School Nursing : More Evidence for Action Natalie E. G. Arnold Radford University Spring 2015.

School Nursing : More Evidence

for Action

Natalie E. G. Arnold Radford University

Spring 2015

Conduct literature review investigating economically disadvantaged student health, absenteeism, & the impact of school nurses

Evaluate whether the nurse-to-student ratio has a correlation to the Standard of Learning (SOL) test passage rates for economically disadvantaged (ED) students in Virginia

Perform a cost analysis of adequately staffing Virginia public schools with nurses

Discuss future ideas how the health and academic needs of ED students can be better served by school systems and nurses

Goals/Objectives of

Capstone

Nationwide average school nurse-to-student ratio is 1:1300 (Krause-Parella & Samms, 2011)

NASN, ANA, VAPTA, & the United States Department of Health and Human Services recommend a 1:750 ratio for students of general health 1:225 for students that

require daily nursing interventions

1:125 for students with complex health care needs

1:1 for students requiring continuous nursing services

An increased ratio is recommended for schools with a high percentage of ED students, homeless students, or students with no medical home because these they are at an increased risk of education failure

Problem Stateme

nt

Nationwide Nurse-to-student ratios

Obtained from (Robert Wood Foundation, 2010, p.1)

Virginia’s average Nurse-to-student ratio is 1:900 (Zeller, 2013) Some ratios are as high as 1:3800

Virginia does not mandate that public schools hire school nurses

Virginia Department of Education states that school boards should endeavor to employ one nurse for every 1,000 students.

However, “in those schools that have more than 1,000 students this stated ratio should not be construed as encouragement to employ more nurses” (VA.gov, 2011).

The Virginia Department of Education also states that the desired ratio of one nurse to 1,000 students is not a state mandate.

In the state of Virginia we have almost 38% or 475,236 students that are economically disadvantaged and at an increased risk for educational failure.

Problem in

Virginia

Literature Review 10 studies

3 correlational studies 2 quasi-experimental studies 1 observational study 1 descriptive study 2 cross-sectional studies 1 randomized controlled trial

2 Literature Reviews

Student Health

Academic Achievement

Economically Disadvantaged Students

Absenteeism

Nurses Saving Schools Money

Literature ReviewHealth, Academic Achievement, and

ED Students Garcy (2009) : Correlational study

Students with reported illness or injury had slightly lower mean math scores (2.18 ponts) than those students with no health issues Academic gaps grew over time. Translates to a 2 week learning deficit for

second graders and an 8 week deficit for 9th graders

Ickovics et al. (2014) : Correlational Study Looked at 14 modifiable health indicators that have protective

benefits against chronic diseases Healthy weight Physical Fitness Sleep Quality Decreased Screen Time

“Students with >9 health assets were 2.2 times more likely to perform at goal or above on standardized tests for reading, writing, and mathematics, than students with <6 assets. Each additional health asset was associated with an 18% increase in the likelihood of meeting academic goals” (p.45).

Literature ReviewHealth, Academic Achievement, and ED Students

Basch (2011) : Literature Review (7 articles) Found that 3 factors are related in reciprocal ways:

Familial, social, physical, and economic environment Academic achievement Health

Basch (2011) : Literature Review (6 articles) Healthy learners are better students “school health programs must be a fundamental mission of schools to help close the

achievement gap” (p. 650) between economically disadvantaged and non-economically disadvantaged students

Andrews & Logan (2010) : Correlational Study Compared healthy students vs, unhealthy students, and found a difference of

27% in reading scores and 25% in math scores Compared healthy parents vs. unhealthy parents and found a difference of

27% in the students’ math scores

Bourp & Holstein (2010) : Quasi-experimental study ED students when compared to non-ED are more likely to follow the school

nurse’s advice when it comes to dialogue about obesity

Literature ReviewAbsenteeism

Rodriquez et al. (2013) Quasi-experimental study

Compared schools with a full-time nurse vs. schools with a part-time nurse and found a reduction in mean absences due to illness was statistically significant (p<.05)

Wyman (2005) Observational Study

Compared the number of ill or injured students who were released from school by school nurses vs. those released by non-nursing personnel. 57% fewer students left school before the end of the school day after having contact with a nurse

Rickard et al. (2010) Cross-sectional study

Assessed school nurses’ perception on whether having health insurance affected students’ health and academic success 95%: students were healthier 84%: more concentration 95%: untreated health problems

decreased 90%: reduction in absentee rates 3%: schools helps students & parents

enroll in eligible health insurance 64%: not enough staff to help with

enrollment

Cicutto, To, Murphy (2013) Randomized Control Trial

Found a 10% absolute reduction (p<.01) of student absences & 66% relative reduction in students requiring ER visits for asthma after a nurse led program was instituted that provided asthmatic students with self-management education and also an asthma resource kit that educated the school on how to be more asthma friendly

Literature ReviewNurses Saving Schools Money

Rodriquez et al. (2013) : Quasi-Experimental Study Compared schools with full-time nurses vs. schools with part-time nurses in 9

San Jose, California public schools Absences with full-time nurse on staff = 3.03 days per student Absences with part-time nurse on staff = 3.51 days per student Averages out to a difference of 0.48 days. Time that parents can stay at work,

instead of staying at home caring for a sick child. O.48 days of work, equals out to $120 annually of regained wages for each family and with a participation rate of n=2877, it equals out to a cumulative value of $259,200 annually of regained parental wages

A decrease in absences also increased the amount of “Average Daily Attendance” revenue the school received. The each school gained $45,518.62 in additional ADA funding.

Wang et al. (2014) : Descriptive Study Cost analysis of providing health services by full-time school nurses in all public

schools throughout the state of Massachusetts compared to having no school nursing services

School Health services had an annual cost of $79.0 million Health services prevented $28.1 million in parental productivity loss Prevented $20.0 million in medical care costs Prevented $129.1 million in productivity loss of teachers & other school staff Net gain of $98.2 million

Literature ReviewNurses Saving Schools Money

Table 1

Summarization of Baisch, Lundeen, & Murphy (2011) study results

Average # of Staff per

School

Salary & Benefits/Hourly

Time regained

with full-time school nurse

Added Value

per Staff Member/

Day

Added Value per

School/Day

Added Value per

School/year (based 0n 199

days for principals & assistant

principals & 191 days for Teachers & Clerical Staff)

Principal/Assistant Principal

1.82 $59.29 0.94 hrs/day

(57 minutes)

$55.73 $101.44 $20,186

Teacher 31.6 $53.90 0.33 hrs/day

(17 minutes)

$17.79 $561.92 $107,327

Clerical Staff 1.47 $26.19 0.77 hrs/day

(47 minutes)

$20.17 $29.65 $5663

Cumulative hourly wages regained per school when full-time school nurse is on staff $133,176

Baisch, Lundeen, & Murphy (2011) : Cross-sectional studyrevealed how hiring a full-time school nurse can not only save money, but time as well

Summarization of Baisch, Lundeen, & Murphy (20110 study results

Research Question

In the state of Virginia, is the school nurse-to-student ratio statistically associated with Standard of Learning test

passage rates when comparing economically

disadvantaged students and non-economically

disadvantaged students, during the 2011-2012 school

year?

Conceptual FrameworkConceptual Framework calling for Health Action in Public Schools

Data Description

Data for SOL participation and passage rate for the 2011-2012 school year was obtained from the Virginia Department of Education website

Each district’s school board was contacted to get the correct number of school nurses that were on staff

Each school district in Virginia was ranked one to 132, depending on their SOL passage rates of its ED student subpopulation

Schools were grouped into quartiles of 33 school each

Using a random number generator, five schools were randomly selected from each quartile giving a representative sample of 20 schools

A simple comparison of placing the schools in order of SOL passage rates for ED students shows a higher nurse-to-student ratio is associated with a higher passage rate for ED students

To further analyze, a Pearson’s product moment correlation was applied to the data

School Districts Included in Study

School districts listed in order of ED

passage rates: ranked highest to lowest

With their mean nurse-to-student ratio for the

highest and lowest half of the school districts

VA School District

Nurse to Student Ratio as Decimal

ED Participation Percentage

Non ED Pass Rate

ED Pass Rate

Mean Nurse To Student Ratio

Mean ED Pass Rate

Franklin County 0.00121 47.51% 0.92 0.84

1:1,056 0.79

Russell County 0.00082 48.97% 0.90 0.81Rockingham County 0.00086 36.82% 0.91 0.79Appomattox County 0.00082 49.69% 0.89 0.79

Nelson County 0.00084 49.68% 0.90 0.79

Colonial Beach 0.00162 77.99% 0.90 0.78

Lee County 0.00141 61.60% 0.88 0.77

Stafford County 0.00047 22.21% 0.91 0.77

Carroll County 0.00076 48.63% 0.86 0.77

Williamsburg-James City Co. 0.00064 27.46% 0.93 0.77

Page County 0.00104 47.57% 0.88 0.76

1:1,398 0.72

Danville City 0.00074 73.44% 0.88 0.75Northumberland Co. 0.00065 61.37% 0.91 0.75

Arlington County 0.00038 30.58% 0.94 0.75

Alleghany County 0.00089 47.98% 0.88 0.74

Winchester City 0.00073 53.31% 0.90 0.72

Albemarle County 0.00077 24.52% 0.93 0.70

Hopewell City 0.00064 69.12% 0.84 0.70

Manassas City 0.00047 53.45% 0.84 0.69

Alexandria City 0.00085 58.51% 0.88 0.67

Pearson’s product moment correlation of nurse-to student ratios and SOL passage rates

Graph of Findings

Graph of Findings

Study Summarization Hypothesis was partially

supported An increased nurse-to-student

ratio has a positive correlation with ED SOL passage rates

Increased nursing services in public schools could have a positive impact on student academic achievement

There was a negative correlation between higher ED participation and non-ED SOL passage rates: higher ED participation = Lower non-ED passage rates

The combination of these two things suggest that academic performance, health, & socio-economic factors may have a reciprocal relationship

Study Limitations The connection between

health and academic achievement can contain many more factors Attendance Health behaviors Psychological well-being Cognitive development Testing environment Quality of testing preparation Family support Family structure Etc.

Larger sample of Virginia school districts may strengthen results

The Commonwealth of Virginia should adhere to ANA and NASN recommendation and adequately staff all public schools with a school nurse-to-student ratio of one 1:750

The state of Virginia should also mandate that every school have a full-time nurse on duty.

Proposal

Summary of Cost Analysis Focused on improved ED student

attendance rate and Average Daily Attendance (ADA) revenue VA’s ADA rate per student = $10,854

(Baker, Seiarra, & Farrie, 2010)

20 schools used in study

Monetary aspects considered in cost analysis ADA revenue per pupil Daily parents income (Median

household income as stated by United States Census Bureau)

Number of students (ED & non-ED) that participated in SOL in 2011-2012 school year

Average attendance rate for each school district

Current number of school nurses Number of school nurses needed to

meet recommended ratio at a median salary (with benefits included) of $66,303 (IBMC, n.d.)

Cost analysis does assume that adding the appropriate number of school nurses will decrease absenteeism by 0.7 days per each enrolled ED student (Smith & Sherrod, 2013).

Showed that the schools that needed to hire the most schools nurses (4/20) actually lost money. Some needed to hire 72% more nurses

State of VA would gain $2,226,653 in additional ADA revenue and regained parental wages (despite aforementioned losses).

Alexandria City ↑ $671,688 in ADA revenue annually

Stafford County regained $1,973,293 in lost parental wages if all 15,095 ED students missed 0.7 days less of school

Colonial Beach & Lee County Public Schools neither gained nor lost any revenue; already have recommended ratio

Discussion/Future Ideas Allow School nurses to perform

to the extent of their license. They are not merely “Band-Aid” ladies.

Coordinate & ensure continuity of care, through enrolling in eligible insurance and working with PCPs or Specialist

School Based Health Centers

Mandate & broaden school health services to decrease health and educational disparities

Provides evidence to begin a movement that can gain momentum to strengthen the health services provided in our public school systems

School health is a nontraditional approach to closing achievement gaps

“Closing the health gap” can help close the “achievement gap” and increasing school health services should be a fundamental mission of every school district (Ickovics et al, 2014, p. 48).

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Running head: SCHOOL NURSING 1

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