
Program Director: M. Kathleen Murphy, DNP, RN,
FNP-BC
Goals
• Demonstrate the value of school nurses to
their schools and the school system
• Identify key outcomes of school nurse
practice in Milwaukee Public Schools
– Using Appreciate Inquiry (AP) as an evaluation
framework
– Underlying practice framework: CDC Coordinated
School Health Program
Evaluation
Process
1. Review literature to determine
1. School nurse role recommendations
2. Nurse-sensitive outcomes
2. Based on goals, establish evaluation
questions and objectives
3. Identify data available to analyze
4. Identify additional data to be collected
5. Analyze data
6. Report results
Identifying and using
nurse-sensitive interventions and
outcomes helps us to articulate
our practice and its value
ANA has recognized Standard Terminologies
to articulate nursing roles
Literature
Review
To Identify Major Outcome Indicators
Student
• Medication management
• Attendance
• Health improvement and management of chronic health
conditions, e.g. asthma
• Satisfaction
• Nursing practice activities
Parent
• Understanding/management of student health concerns
• Satisfaction with health services
• Participation in school health activities
School Community
• Satisfaction
• Value of the nurse to the school
Mixed Methods
Design
Retrospective Analysis
• Quantitative Data
– Matched cohort design
• Compared Title I and matched MPS elementary schools
–
–
–
–
Matched on race/ethnicity
Free/reduced lunch rates
School location
Enrollment including special education
– Analyzed data in ESIS (Electronic Student Information System)
– Surveyed school staff
• Teachers, principals, clerical staff
• Qualitative Data: Interviewed nurses (18/22)
• University of Wisconsin-Milwaukee IRB Approval
ESIS – Matched Cohort
• School attendance
• Immunization rates
• Student health records
– Completeness
– Accuracy
School Health Program
Annual Reports
• Description of school nurse activities
– # and type of screenings
– # and type of visits from children
• Disposition of referrals to the nurse
Survey of Principals/Assts.,
Teachers, and Clerical Staff
• Time required to address health issues daily
• Satisfaction with the nurse in their schools
Outcomes reported in: Baisch, M.J., Lundeen, S.P., & Murphy, M.K. (2011)
Evidence-based research on the value of school nurses in an urban school
system. Journal of School Health 81(2):78-84.
Interviews
Descriptions of • School nurse role
– How they support children with chronic illness
– How medication management is handled
• Nurses’ contribution to the CSHP in their
schools
• Population-based activities of nurses
Interviews
(n=18)
• Nurses are a critical link between students,
caregivers and school staff.
• Nurses supported the academic mission of the
schools
• Nurses struggled with issues of family poverty
• Nurses supported the CDC Coordinated School
Health Program model in their schools and in some
cases, are leaders this effort
• Continued analysis to link to nursing interventions to
the Public Health Interventionheel (Keller, et al
1998).
Analysis of
Population-based
Interventions
Interviews
Specific
Questions
Population-based interventions
1.
Are school nurse interventions provided at individual,
community, and/or system levels?
2.
What are school nurse interventions (case-finding,
surveillance, advocacy, etc.)?
3.
What is the effect of nursing professional education and
experience on school nurse practice?
4.
Is the Wheel of Public Health Interventions valuable in
articulating the school nurse role in a Comprehensive
Coordinated School Health Model?
Data Collection
Population-based
Interventions
• Coding tool developed to document:
– Nurse’s background
– Nurse quotes
– Intervention levels (individual, community, and/or system)
– Intervention type
• Interventions identified were coded according to:
– Individual, community or system level and could be coded
on more than one level
– In one or more of the 17 intervention categories on the
Wheel of Public Health Interventions
• Investigators compared interviews for inter-rater reliability,
any discrepancies in coding were discussed until consensus
was obtained
Interventions School Nurses
Provided by Levels of Practice*
School nurses directed health services toward
individual students, their school communities
and systems.
– Individual – 997 Interventions
– Community – 695 Interventions
– System – 144 Interventions
*Interventions could have been coded at more than one level.
Interventions by
Level of Practice
Level
Individual
Individual/Community
Individual/Community/System
Individual/System
Community
#
816
122
57
2
471
Community/System
44
System
40
Total
1553
%
52.54
7.9
3.7
0.1
30.3
2.9
2.6
100
Interventions by
Wheel Categories
Case Finding 19%
Collaboration 15%
Health Teaching 11%
Advocacy 7%
Policy Develop. 6%
Referral/Follow up 6%
Case Management 6%
Consultation 5%
Outreach 5%
Surveillance 4%
Delegated Function 3%
Counseling 3%
Community Org. 2%
Coalition Build. 2%
Disease Investigate 2%
N=709
Screening 1%
Social Marketing 1%
0
50
100
150
200
250
300
350
Interventions by Public Health Nurse Experience
Public Health Background
Intervention Level
No Public Health Background
#
%
316
49%
Individual
Individual/Community
61
10%
Individual
Community/System
40
6%
2
<1%
Individual/System
187
29%
Community
Community/System
14
2%
System
22
3%
Individual
Individual/System
Community
Intervention Level
#
%
500
55%
Individual/Community
61
7%
Individual
Community/System
17
2%
0
0%
284
31%
Community/System
31
3%
System
18
2%
Intervention Type
by Nurses’ PH
Experience
Top 5 Interventions – Few differences
•
•
•
•
•
•
Case Finding
Collaboration
Health Teaching
Advocacy
Policy Development and Enforcement
Referral and Follow up/Outreach (only those with no PH
experience)
Identifying and using
nurse-sensitive interventions and
outcomes helps us to articulate
our practice and its value
ANA has recognizes Standard Terminologies
that better articulate our roles
ANA Recognized
Standard Terminologies
Supporting Nursing Practice
Nursing Specific Items from the
Nursing Minimum Data Set
Terminology
NANDA (1992)*
NIC (1992)
NOC (1997)
Nursing
Problem
Nursing
Intervention
Nursing
Outcome
Nursing
Intensity
x
x
x
The above three terminologies must be used together to obtain information about the nursing problem
(diagnosis), intervention and outcome. The below terminologies all have terms for the nursing problem,
intervention, and outcome.
Omaha System (1992)
CCC (HHCC) (1992)
PNDS (1997)
ICNP (2000)
x
x
x
x
x
x
x
x
*Parentheses indicate the year the terminology was first recognized.
x
x
x
x
Recommendations
Integrate public health nursing frameworks into
school nursing orientation
• Ensure nurses are at the table when developing school
wellness plans
• Conduct school health assessments on a regular basis
• Integrate the CMS quality measures into new
research/evaluations of school health programs
• Link interventions with outcomes
Interventions
?
Outcomes
We would like to acknowledge the wonderful nurses
who helped with this study. They support children and
families in a multitude of ways every day and make us
very proud to be nurses.