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 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? = = 5.28 nurses

Student: School Nurse Ratios  What outcomes:  Number of staff  Credentials of staff  Under what conditions

Student to School Nurse ratio ?????? = = 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

 OT : Children who have problems obtaining referrals when needed  OT : (a) Children who did not receive care coordination services when needed  OT : (b) Children who did not receive satisfactory communication when needed NQF outcome measures

School nurse sensitive outcomes 1.Increased time in classroom 2.Received first aid, emergency services, acute services 3. Competent health related interventions 4.Chronic health conditions met 5.Wellness promotion disease prevention 6.Appropriate referrals 7.Safe environment 8.Community outreach enhances student health 9.Cost effective 10.Parent, teacher, administration, staff satisfaction (Selekman & Guilday, 2003)

1.Allen 2002 FT nurse -> decrease in children sent home 2.Bonny et al 2000More school nurse visits = less school connectedness 3.Ferson et al 1995More immunizations if nurse called 4.Fryer & Igoe 1995r =.486 wellbeing nurse: student ratio r =.292 teen moms nurse: student ratio r =.412 graduation rate nurse: student ratio 5.Kimel 1996handwashing = 2 month sustained absentee decrease 6.Larsson & CarlsonIntervention = decreased headaches 7.Persaud et al 1996Skills training = decreased anxiety 8.Werch et al 1996Intervention program = decreased heavy EtOH use School nurse sensitive outcomes (Maughan, 2003)

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

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 Outcome

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

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 –OT : Number of school days children miss due to illness  Importance  Scientific acceptability  Usability  Feasibility Evaluation criteria

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 Stage 1 Get school nurses to collect these measures Uniform language to aggregate Electronic data systems

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

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