Measuring nurse sensitive outcomes of school nursing practice

1. Measuring nurse sensitive outcomes of school nursing practice Martha Dewey Bergren, DNS RN NASN Director of Research

2. Martha Dewey Bergren DNS RN NCSN FNASN FASHA mbergren@nasn.org www.nasn.org National Association of School Nurses Director of Research

3. 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

4. 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

5. Student: School Nurse Ratios • Wide disparities • Between states • Within states • Mandated ratios • 19 states have varying mandates • 4 states fund the mandated ratio

6. Student to School Nurse ratio 750:1? 1340 + 150 + 10 + 2 = 750 225 125 1 1.66 + .66 + .08 + 2 = 5.28 nurses

7. Student: School Nurse Ratios • What outcomes: • Number of staff • Credentials of staff • Under what conditions

8. Student to School Nurse ratio ?????? 1340 + 150 + 10 + 2 = 750 225 125 1 1.66 + .66 + .08 + 2 = 2 RNs 1 P/T LPN 1 clerk

9. Many influences on outcomes…. • Poverty • School climate • School system leadership • Parenting • Breadth / quality community health services • and much more…..

10. 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

11. 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

12. Critical Indicator • Structure • Process • Outcome

13. 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

14. Process • Process indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction

15. 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"

16. NDNQI – Sensitive nursing outcomes • Falls • Decubitus – Bed sores • Infected Central Lines • Failure to Rescue • Readmissions • Pain assessment

17. 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

18. AHRQ Prevention Quality Indicators Adult ambulatory care / hospital admission rates • Diabetes short term complications • Diabetes long term complications • Low birth weight • Perforated appendix

19. AHRQPediatric Quality Indicators • Asthma admissions • Diabetes short term complications • Perforated appendix • Urinary tract infection admissions

20. 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

21. School nurse sensitive outcomes 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 Safe environment Community outreach enhances student health Cost effective Parent, teacher, administration, staff satisfaction (Selekman & Guilday, 2003)

22. School nurse sensitive outcomes Allen 2002 FT nurse -> decrease in children sent home Bonny et al 2000 More school nurse visits = less school connectedness Ferson et al 1995 More immunizations if nurse called Fryer & Igoe 1995 r = .486 wellbeing nurse: student ratio r = .292 teen moms nurse: student ratio r = .412 graduation rate nurse: student ratio Kimel 1996 handwashing = 2 month sustained absentee decrease Larsson & Carlson Intervention = decreased headaches Persaud et al 1996 Skills training = decreased anxiety Werch et al 1996 Intervention program = decreased heavy EtOH use (Maughan, 2003)

23. 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

24. 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, 3rd party Medicaid Phone / Fax /Location Structure

25. Hand washing classes UAP Training UAP Supervision AED Immunization practices Medication practices SCHIP Vision Hearing Screening F/U Process • Assessment • Plan • Care plans • Asthma Action Plans • Food Allergy Action Plans • Intervene • Evaluate • Communicate

26. Outcome • Health care costs • Instruction time • Test scores – achievement • Absenteeism • Early dismissal • Attendance • 911 • (Failure to rescue) • Deaths • Serendipitous case finding • Emergency room utilization / Hospitalizations

27. Outcome • Specific health and education outcomes • Vision follow-up • Smoking • Seatbelts • etc •  Medications missed dose wrong dose • Graduation rates • Immunization rate • Inclusion / exclusion • Health office visits • Pregnancy • Injury

28. Outcome • Obesity • Nutrition – health foods • Physical activity • Dental health • Insurance • Medical home • Immunization rate • Inclusion / exclusion • Increased quality of life • Improved behavior • Wellbeing • Depression • Connectedness

29. Outcome • Parent lost time from work •  Revenue • Medicaid • Grants • 3rd party • Policy changes • Parent communication • Parent involvement • Parent satisfaction • Staff communication • Staff satisfaction • Community partnerships

30. Outcome • Increased planned care • Increased AAPlans • Increased FAAPlans • Staff preparedness • Anaphylaxsis response • Asthma response • Safer school environment • IAQ • Bullying • Hazing • Increased case managed students

31. Development of nurse sensitive indicators

32. 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

33. 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

34. 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

35. Evaluation Criteria • Importance • Scientific acceptability • Usability • Feasibility

36. Evaluation criteria • Importance: Quality: safety, timeliness, effectiveness, efficiency, equity, patient-centeredness 1a. High impact1b. Performance gap (variation among providers, overall poor)1c. Process-outcome link supported by evidence

37. Evaluation criteria • Scientific acceptability of the measure Extent to which the measure, as specified, produces consistent, reliable and valid results

38. Evaluation criteria • Scientific acceptability 2a. Precisely specified2b. Reliability & Validity tested2c. Significant & practical/clinical meaningful differences in performance. 2d. Multiple data sources – comparable results2e. Disparities can be identified

39. Evaluation criteria • Usability: Intended audiences (consumers, purchasers, providers, policy makers) understand the measure & can use it in decision making3a. Meaningful, understandable, useful for both public reporting & quality improvement3b. In sync with other endorsed measures3c. Distinctive or adds value to endorsed measures

40. Evaluation criteria • Feasibility: Data available, retrievable without undue burden, & can be implemented to measure performance4a.Clinical data generated during care 4b. Electronic source4c. Susceptible to inaccuracies, errors, unintended consequences 4e. Data collection strategy

41. Evaluation criteria • Attendance –OT3-032-10: Number of school days children miss due to illness • Importance • Scientific acceptability • Usability • Feasibility

42. 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

43. 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

44. NASN Goal: 3 stages • Stage 1 • Get school nurses to collect these measures • Uniform language to aggregate • Electronic data systems

45. NASN Goal: 3 stages • 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

46. NASN Goal: 3 stages • Stage 3 • Become incorporated into NDNQI data collection • Now at 1500 hospitals collecting data at the unit level