Nursing Care Delivery Model For Michigan Schools Copyright 2010

Nursing Care Delivery Model For Michigan Schools Copyright 2010

Michigan Association of School Nurses Standards Committee Members Patricia K. Bednarz, RN, MN, FNP-BC, Project Coordinator, Lansing School District Sharon Davids, RN, MSN, FCNS, School Nurse Calhoun County Public Health Department Stephanie Painter, RN, MSN, Director of School Health Program Spectrum Health Ann Shupe, RN, School Nurse Coordinator Grand Rapids Public Schools Sue Zacharski, RN, MEd, School Health Services Pontiac School District Designed By: Leslie Y. Bednarz, BSME, MBA, Associate Ricardo Strategic Consulting

The MASN Nursing Care Delivery Model provides structure for school nurse services Student Health & Safety Policies & Procedures Training for School Personnel Quality Assurance Nursing Services School-family -community Partnerships Michigan Association of School Nurses

Levels Of Care For Nursing Services Each Level Builds Upon the Previous Level of Care POLICIES & PROCEDURES TRAINING FOR SCHOOL PERSONNEL QUALITY ASSURANCE NURSING SERVICES SCHOOL-FAMILY- COMMUNITY PARTNERSHIPS Level 1: District/Community Primary Focus: Policies, Procedures, and Training Staffing Requirement: Minimum 1.0 FTE per district. Assessment of district policies Lead development of appropriate district policies & procedures Identify and engage appropriate partners Identify personnel to be trained Determine appropriate curriculum Identify resources and district process for training Organize intermittent district wide training Evaluate training Develop and implement a plan that evaluates appropriate services to students Modify plan as services expand School nurse performance evaluation Health care planning for high risk/high acuity students requiring accommodations at school Recommendations for appropriate staffing Consultation, triage and support via phone No direct nursing services are expected Assess overall health needs of the school district Identify community resources needed for health related issues within the entire district Develop relationships within the school district and community to meet health needs Participate in district level school/community groups Level 2: Multiple Buildings Primary Focus: Indirect Nursing Services Staffing Requirement: Minimum 1.0 FTE. Support in the development of district level polices Follow district policies and procedures Participate in district level committees if time allows General education regarding disease management Appropriate treatment and procedure training Teach designated faculty/staff how to monitor and respond to emergencies that may occur in children with chronic conditions Health promotion & education State mandates & reporting requirements School Nurse Performance Evaluation Monitoring and evaluating student/building outcomes Evidence-based school health practice Satisfaction among key stakeholders Intermittent evaluation of non-nurses providing health services Medication Administration & Treatment compliance Direct Nursing Services Indirect Nursing Services NOTE: See Level 2 Nursing Services Detail Enhance health education Access needed services through collaboration and partnerships Participate in school/family groups at the building level Advocate for student health Level: 3 Individual Building Primary Focus: Direct Care Staffing Requirement: 1.0 FTE Serving One School with <750 Well General Education Students Support in the development of district level polices Follow district policies and procedures Participate in district level committees if time allows Health promotion Data collection process is systematic, organized and ongoing Immunization rates Communicable disease rates Direct Nursing Services Indirect Nursing Services NOTE: See Level 3 Nursing Services Detail Coordinate, link, and obtain health services (dental, vision, transportation, access to care for individual students Serve as a liaison/provide leadership for health issues within the building Parent/community/employe e health promotion and education Leadership in school multidisciplinary teams

School Nursing Role Each Level Builds Upon the Previous Level Level 1: District/Community Primary Focus: Policies, Procedures, and Training Staffing Requirement: Minimum 1.0 FTE per district POLICIES & PROCEDURES Assessment of district policies Lead development of appropriate district policies & procedures Identify and engage appropriate partners SCHOOL-FAMILY-COMMUNITY PARTNERSHIPS Assess overall health needs of the school district Identify community resources needed for health related issues within the entire district Develop relationships within the school district and community to meet health needs Participate in district level school/community groups Student Health & Safety Identify personnel to be trained Determine appropriate curriculum Identify resources and district process for training Organize intermittent district wide training Evaluate training TRAINING FOR SCHOOL PERSONNEL Health care planning for high risk/high acuity students requiring accommodations at school Recommendations for appropriate staffing. Consultation, triage and support via phone No direct nursing services are expected NURSING SERVICES Develop and implement a plan that evaluates appropriate services to students Modify plan as services expand School nurse performance evaluation QUALITY ASSURANCE AT DISTRICT LEVEL

School Nursing Role Builds Upon Level 1 Services Level 2: Multiple Buildings Primary Focus: Indirect Nursing Services Staffing Requirement: Minimum 1.0 FTE to Serve a Few Schools in Close Proximity with Trained Support Staff POLICIES & PROCEDURES SCHOOL-FAMILY-COMMUNITY PARTNERSHIPS Enhance health education Access needed services through collaboration and partnerships Participate in school/family groups at the building level Advocate for student health Indirect Nursing Services Direct Nursing Services NOTE: See Level 2 Nursing Services Detail NURSING SERVICES Support in development of appropriate district policies Follow district policies and procedures Participate in district level committees if time allows Student Health & Safety General education regarding disease management Appropriate treatment and procedure training Teach designated faculty/staff how to monitor and respond to emergencies that may occur in children with chronic conditions Health promotion & education State mandates & reporting requirements School Nurse Performance Evaluation Monitoring and evaluating student/building outcomes Evidence-based school health practice Satisfaction among key stakeholders Intermittent evaluation of non-nurses providing health services Medication Administration & Treatment compliance QUALITY ASSURANCE AT INDIVIDUAL BLDG TRAINING FOR SCHOOL PERSONNEL

School Nursing Role Level 2: Nursing Services Detail Primary Focus: Indirect Nursing Services Staffing Requirement: Minimum 1.0 FTE to Serve a Few Schools in Close Proximity with Trained Support Staff Indirect Nursing Services Direct Nursing Services NURSING SERVICES INDIRECT NURSING SERVICES Interpret health status of students to staff, parents, and health providers Connect students to resources including insurance Early detection for communicable diseases Develop and implement a plan of care that specifies interventions to attain expected outcomes for students at high risk or receiving nursing services DIRECT NURSING SERVICES Individual/classroom health education and counseling Health screening and follow-up Monitor medication effectiveness Monitor/support for designated school personnel delivering health services

School Nursing Role Builds Upon Level 1 & 2 Level 3: Individual Building Primary Focus: Direct Nursing Service Staffing Requirement: 1.0 FTE Serving One School with <750 Well General Education Students or 1:1 1:125 Students with complex health care needs POLICIES & PROCEDURES SCHOOL-FAMILY-COMMUNITY PARTNERSHIPS Coordinate, link, and obtain health services (dental, vision, transportation, access to care for individual students Serve as a liaison/provide leadership for health issues within the building Parent/community/employee health promotion and education Leadership in school multidisciplinary teams Support in development of appropriate district level policies Follow district policies and procedures Participate in district level committees if time allows Direct Nursing Services Indirect Nursing Services NOTE: See Level 3 Nursing Services Detail Student Health & Safety Individual classroom and staff health promotion Data collection process is systematic, organized and ongoing Immunization rates Communicable disease rates TRAINING FOR SCHOOL PERSONNEL NURSING SERVICES QUALITY ASSURANCE AT INDIVIDUAL BLDG

School Nursing Role Level 3: Nursing Services Detail Primary Focus: Direct Nursing Service Staffing Requirement: 1.0 FTE Serving One School with <750 Well General Education Students or 1:1 1:125 Students with complex health care needs DIRECT NURSING SERVICES Direct consultation to parents/staff for student health (medical/social) services Individual health education/counseling with appropriate referral Implement Individualized Health Care Plan Medication administration Direct Nursing Services Indirect Nursing Services Treatment/procedures as order in care plan On-site screening and assistance with access to care Employee health (Time permitting) NURSING SERVICES Emergency care Case Management INDIRECT NURSING SERVICES

The MASN Nursing Care Delivery Model provides structure for ensuring students health & safety By implementing the MASN Nursing Care Delivery Model, school nurses across Michigan will have a plan outlining the objectives & expectations that are to be met to ensure the health & safety of our students.

MASN Nursing Care Delivery Model Michigan Association of School Nurses www.michiganschoolnurses.org

School Nurses Assessment Tool to Determine Practice Level of Care Based on the Nursing Care Delivery Model Polices & Procedures Level of Care Criteria Role District Level 1 Assess school district polices related to health care delivery. Provide leadership in the development of policies and guidelines related to school health. Collaborate with partners within the school district and community to develop best practice policies and guidelines for school health. Level 2 Support the development of district policies and guidelines related to school health. Participate in district level committees to develop policies and guidelines if time allows. Follow polices and guidelines related to school health. Level 3 Support the development of district policies and guidelines related to school health. Participate in district level committees to develop policies and guidelines if time allows. Follows policies and guidelines related to school health. Training for School Personnel Level 1 Level 2 Level 3 Identify personnel to be trained Determine appropriate curriculum Identify resources and district processes for training Organize district-wide training Evaluate training General education regarding disease management Appropriate treatment and procedure training Teach designated staff how to monitor and respond to emergencies that may occur in children with chronic illnesses Health promotion and education State mandates and reporting requirements Individual classroom and staff health promotion

Nursing Services Level 1 Level 2 Level 3 Health care planning for high risk/high acuity students requiring accommodations at school Recommendations for appropriate staffing. Consultation, triage and support via phone No direct nursing services are expected Indirect Nursing Services Interpret health status of students to staff, parents, and health providers Connect students to resources including insurance Early detection for communicable diseases Develop and implement a plan of care that specifies interventions to attain expected outcomes for students at high risk or receiving nursing services Direct Nursing Services Individual/classroom health education and counseling Health screening and follow-up Monitor medication effectiveness Monitor/support for designated school personnel delivering health services Direct Nursing Services Direct consultation to parents/staff for student health (medical/social) services Individual health education/counseling with appropriate referral Implement Individualized Health Care Plan Medication administration Treatment/procedures as order in care plan On-site screening and assistance with access to care Employee health (Time permitting) Emergency care Indirect Nursing Services Case management

School Family Community Partnerships Quality Assurance Level 1 Level 2 Level 3 Level 1 Level 2 Level 3 Assess overall health needs of the school district Identify community resources needed for health related issues within the entire district Develop relationships within the school district and community to meet health needs Participate in district level school/community groups Enhance health education Access needed services through collaboration and partnerships Participate in school/family groups at the building level Advocate for student health Coordinate, link, and obtain health services (dental, vision, transportation, access to care for individual students Serve as a liaison/provide leadership for health issues within the building Parent/community/employee health promotion and education Leadership in school multidisciplinary teams Develop and implement a plan that evaluates appropriate services to students Modify plan as services expand School nurse performance evaluation School nurse performance evaluation Monitoring and evaluating student/building outcomes Evidence-based school health practice Satisfaction among key stakeholders Intermittent evaluation of non-nurses providing health services Medication administration & treatment compliance Data collection process is systematic, organized and ongoing Immunization rates Communicable disease rates

Additional Questions School Nurse What is the funding source for your position? Using the assessment tool, determine what services are provided? Are services provided to: All students district-wide? Students in one school or a set of schools? At-risk students? Special education students? What Level best describes your role? District Assessment Are Level 1 services provided in the district? Are Level 2 services provided in the district? Are Level 3 services provided in the district?

Application of the Model to the School Nurse Role 1. Are there overlaps among the three different levels of care? If so, what are they? 2. Are there overlaps because of your expectations? 3. Are there overlaps because of your job description or district expectations? Utilize the Assessment Tool and guided questions to determine your role 4. What services are missing or deficient in the district? 5. Do you feel role strain? 6. Utilizing the model, can you articulate changes that need to be made?

Michigan Association of School Nurses Nursing Care Delivery Model April 10, 2010

Abstract The Nursing Care Delivery Model (NCDM) is intended to describe the spectrum of services provided by school nurses and explain the context in which school nurse s practice in Michigan. The NCDM can be utilized by school districts and nurses to negotiate realistic nursing responsibilities based on the current financial, legal and social constraints. A continuum of services is divided into three levels. In Level 1, the nurse coordinates or oversees health services to an entire district/community. No direct services are provided to students by the nurse functioning in a Level 1 nurse role. The nursing focus is to provide population based interventions and program leadership. The nurse may coordinate or oversee health care professionals or others who provide the direct services. In Level 2, a nurse delivers limited direct services to children/teens in a small cluster of schools in close proximity. The primary responsibility of the Registered Nurse is to support and train others who provide the majority of the direct services. Services that should not be delegated safely are performed by the registered nurse. Level 3 nursing services are provided directly to children by the Registered Nurse in an individual school or center-based program. 2

The Nursing Care Delivery Model was revised to describe the spectrum of services provided by school nurses in Michigan. The availability of school nurses has been impacted by Michigan s current social, fiscal, and legal framework. School nurses practice in many different work environments with varying caseloads (Periard, Knecht, and Birchmeier, 1999). The model describes a continuum of services needed in each district. This continuum is divided into three different levels of service delivery. The role of the nurse should be based on the needs of students. Appropriate allocation of resources will increase the availability of nurses to provide services. The Michigan Association of School Nurses (MASN) strongly advocates for adequate resources to enable safe care delivery to children in the school setting. Health Needs of Children in Schools Most of Michigan s children are healthy while they spend the majority of their day in school. However, an increasing number of students attend school with chronic conditions, such as, diabetes, asthma, life-threatening allergies, seizures, cancer, sickle cell, hemophilia or other serious medical conditions that affect their ability to participate in education. Due to the nature of the chronic illness, problems can arise during the school day requiring an emergency response to avoid serious complications. Furthermore, healthy children may become seriously ill or injured at school and need immediate care by a health professional. According to William s testimony before Governor Granholm s Town Hall meeting on Patient Safety in 2004, children are coming to school with increasingly 3

complex health conditions that often require treatment during the school day. Requests and doctor s orders are increasing for the administration of insulin and rectal medications. Physical ease of medication administration is not the only consideration when evaluating who can be trained to do a task safely. Knowing how to quickly assess a student for medication needs and know if the student is having the desired and timely effect from the administration requires professional training and experience (Williams, 2004, p.1). Increased utilization of pharmaceuticals and technology to treat children create challenges for districts. Children are coming to school with implantable pumps, external devices, and intravenous lines and complex treatments or emergency protocols. Children with diabetes require frequent blood sugar testing, carbohydrate counting, and insulin administered via various pumps or syringes. School Nurses have noted a marked increase in life threatening allergies to insects, foods and latex. Children with serious medical problems are attending school and living longer. The number of students enrolled in each school has increased over the past few years as districts close schools and consolidate to cut cost of operations. As the enrollment in each school increases, individual schools experience an increased number of children with chronic health conditions who need medications, treatments, or first aid. As the enrollment in each school increases, there is an increase in the number of children who become sick during the day with communicable diseases. School districts are challenged to meet the increased need for services. However, school personnel who care for children in some districts do not even have access to a school nurse to answer questions or train them. 4

Strategies to prevent serious chronic diseases are increasingly targeted to children at school. Pediatric obesity, adolescent tobacco, alcohol and drug use, physical inactivity, and poor nutrition and diet were identified as risky health behaviors in the Michigan Critical Health Indicators: 2007 (Michigan Department of Community Health [MDCD], 2007). Prevalence of overweight and at risk for overweight among adolescent students in grades 9 12 is 12% in Michigan (MDCH, 2007). In districts with successful prevention activities, it is often because there is a school nurse to coordinate or lead in these initiatives. Limited access to medical, dental and mental health care is a significant issue affecting our children s health. Locating providers who accept Medicaid can be a challenge. Some parents cannot afford co-pays or medications or preventive care. Statistics and reports of children s health from The Michigan Department of Community Health (MDCH, 2007) validate the need for school nursing services. For example, 9.1% of children in Michigan have asthma. The average age of a child who dies from asthma in Michigan is 12.4 years of age and 80% of those children are African American. The Michigan Child and Safety Risk Survey (MCHSRS) reported that 8.7 % of children had not seen a dentist in the past 24 months or had never seen a dentist and 34.3 % of households with a child 1-14 years of age had a special health need or condition (MDCH, 2007). Lack of Clear Legal Support for Safe Health Care in Schools Michigan continues to lack a strong legal infrastructure for delivery of health services in schools. Legislators hesitate or are prohibited from creation of mandates that they are unable to fund. The Office of Civil Rights requires schools to make 5

accommodations for children with disabilities, though it is not clear what accommodations are considered reasonable (Section 504 of the Rehabilitation Act of 1973). The Public Health Code in Michigan mandates that the Michigan Department of Community Health establish a plan for health services for pupils in elementary and secondary schools of this state (Michigan Public Act 368, 1978). The plan shall include a definition of school health services and standards for implementation. Yet, this plan has not been updated since the original 1980 plan. The Michigan Department of Education (MDE) recommends, but does not even require, training for non-nurses who deliver medications or provide treatments. Though many court rulings have backed the requirement for health services, some school administrators will still tell a parent that they have no one to provide these services (Williams, 2004, p.2). The Public Health Code and Michigan Board of Nursing Rules (Michigan Public Health Code Part 172, 1978) which specifies that only the Registered Nurse may delegate and supervise nursing acts has not been applied to services provided to children in schools. It has been advised that districts may be considered as the in loco parentis and therefore are not held to the same standards as nursing homes, hospitals etc. Nurses, as licensed professionals by the Public Health Code struggle to apply the standards for delegation and supervision in this context. The volume of children in need of nursing services, and the insufficient time allotted to nurses to provide care, creates obstacles to meeting nursing licensure requirements for delegation and supervision. Many school nurses are hesitant to train large numbers of personnel unless they have time to determine if the non-nurses have the skills required to provide services safely. The focus of current laws in the Michigan 6

School Code seems to be to reduce liability from the school district rather than to advocate for the safety of students. School nurses work in a gray area trying to be accountable to both codes (Williams, 2004, p.1). Within this legal framework, districts choose whether to employ school nurses to meet student needs, resulting in unequal access to safe health care services across districts. In 1999, the Supreme Court upheld in Cedar Rapids Community School District v. Garret F that districts must provide nursing services during school hours to medically fragile children even if that means one nurse to one student to comply with the Individuals with Disabilities Education Act (IDEA), (ADA, 1990). The Court noted the district s legitimate concerns about the financial burden of providing the services but they ruled that it was the responsibility of Congress to address this issue. No action by Congress has been taken. This decision caused a shift of cost to provide care to medically needy children from other sources to districts. Lack of Clear Funding Mechanisms for Services School health services are commonly supported by several different funding sources. Sources may include Federal, State and Local resources. Potential funding sources include: Federal (Title 1. IV, V, IDEA, Title V or XIX of the Social Security Act), Federal and State (31-A, Intermediate School Districts, Michigan Model, or grants), or local sources (school district, hospitals, county health department, community mental health, social services, service clubs, health organizations, corporations, or private donors). Potential funding sources to increase access to healthcare services for children in schools can be found at the Michigan Association of School Nurses web-site (MASN, 2008). Some cost recovery is available through Medicaid billing for direct nursing 7

services to special education eligible students through the Intermediate School District. Billing insurance for dental, social work and medical services through clinics is also a possible funding source (Aldritt, 2006). Each funding source is specific to services and certain populations. Services must be documented and outcomes measured for continuation of funding. Districts may combine different funding sources in creative ways to subsidize school nurses. Managing this can be complex and time consuming and few districts have administrators who have the time or capacity to perform these duties. At the same time, school districts are being pressured to reduce costs and utilize money for other mandated purposes. Creation and maintenance of stable funding for school health services is very challenging. School Nurse s Role School nurses often define their role in response to many varied expectations from parents, administrators, children s needs and funding sources. They may be the only health professional in a district. They are often supervised by non-nurses or non-medical personnel. This creates further disparities in clarity of the school nurses role and standards of care across the state. The Nursing Care Delivery Model Michigan Association of School Nurses (MASN) updated the Nursing Care Delivery Model to provide school nurses, school districts, and key stakeholders a visual model of school nursing services. The Model attempts to provide guidance to school nurses in Michigan as they define their roles and responsibilities with varying caseloads and acuity levels to assure student health and safety. The model can also assist school 8

districts meet the health needs of students by providing guidelines for nursing services based on expectations at differing levels of service. Pillars for Delivery The 2010 Nursing Care Delivery Model includes five key concepts for delivering nursing care in schools: Policies and Procedures, Training for School Personnel, School- Family-Community Partnerships, Quality Assurance, and Direct Nursing Services. Policies and Procedures Policies are principles, rules and guidelines adopted by a school district to reach its long term goals. They are designed to influence and determine all major decisions, actions, and activities that take place within the boundaries set by them. Procedures are specific methods employed to express policies in action in day-to-day operations of the school district (Business Dictionary, 2010.). The nurse s participation as a health care professional to assess and lead in the development and implementation of appropriate health related policies and procedures, is critical. Policies for Health and Wellness, Administration of Medications/Treatments, Emergency Preparedness, Communicable Diseases, Blood borne Pathogens, Health Services, Delegation of Health Services and Child Abuse are an essential infrastructure for safe health service provision. Procedures for identification of children with health conditions, care planning, providing treatments/medications, or triage are all important components to facilitate safe health services. Appropriate job descriptions, evaluations, orientations and competency measures for all providing health care are also essential. 9

School-Family-Community Partnerships Developing relationships with individuals, community, school staff, and other agencies to identify problems and issues is important in working together for solutions (Community Partnership, n.d.). Community partners may include local health providers, parents, school personnel, the local health department, social services, community mental health, local emergency medical service providers, and donors of glasses, clothing, shoes boots, or mentors. It must be recognized that care provided in school must be coordinated between parents, school personnel, doctors, dentists, mental health providers and other health professionals. Communication with recognition of clear roles and responsibilities are critical to meet the health needs of students. The school nurse makes a significant contribution to this process. Nurses are in the optimal place to recognize population based needs and deficiencies in community resources and advocate for missing services. Training for School Personnel Training is defined as an organized activity aimed at imparting information and/or instruction to improve the recipient s performance or to help him or her attain a required knowledge or skill (Business Dictionary, 2010). The School Nurse s responsibility should be to identify training needs, personnel to be trained, select appropriate curriculum, and identify resources for training. The School Nurse will assure that appropriate training is provided and evaluate competencies after the training. School personnel need basic Cardio Pulmonary Resuscitation (CPR) and First Aid Training, as well as training to recognize urgent needs for medications to treat severe allergies, asthma or seizures. All personnel need blood borne pathogen training and education about 10

common medical conditions. Additional training is needed if non-nurses are providing direct care. This training is not static, as the needs of students and care provided change. Quality Assurance at District Level Quality assurance (QA) can be defined as all activities that contribute to defining, designing, assessing, monitoring, and improving the quality of healthcare (Healthcare and Workforce Improvement Quality Assurance Project, 2008). The School Nurse s role is to develop and implement a plan to evaluate health services and outcomes. Some components measured include school emergency readiness, qualifications or competencies of all providing health services, medication administration and treatment compliance. Additional measures may include incident reports, attendance, graduation rates, accidents/injuries, communicable disease reporting, satisfaction surveys, health screening results, access to care, outcomes of referrals, immunization rates, or communicable disease rates. Nursing Services A determination of services requiring a registered nurse should be made in accordance with the Public Health Code. Since schools may be considered the in loco parentis, services required by a registered nurse have been determined by districts. Districts need to recognize the value of creating policies and job descriptions in accordance with the Public Health Code to assure safe care for children. District policies and job descriptions should clearly define the services needed by children in the district, who is competent to provide them and how the safety of services will be supervised and monitored by qualified staff. Health service responsibilities need to be clearly defined to protect the child and the employees providing care. Safe care should be the priority. 11

Care may be provided by the nurse directly or indirectly. Direct Care interventions are performed by the registered nurse through interactions with patients (American Nurses Association [ANA], 2003). Indirect Care are interventions performed away from the patient but on behalf of the patient or group of patients, and are aimed at management of the care environment and interdisciplinary collaboration (ANA, 2003). Care may be provided by other school personnel or unlicensed assistive personnel as appropriate but the registered nurse develops policies, procedures or care plans; delegates, provides training and supervises services to assure that these are provided safely. It may be legal, for a nurse to train and monitor some health services (vs. delegate and supervise) but her ability to assure patient safety and quality of services will be limited. Nursing Care Delivery Model Levels of Care The 2010 Nursing Care Delivery Model includes three levels of care to clarify the role and expectations of the school nurse. It is important to determine if the nurse s role is to provide care through population based strategies (or indirect services) or to give direct services to individual students. Many nurses and districts have created unrealistic expectations for services by the nurse. Some expect direct service delivery but the nurse is assigned to serve more than a thousand students in several school buildings. A nurse may be hired to fulfill grant requirements for nutrition education. Meanwhile, the majority of children in the district lack basic services such as safe regular administration of a medication or care by appropriately trained staff. The Nursing Care Delivery Model 12

creates a visual model to illustrate the levels of service a nurse might provide to facilitate a clarification of the nurse s role. Level 1 Nursing Services The role of this nurse is a leadership role. These services are provided at a district/community level. All school districts in Michigan should have a minimum of district wide services as the majority of student health needs are universally experienced. This school nurse may be the only nurse in the district or the district coordinator or manager of the school nurses. An identified leader is important. The volume or acuity of need for services may vary tremendously from school to school or year to year. The Level 1 nursing role is primarily focused on development and maintenance of relevant district policies and procedures. The nurse plans and/or provides training to others who are responsible for direct care and services. The school nurse may manage other professionals and non-professionals who provide the services. Services and outcomes are evaluated at a district level. Level 2 Nursing Services Care is provided by one nurse who serves multiple schools in close proximity or no more than 1000 students. This number may also depend on the acuity of students and distance between school buildings. The primary focus is indirect nursing services but the nurse may also provide some direct services. Some districts utilize a trained Unlicensed Assistive Personnel (UAP) or school secretary working under the supervision and direction of a school nurse. The UAP provides direct health services to students in one school under the supervision of a Registered Nurse who is available for immediate consultation or support. Level 3 Nursing Services One school nurse provides direct services to students in one school (or an appropriate ratio of nurse to students with complex health care 13

needs). All health services to students are provided by the registered nurse. An acuity rating is done to determine the appropriate number of nurses needed and is based on student needs. Some students may even require a nurse (RN or LPN) if they have a high acuity. Summary The primary purpose for developing the Nursing Care Delivery Model for Michigan Schools was to help school nurses define their role in various school settings. Many nurses have the responsibility of serving a large population of students, while other nurses have a student-to-nurse ratio of less than 1:1000 students. The school nurse will need to work collaboratively with school administrators to prioritize plans and interventions based on funding sources, job descriptions, acuity levels, and other available resources. This model takes into account nurses who provide direct services to students, (such as in a special education setting,) and others who act as a nurse consultant (providing oversight to health services in an entire school district.) The Michigan Association of School Nurses (MASN) recommends a minimum staffing of at least Level One in all Michigan districts. In rare circumstances, small districts who have very few students in close geographic proximity with strong parental, administrative and community support may have a nurse who is able to combine roles or levels of service delivery. Large districts would need to include nurses who function at the district level as an administrator or coordinator, nurses who provide direct/indirect services at the building level, and possibly Licensed Practical Nurses or unlicensed assistive personnel. The goal of the Nursing Care Delivery Model is to clarify the different levels of care for 14

school nurses, school districts and key stakeholders. The building block for this model was the Scope and Standards of Professional School Nursing Practice (NASN, 2005). School nurses understand that school health services are vital for the health, safety and success of Michigan s children (MASN, 2003). Having a model for the delivery of school health services is one of the first steps taken to secure the prospects for a healthier population resulting from expert school nursing services. 15

References Aldritt, L. (2006). Budgeting and accessing funding. In J. Selekman (Ed.), School nursing: A comprehensive text (pp. 1035-1054). Philadelphia: F.A. Davis Company. American s with Disabilities Act of 1990, 42 U.S.C.A. 12101 et seq. (West 1993). American Nurses Association. (2004). Nursing: Scope and standards of practice. Washington, DC: American Nurses Publishing. American Nurses Association (2003). Nursing s social policy statement. Washington DC: American Nurses Publishing. Business Dictionary. (2010). Policies and procedures. Retrieved April 10, 2010, from http://www.businessdictionary.com/definition/policies-and-procedures.html Business Dictionary (2010). Training. Retrieved April 10, 2010, from http://www.businessdictionary.com/definition/training.html Cedar Rapids Community School District v. Garret F, 119 S. Ct. 992, 29 IDELR (U.S. 199). To view the full decision, go to: http://supct.law.cornell.edu/supct/html/96-1793.zs.html Community Partnership, (n.d.). Retrieved April 28, 2009, from http://www.commpartnership.org/ Healthcare and Workforce Improvement Quality Assurance Project, (2008). Retrieved April 10, 2010, from http://www.qaproject.org/methods/resqa.html Michigan Association of School Nurses (2005). Nursing Care Delivery Model for Schools. Michigan Association of School Nurses (2003). School nursing agenda for Michigan. Retrieved March 24, 2005, from http://www.michigan schoolnurses.org/documents/schoolnursingagendaformichigan.pdf Michigan Department of Community Health (2007). Michigan Critical Health 16

Indicators. Retrieved date, from www.michigan.gov/mdch/0,1607,7-132,2944_5327---,00.html Michigan Public Act 368 Part 9101 (1978). Retrieved April 30, 2009, from http://www.legislature.mi.gov/(s(tk1xyefutcv0yg45cow3v455))/mileg.aspx?p age=getobject&objectname=mcl-act-368-of-1978 Michigan Public Health Code Part 172, Nursing 333.17201 Delegation 333.16104, 333.16215; Michigan Board of Nursing Rules regarding delegation 8338.0104. (1978). Michigan School Code Act 451. Administrative Rule, R380.1178 (1976). Retrieved April 30, 2009, from www.legislature.mi.gov/documents/mcl/pdf/mcl-act-451-of-1976.pdf National Association of School Nurses (2005). Scope and standards of professional school nursing practice. Washington, DC: American Nurses Association. MASN (2008). Potential funding resources. Retrieved April 26, 2009, from http://www.michiganschoolnurses.org/documents/funding.pdf Section 504 of the Rehabilitation Act of 1973. Retrieved April 26, 2009, from http://www.ed.gov/about/offices/list/ocr/504faq.html#terms Williams, K. (2004). MASN testimony before the governor's commission on patient safety. Retrieved April 26, 2009, from http://www.michiganschoolnurses.org/legislation/masntestimonybeforethe Governor.pdf 17