M. Kathleen Murphy, DNP, RN, FNP-BC Mary Jo Baisch, PhD, RN Teresa DuChateau, DNP, RN, PNP-BC

1. School Nurses’ Roles in Promoting Population Level Health in an Urban School District M. Kathleen Murphy, DNP, RN, FNP-BC Mary Jo Baisch, PhD, RNTeresa DuChateau, DNP, RN, PNP-BC TSNO Annual Conference November, 2012

2. 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

3. 1900s School Nurse • One monthdemonstrationwith first US School Nurse Lina Rogers • Outcomes • 9/1902 – 10,567 exclusions • 9/1903 – 1101 exclusions (89.6% reduction) • Most exclusions for minorillnesses: pediculosis, ringworm, scabies • Source: Kalisch & Kalisch. (1978). The Advance of American Nursing

4. 1920 School Nurse—Lice Check!

5. 1930 The School Nurse as Superhero

6. 1940 Lice Check and Castor Oil

7. 1950Mary DempseySchool Nurse and Attendance Supervisor

8. 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

9. 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

10. 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

11. Background Conceptual Frameworks for SN Basic assumptions • Primary goal of schoolsiseducation • Education and health are linked • Schoolcanbe a part of health care deliverysystems for children • CSHP • Public health nursing

12. GOALS Increase health knowledge, attitudes, and skills. Increase positive health behaviors and health outcomes. Improve education outcomes. Improve social outcomes. Coordinated School Health Program (Washington Office of Public Instruction, 2011)

13. Wheel of Public Health Interventions (Minnesota Department of Health, 2001)

14. Coordinated School Health and the Wheel Family and Community Involvement Health Services Counseling and Support Services (Minnesota Department of Health, 2001)

15. 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

16. Demonstrating the Value of School NursingMPS 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

17. 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

18. Evaluation Process • Review literature to determine • School nurse role recommendations • Nurse-sensitive outcomes • Based on goals, establish evaluation questions and objectives • Identify data available to analyze • Identify additional data to be collected • Analyze data • Report results

19. 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

20. LiteratureReview To Identify Major Outcome Indicators Student • Medication management • Attendance • Healthimprovement and management of chronichealth conditions, e.g. asthma • Satisfaction • Nursing practice activities Parent • Understanding/management of studenthealthconcerns • Satisfaction withhealth services • Participation in schoolhealthactivities SchoolCommunity • Satisfaction • Value of the nurse to the school

21. MixedMethods 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

22. ESIS – Matched Cohort • School attendance • Immunization rates • Student health records • Completeness • Accuracy

23. 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

24. Survey of Principals/Assts., Teachers, and Clerical Staff • Time required to addresshealth issues daily • Satisfaction with the nurse in theirschools 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.

25. Interviews Descriptions of - • School nurse role • How they support childrenwithchronicillness • How medication management ishandled • Nurses’ contribution to the CSHP in theirschools • Population-basedactivities of nurses

26. 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).

27. Analysis of Population-based Interventions Interviews

28. Specific Questions Population-based interventions • Are school nurse interventions provided at individual, community, and/or system levels? • What are school nurse interventions (case-finding, surveillance, advocacy, etc.)? • What is the effect of nursing professional education and experience on school nurse practice? • Is the Wheel of Public Health Interventions valuable in articulating the school nurse role in a Comprehensive Coordinated School Health Model?

29. 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

30. 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.

31. Interventions by Level of Practice

32. Interventions by Wheel Categories

33. Interventions by Public Health Nurse Experience Public Health Background No Public Health Background

34. Intervention Typeby 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)

35. 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

36. ANA Recognized Standard Terminologies Supporting Nursing Practice *Parentheses indicate the year the terminology was first recognized.

37. 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 ?

38. 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.