School Nurse Production - Licensing Models for Michigan

Transcription

1 Michigan School Nurse Task Force Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan September 2013

2 Michigan School Nurse Task Force: Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan Introduction The statewide School Nurse Task Force identified a great need in Michigan to address the lack of school nursing services and school nurses. Increasing health need demands mandates, and requirements for school nurses exist and the lack of school nurses available to respond to the needs creates a gap between what needs to be and what is. The gap between the two creates lost opportunity for Michigan to support the educational success of students by addressing the ongoing, day to day health demands that keep our students from being in the classroom and ready to learn resulting in less than optimal health outcomes, increasing absenteeism, potential legal and liability ramifications, and lost learning time. The data and staffing subcommittee of the School Nurse Task Force was charged with: 1. Developing a strategic plan to provide access to school nurses for all children in the state with the ultimate goal of a ratio of one school nurse to 750 well students. 2. Providing recommendations and guidance on systematic data collection statewide in order to obtain an accurate count of school nurses in the state and to determine the geographic distribution of SNs. 3. Analyzing and preparing administrative models school district led, health department led, and hospital led, etc. that can be shared with school districts based on the school-communities identified needs. 4. Exploring e technology solutions (telemedicine) to assist school nurses covering multiple sites. This report addresses tasks one and three. The School Nurse Task Force recommends a 5-step process to implementing a school nurse program in a school district: 1. Assess the needs of the district using nurse auditor(s) 2. Establish clinical oversight 3. Select a staffing model (using the recommendations of the audit report) 4. Implement plan for staffing model within 5 years 5. Evaluation/data collection is ongoing. Formal report submitted yearly to MDE/MDCH. The members of the staffing subcommittee feel strongly that: Core Components of any school nurse staffing model: A school nurse should have a bachelor s degree in nursing (BSN) or an RN and bachelor s degree in a related field. Certification as a school nurse the state of Michigan 1 should be required and National School Nurse Certification is recommended. Any school nursing staffing model recommended by the SNTF and implemented by a school district must contain core components at a minimum. Appendix A outlines those recommended core components. Clinical Oversight: In order to meet those core components in any staffing model, at a minimum, there will be clinical oversight for the school nurse. Regardless of who employs and manages the school nurse program, clinical oversight is essential to the coordination of the program with the school administration. School nursing is a profession that requires unique preparation and skills and a license to practice, and is an independent practice arena, where the school nurse is often the only health care staff on site. While the school nurse is accountable for his/her own practice, that practice may be compromised when non-nurses supervise nursing practice. It is important to plan for clinical oversight in any staffing plan. This assures that the school nurse is accountable to a nursing administrator/supervisor, physician or hospital department/manager and not an educational administrator, assuring quality, evidenced based and current nursing practices are being used. 1 Currently only school nurses employed by school districts can apply for state certification, but the SNTF is working to change the certification rules in order that all school nurses, regardless of employer, can apply for state certification. 1

3 Michigan School Nurse Task Force: Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan If a school district/program begins with a district-wide nurse who can meet the core components of a program, the position could evolve into the school nurse supervisor as staff are hired. (See Appendix B, sample school health program manager job description). Determining Staffing Model: The SNTF recommends that a school/student health audit be conducted for each district in the state of Michigan. A nurse auditor (or team of auditors) would audit the current health policies and practices in each school district. Based on their findings, a recommendation for a school nurse staffing model that would best fit all variables (need, cost, geographic location, etc.) would be made. While setting forth ratios may help to support school nursing staffing, ratios are not without some concerns. If a school system or school health services program utilizes 1:750 student ratio, how do you serve a school of 3,000? While a school district might add a nurse or two to meet the established ratio, what about the elementary school that may have 350 students - do you only provide a part time nurse? Student s health needs exist daily and therein lies the challenge of nurse to student ratios. The overarching principle for determining staffing should be adequately meeting students health needs. There are many school nursing staffing models. This report highlights the ones that after careful research, the staffing group felt should be considered to best meet student s needs for the state. (See Appendix C). A school district, a hospital, a health department, or another organization can implement any of these staffing models. Eighty-five (85%) of school nurses are currently hired by school districts. There are existing models of each of the staffing models described in this document across the state. We recommend that the state begin with a demonstration project in a few select districts. This would allow for staffing and cost issues to be examined in detail. Data can be gathered and carefully evaluated before moving forward to other districts/schools. Note: Often folk believe if a school has a school based health center, no school nurse is required. School nursing is different from a school based health center. SBHCs are a medical model providing primary care to students at a center facility located on a school campus for those students enrolled in the center, often on an appointment basis. School nurses provide comprehensive, preventative care coordination and plan for required direct care to all students in a school. School nurses provide basic health care and education to the entire student population, overseeing day-to-day care required for the student to attend school. They are responsible for assisting in the development of school policies on health related issues and serve as a referral resource for the students and their families. They are an integral part of the school team serving on IEP/504 teams and emergency response teams. SBHCs are an enhancement to those basic needs for schools that have the need. When a SBHC is opened at a school, it should be in conjunction with the school nursing program. The two programs should work hand in hand. Next Steps 1. Secure funding for nurse auditors as a first step. 2. Nurse auditors would complete audits of individual districts over a certain time period with the intention of completing the assessment in all the districts in Michigan quickly as time and funds permit. 3. The SNTF will develop goals to be completed during these audits. 4. The auditors would be equipped with the tools (surveys, questionnaires, audit tools) to accomplish these goals. Areas to assess may include: a) medication audit b) crisis/emergency medical response plan c) health plans r/t care of students with chronic medical conditions *Currently only school nurses employed by school districts can apply for state certification, but the SNTF is working to change the certification rules in order that all school nurses, regardless of employer, can apply for state certification. 2

4 Michigan School Nurse Task Force: Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan APPENDIX A Core Components of a School Nurse Program School Health Policies and Procedures Training for School Personnel Quality Assurance Nursing Services School-Family-Community Partnerships Assessment, evaluation, and compliance of district health and policies. Development of needed policies related to things such as: health and wellness, delegation, mental health needs, nursing services on IEP and 504 plans, Medical Emergency Response Teams in each building, and infectious disease plans. Policies must be in accordance with the Public Health Code to assure safe care for children. Identify and engage appropriate partners in developing policies. Identify training needs including training for high risk/high acuity students, medication administration, emergency response teams, and bloodborne pathogens. Identify personnel that require training with building administrator. Determine and/or develop appropriate curriculum. Identify resources to assist in the training. Organize and perform training for district and/or individual groups. Evaluate training. Develop and implement a plan to evaluate health services and outcomes. Intermittent evaluation (competency) of non-nurses providing health services including medication administration and treatment compliance. Evaluation of school emergency readiness. Documentation of health services including reports for incidents, health screening, referral outcomes, immunization rates, and communicable disease. Develop Individual Health Plans for high risk/high acuity students. Case management of students with health concerns. Medication management i.e. medication training for those administering the meds, periodic evaluation of staff assigned to assure competency, and reviewing individual medication orders. Recommendations for appropriate staffing. Consultation, triage, and support via phone. Consultation for health education and possibly some classroom or larger group health education. Assess overall health needs of the school district. Identify community resources for particular health needs of students. Coordination with local health department on infectious disease outbreaks, immunization compliance, and health screenings. Participate in district level school/community groups. Reference: Michigan Association of School Nurses (2010). Nursing Care Delivery Model for Michigan School 3

5 Michigan School Nurse Task Force: Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan APPENDIX B Position of School Health Program Manager providing Clinical Oversight Sample Job description: A licensed health professional that enhances the quality and effectiveness of school nursing. Provides leadership in the professional practice setting and provides program management. Demonstrates knowledge and competency that reflects current school nursing practice, is able to evaluate one s own practice in relation to professional standards, and contributes to the professional development of the school nurse. Collaborates with other team members to enhance school health, integrates ethical provision in all areas of practice, and integrates evidence based research findings into practice. Considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services. Responsible for the clinical oversight of the school nursing program. Responsible for orienting and maintaining the required training and skills of school nurse staff. Conducts performance evaluations of the school nurse staff and implements corrective actions as necessary. Develops, implements, and evaluates program and activities surrounding the school health program. Recruits and retains highly qualified staff. Effectively works in collaboration with outside agencies, physicians, other healthcare providers, and school personnel/administrators. Operates within approved budget and efficiently manages resources. Provides nursing staff with educational opportunities and support to enhance their personal and professional growth. Evaluates staff competency by direct observation, peer review, orientation, and employee input. Qualifications: Required: BSN or RN with bachelor in related field Required: State of Michigan school nurse certification* Prefer: National School Nurse certification. Master s Degree *Currently only school nurses employed by school districts can apply for state certification, but the SNTF is working to change the certification rules in order that all school nurses, regardless of employer, can apply for state certification. 4

6 Michigan School Nurse Task Force: Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan APPENDIX C POTENTIAL STAFFING MODELS (Determined after an assessment of needs is made by a nurse auditor.) NASN and AAP recommended model RN per school/s 1:750 CORE COMPONENTS PROS CONS COMMENTS COST Met plus : o More direct care for general o Cost o Could have some o Implement individual health education students o Staff recruitment leeway regarding the plans for students o Can meet day to day needs 1:750 for high school o Coordinate, link and obtain o Can typically be in one students as the hands health services for individual building to address all on nursing needs are students concerns/including not as great i.e. o Communicable disease emergencies students are more self surveillance o Able to address things sufficient in caring for o Classroom education immediately as they present their chronic health o Staff health promotion conditions such as o Heightened data collection diabetes o reproductive health instruction o Leadership in schools multidisciplinary teams o Collaboration with counselors to better address the students with mental health needs o Oversight of medication administration 5

7 Acuity based model Michigan School Nurse Task Force: Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan RN coverage in district/school based on individual student and population health needs/acuity. Examines student need in conjunction with population needs based using all data sources. CORE COMPONENTS PROS CONS COMMENTS COST Met plus : o Schools with higher needs o Cost o Implementation can be o o Implement individual health would have more nursing o Staff recruitment introduced incrementally plans for students staff. Statistics show that o Number of staff is a fluid. As based on hierarchy of o Coordinate, link and obtain students in poverty have less student needs change, RN need health services for individual access to health care and assignment may need to be o Often the only health care students thus health needs go adjusted. these students receive is o Communicable disease unaddressed o Not being able to have current from the school nurse surveillance o Data on the 10 variables is health needs acuity at the o Would need to establish o Classroom education currently collected and beginning of the school year. what basic coverage is o Staff health promotion available. o Reassessment of acuity needs for all students o Heightened data collection o Basic coverage for all would occur routinely. o Would need to develop an o Assisting in reproductive health students and possible more o Would need to be able to collect acuity scale/system to instruction and 1:1 student direct care for general data on health needs of students determine health needs in reproductive health concerns education students which we don t necessarily have each school/district o Leadership in schools o Potential for having a nurse in in all schools at this time multidisciplinary teams more buildings to address all o Collaboration with counselors concerns/including to better address the students emergencies with mental health needs o Can meet day to day needs o Oversight of medication o Can typically be in one administration building to address all concerns/including emergencies o Able to address things immediately as they present 6

8 Michigan School Nurse Task Force: Staffing subcommittee report on recommended school nurse staffing models for the state of Michigan RN/unlicensed assistant model RN/Health Aide team. 1 RN: approximately 1200 students. RN could cover 2-3 schools in geographic proximity. Health aide would be assigned to one building, thus an RN: Health Aide ratio of 1:3. CORE COMPONENTS PROS CONS COMMENTS COST Met: o Meeting needs of more o May require several RN s for large o Implement individual health students than we are currently district o Sometimes districts appoint plans for students in the state o Could be a large area for RN to someone the health person o Coordinate, link and obtain o One nurse could possibly cover geographically (such as the secretary, an health services for individual cover 2 smaller districts in o If there is an emergency in a instructional assistant, the students close proximity building, nurse could be at another lunchroom aide or the o Communicable disease o More hands on direct care for campus and delayed in getting playground aide) but they are surveillance day to day like diabetes care, there assigned other duties as o Classroom education medication administration, first o Can t train teachers and staff on well. For this model to work, o Staff health promotion aide how to handle every medical the health aide needs to be o Heightened data collection o Frees SN to attend meetings, situation in the absence of a nurse assigned to the health room o Assisting in reproductive health do classroom teaching and o If a child requires direct nursing full time and under the instruction and 1:1 student home visits services, school would have to supervision of the school RN reproductive health concerns hire another nurse for this child o A school nurse/nurse o Leadership in schools health aide could not perform supervisor should be part of multidisciplinary teams services the selection process to hire o Collaboration with counselors o Difficulty with role delineation- the health aide to better address the students confusion of roles by the school o Would recommend that this with mental health needs staff. The health aide is often staffing model is a short-term o RN would provide oversight of approached by school staff to do goal in the interim to the next the medication administration; an RN function. goal of 1:750 health aide would administer o RN may cover several buildings medications and thus does not have the presence in all buildings to build relationships with school staff o Many functions are not in the scope of practice for the health aide and thus puts more demands on RN o Increased liability if health aide is doing things out of his/her scope of practice o Minimal time that RN is directly supervising health aide Reference: Grabeel, J., & Shaw, P. (2013). Staffing school health services for effectiveness. In C. Costante (Ed.), School nurse administrators leadership and management (pp ). Silver Spring, MD: National Association of School Nurses. 7