CNA Webinar Series: Progress in Practice Creating a strong nursing safety net in our schools Elizabeth M. Saewyc, PhD, RN, FSAHM, FCAHS Professor of Nursing, University of British Columbia School of Nursing
The information and views in this webinar are those of the presenter(s) and do not necessarily reflect the official opinion of the Canadian Nurses Association.
Josette Roussel, RN, MSc., M.Ed. Senior Nurse Advisor Canadian Nurses Association
Elizabeth M. Saewyc, PhD, RN, FSAHM, FCAHS Professor University of British Columbia School of Nursing
Outline The role of school nurses in Western Canada: Historical context, recent changes Research/practice evidence re: roles of school nurses A model for public health nurse interventions applied to school health Developing and using a tracking tool to document practice Results of our mixed methods study on schools responses to the increased presence of school nurses.
Public health vs. primary care? School nurses in many countries historically have been viewed as providing individual clinical care: First aid and emergency care Initial assessment of illness at school Medications Treatments for children with special needs (catheterization, suctioning, nebulizers, NG tube feeds)
Public health vs. primary care? In Canada, New Zealand, Wales, Hong Kong, parts of U.S., public health nurses in schools Health promotion and health care for individual students AND groups AND whole school community Population-focused, full PHN scope of practice A focus on health promotion, primary and secondary prevention, more than treatment
Locating the school nurse role Relatively independent practice Some models have one nurse per school Others have multiple schools per nurse An office within the school, sometimes including a room with bed(s) for ill/injured students or Located within a primary health care clinic embedded in the school with interdisciplinary team
Recommended staffing levels New Zealand: 10 hours nurse staffing per 100 students in schools optimal for sexual health outcomes [Denny et al., AJPH 2012] Hong Kong & U.K.: 1 full-time nurse per school ( 1200) National Association of School Nurses (U.S.): 1 full-time nurse per 750 students, 1:250 with special health needs School-based health centres/clinics (U.S.): at least 1 full-time NP or RN with additional part-time providers Europe (37 countries): Ranges 1:400 up to 1:1,500 for school nurses; 1:1,000 to 1:10,000 for school doctors European countries with upper-end ratios report significant need for better staffing levels (80% say currently too high)
Recommended vs. actual staffing New Zealand: <25% schools actually achieved Hong Kong, U.K.: 1 nurse per school achieved Europe: generally some shortages, 30% severe U.S.: 1:750 students, some states mandate, most do not; where not required, varies widely Canada (esp. B.C.): Varies widely, often 1 nurse for multiple schools, less than 1 day per week per school
North Shore Vancouver PHNs In the 1990s and 2000s, PHNs mostly out of schools in Vancouver, except for immunizations and some health teaching In 2012, B.C. Ministry of Health introduced comprehensive school health approach In September 2012, North Shore PHNs started office hours 3 hours per week per school Partnered with UBC for identifying practice models and evaluating the service
Identifying the scope of school nursing practice UBC school of nursing had adopted the Minnesota PHN wheel of interventions for education North Shore requested training and ongoing consultation Developed a tool to track practices Evaluation with schools: their view of the shift to more nursing presence in schools
Wheel of PHN interventions Minnesota Dept. of Health, 2001
Surveillance Monitoring for health problems within a school setting, or outbreaks of disease Example 1: Tracking levels of chronic conditions like asthma or peanut allergies that might have school environment exacerbation Example 2: Monitoring increase in absences due to flu-like illness, or other infectious diseases, reports to public health system Example 3: Helps administer the regional or national youth health survey in classes
Health teaching One of the most common roles of school nurses, at the individual and group level Example 1: Teaching students oral health Example 2: Session for teachers and staff on recognizing and responding to anaphylaxis Example 3: Growth and development classes for 10-12-year-olds. Example 4: Teaching children and youth with diabetes healthy nutritional options Example 5: Teaching the entire school strategies for coping with stress
Outreach Identifying and engaging with youth or families at risk for particular health issues Example 1: Contacting students who have asthma or obesity to set up a group to foster physical activity Example 2: Sending home notices to parents about a teen growth and development talk the nurse will offer to parents Example 3: Organizing a health fair at the school to do blood pressure screenings of parents, other kinds of health teaching, connecting to health-care services
Community organizing Not at the individual level; different from coalition-building in that individuals as well as organizations can be part Example 1: Setting up and facilitating the comprehensive school health committee Example 2: Helping create a youth health council within the school to address health priorities identified by youth Example 3: Working with students, the school staff, parents, and vendors in changing snack vending machines
Advocacy Helping those who have difficulty speaking for themselves Example 1: Advocating for adaptive services for a student with disabilities Example 2: Representing a student group in bringing their health-related concerns to the school administration Example 3: After several unsuccessful referrals to mental health care, long waiting lists, advocating for an increase in mental health staffing allocated to serving children & youth in the region
Policy development/enforcement Less of a role in policy enforcement, other than notification of reportable disease, more on policy development Example 1: Working with the school health committee to develop an anti-smoking policy Example 2: With other school nurses, developing policy recommendations related to their role in schools (staffing, hours, tasks) Example 3: Contributing local data and youth feedback for proposed national health policies related to school health
Developing the tracking tool Created with the frontline PHNs Based on the wheel matching colours to interventions Links to pages describing the interventions on workplace intranet
Feedback and tweaks on the tracking tool Slight changes each half year, with training for consistency. Tracking tool data extracted for each nurse Summary reports for the whole unit, individual reports for each participating nurse
Wheel of intervention tracking tool Observation #1: The PHNs engaged with a LOT of people! September 2012-June 2013: 22,693 people 1 person up to 800 people in each encounter Most practice was groups of 10-30 youth at a time No differences between nurses, avg. 20-30 Interventions that reached the most people: Health education: 15,000+ Certified practice, advocacy, & consultation: all 7,000+
Tracking tool results Increasing number of activities and people reached with subsequent years PHNs used the full scope of the wheel in schools More time is spent in schools than just office hours and immunization
Interventions done by all PHNs September 2013 to June 2014 PHN Wheel Interventions Outreach 5% Surveillance 4% EventInvestigate 1% Policy 3% SocialMarket 4% Advocacy 10% CommOrg 2% Coalition 3% Top 2 and bottom 2 same as last year, but others have shifted Followup 3% Referral 3% CaseManage 2% CertPractice 11% Screening 8% HealthEd 13% Collaborating 9% Consultation 11% Counseling 8% Advocacy CommOrg Coalition Collaborating Consultation Counseling HealthEd CertPractice CaseManage Referral Followup Screening Outreach EventInvestigate Surveillance Policy SocialMarket
Health education topics, all PHNs September 2013 to June 2014 PHN Health Education Topics Tobacco 6% Anaphylaxis 5% Most and least common topics same as last year Nutrition 9% Reproductive 12% CDC 31% Mental Health 12% Relationships 13% Drugs & Alcohol 7% Hygiene 5% Anaphylaxis CDC Drugs & Alcohol Hygiene Relationships Mental Health Nutrition Reproductive Tobacco
Outcomes of tracking tool The team used the full scope of the wheel, though not all nurses do all each month Clear shift to including more community and systems level interventions Nurses have said this has helped them become aware of their full scope of practice Model has been adopted across all of Vancouver Coastal Health PHN services
Qualitative interviews Both West Vancouver and North Vancouver school districts 10 secondary schools, 2 alternative schools 26 teachers, principals, school support staff 11 PHNs who provide school nurse services Recorded, transcribed, analyzed
Findings Staff identified loss of PHN care previously, felt it reduced health access for students With increased presence in schools, staff felt a safety net of expertise to draw on Accessed for teaching and curriculum too Better understanding of PHN scope of practice Parents, students, staff enthusiastic about PHNs More effective communication, better able to plan group health activities for students
School staff identified challenges The challenge of space many of the schools did not have a dedicated space for the PHN Wanting more hours than the PHN was able to provide Well, just not enough time now that she s here, you realize that you re probably just scratching the surface of our population here.
Identified challenges Concerned about the local PH agency commitment to maintaining or increasing time I m always concerned that they could change health nurses in the school we ve been lucky. The health nurse that we have in our school, we ve worked with her for five or six years we trust her; she trusts us. So I m always concerned about budget time whether they re going to allow [our school] to have the nurse... I mean, they could take that away. We re wanting her for more. So it s those budget constraints that [are] a major concern. And it s also a change of personnel. (principal)
Recommendations Develop strategic plans and formal agreements with school districts to set expectations Foster health equity through proportional service Larger schools, more hours Establish school nurse staffing ratios from evidence Youth-positive, youth-centred care Further professional development for PHNs Increase visibility of PHN roles in schools
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For More Information Elizabeth M. Saewyc Elizabeth.saewyc@ubc.ca Josette Roussel jroussel@cna-aiic.ca www.saravyc.ubc.ca
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Thank you!