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Transformational Models of Nursing Across Different Care Settings1

Edited by Linda Norlander R.N., B.S.N., M.S. Group Health Home Care and Hospice

INTRODUCTION

From the time of Florence Nightingale when nursing introduced public health and hygiene principals to the care of wounded soldiers, to the 20th century establishment of advance practice nurses, nursing has been at the forefront of health care transformation. We are now challenged as the health care needs of the population change from an acute and infectious disease focus to that of an aging population with chronic disease. The cost of health care is rising and the number of people who are poorly served by our health care system is increasing.

Along with the change in the health care landscape we are facing a nursing workforce shortage and a nursing leadership shortage. By the year 2025, it is estimated that we will have a shortfall of between 300,000 and a million nurses. Four out of every 10 nurses will be over the age of 50 (Buerhaus, 2008). Moreover, by 2020, 75 percent of the current nurse leaders will have left the nursing workforce (Hodes Aging Workforce Study, 2009).

The following briefs represent the creative and innovative thinking of nurse leaders to address our current and future challenges. They were prepared for the Robert Wood Johnson Foundation Initiative on the Future of Nursing Institute of Medicine Committee, by fellows of the Robert Wood Johnson Foundation Executive Nurse Fellows program. This is an advanced leadership program for nurses in senior executive roles in health services, public health and nursing education who aspire to help lead and shape the U.S. health care system. The program is

1

The responsibility for the content of this article rests with the authors and does not necessarily represent the views of the Institute of Medicine or its committees and convening bodies.



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G Transformational Models of Nursing Across Different Care Settings1 Edited by Linda Norlander R.N., B.S.N., M.S. Group Health Home Care and Hospice INTRODUCTION From the time of Florence Nightingale when nursing introduced public health and hygiene principals to the care of wounded soldiers, to the 20th century establishment of advance practice nurses, nursing has been at the forefront of health care transformation. We are now challenged as the health care needs of the population change from an acute and infectious disease focus to that of an aging population with chronic disease. The cost of health care is rising and the number of people who are poorly served by our health care system is increasing. Along with the change in the health care landscape we are facing a nursing workforce shortage and a nursing leadership shortage. By the year 2025, it is estimated that we will have a shortfall of between 300,000 and a million nurses. Four out of every 10 nurses will be over the age of 50 (Buerhaus, 2008). More- over, by 2020, 75 percent of the current nurse leaders will have left the nursing workforce (Hodes Aging Workforce Study, 2009). The following briefs represent the creative and innovative thinking of nurse leaders to address our current and future challenges. They were prepared for the Robert Wood Johnson Foundation Initiative on the Future of Nursing Institute of Medicine Committee, by fellows of the Robert Wood Johnson Foundation Execu- tive Nurse Fellows program. This is an advanced leadership program for nurses in senior executive roles in health services, public health and nursing education who aspire to help lead and shape the U.S. health care system. The program is 1 The responsibility for the content of this article rests with the authors and does not necessarily represent the views of the Institute of Medicine or its committees and convening bodies. 401

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402 THE FUTURE OF NURSING designed to give nursing and nurses a more influential role across many sectors of the economy. Fellows in this program represent the expertise and leadership of today and the leadership of the future. These briefs include background on the needs, evidence-based innovations and most important, recommendations for healthcare in 21st century. The briefs include the following areas in health care and health care education: • Transformational Partnerships in Nursing Education • Innovative Nursing Education Curriculum • Acute Care • Chronic Care • Palliative and End-of-Life Care • Community Health • School Health COMMON THEMES A number of common themes emerge from the briefs. In order to meet the challenges of the future we must embrace technology, foster partnerships, encour- age collaboration across disciplines and settings, ensure continuity of care and promote nurse-lead/nurse managed health care. • Technology. Advances in technology open a new world in the provision of health care. The use of technology includes electronic health records, telehealth, remote monitoring, education through simulation, and a host of as yet undiscovered innovations. • Partnerships and Collaboration. The importance of partnering and collaborating extends beyond interdisciplinary care at the bedside to nursing education-community partnerships, community and business partnerships, and public and private partnerships. • Continuity of Care Across Settings. Our current “siloed” system leaves significant gaps in care. Smooth transition of patients from set- ting to setting is especially needed with the elderly and chronically ill populations. • Nurse-lead and Nurse Managed Health Care. From the developing model of primary care community based programs to retail-based nurse practitioner clinics, nurses are filling in the primary care gap. RECOMMENDATIONS Each brief includes an important set of recommendations specific to the area addressed. However, a number of universal recommendations emerge that direct the future of nursing and health care.

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403 APPENDIX G • Education. The current nursing education model is not adequate to meet the needs of the future. Education must develop new partnerships with the community, business and healthcare institutions. More emphasis and resources must be directed to preparing master’s- and PhD-level nurses. • Public Policy. Solid funding sources are needed to support nurse prac- titioners, nurse managed community health programs and nursing ed- ucation. Funding must cross settings from acute care to home and community based care. Nurses must be included on local, state, and national health care advisory and policy committees. • Care Models. We must continue to develop innovative care models based on current successes such as the acute care agile self-directed nursing teams, the rural healthy aging community model and school- based and community-based nurse managed clinics. These models should cross disciplines, foster collaboration and partner with communi- ties, business and other organizations. The future of health care rests solidly with the strength nursing brings in ho- listic care, ability to collaborate and innovate from the bedside to the community and the ability to adapt to the changing environment. In order to make this happen nursing must adapt education and curriculum to the new century, promote higher education, advocate for innovative models of care and advocate for the health care and education policy to support those innovations. REFERENCES Buerhaus, P.I. 2008. Current and future state of the U.S. nursing workforce. Journal of the American Medical Association 300(20):2422−2424. Hodes Aging Workforce Study. 2009. http://www.hodes.com/industries/healthcare/resources/research/ agingworkforce.asp (accessed January 10, 2010).

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404 THE FUTURE OF NURSING TRANSFORMATIONAL PARTNERSHIPS IN NURSING EDUCATION Victoria Niederhauser, Dr.P.H., A.P.R.N., M.S.N., P.N.P.-C. University of Hawaii Richard C. MacIntyre, Ph.D., R.N., FAAN Samuel Merritt University Catherine Garner, Dr.P.H., R.N., FAAN American Sentinel University Cynthia Teel, Ph.D., R.N. University of Kansas Teri A. Murray, Ph.D., R.N. Saint Louis University INTRODUCTION Although the nursing care environment has changed significantly over the past 30 years, little has changed in the educational methods used to prepare new nurses. Since the 1930s, most clinical education in nursing has been structured with a faculty member supervising a small group of students on one or more in-patient units. Students usually move to new settings for each clinical rotation. This traditional model is heavily dependent on nursing faculty and often requires students to wait for direct faculty supervision. Students often are “strangers” to the registered nurses providing patient care in these settings. This arrangement can compromise the cohesiveness of the nursing team and limit opportunities for building professional relationships between students, registered nurses, and other members of the health care team. Developing a more structured and co- hesive partnership between the registered nurse and the student, both of whom are providing care to the same patients, has the potential to revitalize clinical education in nursing. BACKGROUND Since Buerhaus and colleagues (2000) first documented the nursing shortage facing the United States, educational institutions have been challenged to increase capacity. The most commonly cited reasons for lack of nursing school capacity are a shortage of nursing faculty and availability of clinical sites (AACN, 2005). Over the last decade new partnership models have developed to finance the cre- ation and expansion of nursing programs, create access to nursing education at all levels, expand and support faculty members, and increase capacity to—and experiences at—clinical sites for students.

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40 APPENDIX G As early as 1993, the Robert Wood Johnson Foundation provided stimulus grants through Colleagues in Caring, a grassroots, state-by-state initiative to bring together healthcare administrators, academics, state regulators, and legislators. This early dialogue prompted states and health care providers to broaden finan- cial support for colleges of nursing, develop joint simulation training centers, and create new approaches to placing nursing students in clinical settings. The initial support from a major philanthropic organization evolved into centers for nursing workforce expansion in a number of states. The number of graduates has increased, but is still not sufficient for future workforce needs (Buerhaus et al., 2009). New models for accelerated doctoral programs are key to producing more nursing faculty and innovative partnerships are imperative the success of these programs. Pre-licensure nursing education is a costly endeavor. While health care or- ganizations have contributed to existing schools, others have acquired nursing schools as part of broader hospital acquisitions. Feeling the pressure of nursing shortages as they plan future organizational growth, large health systems have forged partnerships with private universities to open additional schools of nurs- ing. Institutions such as DeVry, Kaplan, the University of Phoenix, and Western Governors University have business models that can respond to market needs with rapid expansion. The International University of Nursing in St. Kitts, West Indies is the first offshore U.S.-based college of nursing. This sector can be expected to grow, especially as states and local communities respond to budget shortfalls in a downturn economy. INNOVATIONS Across the nation, innovative academic-service partnerships are reenvision- ing the role of the registered nurse as clinical teacher and facilitating 1:1 rela- tionships between nurses and students over extended periods of time (Allen et al., 2007; Joynt and Kimball, 2008; Moscato et al., 2007). In these partnerships, students, faculty, and staff report that students have less unproductive time spent waiting for clinical supervision and better socialization to the professional nurs- ing role (Udlis, 2008). When clinical education is structured to facilitate rela- tionships between students and nursing staff, the faculty role changes as well and includes more involvement with the professional development of nurses as preceptors, coaches, and clinical teachers. Most importantly, students and faculty are not viewed as visitors in the clinical setting, but rather as integral members of the nursing team, committed to building cultures of quality and safety (MacIntyre et al., 2009). Many hospitals are requiring faculty to participate in internal continuing education and competency validation. Innovative partnerships are re- engineering the faculty role to take advantage of what graduate prepared faculty can bring to the clinical setting. The National Council of State Boards of Nursing (2008) reports a wide varia-

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40 THE FUTURE OF NURSING tion in clinical hours between schools of nursing. There is no evidence linking any specific number of hours to improved student outcomes. A change in focus from hours to demonstrated competencies, whether in simulation labs or clinical settings, would make more optimal use of the clinical sites available for student experiences and help make education available to more students. Program evalu- ation studies that document the relative worth of breadth verses depth in the clini- cal experience will help academic–service partnerships move from traditional to evidence-based approaches. Universities and community colleges are increasing their efforts to adopt statewide curriculum models, allowing for seamless transition between pro- grams. These partnerships between associate and baccalaureate nursing programs create more efficient and effective educational advancement pathways for stu- dents. Recognizing the link between improved patient outcomes and baccalaure- ate nursing education (Aiken et al., 2003; Heller et al., 2000) and the need to build efficiencies in nursing educational programs, the state nursing schools in Oregon (http://ocne.org) and Hawaii (www.nursing.hawaii.edu) created Statewide Nursing Consortiums Curriculums that provide a seamless transition to a bac - calaureate in nursing for nurses with associate degrees in one additional year of full-time study. These programs are creating reusable learning objects (i.e., case studies, simulation scenarios, concept-based clinical learning activities) that are immediate, portable, accessible, and ready for on-demand education, suitable for a technology-savvy student population. Initial outcomes from these programs are promising include an increase in the student’s national nursing certification rates and positive student learning outcomes (Tanner, 2009). Innovations in interdisciplinary education on college campuses include new health care models that are designed to produce collaborative learning among stu- dents in nursing, management, journalism and communication, and architecture programs (Melnyk and Davidson, 2009). These nontraditional academic partner- ships bring a variety of perspectives and expertise together that could define the future of education, health, and health care. The dramatic expansion of second- degree programs in nursing is producing a more liberally educated nursing work- force that should facilitate interdisciplinary competence in practice settings. Partnerships between states are also transforming nursing education by cre- ating access to educational opportunities across state lines. These interstate col- laborations between educational institutions are offering joint programs that increase access to all levels of nursing education in rural and underserved areas in the United States through course sharing and collaborative program develop- ment across educational institutions (i.e., the joint Neonatal Nurse Practitioner program at University of California San Francisco and University of Hawaii and The Nursing Educational Xchange). Although these opportunities are emerging, there is still work to be accomplished on a national level to further support inter- state partnership in nursing education. National nursing licensure at both the RN and Advanced Practice levels would allow the state boards of nursing to focus

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40 APPENDIX G more on consumer protection in their state rather than the regulatory issues of granting state licenses. RECOMMENDATIONS Cultivating partnerships will provide many avenues for building capacity in innovative ways for nursing education. Ten recommendations for the future of nursing education are • Create nontraditional partnerships within and outside of educational institutions; • Explore opportunities for the creation and expansion of nursing pro - grams through private partnerships and health care institutions; • Develop, implement, and evaluate innovative academic–practice partner- ships between nursing programs and acute care, primary care, long-term care, community, and public health settings; • Move from a time-based model of clinical nursing education to a competency-based model, and evaluate the evidence to support this type of learning in nursing education; • Support the implementation and evaluation of statewide curriculum models between universities and community college systems; • Expand interdisciplinary educational opportunities and programs; • Champion interstate partnerships to increase access to educational opportunities; • Support research for evidenced based educational practices that chal - lenge existing norms; • Build stronger relationships between nursing students and registered nurses providing patient care; and • Address policy issues that create barriers to the above recommendations. Innovative partnerships between nursing education and nursing practice are essential if the nursing profession is to meet the challenges ahead. The dissemi- nation of successful innovative models in nursing education requires evidence as well as creative and adaptive partnerships that are developed, nurtured, and evaluated. REFERENCES AACN (American Association of Colleges of Nursing). (2005). Faculty Shortages in Baccalaureate and Graduate Nursing Programs: Scope of the Problem and Strategies for Expanding the Sup- ply accessed at http://www.aacn.nche.edu/Publications/WhitePapers/FacultyShortages.htm on December 3, 2009.

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40 THE FUTURE OF NURSING Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., and Silber, J. H. (2003). Educational level of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290(2), 1617−1623. Allen, P., Schumann, R., Collins, C., and Selz, N. (2007). Reinventing practice and education partner- ships for capacity expansion. Journal of Nursing Education, 46(4), 170−175. Buerhaus, P., Staiger, D., and Auerbach, D., (2000). Implications of a rapidly aging nursing work- force. Journal of the American Medical Association, 283(22), 2948−2954. Buerhaus, P., Auerback, D., and Staiger, D. (2009). The recent surge in nurse employment: causes and implications. Heatlh Affairs, July/August, 28(4): w657−w668. Heller, B. R., Oros, M. T., and Durney-Crowley, J. (2000). The future of nursing education: Ten trends to watch. Nursing and Health Care Perspectives, 21(1), 9−13. Joynt, J., and Kamball, B. (2008). Blowing open the bottleneck: Designing new approaches to in- crease nurse education capacity. Retrieved September 14, 2008, from http://championnursing. org/uploads/NursingEducationa/CapacityWhitePaper20080618.pdf. MacIntyre, R., Murray, T., Teel, C., and Karshmer, J. (2009). Five recommendations for prelicensure nursing education. Journal of Nursing Education, 48, 447−453. Melnyk, B. M., and Davidson, S. (2009). Creating a culture of innovation in nursing education through shared vision, leadership, interdisciplinary partnership, and positive deviance. Nurs Admin Q, 33(4), 288−295. Moscato, S., Miller, J., Logsdon, K., Weinberg, S., and Chorpenning, L. (2007). Dedicated education unit: An innovative clinical partner education model. Nursing Outlook, 55, 31−37. National Council of State Boards of Nursing (2008). Member board profiles: Educational programs. Retrieved April 26, 2008, from https://www.ncsbn.org/983.htm. Tanner, C. (2009). Evaluation of the outcomes of the Oregon consortium for nursing education’s model to address the nursing shortage in Oregon 5/15/2008-5/14/2009. Annual Narrative Report. Udlis, K. A. (2008). Preceptorship in undergraduate nursing education: An integrative review. Journal of Nursing Education, 47, 20−29.

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40 APPENDIX G INNOVATIVE NURSING EDUCATIONAL CURRICULUM FOR THE 21ST CENTURY Mary Ellen Smith Glasgow, Ph.D., R.N., A.C.N.S.-B.C. Drexel University Lynne M. Dunphy, Ph.D., F.N.P.-B.C. College of Nursing, University of Rhode Island Rosalie O. Mainous, Ph.D., A.R.N.P., N.N.P.-B.C. University of Louisville INTRODUCTION The changing landscape of healthcare in America requires that clinicians be skilled in responding to varying patient expectations and values; provide ongo- ing patient management; deliver and coordinate care across teams, setting, and time frames; and support patients’ endeavors to change behavior and lifestyle— education which is in short supply in today’s academic and clinical settings (IOM, 2003). Nursing education needs to innovate at the micro and macro system level for the 21st century. It cannot be business as usual. In order to truly transform care, practice and education will need to partner on curriculum development and the professional socialization of the new nurse. BACKGROUND Innovation in academic settings, specifically colleges of nursing is often hin- dered by the pressure to meet educational and regulatory requirements established by national organizations, accrediting agencies, and the state boards of nursing that govern and set standards for nursing practice at both the baccalaureate and graduate levels (Melnyk and Davidson, 2009). These regulations should not be barriers to innovation. Time-honored traditions in nursing education such as the current undergraduate clinical instruction model, a disease and illness-oriented curriculum, and the need for extensive clinical practice before matriculating in doctoral programs should be reexamined. There is a need to embrace technology- infused education, transdisciplinary approaches to care, and translational research. Students need to learn how to effectively assess and manage some of the most significant health problems currently confronting our society (e.g., mental health disorders, obesity, patient safety) and how to innovate changes in our health care system (Melnyk and Davidson, 2009). Furthermore, a very uncomfortable, diffi- cult question needs to be asked: “What should be the most appropriate degree for entry into nursing practice?” Given the complexity and wide range of knowledge and competencies that will be required of nurses in the 21st century, it is strongly recommended that nurses be prepared at the baccalaureate level for entry into

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410 THE FUTURE OF NURSING practice. Moreover, the entry into practice debate needs to be resolved in the 21st century (Benner et al., 2010). INNOVATIONS: TECHNOLOGY-INFUSED EDUCATION, TRANSDISCIPLINARY APPROACHES TO CARE, AND TRANSLATIONAL RESEARCH Simulation is one very effective tool that exposes students to the complexity of clinical settings without the hazards of real life (Ironside et al., 2009). Future nursing curricula need to develop interdisciplinary simulation scenarios focusing on collaboration and crucial conversations so that students can learn how to deal with ineffective professional relationships and unsafe practice in a controlled environment (AACN, 2005). Transdisciplinary or interprofessional models of simulation and debriefing can examine and dissect failed communication in health profession’s education and result in a series of recommendations to im- prove health care environments and patient outcomes. The curriculum for the 21st century needs to provide an opportunity for future health care providers to partici- pate in collaborative education to obtain the necessary advocacy skills to promote a safe, healthy work environment for the patients they serve. Additionally, with the rapid expansion of knowledge, the development of information appraisal and navigation skills are essential for future nurses (Melnyk and Davidson, 2009). Transdisciplinary or interprofessional models of education are at the core of new type of dedicated education unit: one that educates nurses, physicians, pharmacists, and other professionals depending on the type of patient needs ad- dressed. Dedicated education units have previously implemented best practices utilizing the staff nurse as educator (Moscato et al., 2007). This new model of education is broader, more inclusive, and seeks to find commonalties in the cultures of both service and academe and may provide an ideal site for faculty practice as well. As a starting point, a hospital environment is chosen as an ex- emplar to demonstrate the feasibility of the model. Chief nursing officers would dedicate select units and develop methods to choose seasoned nurses to work in the new environments as change agents. Clinical educators in nursing and other disciplines would establish daily rounds with input from all students at varying levels based on Benner’s Novice to Expert (Benner, 1984). More experienced students would mentor the novice. A model of leveled reflective learning has been described in Sweden utilizing different hospitals for different levels of learning within the context of the dedicated education unit (Lindahl et al., 2009). Nurses, hospitalists, and other health professionals are educated in teaching pedagogy and contribute to the education and evaluation of the students. This innovative model also facilitates a better understanding of what each discipline contributes to the overall plan of health improvement. Students are exposed to multiple faculty members who share responsibility for students and students become a member of the team (Budgen and Gamroth, 2007). Transdisciplinary

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411 APPENDIX G team meetings will periodically assess the adequacy of the model, the experience of the student, and the areas for growth. BUILDING THE SCIENCE It has been well documented that the nursing profession faces a serious short- age of nursing faculty, as well as a severe dearth of underrepresented minority (URM) faculty (Potempa et al., 2008; Sullivan Commission, 2004), that has dra- matic implications for, and is a threat to, the future of nursing. In order for nursing to be a truly resonating force for health in the 21st century, it is essential that we grow the science of nursing and demonstrate its effectiveness in fostering health. The case can be made that the production of masters and doctorally prepared nurses is more critical than a focus on preparation of Registered Nurses. Difficult decisions must be made. Which educational setting best supports the preparation of different levels of practice? Advanced Practice Nurses across the board are needed; nurse faculty, nurse leaders, and nurse scientists are all in high demand. Masters Entry into professional nursing programs has brought a needed cadre of adult learners with broad-based backgrounds into nursing that enhance the dis- cipline. The emergence of the professional doctorate (DNP) is integral to support- ing disciplinary growth. We promote a view of the practice doctorate as one not divorced from research but rather additive to the development and use of science. But this will not be enough. A solid background in science, scientific inquiry, and the scientific basis of health is essential to develop health care innovation. RECOMMENDATIONS The authors propose strategies to shape the future of healthcare by creating models of nursing education focused not only on curriculum changes, but also on transforming the student population, integrating the science and research in the curriculum and influencing health care policy. Curriculum and Technology • Create truly unique Transdisciplinary Simulation Centers across the country where students from the health disciplines of nursing, health professions, and medicine will be exposed to the complexities of team- work situations within the clinical setting. • Develop curriculum well grounded in disease prevention, health promo- tion, and screening, and public health. Include greater emphasis on the aging, older adult, ethics, genetics, public speaking, and writing skills (Sauder et al., 2006). • Develop sufficient technology skills to better support increased knowl- edge management including point-of-care technology.

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432 THE FUTURE OF NURSING SCHOOL NURSES, SCHOOL-BASED HEALTH CENTERS, AND PRIVATE PROGRAMS SUCCESSFULLY IMPROVE CHILDREN’S HEALTH Maxine Proskurowski, R.N., M.S.N. 4J Health Services Eugene School District Mary E. Newell, R.N., M.S.N. Kent School District Marykay Vandriel, R.N., M.S.N., Ed.D. Value Health Partners “Investing in children is not a national luxury or a national choice. It’s a na- tional necessity.” Marian Wright Edelman INTRODUCTION School nurses serve nearly 50 million students in approximately 97,000 public elementary and secondary schools (USDE, 2008). Sadly, almost a quarter of the nation’s schools do not have the benefits of a skilled nurse, and yet stud- ies like one conducted by the Milwaukee Public School System found that “in schools with nurses, principals and clerical staff reported significant reductions in the time that they spent addressing student health issues. In support of students attending classes, nurses returned students to their classroom over 90% of the time” (Baisch et al., 2009). HISTORICAL AND CURRENT OVERVIEW Nurses have been a part of the school setting since the late 1800s, with the initial mandate to monitor vaccinations, decrease school absenteeism, and prevent the spread of communicable diseases. In the last 10 years school nurses have concentrated on new areas of care that have emerged as a result of • Medical advancements that allow children with multiple medical issues to survive; • A rising incidence of diseases with life-threatening implications like diabetes, seizures, severe allergic reactions, asthma, bleeding disorders, and genetic conditions; • An increase in mental health disorders, including rising incidence of au - tism and related neurodevelopment disorders; youth gambling, alcohol, tobacco, drug abuse, and other addictive behaviors; youth with eating disorders, anxiety, depression, and suicidal ideation; youth exhibiting bullying, harassment and violent behaviors; and • An increasing number of children living in poverty, including those who are homeless, migrants, immigrants or refugees.

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433 APPENDIX G As school districts face budget cuts nationwide, school nurses are often the first to lose their jobs. This is especially true in states that do not mandate school nurses. The federal government requires that children who have health impair- ments need to have a connection with a school nurse, but in many school districts this may mean contracting for a few hours of nursing service from an agency source. The national federal guidelines for school nurses are a ratio of one nurse to 750 students. Only 12 states comply with this ratio—Vermont has the lowest ratio: one nurse for 305 students, Utah the highest: one nurse for 4,952 students (Zaslow, 2006). The current nurse-to-student ratio means that nurses cover multiple schools and run from one emergency to another. To address the current inadequacies where nurses face work overload, nurse leaders, together with parents, children, and communities have developed two innovative school health programs: school- based health centers and public–private partnerships, that can be replicated na- tionwide and can provide many new and exciting opportunities for nurses to expand their scope of practice. SCHOOL-BASED HEALTH CENTERS School Based Health Centers (SBHCs) are primary care clinics in the schools that provide developmentally appropriate physical, emotional, behavioral and preventive health care to students regardless of their ability to pay. SBHCs are similar to a local primary care office: with a secretary or receptionist, nurse, nurse practitioner, and at some sites a mental health therapist. Currently there are 2,000 SBHCs nationwide, and have had the following positive impacts: • SBHCs are prevention and wellness oriented. • SBHCs see children who otherwise would not get care. • One in four adolescents who are at risk for adverse health outcomes such as teen pregnancies, suicide, and substance abuse can easily and readily access services in a setting where they spend the majority of their days. Nationwide satisfaction surveys indicate that 97 percent of the students ap- preciate and value the care they receive; and 60 percent report that they would not have received health services without the health centers (Schlitt, 2007). SUCCESS: SCHOOL NURSES AND SBHCS COMPLEMENT EACH OTHER Jack, a 10th grade student at a local high school, had been to school only 11 days as of December 1, 2008, due to sickness. The school nurse reviewed the absent record with Jack. Jack complained that he would become short of breath walking the half mile to school so he stayed home. With parent permission, she referred Jack to the SBHC. The nurse practitioner diagnosed Jack with asthma

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434 THE FUTURE OF NURSING and prescribed medication. During the exam she also noted symptoms of depres - sion and referred Jack to the mental health specialist at the SBHC. The mental health specialist confirmed the diagnosis of depression along with suicide ide- ation and additionally the potential to do harm to himself and others. Jack has re- mained under the care of the practitioners in the SBHC. December 1, 2009, Jack continues with a stellar attendance and academic achievement record. His asthma and mental health conditions are under control through the combination of care delivery between the school nurse and the staff in the SBHC. This partnership has been successful in keeping Jack safe and healthy and engaged in learning. PUBLIC–PRIVATE PARTNERSHIPS INITIATED BY SCHOOL NURSES Another innovative example in school health programs are the public–private partnerships that nurses are developing in communities around the country. One of the primary tenets of a nurse is to be a coordinator of care. In research studies conducted by both Lamb and Sofaer, care coordination is identified as one of the most important processes that nurses perform. The IOM has identified care coordination as one of the top 20 priorities for national action to transform the health care system. In the community, the school nurse coordinates care in the public school among a variety of providers and community agencies that offer services to children and their families. The nurse can provide point of service care at the site and manage almost all of the health concerns that students present. This arrangement increases the student’s time in the classroom and maximizes educa- tion. The nurse is also in an ideal position to guide children and their families into appropriate acute care, if needed. SUCCESS: NURSES DEVELOP COMMUNITY PARTNERSHIPS Michigan is experiencing the brunt of the economic downturn with their automotive manufacturing base disintegrating. They have been forced to create a model of public–private partnership in order to provide health care to one of their most vulnerable populations: children. The Michigan model has placed the nurse in the driver’s seat of coordinating care in the school. Funding is primarily provided by the both the health system and the educational system. However, the school nurse typically coordinates over 80 community agencies to provide services for students and their families. This coordination equates to thousands of in-kind hours and dollars. None of which would happen without the nurse. The Michigan model has utilized Community Health Workers (CHWs) in their schools as well. It is imperative to note that this is only under the supervi- sion of the registered nurse. The broadened responsibility has challenged nursing to gain new leadership and delegation skills. This model requires clear prac- tice guidelines and health policies developed by the state board of nursing and adapted by the school system. The school nurse is the health leader in the school

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43 APPENDIX G community. She has demonstrated leadership in delivering health outcomes, re - ducing costs, and providing extraordinary benefit to the community. This model has also been replicated and is exportable. RECOMMENDATIONS AND ACTIONS NEEDED Certificated School Nurses need to be present in the schools in order to advocate for school nursing services for every child. SBHCs contribute to aca- demic achievement by taking physical and behavioral health problems out of the classroom and place them into the hands of qualified medical professions and link students to health services and resources available in the community. Through collaboration with community providers and building public–private partnerships, primary care, mental health, health education and dental care services can be provided at little or no cost to the students and their families. Improved student outcomes and academic achievement result where schools have a partnership with a school nurse, an established SBHC, and community collaborations. • Mandate a certified school nurse/student ratio of 1:750 students in every state and in all schools. • Allocate federal and state governments funds to school-based health centers so that all students, regardless of their ability to pay, can access comprehensive medical, dental and mental health care by nurse practi- tioners, nurses, and other health care professionals. • Establish funding for school health development of public–private part- nerships, including community health worker programs that are led by certified school nurses. • Require nurses who work in schools to have a minimum of a bachelor’s degree and a school nurse certificate. SUMMARY With an expected increase in the number of children who have complex medical, genetic and psychiatric health conditions that require more nursing oversight, school nursing provides the expertise and coordination to assure that children receive the care they need. School nurses are at the forefront of promot- ing and developing innovative school programs like School-Based Health Centers and coordinated partnerships with private and public agencies. REFERENCES Baisch, M. J., Lundeen, S. P., Stetzer, F. P., Kelber, S., Carey, L. K., and Holmes, M. B. (2009). Coordinated School Health Program Title I Funded Nursing Services 200-200 Program

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43 THE FUTURE OF NURSING Evaluation, University of Wisconsin-Milwaukee College of Nursing Institute for Urban Health Partnership. Schlitt, J. (2007, June). Presentation at National School based Health Conference, Washington, DC. USDE (U.S. Department of Education). (2008). Back to school fast facts. National Center for Educa- tion Statistics. Retrieved 12/2/2009 from http://nces.ed.gov/fastfacts/# (Institute of Medicine, Priority Areas for National Action: Transforming Health Care Quality, Washington: National Academies Press, 2003) Retrieved 12/7/09 http://www.rwjf.org/qualityequality/product.jsp? id=27811. Zaslow, J. (2006, November 2). Is there a nurse in the house? Schools endure shortage as health needs rise, Wall Street Journal.

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43 APPENDIX G PUBLIC HEALTH NURSING: TRANSFORMING HEALTH ACROSS POPULATIONS Linda Olson Keller, D.N.P., R.N., FAAN University of Minnesota Teresa Garrett, R.N., M.S. Utah Department of Health Patricia Drehobl, R.N., M.P.H. Centers for Disease Control and Prevention INTRODUCTION A well-educated public health nursing workforce would improve the health of all people and minimize health differences among populations by addressing the physical and social determinants of health (Manitoba Health, 1998). Public health nursing is unique among the nursing specialties in its integration of the art and science of two distinct disciplines—public health and nursing. Public health nurses (PHNs) employ their considerable expertise in promoting health and preventing disease to address the health needs of populations, such as emerg- ing and reemerging infectious disease, an epidemic of chronic disease, a rapidly aging population with increasing health needs, escalating health care costs, and pressure to prepare for and respond to public health emergencies ranging from H1N1influenza to bioterrorism. Many of these challenges cannot be resolved at the individual level and must be addressed through policy and environmental change. PHNs work in partnership with multidisciplinary teams and community members to create conditions in which people can be healthy. PUBLIC HEALTH NURSING ISSUES As the largest component of the public health workforce, PHNs are vital to the protection of health in America’s communities; almost every health depart- ment in the nation, large or small, employs PHNs (NACCHO, 2009). Unfortu- nately, public health nursing is in the midst of a crisis—the erosion of the public health nursing infrastructure. • Historically, every state health department had an executive PHN posi- tion. Today, only 23 states support such a leadership position (ASTDN, 2008). Severe budget cuts in local and state health departments have led to the reduction or elimination of PHN positions. In 2004, decrease was reported in registered nurses working in community and public health settings, down from 18.3 to 14.9 percent (HRSA, 2004). • Health departments currently face a PHN shortage; 30 out of 37 states

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43 THE FUTURE OF NURSING reported public health nursing as the field that will be most affected by workforce shortages in the future (ASTHO, 2004). This critical PHN shortage may jeopardize the system’s ability to respond to new and emerging public health threats. • Many health departments, particularly those in more rural states, hire nurses from 2-year associate degree programs that do not provide pub- lic health content, and who are not prepared to practice public health nursing. • The educational system faces a growing shortage of faculty adequately prepared to teach public health nursing, a lack of clinical sites that pro- vide meaningful PHN clinical experiences, and little incentive or sup- port for advanced PHN graduate study, which has led to low enrollment in PHN graduate programs. EVIDENCE-BASED PUBLIC HEALTH NURSING MODELS ELECTRONIC HEALTH RECORDS AND PUBLIC HEALTH NURSING OUTCOMES A joint practice and data quality project was undertaken by public health nurse managers in four local health departments. The project utilized the Omaha System, a standardized nursing language and a computerized clinical documenta- tion system. This project articulated standards for client assessment, developed pathways of care for typical PHN client groups and/or client problems, and defined common quality assurance standards to monitor PHN practice and data quality. Standardized data allowed PHNs to compare client outcomes between health departments. As a result, public health nurses were able to influence policy decisions by reporting data to funders, stakeholders, and the community (Monsen et al., 2006). HOME VISITING PROGRAMS The Nurse Family Partnership (NFP) is an evidence-based program in which public health nurses visit the homes of pregnant, low-income families during pregnancy and teach them to parent during the baby’s first 2 years of life. This program has demonstrated consistently positive outcomes in randomized con- trolled trials, including pregnancy (reduction in subsequent pregnancies 2 years after child’s birth, reduction in preterm deliveries among women who smoked), parenting (less child abuse and neglect, reduction in behavioral and intellectual problems in child age 6, reduction in arrests of child age 15), and family self-suf- ficiency (fewer arrests of mothers 15 years after child’s birth, increase in father presence in the household, reduction in welfare use) (NFP, no date). The program has been shown to save taxpayers money, paying for itself based on government spending alone (Isaacs, 2008). It is important to note that nurses are central to the success of this home visiting program. Utilization of paraprofessionals to

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43 APPENDIX G deliver the NFP demonstrated little to no effects as few as 2 years after program completion (Olds et al., 2004). PHNs across the nation are implementing the NFP in over 300 counties and several statewide programs. Various versions of the Health Care Reform Bill of 2010 have proposed nationwide implementation of the NFP. Public health nurses, with over a century of expertise in home visiting and established relationships with their communities, are in a position to lead this national initiative. PREVENTION AND CONTROL OF INFECTIOUS DISEASE Not all evidence-based programs are new. Public health nurses continue as critical players in some of the most dramatic evidence-based programs in his- tory—the eradication/reduction of vaccine preventable diseases and tuberculosis. A recent PHN task analysis of 60 PHNs from 29 states revealed that the detec- tion, prevention and control of infectious diseases are core public health nursing activities (ASTDN). Despite the fact that the PHNs in the task analysis worked in many different program areas ranging from emergency preparedness to fam- ily planning, they were all involved with the prevention and control of vaccine preventable diseases and tuberculosis. Over 90 percent of PHNs reported working in immunization clinics, a clas- sic evidence-based intervention. Most of the disease prevention and control work that the PHNs reported was population-focused: surveillance and disease investigation; identification and outreach to high risk populations; audits of im- munization records in schools; audits of clinics to determine compliance with recommended immunization standards; and development of population-based immunization registries. As part of emergency preparedness, half of the PHNs were involved in planning and staffing mass dispensing clinics. Tuberculosis (TB) is a similar cross-cutting issue. Three fourths of the PHNs reported that they work with clients who have latent or active TB; over 80 percent of PHNs administer and read tuberculin skin tests. The current CDC recom- mendation for the treatment of persons with TB is Directly Observed Therapy (DOT), or watching clients take their medications to ensure compliance. Over two-thirds of PHNs in the task analysis reported that they conduct Directly Ob- served Therapy home visits. Evidence demonstrates that PHN case management dramatically increases successful DOT completion rates (Mangura et al., 2002). In 1994, Massachusetts mandated that health departments use nurses to assess suspected TB cases and manage treatment, resulting in completion rates between 93 and 95 percent, which are among the highest in the nation (Geiter, 2000). REINVIGORATING PUBLIC HEALTH NURSING EDUCATION Two federal grants—one in Minnesota and another in Wisconsin—developed a new model for public health nursing education. “Linking Public Health Nursing Practice and Education to Promote Population Health” and “Linking Education

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440 THE FUTURE OF NURSING and Practice for Excellence in Public Health Nursing Project” (http://www.son. wisc.edu/LEAP/) brought together public health nursing faculty from baccalaure- ate schools of nursing with public health nurses from local health departments that provide clinical sites for PHN students. They formed regional projects that redesigned the PHN student experience based on community priorities. Both projects recruited, trained, and supported a network of preceptors. These projects resulted in a significant increase in collaboration among and between schools of nursing and local health departments, expansion of clinical placement sites, student clinical experiences that contribute to meeting the goals of local health departments, a more active role for local health departments in assuring compe- tencies necessary to begin PHN practice, greater emphasis on population-based PHN practice in schools of nursing curricula, and increased numbers of graduates indicating interest in pursuing a career in public health nursing. RECOMMENDATIONS A well-prepared public health nursing workforce in numbers sufficient to deliver essential public health services is critical for the health and economic well-being of communities. Public health nurses possess a core set of skills and knowledge that allow them to adapt to ever-changing community needs. In order to achieve public health nurses’ potential, however, they must increase their vis- ibility and policy advocacy. Education and Leadership Development • Partner with PHN organizations to create leadership development pro- grams for PHNs in federal, state and local health departments. This is particularly important for state PHN leaders, of whom 80 percent are new to their job since 2005. • Advocate for public health nursing leadership positions in all state health departments. • Develop new models to fund, prepare and advance associate degree nurses who are working in PHN positions. • Develop and share effective, innovative strategies to teach public health nursing, including clinical simulations, cross-disciplinary classes, and clinical immersion experiences in the community. • Provide incentives for graduate school, including traineeships and loan forgiveness programs for advanced PHN graduate study. • Develop and disseminate a tailored curriculum for teaching public health nursing. • Work with stakeholders to conduct a national enumeration to determine the actual number, educational preparation, and distribution of PHNs in the United States.

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441 APPENDIX G Public Health Policy • Fund research to better articulate the contributions and outcomes of public health nursing interventions. Unfortunately, when public health nurses are doing their jobs well, they are invisible and their work is often not valued. • Market the pivotal role of PHNs to increase political influence and se - cure more funding. The flexibility, versatility, and passionate commitment to the communities they serve place PHNs in a position to lead the changes necessary for creating the conditions in which people can be healthy. REFERENCES ASTHO (Association of State and Territorial Health Officials). (2004). State public health employee worker shortage report: A civil service recruitment and retention crises. Retrieved April 25, 2006 from http://astho.org/pubs/WorkforceShortageReportFinal.pdf. ASTDN (Association of State and Territorial Directors of Nursing). (2008). Report on a Public Health Nurse to Population Ratio. Retrieved April 20, 2006 from http://www.astdn.org/ downloadablefiles/draft-PHN-to-Population-Ratio.pdf. HRSA (Health Resources and Services Administration). (2004). The registered nurse population: national sample survey of registered nurses. Retrieved September 25, 2006 from http://bhpr. hrsa.gov/healthworkforce/reports/rnpopulation/preliminaryfindings.htm. Isaacs, J. (2008). Supporting Young Children and Families Opportunity 08: An Investment Strategy That Pays. A Project of the Brookings Institution. Retrieved December 14, 2009 from http:// www.brookings.edu/~/media/Files/Projects/Opportunity08/PB_Children_Isaacs.pdf. Geiter, L. (ed.) (2000). Ending Neglect: The Elimination of Tuberculosis in the United States. Institute of Medicine/National Academies of Sciences, Washington, DC. Mangura, B., Napolitano, E., Passannante, M., Sarrel, M., McDonald, R., Galanowsky, K., Reichman, L. (2002). Directly observed therapy (DOT) is not the entire answer: An operational cohort analysis. International Journal of Tuberculosis and Lung Disease 6:654-61. Manitoba Health. (1998). The Role of the Public Health Nurse within the Regional Health Authority. Retrieved December 7, 2009 from www.gov.mb.ca/health. Monsen, K., Fitzsimmons, L., Lescenski, B., Lytton, A., Schwichtenberg, L., and Martin, K. (2006). A public health nursing informatics data-and-practice quality project. CIN, 24, 152-158. NACCHO (National Association of County & City Health Officials). (2008). National Profile of Local Health Departments. Retrieved December 7, 2009 from http://www.naccho.org/topics/ infrastructure/profile/resources/2008reports/upload/NACCHO_2008_ProfileReport_post-to- website-2.pdf. NFP (Nurse Family Partnership). Retrieved November 28, 2009 from http://www.nursefamilypartnership. org/content/index.cfm?fuseaction=showContent&contentID=4&navID=4. Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., Isaks, K., Sheff, K., and Henderson, C. R. Jr. (2004). Effects of home visits by paraprofessionals and by nurses: age 4 follow-up results of a randomized trial. Pediatrics, December, 114(6), 1560-1568.

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