Running head: INCREASED NURSE STAFFING IN SCHOOL CLINICS 1

Improving the Quality and Safety of Student Care in Schools Through Increased Nurse Staffing

Elizabeth Blanton

Bon Secours Memorial College of Nursing

Instructor Tomeka Dowling, DNP, RN

NURS 3207

July 21, 2016

Honor Code I pledge

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Improving the Quality and Safety of Student Care in Schools Through Increased Nurse Staffing

Nurse staffing has a significant impact on the quality of patient care and on patient

outcomes in all types of environments in which nurses work, from the acute care hospital setting

to the school health clinic. Schools serve students and their families for a considerable portion of

a students day and have a fiduciary responsibility to meet the needs of all aspects of a students

life while under a schools supervision, which includes students health care needs. The specific

needs of a student in a school setting may be different from the needs of a patient in an acute care

unit in a hospital, but the responsibility of the nurse to provide adequate and safe care to patients

or students is the same. A nurses ability to provide high quality care depends on the

environment in which she practices and includes variables such as access to resources, support

from administration, and safe nurse to patient ratios (Cho, Chin, Kim, & Hong, 2015). As

advances in medical technology and medical treatments continue, the care a student may require

in the school setting changes as well. The National Association of School Nurses (NASN)

reports that the number of students requiring special care in schools and the percentage of

students with chronic conditions requiring specialized nursing care has increased significantly in

recent years (NASN Position Statement, 2015). In order to provide adequate care in schools,

there must be adequate staff, which should be continually evaluated based on the acuity of

student health needs and the overall student body population. To make this evaluation,

consistent monitoring using nurse-sensitive indicators should be implemented, allowing schools

to have a data driven understanding of student health outcomes and staffing needs. The collected

data can then be evaluated in consideration of staffing recommendations by NASN, which

recommends a nurse to student ratio of 1:750, with the ratio decreasing to 1:225 and 1:125 as the

complexity of student care increases (NASN Position Statement, 2015).

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Nurse staffing is a critical component of creating a high quality and safe environment for

patients. Researchers have found that there is an inverse relationship between a nurses work

environment, which includes nurse staffing, and adverse patient events, including medication

errors (Cho et al, 2015). Specifically, the study demonstrated that for every increase of one

patient per nurse on a shift, the unit saw a 1% increase in medication errors, 1% increase in

pressure ulcers, and a 2% increase in patient falls (Cho et al, 2015). Other researchers have

found that the risk of patient death increased 6% when a unit had a nurse staffing shortage during

just one 8-hour shift (Hair et al, 2014). These adverse patient outcomes due to reduced nurse

staffing relate to the school environment as well. School nurses actively participate in health

promotion and education, disease prevention, triage and treatment of acute care issues, chronic

care management, and psychological services (Lineberry & Ickes, 2015). Researchers have

found that appropriate school nurse to student ratios are related to improved student outcomes,

such as improved attendance rates and academic success (NASN, 2015). Lineberry & Ickes

examined 30 peer reviewed journal articles and found evidence that demonstrated that the

presence of a school nurse improves student attendance, improves the quality of the school, and

creates a learning environment in which all youth are able to participate, even those with specific

health concerns (Lineberry & Ickes, 2015). In addition to the positive influences a school nurse

has on a students education, maintaining adequate staffing decreases the risk for adverse student

events, such as medication errors. According to one study, researchers found that inadequate

staffing can lead to more physically and psychologically demanding workdays that can result in

errors in medication or dose (Cho et al, 2015, p.80). The implications of inadequately staffing

schools with nurses could result in serious harm to children and even death.
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Nursing-sensitive indicators are based on quality and safety care structures and processes

that influence patient outcomes. These indicators are specific to nursing and demonstrate a

measurable standard of nursing care that directly impacts a patient care outcome (Montalvo,

2007). These indicators can be used on an individual nursing unit or evaluated collectively to

identify ways in which nursing care can be improved, or the results can be shared within the field

of nursing when best practices are recognized. The National Database of Nursing Quality

Indicators (NDNQI) is a collection of nursing-sensitive indicators used for this purpose. The

NDNQI database includes indicators that evaluate issues such as nurse satisfaction, nurse

staffing, and the quality of nursing care (Press Ganey Associates, 2015). In order to implement a

quality improvement project regarding RN staffing in the school health clinic setting, applicable

nursing-sensitive indicators and quality and safety care structures should be identified. Quality

and safety care standards that could be addressed to evaluate the nursing practice issue of staffing

in school health clinics include RN staffing hours, RN to student ratio, school employee staffing

hours, hours of RN administrative duties, student outcome variables, and RN satisfaction and

turnover.

The proposed quality improvement project to address RN staffing concerns in schools is

to evaluate the effects of adding a part-time RN to assist two full-time RNs in a school that

serves a student body of 1,000 students, which includes 8 diabetic students, 5 students at risk of

seizure, 55 students at risk of an anaphylactic reaction to food allergies, 51 students requiring an

inhaler, 7 students requiring daily medication administration, and 14 students with serious health

conditions. The work structure of the part-time RNs position would entail working from 10am-

1pm daily, during the peak volume of student clinic visits. The goal of this quality improvement

change would be to allow the full-time RNs to complete administrative tasks, allow the
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dedication of 65% of full-time RN work time to direct student care, decrease medication errors,

decrease the nurse to student ratio, decrease the number of return student visits to the clinic in

one day, decrease the amount of time spent on student care by non-medical school staff,

eliminate nurse turnover and improve nurse satisfaction. Using identified nurse-sensitive

indicators, school administrators and nurses could perform ongoing monitoring throughout the

school-year and evaluate the impact of RN care and processes on student health outcomes.

Specifically, these indicators and care structures would allow school administrators to evaluate

the time RNs are spending with students in relation to their total work time, how many students

for whom RNs are required to provide care, the hours that a substitute nurses assistance is

needed, and how many work hours other staff members are spending on student care. In

addition, RN hours could be broken down into time spent on student care versus administrative

tasks. Patient outcome variables would include medication errors by RNs, the average length of

time a student spends in the clinic away from class, the number of student visits requiring a

return clinic visit in the same day, the number of student visits requiring the RN to follow-up

with a parent or school staff member, and the number of students sent home for illness. Finally,

nurse turnover could be monitored and the RNs overall job satisfaction could be tracked, using a

10-point scale with 1 being the lowest rating and 10 being the highest rating of satisfaction.

Below is a sample dashboard that could be used by the nurses and office staff to track nurse-

sensitive indicators related to a school health clinic; the timeframe covers one full school year.
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Sample Dashboard for Nurse Staffing in a School Setting

Data similar to the data collected from this dashboard examining the effects on student

outcomes from increased nurse staffing levels in a school clinic has been examined previously in

other research studies and has demonstrated improvements in student outcomes. The outcome of

adding a part-time RN position to the nurse workforce in this project should see positive changes

in student outcome variables and decreases in the workload of non-medical school staff.

Previous research has demonstrated a time-savings of 46 minutes per day for clerical staff and 20

minutes per day for teachers, when a school had one full-time RN present, which should

continue to increase as the number of nurses increases. This time-savings equated to a $133,000

cost-savings for the school each year (Baisch, Lundeen, & Murphy, 2011). Additional studies

have demonstrated that for every dollar invested in school health, society gained $2.20 (Wang,

Vernon-Smiley, Gapinski, DeSisto, Maughan, & Sheetz, 2014). This savings was related to early

dismissals due to illness, medication administration, teachers productivity loss due to student

illness, and parent work absence. The Wang et al study in 2014 found that by spending $79.0

million dollars, the presence of a school nurse saved approximately $20.0 million in medical care
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costs, $28.1 million in parents productivity loss, and $129.1 million in teachers productivity

loss per year. This is a net benefit of $92.2 million dollars to society (Wang et al, 2014). Safe

staffing levels should also lead to improved job satisfaction for the nurses, which is an important

strategy for nurse retention (Hairr, Salisbury, Johannsson, & Redfern-Vance, 2014). Improved

job satisfaction leads to a decrease in nurse turnover, which ultimately improves patient

outcomes and improves safety. It is a significant cost to organizations when there is high nurse

turnover. Training a new nurse can cost between $42,000 to $80,000 depending on the specialty

(Hairr et al, 2014). After completing this quality improvement project, one would expect to see

similar improvements as in previous studies and be able to gather data that would help develop

staffing levels to accommodate safely the health needs of students in this particular school, such

as by decreasing the nurse to student ratio and reaching the target of 65% of total RN work time

dedicated to student care.

As research has consistently found that there is a positive relationship between increased

RN staffing levels and improved patient outcomes, it stands that school administrators should be

taking a closer look at nurse staffing levels. It is the role of the nurse to advocate for and work

towards protecting the health, safety and rights of the patient (Montalvo, 2007, para. 6), which

includes supporting appropriate staffing levels in school health clinics. School nurses can

perform their own research, develop their own dashboards, and collaborate with other school

nurses to develop research based, data driven recommendations for keeping students safe and

improving the quality of student care through adequate staffing in school health clinics.
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References

Baisch, M., Lundeen, S., & Murphy, M. (2011). Evidence-based research on the value of school

nurses in an urban school system. The Journal Of School Health, 81(2), 74-80.

doi:10.1111/j.1746-1561.2010.00563.x

Cho, E., Chin, D.L., Kim, S., & Hong, O. (2015). The relationship of nurse staffing level and

work environment with patient adverse events. Journal of Nursing Scholarship, 48(1),

74-82.

Hairr, D., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and the

relationship to job satisfaction and retention. Nurse Economics, 32(3), 142-147.

Lineberry, M. J., & Ickes, M. J. (2015). The Role and Impact of Nurses in American Elementary

Schools: A Systematic Review of the Research. The Journal Of School Nursing, 31(1),

22-33.

Montalvo, I. (2007). Nursing Quality Indicators (NDNQI). The Online Journal of Issues in

Nursing, 12(3). Retrieved from www.nursingworld.org

National Association of School Nurses. (2015, January). Position Statement:

School nurse workload: Staffing for safe care. Retrieved from www.nasn.org.

Press Ganey Associates, Inc. (2015). Nursing Quality (NDNQI). Retrieved July 3,

2016, from Press Ganey website: http://www.pressganey.com/solutions/

clinical-quality/nursing-quality
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Wang, L.Y., Vernon-Smiley, M., Gapinski, M.A., DeSisto, M., Maughan, E. & Sheetz, A. (2014).

Cost-benefit study of school nursing services. JAMA Pediatrics, 168(7), 642-648.

doi:10.1001/jamapediatrics.2013.5441