Integration of the Family Nurse Practitioner in a School Based Setting Michelle Heusi Krystal Morris Spring and Summer 2012

Purpose Statement To determine the need and potential usage of Nurse Practitioners in Kansas public schools To perform a needs assessment by gathering aggregate data through a parent/guardian survey and by an open ended script to be completed by the school nurse In Kansas only 4 school based health centers exist. 3 programs in Wichita, KS, the other in Pittsburg, KS In July 2011, federal grants under the school based health center capital program were given throughout the US. Kansas programs received funding of 1.87 million dollars In Northeast and Southwest Kansas, target populations for this project, there are no school based health centers. Implementing a school based health center staffed by Family Nurse Practitioners would positively impact the health of many students.

School Based Health Care First School Based Nurse Practitioners in the early 1970s Initial focus targeted teen pregnancy in inner city high schools Common goal of “decreasing school absenteeism and missed work days by providing convenient primary and acute care while children are in school” Initial focus targeted preventing teen pregnancy in inner city high schools Focus shifted to all encompassing primary care All encompassing care: Addressed physical and emotional needs with the goal of providing care that is “culturally sensitive, confidential, comfortable and safe” They collaborate with Physicians and Physician’s Assistants Provide services to insured and uninsured populations, some of which would never had the opportunity to receive care if a school based health center was not in place. School based Nurse Practitioners have the fundamental knowledge and background to provide individualized care while taking into consideration growth and developmental stages and health problems of school aged children

Review of Literature Databases CINAHL, SAGE, Cochrane Keywords Nurse Practitioners and Schools School Based Clinics Key Points Nurse Practitioners expand the care given in public schools School Based Clinics with Nurse Practitioners are financially sustainable Legal Issues and Scrutiny surround Nurse Practitioners in School Based Clinics School based health centers have been shown to provide care for the underprivileged and bridge the gap of care for the uninsured. Nurse practitioners provide expanded care in school based clinics when compared to registered nurses. Nurse practitioners have graduate level education that allows them to provide health education, diagnostic abilities and prescriptive abilities. Nurse practitioners are also able to work collaboratively with outside professionals and make referrals when necessary. In reviewing this research, a lack of Kansas based research was identified. With a large poverty level population in Kansas, the development of school based clinics with nurse practitioners in Kansas should be further explored. The need and potential utilization of nurse practitioners as healthcare providers should be examined for this particular state. Not only would Kansas based research potentially help develop these clinics in Kansas, but also help to improve the recent research of this kind in the Midwest and United States as a whole.

The Science of Unitary Human Beings Martha Rogers The Science of Unitary Human Beings The Science of Unitary Human Beings was used as the theoretical framework for this project because this theory discusses how environmental energy effects the energy of the human being. This project is based on how the energy of public school environment effects the child. Doctor Martha Rogers developed the Science of Unitary Human Beings which defines human beings as multidimensional energy fields that follow the principles of homeodynamics; resonancy, helicy, and integrality (Barrett, 1990). Students enrolled in elementary school spend the majority of their waking hours in school where their “person” is influenced through education, social interaction with peers and educators, and expansion of their environment outside their immediate family unit and structural home. Rogers’ view of disease and illness is not one that describes these processes as negative but rather as expressions of life Nurse practitioners facilitate the return of humans to tolerable energy states and optimize their ability to remain part of the environment. By placing nurse practitioners in public schools, the energy of the healthcare provider can be transferred to public school students and aid them by guiding them through the processes of illnes

Project Objectives Survey parents/guardians of Tecumseh South and Jennie Wilson Elementary students Perform written interviews of the nurses at both schools regarding their role and expectations of their job Analyze data results from the surveys to determine the needs for a Nurse Practitioner in the school based setting Implementing a school based health center would require years of research work and money Development of a 10 question survey/needs assessment to investigate feasibility of incorporating a Nurse Practitioner into the school setting. Surveys will assess student’s current access to health care, potential usage of school based nurse practitioners and parents concerns regarding NPs in the school setting. Survey Data will then be assessed and compared. The written interview/script will be designed to assess the nurse’s current roles, responsibilities, and expectations. This data will be assessed and compared using rich description. The two populations will be compared and differences in needs will be identified based on the location of schools, and differences in socioeconomic statuses that can be key components of access to health care.

Tecumseh South Elementary USD 450: Shawnee Heights School District in Topeka, KS 2011-2012 enrollment 468 students Kindergarten – 6th Grade Principal: Mr. Scott Dial -Located on the south east side of Shawnee County

Tecumseh South Demographics Ksde.org

Jennie Wilson Elementary USD 457: Garden City, KS 2011-2012 enrollment 215 students Kindergarten- 4th grade Principal: Ms. Melinda Stewart Combined, these schools have 683 students. With the large volumes of students, school nurses’ demands are great. The implementation of a nurse practitioner could help fill the gap in healthcare, as it would be feasible to address a wide array of health concerns without ever being absent from school.

Jennie Wilson Demographics Kdse.org

Tecumseh South Implementation Online Survey sent to parents through email Email sent to 480 parents/guardians Survey emailed on April 16, 2012 and closed on April 30, 2012 Say first before anything else on slide: Washburn IRB approval took place on April 11, 2012. After discussing this project with Mr. Dial, it was determined that best parental response would happen through an online survey. Most parental communication occurs electronically at this particular school. Online site Survey Monkey was used to make the 10 question survey to be filled out by Tecumseh south elementary. Link to the survey then sent to Mr. Dial where he distributed it to 480 parental emails that he had built into a mass group.

Jennie Wilson Implementation Paper surveys sent home with students with consent form and envelope to use to return the survey to school 220 Parents Surveyed, 1/3 of surveys printed in Spanish Survey distributed on April 26, 2012, picked up from school on May 10, 2012 After discussing project with Ms. Stewart, it was determined that the best response for this parental population would occur by sending home paper surveys to be filled out and returned to the school. She said that only 1/3 of their parents have email addresses utilized by the school. 1/3 of the parental population speak Spanish as a primary language. In order to accommodate the needs of the parents/guardians participating, the survey was translated into Spanish utilizing a district language interpreter. -In order to maintain confidentiality, we asked that parents return the surveys in an unmarked envelope that was provided to them

Data Analysis Tecumseh South Jennie Wilson 72 English surveys returned Tecumseh South: 480 total surveys Jennie Wilson : 220 total surveys 72 English surveys returned 15 Spanish surveys returned 72 English surveys returned 15 Spanish surveys returned

When looking at trends, most students tend to miss 1-2 days of school on average, with a respiratory illness being the main cause of the absence

Jennie Wilson parents tend to miss less work than Tecumseh South parents due to their child being ill

Tecumseh south parents had more privately insured children than Jennie Wilson.

Both schools utilize a physician/doctor rather than another type of healthcare provider.

The majority of parents from both schools responded that they would be willing to allow their child to see a nurse practitioner if one was available in their school.

Tecumseh parents responded that they would allow their children to be seen most commonly for sick visits if a waiver were signed Jennie Wilson responded that they would most commonly allow visits for well visits.

Comments from Tecumseh South Parents “What an asset nurse practitioner could be inside the school system. So often it is such a natural environment to identify needs, academic-social emotional-socioeconomic-personal-peer...not all families have access to the services they need but all children have access to a public education. Collaboration between school counselors/social workers, educators, and trained and qualified medical providers comprehensively assesses the whole person.” “I would feel comfortable with having a NP at the school if the fees are included with the enrollment or at no cost to the parents. Also, the NP at the school would be in addition to and not replacing the family Doctor.” “This survey does not really pertain to my child in that she has health insurance readily available to her. If she did not, then I believe a school-based health service would be great.”   “As a parent and also staff working in the school health room I would like to have an NP here for minor issues ie. dx congestion, strep tests, look at rashes. I would still have a pediatrician to see my child for yearly check ups and more serious issues.” “I think this is a great idea. My son has reactive airways/asthma and he is always in the nurses office. Sometimes I don't think he needs his inhaler, but he gets it anyway. Having a NP in the school who could keep an eye on chronic conditions would be great in addition to being able to check ears if needed... I've made many a trip to our doctor to have ears checked only to find there was no infection...” “Received concussion at school would have been nice to have her checked out at school and receive the follow up visits at school. I understand the xray may be hospital bound but follow ups at school would be great.”

Comments from Jennie Wilson Parents “Nurse practitioners in schools are a great assist, especially for families that aren’t able to afford to take their kids to the doctor. “It is nice to have medical services offered in a convenient fashion, however a parent should never be told which medical services are required for their child.” “I think it would be of great assistance for those children without access to health care.” “If the ARNP could see my child year around and work with the pediatrician, I might let them treat my child’s asthma and other chronic issues.” “Although a health clinic at the school would be very convenient, I feel it is not appropriate. I sent my children to school for education not to be treated for medical needs. Would clinic be available to anyone, or just students? I like having my children see the same doctor from birth through adolescence. It seems counterproductive to switch when my children are in elementary school and again when they leave elementary school. Garden City, KS could definitely use more access to health care. It seems most places I call are so booked they are not accepting new patients or services do not exist and you are forced to drive four our more hours to find a physician. I feel the health of our children is our responsibility as parents, not the schools.” “I would be interested in services for ADHD education and home solutions.”

School Nurse Script   How many hours are you present in the school weekly? When you aren’t present in the school, who is responsible for the healthcare of the students? In your own words, what do you consider your job description? As a school nurse, what types of chronic conditions do you see among your student population? Do you know specific numbers of students with each condition? What are the most common reasons that students at your school come see you? On an average week, approximately how many students do not come to school because of illness? On an average week, approximately how many students leave school early due to illness? Do you have specific criteria for sending students home early from school? Do you feel that your students have primary care providers outside of school? Where do you think they get their primary care at? We thought that an important part of performing a needs assessment is to look at the types of services that the school nurse currently cares for. This interview/script was emailed to both school nurses on April 12, 2012 and returned back via email. Both Nurses are Registered Nurses who spend 40 hours a week between 2 elementary schools. Both nurses travel back and forth between schools and are available by phone when away from the school. Tecumseh South has an LPN and health aide at each school that the school Nurse supervise When asked how they would describe their job description there were many common points. For example,. Both perform vision and hearing screenings, height and weight screenings, make sure all immunizations are up to date, provide education to teachers about various health issues, contact parents through phone calls and letters to let them know the status of screenings. They both provide health promotion activities and education whenever possible, for example during theme days, health week, etc At Tecumseh the school RN coordinates care for 6 insulin dependent type 1 diabetics, 9 type 2 diabetics, 1 child with Mitochondrial disease, 1 with sickle cell anemia, 1 with hemophilia, 1 with leukemia, 1 with spinal tumor, 1 with cerebral palsey, and around 100 children with asthma. Appx 200/1000 total students have ADHD, ADD or a behavioral disorder. They see around 125 students daily for first aid, medication delivery including insulin, blood sugar checks. Care for students with asthma flare ups, tube feedings, screenings, etc. A daily log of visits is kept and put into a computer system. The number of visits per school per month. Approximately 25 students per day miss school. Approximately 2 per day leave early due to illness. She estimates that approximately 75% of the students have insurance. Others rely on emergency rooms or county health department The Jennie Wilson school nurse has around 10 asthmatics per school, 6 with severe food allergies, 8 with known ADD/ADHD, 3 students with tick disorders, no diabetics or serious seizure disorders, although the numbers and variations change with each school year. An average of 20 kids per week between both schools she works at miss school due to illness, while an average of 8-10 kids go home a week due to illness She estimates that 50% of students have insurance. Others supplement with the ER or health department. Both have similar criteria for sending a child home from school: Fever above 100 degrees, vomitting, unexplained rash, head lice, serious injury, paleness

Dissemination of Plan Project objectives were met: Aggregate data was gathered regarding current health care, potential usage, and concerns about Nurse Practitioners in the school setting Description of roles and expectations of the Nurse at both schools was explored Data synthesis and comparison was made with data from each school This research represents the potential for a beginning trend in Kansas Schools. The information will be made available to the respective school systems. This project represents the potential for change in both public school health and utilization of nurse practitioners as independent providers. Nurse Practitioners in school based settings in Kansas could offer easily accessible services to students without having to leave school. This would help reduce the number days missed from school and work for both students and parents.