Measuring nurse sensitive outcomes of school nursing practice
Martha Dewey Bergren, DNS RN NASN Director of Research
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Martha Dewey Bergren DNS RN NCSN FNASN FASHA [email protected]
www.nasn.org National Association of School Nurses Director of
Researc h
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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
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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
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Student: School Nurse Ratios Wide disparities Between states
Within states Mandated ratios 19 states have varying mandates 4
states fund the mandated ratio
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Student to School Nurse ratio 750:1? 1340+ 150 + 10+ 2 = 750
225 125 1 1.66 +.66 +.08 + 2 = 5.28 nurses
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Student: School Nurse Ratios What outcomes: Number of staff
Credentials of staff Under what conditions
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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
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Many influences on outcomes. Poverty School climate School
system leadership Parenting Breadth / quality community health
services and much more..
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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
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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
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Critical Indicator Structure Process Outcome
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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
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Process Process indicators measure aspects of nursing care such
as assessment, intervention, and RN job satisfaction
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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"
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NDNQI Sensitive nursing outcomes Falls Decubitus Bed sores
Infected Central Lines Failure to Rescue Readmissions Pain
assessment
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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
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AHRQ Prevention Quality Indicators Adult ambulatory care /
hospital admission rates Diabetes short term complications Diabetes
long term complications Low birth weight Perforated appendix
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AHRQ Pediatric Quality Indicators Asthma admissions Diabetes
short term complications Perforated appendix Urinary tract
infection admissions
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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 NQF outcome
measures
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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)
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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)
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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
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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
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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
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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
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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
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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
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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
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Safer school environment IAQ Bullying Hazing Increased case
managed students Increased planned care Increased AAPlans Increased
FAAPlans Staff preparedness Anaphylaxsis response Asthma response
Outcome
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DEVELOPMENT OF NURSE SENSITIVE INDICATORS
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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
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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
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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
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
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2.Scientific acceptability of the measure Extent to which the
measure, as specified, produces consistent, reliable and valid
results Evaluation criteria
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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
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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
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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
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Attendance OT3-032-10: Number of school days children miss due
to illness Importance Scientific acceptability Usability
Feasibility Evaluation criteria
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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 Childrens National Medical Center
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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
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NASN Goal: 3 stages Stage 1 Get school nurses to collect these
measures Uniform language to aggregate Electronic data systems
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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
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NASN Goal: 3 stages Stage 3 Become incorporated into NDNQI data
collection Now at 1500 hospitals collecting data at the unit
level
