Measuring nurse sensitive outcomes of school nursing practice Martha Dewey Bergren, DNS RN NASN Director of Research.
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Measuring nurse sensitive outcomes of school nursing practice
Martha Dewey Bergren, DNS RN NASN Director of Research
Martha Dewey Bergren DNS RN NCSN FNASN FASHA [email protected] www.nasn.org National Association of School Nurses Director of Researc h
NASN Research Priority
Identify school nurse delivery models (school nurse caseloads, credentials, experience, etc.) necessary for quality nursing care School nurses must identify and measure outcomes expected as a result of quality school nursing care
Recommended Caseloads
NASN Case Load Position Statement 1:750 for well students 1:225 for chronic conditions 1:125 for complex conditions 1:1 as needed for multiple disabilities
Student: School Nurse Ratios
Wide disparities Between states Within states Mandated ratios 19 states have varying mandates 4 states fund the mandated ratio
Student to School Nurse ratio 750:1?
1340 + 150 750 225 + 10 + 2 = 125 1 1.66 + .66 + .08 + 2 = 5.28 nurses
Student: School Nurse Ratios
What outcomes: Number of staff Credentials of staff Under what conditions
Student to School Nurse ratio ??????
1340 + 150 750 225 + 10 + 2 = 125 1 1.66 + .66 + .08 + 2 = 2 RNs 1 P/T LPN 1 clerk
Many influences on outcomes….
Poverty School climate School system leadership Parenting Breadth / quality community health services and much more…..
School nurse sensitive outcomes
Identify factors that measure the impact of nursing care over and above other factors Outcomes “sensitive” enough to distinguish between the effects of family and community and the effects of the quality and the quantity school nursing interventions on child, family and school community outcomes
Definition
Nursing-sensitive indicators identify structures of care & care processes, both of which influence care outcomes Nursing-sensitive indicators are distinct and specific to nursing, and differ from medical indicators of care quality Nursing outcome indicators are those outcomes most influenced by nursing care
Critical Indicator • Structure • Process • Outcome
Structure
The structure of nursing care is indicated by the supply of nursing staff, the skill level of the nursing staff, and the education/certification of nursing staff
Process
Process indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction
Nurse sensitive outcomes
Outcomes that improve with a greater quantity or quality of nursing care Some outcomes are more highly related to other factors and are not considered "nursing sensitive"
NDNQI – Sensitive nursing outcomes
Falls Decubitus – Bed sores Infected Central Lines Failure to Rescue Readmissions Pain assessment
NDNQI impact
Researchers studying nurse staffing on acute adult medical surgical units determined that nurses responsible for fewer patients perform significantly better on these measures than nurses with heavier caseloads
AHRQ Prevention Quality Indicators
Adult ambulatory care / hospital admission rates Diabetes short term complications Diabetes long term complications Low birth weight Perforated appendix
AHRQ Pediatric Quality Indicators
Asthma admissions Diabetes short term complications Perforated appendix Urinary tract infection admissions
NQF outcome measures
OT3-036-10: Children who have problems obtaining referrals when needed OT3-038-10: (a) Children who did not receive care coordination services when needed OT3-038-10: (b) Children who did not receive satisfactory communication when needed
School nurse sensitive outcomes
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Increased time in classroom Received first aid, emergency services, acute services Competent health related interventions Chronic health conditions met Wellness promotion disease prevention Appropriate referrals 7.
8.
Safe environment Community outreach enhances student health 9.
Cost effective 10.
Parent, teacher, administration, staff satisfaction (Selekman & Guilday, 2003)
School nurse sensitive outcomes
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Allen 2002 Bonny et al 2000 Ferson et al 1995 Fryer & Igoe 1995 5.
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Kimel 1996 Larsson & Carlson Persaud et al 1996 Werch et al 1996 FT nurse -> decrease in children sent home More school nurse visits = less school connectedness More immunizations if nurse called r = .486 wellbeing r = .292 teen moms r = .412 graduation rate nurse: student ratio nurse: student ratio nurse: student ratio handwashing = 2 month sustained absentee decrease Intervention = decreased headaches Skills training = decreased anxiety Intervention program = decreased heavy EtOH use (Maughan, 2003)
Structure
• • • • • • • • • • LPN RN BSN Bachelors MSN masters doctorate Counseling Leadership /Coordinator Number of schools Policy State standards Mandated services Nurse practice act Practice guidelines P & P – national state local • • • • • • • • • Documentation system Percent time/hours per day/Days per year Clerical assistance Prep time State consultant District size Uninsured poverty Mobility rate Density
Structure
• • • • • • • • Income Graduation rate Disabilities Pregnancy Substance abuse Acute community, SBHC, providers EMS response time Social worker • • • • • Geography Distance lakes mountains highways weather Rural urban suburban Transportation, public health system, acute, HMO, 3 rd party Medicaid Phone / Fax /Location
Process
• Assessment • Plan • • Care plans Asthma Action Plans • Food Allergy Action Plans • Intervene • Evaluate • Communicate • • • • • Hand washing classes UAP Training UAP Supervision AED Immunization practices • • • Medication practices SCHIP Vision Hearing Screening F/U
Outcome
• 911 • (Failure to rescue) • Deaths • Serendipitous case finding • Emergency room utilization / Hospitalizations • Health care costs • Instruction time • Test scores – achievement • Absenteeism • Early dismissal • Attendance
Outcome
• Graduation rates • Immunization rate • Inclusion / exclusion • Health office visits • Pregnancy • Injury • • • Specific health and education outcomes Vision follow-up Smoking • Seatbelts • etc • Medications missed dose wrong dose
Outcome
• Increased quality of life • Improved behavior • Wellbeing • Depression • Connectedness • Obesity • Nutrition – health foods • Physical activity • Dental health • Insurance • Medical home • Immunization rate • Inclusion / exclusion
Outcome
• Parent communication • Parent involvement • Parent satisfaction • Staff communication • Staff satisfaction • Community partnerships • • • Parent lost time from work Revenue Medicaid • Grants • 3 rd party • Policy changes
Outcome
• • • Safer school environment IAQ Bullying • Hazing • Increased case managed students • Increased planned care • Increased AAPlans • Increased FAAPlans • Staff preparedness • Anaphylaxsis response • Asthma response
DEVELOPMENT OF NURSE SENSITIVE INDICATORS
Development:
1. Review of the literature, determine which indicators are nursing sensitive 2. Discuss with content experts to identify measurement issues & relevant information that should be collected to support analysis, for example, poverty 3. Develop a plan for data collection & reports
Development:
4. Solicit comments on feasibility of proposed data collection plan & utility of indicators 5. Conduct pilot studies with volunteer school systems to test data collection & forms 6. Revise plan for data collection and reports
Development:
7. Develop web data collection system, including, data entry screens & tutorial 8. Announce availability of an indicator to test 9. Volunteer nurses take tutorial, begin data collection & submission 10. Conduct data analysis & development of quarterly reports
Evaluation Criteria
Importance Scientific acceptability Usability Feasibility
Evaluation criteria
1.
Importance: Quality: safety, timeliness, effectiveness, efficiency, equity, patient-centeredness 1a. High impact 1b. Performance gap (variation among providers, overall poor) 1c. Process-outcome link supported by evidence
Evaluation criteria
2.
Scientific acceptability of the measure Extent to which the measure, as specified, produces consistent, reliable and valid results
Evaluation criteria
Scientific acceptability 2a. Precisely specified 2b. Reliability & Validity tested 2c. Significant & practical/clinical meaningful differences in performance. 2d. Multiple data sources – comparable results 2e. Disparities can be identified
Evaluation criteria
3.
Usability: Intended audiences (consumers, purchasers, providers, policy makers) understand the measure & can use it in decision making 3a. Meaningful, understandable, useful for both public reporting & quality improvement 3b. In sync with other endorsed measures 3c. Distinctive or adds value to endorsed measures
Evaluation criteria
4.
Feasibility: Data available, retrievable without undue burden, & can be implemented to measure performance 4a.Clinical data generated during care 4b. Electronic source 4c. Susceptible to inaccuracies, errors, unintended consequences 4e. Data collection strategy
Evaluation criteria
Attendance –OT3-032-10: Number of school days children miss due to illness Importance Scientific acceptability Usability Feasibility
Who are the players?
AHRQ – Agency of Health Research & Quality NQF - National Quality Forum NDNQI - National Database of Nursing Quality Indicators UCLA School Mental Health Project NASSNC – State SN Consultants Children’s National Medical Center
Partnerships
School Nurse Research networks – Massachusetts, Alabama DC, Delaware, North Carolina Universities NASN School Nurse Educator Consortia Center for Disease Control and Prevention Non Governmental Agencies
NASN Goal: 3 stages
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Stage 1
• Get school nurses to collect these measures • Uniform language to aggregate • Electronic data systems
NASN Goal: 3 stages
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Stage 2
• Incentivize researchers to study school nurse ratios and quality impact on outcomes • Identify the best measures • Determine nurses responsible for fewer students in fewer locations perform significantly better than nurses with heavier caseloads
NASN Goal: 3 stages
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Stage 3
• Become incorporated into NDNQI data collection • Now at 1500 hospitals collecting data at the unit level