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thesis entitled

WHAT ARE THE TYPES AND FREQUENCY OF INTERVENTIONS EMPLOYED
BY A CLINICAL NURSE SPECIALIST FOR CASES REFERRED TO THE
CHAPTER ONE PROGRAM WITH MULTIPLE IDENTIFIED PROBLEMS?

presented by

Sara Ann Daniel

has been accepted towards fulfillment
of the requirements for

 

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WHAT ARE THE TYPES AND FREQUENCY OF INTERVENTIONS EMPLOYED
BY A CLINICAL NURSE SPECIALIST FOR CASES REFERRED TO THE
CHAPTER ONE PROGRAM WITH MULTIPLE IDENTIFIED PROBLEMS?

By

Sara Ann Daniel

A THESIS
Submitted to
Michigan State University

in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing
1995

ABSTRACT
UHAT ARE THE TYPES AND FREQUENCY OF INTERVENTIONS EMPLOYED

BY A CLINICAL NURSE SPECIALIST FOR CASES REFERRED TO THE
CHAPTER ONE PROGRAM WITH MULTIPLE IDENTIFIED PROBLEMS?

By

Sara Ann Daniel

Chapter One, a federally-funded education program initially
targeted to the comparatively low academic scores of students in poor
school districts, is administered in the Lansing School District by a
Clinical Nurse Specialist (CNS) to provide identification of health
problems and interventions. In order to conduct future outcomes
research, a study of data collected in the 1993-94 school year was
performed. Interventions employed were categorized using the Domains of
Nursing (Benner, 1984), and a modified Culture Broker Model (Jezewski,
1993) to display the process. The sample of 86 elementary school
children's cases, each with three or more identified problems, was
described using demographic data and information specific to the nature
and status of the problems identified, the frequency of encounters, and
the interventions employed. In addition to identifying the 35
interventions, initial findings revealed a significant difference

between the ratings of the problem's status pre- and post-interVention.

Copyright by
SARA ANN DANIEL
1995

ACKNOWLEDGEMENTS

The preparation of this thesis would not have been possible without
the assistance of several individuals. First and foremost, Patricia
Bednarz, RNC, MN, was not only an invaluable resource for the
information contained herein, but also a positive and professional model
of the Clinical Nurse Specialist role.

My thesis committee members, Barbara Given, PhD, RN, Linda Spence,
PhD, RN, and Jacqueline Wright, RN, MSN, provided timely and
constructive feedback along the way, as well as support and
encouragement.

Finally, my family and friends, especially my husband, Jim, have
provided a great deal of support and assistance during my graduate

studies and I acknowledge them all with gratitude.

iv

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS .......................... iv
LIST OF TABLES .......................... vii
LIST OF FIGURES .......................... viii
INTRODUCTION ............................ 1
Background of the Problem ................... 1
Purpose of the Study ...................... 9
CONCEPTUAL FRAMEWORK ........................ 11
Overview ............................ ll
Conceptual Definitions ..................... 12
Application of the Study .................... 23
Summary ............................ 26
REVIEW OF THE LITERATURE ...................... 26
Overview ............................ 26
Summary ............................ 49
METHODS ............................... 50
Description of Research Design ................. 50
Sample Techniques ....................... 51

Data Collection Procedures and Recording ............ 52
Protecting Human Subjects ................... 54
Operational Definitions of the Variables ............ 54
Instrumentation ............... . ......... 55

Data Summarizing Procedures .................. 58
Plans for Data Processing and Analysis ............. 58
RESULTS ............................... 59
Overview ............................ 59
Sample Description ....................... 60
Findings ............................ 68
Summary ............................ 76

 

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TABLE OF CONTENTS (Cont.)

DISCUSSION ............................. 78
Interpretation of Findings ................... 78
Study Limitations ....................... 89
Implications for Advanced Nursing Practice ........... 92
Implications for Research ................... 97
Conclusion .......................... 101

LIST OF REFERENCES ........................ 102

APPENDIX A ............................ 108

APPENDIX B ............................ 110

APPENDIX C ............................ 111

APPENDIX D ............................ 113

APPENDIX E ............................ 114

vi

Table
Table
Table
Table
Table
Table
Table
Table
Table

Table

Table

Table
Table
Table

LIST OF TABLES

Page
1: Sex of Students ...................... 61
2: Age of Students ...................... 61
3: Grades of Students .................... 52
4: School Building ...................... 62
5: Payment Source ...................... 64
6: Initial Status of the Problem ............... 66
7: Status of Problem Following Intervention ......... 66
8: Comparison of Problem Status I to Status II ........ 67
9: Comparison of Means, Initial Status and Status
Following Intervention .................. 67
10: Frequency and Percentage of Encounters by the
CNS Per Case ....................... 69
11: Problem, Frequency and Percentage by Omaha
System Domain Categorization ............... 70
12: Interventions by Benner's Domains of Nursing ....... 72
13: Correlation Coefficients of Demographic Variables ..... 75
14: Correlation Coefficients of Problem Focused Variables . . . 76

vii

Figure 1:

Figure 2:

LIST OF FIGURES

Page

Culture broker model used to describe the advocacy
role of nursing ..................... 20

Modified culture broker model used to describe CNS
role in the Chapter One program ............. 22

viii

INTRODUCTION
Background of the Problem

In today's health care environment, increasingemphasis is being
placed on health promotion, health protection and disease prevention, as
set forth by the United States Public Health Service in Healthy People
2000 (1990). Health promotion strategies are related to individual
lifestyle habits that influence one's health prospects; health
protection strategies relate to environmental or regulatory measures
that confer protection on large population groups, and disease
prevention strategies include counseling, screening, immunization and
chemoprophylactic interventions in the clinical setting (McGinnis &
DeGraw, 1991). A basic component of the American Nurses Association
Agenda for Health Care Reform is the creation of an orientation toward
wellness and health promotion (American Nurses Association, 1991). In
the National Nursing Research Agenda (National Institute of Health,
1993), a Phase 1 goal is health promotion for older children and
adolescents.

Many health promotion interventions are based on promoting healthy
living habits (Igoe, 1992). The greater emphasis on health promotion
directed toward school age children is justified by numerous factors:
0 The rising economic and social costs of preventable conditions;
0 the greater understanding and awareness of the early natural

history of chronic diseases, such as cardiovascular disease;

0 the increased awareness that health habits are established early
in life, with one's destiny shaped by the knowledge, attitudes,

values, beliefs, and behaviors acquired and adopted at this time;

1

2
o the heightened appreciation of the difficulties involved in
changing or modifying unhealthy behavioral patterns as adults

(Downey, Cresanta & Berenson, 1989).

To provide the education and intervention needed to the school-age
child, it is first necessary to perform a sound needs assessment.

Health promotive interventions with children are often based on
professional intuition and not on specific knowledge of the child and
family (Farrand & Cox, 1993). There is frequently no consideration of
the child and family's developmental levels, both cognitive and
psychological, as a factor affecting the direction of health promotive
interventions. There needs to be research and understanding of the
needs of school-age children (Igoe & Giordano, 1992).

In order to meet these goals, it is necessary to assure that every
member of society has access to health care and seeks the appropriate
input, relative to health information and health-related practices. For
many individuals, this will require education, intervention and ongoing
follow-up, but the effort is essential, as these individuals are
commonly the most vulnerable. Children of low socioeconomic families
compose a large component of the underserved in the United States. In
1989, it is estimated that 12.6 million children lived in poverty, or
one in five children from age 1 through 17 who were at or below the
poverty line of $12,675 per year for a family of four (Children's
Defense Fund, 1991). Poverty affects child health in ways that cause
children to be at risk for a myriad of physical, emotional, spiritual,
and intellectual problems (Malloy, 1992). Children from poor families
have been found to have substantially higher rates of developmental

disabilities, chronic illness, and infectious diseases than children

 

 

 

 

 

 

3
from higher income families (Martin, 1992). Family socioeconomic status
is a powerful predictor of health outcome for children (OTA, 1988,
p.47).

Children of low socioeconomic families often lack preventive
health care (Goon & Berger, 1989). This places them at risk for the
development of acute and chronic health care problems, as well as the
unnecessary complication of simple problems due to delayed intervention.
Access to health care for poor children is a grave national concern
(Malloy, 1992). Insurance coverage, clinic locations, hours, lack of
availability of certain practitioners and services are all barriers that
prevent families-especially those with young children- from seeking care
(Gardner, 1993). Care is often theoretically available through public
or private clinics and other settings, both funded and voluntary,
however, these are often so overloaded that access is illusory
(Friedman, 1991). This inadequate access to health-related services for
uninsured children may contribute to poor health outcomes in later
childhood and adolescence (Oberg, 1990). To improve accessibility to
health services, many communities are placing health care providers
where children spend most of their time- in public schools (Elders,
1993). Schools offer the most systematic and efficient means available
to improve the health of youth and enable young people to avoid health
risks (US Public Health Service, 1990).

It is especially important when working with children to consider
the family environment. Families create bio-psycho-social systems and
physical environment for a child (Keltner, 1992). An ongoing challenge
in children's health promotion is how to involve the parents in those

efforts. Healthy children who are ready to learn come from healthy

4

families (Novello, 1991). Parents act as role models of appropriate
health-related behaviors (Perry, Luepker, Murray, Hearn, Halper,
Dudovitz, Maile, & Smythe, 1989). Parental health behavior guides the
development of health practices in children, and children can also
influence siblings and parents (Nader, Sallis, Patterson, Abramson,
Rupp, Senn, Atkins, Roppe, Morris, Wallace & Vega, 1989).

Nurses in school health, as well as in all other specialties, must
be continually aware of the challenges posed by society's
multiculturalism and ethnic diversity. Just as one cannot provide
health care and health education to a child outside of the context of
the child's family, one cannot overlook the child's ethnic and cultural
milieu and its contribution to his or her health practices. School
classrooms contain a cultural and ethnic variety of students of both
genders from different economic backgrounds (Schneider & Grimes, 1993).

The issues of access, parental health behaviors, and the child's
physical environment are compounded in the case of homeless children.
In addition to the barriers to accessing primary care representative of
children living in poverty, there are also barriers to school
attendance. The most common educational barrier to homeless children
involves the families moving frequently (Wiley & Ballard, 1993). The
complex health concerns of homeless students, combined with lack of
parental support, place additional burdens on the school nurse (Wiley &
Ballard, 1993).

Complicating the picture of school-based health service further is
the legislatively mandated mainstreaming of children with significant
disabilities and chronic illness. Prior to these laws, disabled

children were excluded from schools or community programs such as

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5
recreational and leisure activities (Todaro, Failla & Caldwell, 1993).
Laws affecting children's participation in community settings include:
The Education of the Handicapped Act of 1975 (PL 94 -142), The Education
of the Handicapped Amendments of 1986 (PL 99-457), Omnibus
Reconciliation Act (OBRA) 1989, The Americans with Disabilities Act,
1990, and The Education of the Handicapped Amendments of 1990 (PL
101-476) (Todaro, Failla & Caldwell, 1993). The challenges and
requirements presented by the children benefitting from these laws have
further strained the existing school health programs. In many school
systems the nurse deals only with illness, emergencies and medical
problems of children with special needs (Salmon, 1994). Health
promotion/disease prevention activities such as counseling, health
teaching, screening, case finding, referral, and outreach fall outside
the role of these school nurses (Salmon, 1994).

Historically, school systems have faced cycles of alternating
economic prosperity and constraint and, therefore, school nursing
services have experienced stability of services as well as elimination
of positions due to budget cuts (Passerelli, 1994).

The school is the common environment for children of all
backgrounds and health status. Health care policy makers have long
recognized the value of early care needs identification in that setting,
as well as promoting healthy lifestyles by school educational programs.
In recent years the relationship between health and learning has
received growing attention (Elders, 1993). Certain health conditions
make a statistically significant contribution to explaining variations
in school performance and cognitive functioning (Oberg, 1990). Low

birth weight, poor hearing, uncorrected or poor vision, and school

 

 

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absences due to illness are among the major correlates of below-average
achievement and IQ (Oberg, 1990).

The missing ingredient in the efforts to make an impact on the
twin issues of access to preventive health care and optimal school
performance in school-age children has been a coordination of the
efforts of the school systems, the health care system and the community
resources. The term "full-service schools“ has been proposed as
interagency partnerships of services among state and local governments
and public and private entities (Dryfoos, 1993). As a model of the
multidisciplinary delivery of primary preventive care, school-based
clinics (SBCs), originally developed to address the issues of
adolescents, have been implemented in some communities around the
country. School-based clinics have met opposition in many areas due to
the usual focus on adolescent health issues and the inevitable
controversy over contraception related services. One key to development
of a successful clinic is to understand and agree on the types of
school-based health services that can be delivered at the school
(Elders, 1993). Although family planning draws the most criticism from
opponents, it is actually far down the list of reasons children and
adolescents visit the clinics (Vessey & Swanson, 1993).

It is recognized that, in order to conduct health promotion, it is
initially necessary to intervene with the individuals who have more
immediate, pressing needs. The Federal government, in 1965, enacted
several social programs as part of President Lyndon Johnson's Great
Society, one of which was the Medicaid, enacted as Title XIX of the
Social Security Act, intended to serve as the primary health insurance

provider for the poor. However, in 1991, only an estimated 50% of

7
low-income children were actually covered by Medicaid, as a result of
state by state eligibility requirements and the inclusion of the poor
elderly (Martin, 1992). The other 50% of the children, for whom this
program was originally designed, are part of what we know as the
"uninsured”. Another major piece of legislation of that era was the
Elementary and Secondary Education Act, which included Title I - Better
Schooling for the Educationally Deprived Children. Renamed Chapter I in
its 1981 re-authorization, the program has been renewed five times
(Jendryka, 1993). This program was envisioned as one in which the
Federal government would provide funding allocations to school systems
which, based on the U.S. census of poor children, had sufficient numbers
of school children requiring help to bring them up to par with their
classmates in standard test scores (Zuckman, 1993). In practice, the
program sends more than $6 billion in federal funds to 95% of all school
districts to provide extra help in reading, math and other areas in
which they have fallen behind (Zuckman, 1993). Today, more than half
the students served are not poor (Zuckman, 1993). Since 1988, the
high-poverty school districts, in which 75% of the students qualify for
free or reduced-price lunches, have been given more leeway in deploying
the available funds, and many have gone beyond the traditional remedial
reading and math programs (Zuckman, 1993).

To summarize the background of the problem, there is an increasing
recognition of and concern with the unmet health care needs of school
age children in the United States today. These needs encompass
preventive measures, such as immunizations, access to services for
simple acute care, and health promotion strategies, such as educating

children regarding the need for a sound diet, adequate physical

8
exercise, and avoidance of detrimental practices such as tobacco,
alcohol, and drug use. The common milieu for children from diverse
cultural, ethnic, and economic backgrounds is the school system. The
school system can provide the access to care and information in a
standardized manner, that may not be otherwise available to many
children.

There is a need to identify those nursing interventions which are
most effective. Although many school-based health services exist across
the nation, they are vulnerable to budgetary cutbacks, due to the lack
of understanding regarding the purpose of the programs and of sound data
regarding their effectiveness. It is important for professional nurses
in the school health environment to begin measuring the outcomes of
their interventions to assure that effective programs continue to
receive adequate funding. Prior to measuring outcomes, however, it is
necessary to describe the interventions employed by professional nurses
in school-based health programs for a variety of presenting conditions.

Programs for providing health care services differ from school
system to school system relevant to the extent of services provided and
funding available. One innovative use of the federal Chapter I funding
is found in the Lansing School District program, which is administered
by a Clinical Nurse Specialist (CNS). The data collected by the CNS
regarding cases referred to this program in the 1993-94 school year will
be described and analyzed to answer the question, "What are the types
and frequency of interventions employed by a Clinical Nurse Specialist
for cases referred to the Chapter I program with multiple identified

problems?”

9
Purpose of the Study

The purpose of this study is to answer the question, "What are the
types and frequency of interventions employed by the Clinical Nurse
Specialist for children referred to the Chapter One program with
multiple identified problems, from August, 1993 to June, 1994?".

The Chapter One program of the Lansing School District in Lansing,
Michigan, receives referrals from school nurses, social workers,
principals, and teachers from throughout the school system for
elementary school children for specifically identified health care
needs. The children referred to and assisted by the program are not
required to fall under a certain family income level, however, their
health care needs are intended to be in some way related to poor school
performance, as evidenced by test scores. Although the program has been
in effect for several years, there has been no systematic data
collection until the 1993 - 94 school year, to allow for the analysis of
the effectiveness of the program.

The interventions to be described in this study are defined as the
action taken by the CNS and her staff to assess, refer, and evaluate the
child's problem(s) and the strategies employed on his or her behalf.
Interventions include communication with the family, direct physical
care, education, referral to other health care providers, providing
supplies, and referral to community agencies.

A Clinical Nurse Specialist (CNS) is an experienced practitioner
who exhibits clinical competency and advanced knowledge of

physiological, psychosocial, and therapeutic components (Bass, Rabbett,

& Siskind, 1993).

 

 

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Children with multiple identified problems are those children who
are referred to the Chapter I CNS for evaluation and intervention, and
found to have three or more clinical and/or social problems which
required intervention. The children are often referred to the program
with one identified problem, with the CNS's assessment revealing the
additional problems requiring intervention.

In today's health care environment, it is important to be able to
demonstrate the outcomes of a provider's interventions. Beginning with
the 1993-94 school year, the CNS began collecting pertinent data using
an instrument adapted from the OMAHA system (Martin & Scheet, 1992)
which codifies clinical conditions, interventions and outcomes. The
data collected need to be analyzed to describe the children's conditions
and the interventions that were employed by the staff of this program.
The eventual ability to relate that information to outcomes will add to
the body of nursing knowledge regarding the effectiveness of specific
interventions for certain clinical conditions. It will additionally
provide the basis for demonstrating the effectiveness or outcomes of the
program in the identification of and management of children's health
care needs. The needs identified should provide sufficient information
regarding educational programs that are specifically tailored to the
community-based and individual health promotion and disease prevention
issues. The cost-benefit ratio is an important source of information,
and one which requires outcomes-oriented data. Finally, research can be
designed, subsequent to this study, which will demonstrate the
contribution of a CNS to this effort.

The research question to be addressed with this research was the

types and frequency of interventions employed by a Clinical Nurse

 

 

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Specialist for cases referred to the Chapter One program with multiple
(three or more) identified problems. This problem will be addressed by
analysis of the data collected by the CNS for 1993-94 school year
relevant to children referred to the Chapter I program who were
determined to have three or more problems requiring intervention.
CONCEPTUAL FRAMEWORK
Overview

The conceptual framework used to operationalize the conceptual
definitions and provide direction to the literature review, was the
model of expert practice applied by Benner (1984), from which she
derived seven domains, based upon 31 competencies identified in actual
clinical situations. From her studies of nurses in clinical situations,
Benner (1984) applied the Dreyfus model of skill acquisition and skill
development to clinical nursing situations, and described them by using
examples, which she called "exemplars". The model describes five levels
of skill development: novice, advanced beginner, competent, proficient,
and expert (Benner, 1984). Benner (1984) describes the expert nurse as
making accurate decisions and solving problems with a minimal amount of
effort. The seven domains were identified after the exemplars were
interpreted as representative of a particular competency (Benner, 1984).
The domains of nursing practice, as labeled by Benner (1984) are:
0 The Helping Role
0 The Teaching-Coaching Function
0 The Diagnostic and Patient-Monitoring Function
0 Effective Management of Rapidly Changing Situations

- Administering and Monitoring Therapeutic Interventions and

Regimens

12

- Monitoring and Ensuring the Quality of Health Care Practices
0 Organizational and Work-Role Competencies

These domains, while originally specific to nursing in an acute
care environment, adapt well to ambulatory care with further discussion
of the competencies involved in each. Brykczynski (1989) redefined the
domains and competencies specific to primary care to study the clinical
judgement of nurse practitioners. The expansion of the domains provided
still does not provide a complete description of the functioning of the
CNS in a school health setting. Additional discussion will be included
in both the conceptual definitions and the literature review to
operationalize the domains and competencies more specifically to the
specialty of school nursing. In the following conceptual definitions,
Brykczynski's (1989) definitions are also included, where relevant.

Conceptual Definitions

[he Helping Role

The helping role of the nurse is defined by the eight competencies

derived from Benner's (1984) exemplars:

- The healing relationship: Creating a climate for and establishing
a commitment to healing;

- Providing comfort measures and preserving personhood in the face
of pain and extreme breakdown;

- Presencing: Being with a patient;

- Maximizing the patient's participation and control in his or her
own recovery;

- Interpreting kinds of pain and selecting appropriate strategies
for pain management and control;

0 Providing comfort and communication through touch;

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0 Providing emotional and informational support to patient's

families;

- Guiding patients through emotional and developmental change:
0 Providing new options, closing off old ones:
- Channeling, teaching, mediating
- Acting as a psychological and cultural mediator;
- Using goals therapeutically;
- Working to build and maintain a therapeutic community.

Brykczynski (1989) did not add anything to this domain to make it
more specific to primary care, and it also works well with the
functioning of the CNS in the school health setting. In the literature
review, this domain will be operationalized as relating to client
advocacy and the role of the family in determining a child's health
practices. Another advocacy function which is included is assuring
access to health care services and the provision of culturally sensitive
care.

The Teaching-Coaching Function

The teaching-coaching function is defined by Benner (1984) by the
following five competencies derived from the analysis of the exemplars:
- Timing: Capturing a person's readiness to learn;

- Assisting patients to integrate the implications of illness and
recovery into their lifestyles;

- Eliciting and understanding the patient's interpretation of his or
her illness;

0 Providing an interpretation of the patient's condition and giving

a rationale for procedures;

 

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14
o The coaching function: Making culturally avoided aspects of an
illness approachable and understandable.

Brykczynski (1989) expanded these competencies to include three
more which were additionally specific to primary care:

0 Motivating a patient to change;

- Assisting patients to alter their lifestyle to meet changing
health care needs and capacities: Teaching for self-care;

- Negotiating agreement about how to proceed when priorities of
patient and provider differ.

These three additions could be further expanded for school nursing
by adding "and family" to the statements above, as families must be
considered when dealing with children, especially. The domain will be
reviewed in the literature specific to school health education, which to
be effective must include a component which deals with the family.
Health education and health promotion are key aspects of long term
health care cost containment, which is becoming widely recognized. The
competencies of motivating people to change and assisting patients to
alter their lifestyles will be important aspects of the CNS's practice.
T i n ic and Monit in nction

The diagnostic and monitoring functions of a clinician's practice

are defined by Benner (1984) from the following five competencies

derived from the exemplars:

. Detection and documentation of significant changes in a patient's
condition;
0 Providing an early warning signal: Anticipating breakdown and

deterioration prior to explicit confirming diagnostic signs;

- Anticipating problems: future think;

15
Understanding the particular demands and experiences of an
illness: Anticipating patient care needs;
Assessing the patient's potential for wellness and for responding

to various treatment strategies.

Brykczynski (1989) renamed this domain Management of Patient

Health/Illness in Ambulatory Care Settings and redefined the

competencies as follows:

Assessing, monitoring, coordinating, and managing the health
status of patients over time: Being a primary care provider;
Detecting acute and chronic diseases while attending to the
experience of illness;

Providing anticipatory guidance for expected changes, potential
changes, and situational changes;

Building and maintaining a supportive and caring attitude towards

patients;

Scheduling follow-up visits to closely monitor patients in
uncertain situations;

Selecting and recommending appropriate diagnostic and therapeutic
interventions and regimens with attention to safety, cost,
invasiveness, simplicity, acceptability, and efficacy.

This domain is operationalized in the literature review as

relating to the traditional role of school nursing. The school nurse

acts as a referral source to the CNS, as well as an expert clinician

whose competencies have expanded to provide care to the mainstreamed

handicapped child and the chronically ill child.

16
Effeetiye Management of Rapidly Chanqinq Situetiene

The concept of the effective management of rapidly changing
situations was defined by Benner (1984) by the following three
competencies derived from the exemplars:

- Skilled performance in extreme life-threatening emergencies: Rapid
grasp of a problem;

0 Contingency management: Rapid matching of demands and resources
in emergency situations;

0 Identifying and managing a patient crisis until physician
assistance is available.

This domain was not further expanded by Brykczynski (1989), as it
was felt to be less relevant to the ambulatory care setting. In the
literature review, this domain is operationalized as conditions in the
child's family, social and physical environment and the ways in which
situations such as homelessness impact the child's health.
Administering end Monitoring Therapegtie interyentione end Regimens

The concept of administering and monitoring therapeutic
interventions and regimens is defined by Benner (1984) by the following

four competencies derived from the exemplars:

- Starting and maintaining intravenous therapy with minimal risks
and complications;

- Administering medications accurately and safely: Monitoring

untoward effects, reactions, therapeutic responses, toxicity, and

incompatibilities;

17
0 Combatting the hazards of immobility: Preventing and intervening
with skin breakdown, ambulating and exercising patients to
maximize mobility and rehabilitation, preventing respiratory
complications;
0 Creating a wound management strategy that fosters healing,
comfort, and appropriate drainage.

This domain was omitted by Brykczynski (1989) as being irrelevant
to the ambulatory care setting. The literature review operationalizes
this concept relative to nursing in the school health setting as the
school-based delivery of primary health care. The need to design
programs which are integrated with other school departments, as well as
community-based services, is reviewed.

Menitering and Ensuring the Quality of Health Cege Preetieee

The concept of monitoring and ensuring the quality of health care

practices was defined by Benner (1984) by the following three

competencies derived from the exemplars:

0 Providing a backup system to ensure safe medical and nursing care;

0 Assessing what can be safely omitted from or added to medical
orders;

0 Getting appropriate and timely responses from physicians.

Brykczynski (1989) added the following competencies to address

primary care more specifically:

0 Developing fail-safe strategies when concern arises over physician
consultation;
0 Using physician consultation effectively;

- Self-monitoring and seeking consultation as necessary;

18
0 Giving constructive feedback to physicians and other care
providers to ensure safe care practices.

These additional competencies are very relevant to the functioning
of the CNS in the school setting, as one commonly employed intervention
is the referral of a child to a specialty physician for consultation.
The ongoing management of the child's chronic illness is often returned
to the primary care provider or the school. This domain is
operationalized in the literature review as the research which has been
done that is school-based.

Orgenizetienel and Work-Rgle Competegeiee

Organizational and work—role competencies are defined by Benner
(1984) by using the following four competencies derived from the
exemplars:

0 Coordinating, ordering, and meeting multiple patient needs and

requests: Setting priorities;

0 Building and maintaining a therapeutic team to provide optimum
therapy;

- Coping with staff shortages and high turnover:
0 Contingency planning;
0 Anticipating and preventing periods of extreme work overload

within a shift;

0 Using and maintaining team spirit;
0 Gaining social support from other nurses;
- Maintaining a caring attitude toward patients even in the

absence of close and frequent contact;

- Maintaining a flexible stance toward patients, technology,

and bureaucracy.

19

Brykczynski (1989) added two additional competencies relevant to

the ambulatory care setting:

0 Making the bureaucracy respond to patients' and families' needs;

- Obtaining specialist care for patients while remaining the primary
care provider.

The competencies in this domain have been operationalized in the
literature review as the professional nurse's responsibility to be aware
of the proposed and actual changes in public policy at all levels,
whether directly impacting his or her practice or not. These policies
relate primarily to health care reform, school—based health care, and
education finance reform.

The competencies in all the domains above are further defined by
way of specific clinical examples; the exemplars from which they are
derived. They are considered to be generalizable across clinical
settings and will be further defined according to the school setting
examined in this study.

In order to visually represent the ways in which a CNS intervenes
with a child in the school health setting, a model needed to be found.
The figure (Figure 1) which best illustrates the relevance of the CNS
interventions within the domains is the Culture Brokering Model,
presented by Jezewski (1993). The model is very specific to the
diversity of the children referred to the CNS in the school health
setting. The CNS acts as a culture broker by providing entry to and
understanding of the health care system to a child and his or her
family. There is a continuous feedback loop of problem identification,
strategies, interventions, and evaluation, which accurately represents

the CNS's role in the setting. Of primary importance, the intervening

20
Eigure_1_. Culture broker model used to describe the advocacy role of nursing

 

 

lntervening Conditions
Patient/Provider Power/Powerlessness
Age/Culture Sensitivity Economics
Diagnosis/Professional Status Politics
Education Networks
Time Orientation Stigma

 

 

 

l l l

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stage 1 Stage 2 Stage 3
Perception Intervention Outcome
Perception of Properties of Facilitation
the need for brokering that of health
brokering resolve care
breakdowns evaluated
PROBLEMS STRATEGIES RESOLUTION
Mediating
Caused by Negotiating Lack of
conflicts lntervening facilitation
in values Sensitizing continued
access Innovating breakdown
4 4 4—]
Jezewski, M. (1993). Culture brokering as a model for advocacy. W

HealtlLQaLe. 111(2). 78-84.

 

21
conditions with which the child and his family present, require the CNS
to assess the factors which will affect their ability to participate in
goal setting, behavior change, or any other interventions planned by the
CNS.

In order to make this model even more specific to the Domains of
Nursing conceptualized by Benner (1984), the Culture Brokering Model was
adapted by the author to include specific language to the area of the
model in which interventions are addressed. In Figure 2 the modified
model is represented which includes the specific Domains of Nursing in
the intervention area of the model. By examining this representation,
it is possible to more easily track the entry of the child and family
into the process whereby the CNS is encountered. The initial referral
of the student to the Chapter One program occurs in the Perception
stage, in the box labelled "Problems". The CNS's assessment and
ultimately the interventions employed are found in Stage 2, the
intervention stage, the box labelled “Strategies". The lntervening
Conditions, which include student and the family's socioeconomic status,
cultural background, and education level, are assessed by the CNS to
assure that the school and health care "cultures" are made
understandable to them. Factors that influence the difficulties a
family may experience relative to this process are related to the issues
of power and powerlessness. By communicating extensively with the
student's caregiver, the CNS provides information regarding the
student's identified problems, the intervention plan, and the outcomes.
In this way, the CNS as a culture broker operationalizes the roles of
advocate, educator, assessor, and coordinator of care. The outcome

stage, in the box labelled "Resolution", is defined as the status of the

22

figure}. Modified culture broker model used to describe CNS role in the Chapter
One program.

 

lntervening Conditions

Patlent/Provlder Power/Powerlessness
Age/Culture Sensitivity Economics
Diagnosis/Professional Status Politics
Status/Cultural Background Networks
Education Stigma

Time Orientation

 

 

 

 

l l l

 

 

 

Stage 1 Stage 2 Stage 3

Referral Intervention Outcome
Identification of Domains of Nursing from Evaluation of the

need for which CNS derives effectiveness of the
intervention by strategies for intervention intervention

referral source and
CNS assessment

 

 

 

 

PROBLEMS L—p STRATEGIES —> RESOLUTION
Caused by conflict $92339 R8: ghqmpzteges Reassessment
- , ea mg- a mg u ton
In values' laCK Of Diagnostic 8 Patient Monitoring CIOSUI’G
access Effective Management of Rapidly I 068190 New
Changing Situations Intervention Plan

 

 

Administering 8 Monitoring

 

 

Therapeutic Regimens
Monitoring 8 Ensuring Quality of
Health Care Practices
Organizational and Work-Role
Competencies

L 4

 

 

 

 

+

Jezewski, M. (1993). Culture brokering as a model for advocacy. NOszflgjfld.
HeaImCara JAR). 78-84.

23
case at either the closure of the case by the CNS or the status of the
case at the end of the school year. Evaluation of the effectiveness of
the strategies employed also occurs at this stage, which leads to either
closure of the case or maintenance of the intervention, in the event of
an effective intervention, or the implementation of a new intervention
plan based on a reassessment. In this representation, there is a
feedback loop component relevant to the evaluation and reassessment,
which allows for the continuity inherent to the relationship between the
CNS in the school health setting and children and families.
Application of the Study

The concepts, as defined above by Benner (1984) form the basis for
operationalizing the pertinent data to be examined in this study. To
clarify the aspects of each domain which are relevant to the role of the
CNS in the previously described Chapter One program, each domain will be
further defined.
T H Domai

In the Chapter One program, the CNS employs the competencies of
this domain to act as an advocate, mediating between the student, his or
her family, the school system, and the health care system to assure the
student is appropriately referred to the physician specialist, community
resource, and/or ongoing therapeutic intervention which has been
determined to address the identified needs of the student. Competency
within this domain is required to provide the necessary services to
students who are physically and mentally handicapped, chronically ill,

homeless, and/or have ethnic or cultural beliefs to be considered.

24

T T —Coa hin Function

An essential part of health promotion in the school setting is the
modification of lifestyle factors which can negatively impact future
health. Programs which are planned for health promotion/disease
prevention must consider the student's family, ethnic and cultural
heritage, and his or her readiness to learn. Health promotion within
this domain can take the form of individualized education, group
presentations, and formal school-based intervention research. In
addition to the information provided in the teaching function, will be
the encouragement and motivation provided as part of the coaching
function.
Ibe Diegngetie and Mgnitoring Eunctiop

The competencies within this domain are applicable to the success
of the entire program. The teachers are the frontline referral source,
as they will alert the school nurse to a student requiring evaluation.
In this sense, the teacher is required to have a level of diagnostic
skill, sufficient to recognize deviations from the norm. It is also
frequently the teacher who first makes a connection between a child's
difficulty with schoolwork and an unmet health need. The school nurse
will further refer those students requiring external health care to the
Chapter I program. The monitoring function becomes a key component of
the CNS role in assessing the student's potential for wellness by
evaluating not only any medical conditions, but also the home and family
setting. The CNS will anticipate future needs of the student and
communicate with the family, school nurses, and teachers regarding
warning signals, demands of an illness, and potential for future

wellness. These competencies are particularly relevant with students

25

with special needs, such as the handicapped child, the homeless child,
and children living in poverty.

v e Ra i I ha ' i ation

The competencies of this domain would appear to be specific to the
acute care setting, however, by expanding the definition of a crisis
situation to include the social crises of homelessness and poverty, it
is possible to apply this domain to a school setting. The tenuous,
unstable home lives of some students, as well as their health
conditions, including the medically fragile and technologically
dependent, can easily meet the definition of rapidly changing
situations, requiring management.
Adminieterieg_endiMonitoring Therapeutie Regimens

The school nurse, particularly in the age of mainstreaming
children with serious physical, mental, and emotional limitations, is
commonly expected to administer and monitor therapeutic regimens. The
CNS in the Chapter I program has the further responsibility of
advocating for the modification and coordination of the regimens of a
multidisciplinary team. These regimens will be communicated with the
families, school nurses, and teachers of the student, in order to
assure consistent understanding and treatment.
Meeitoring and Enegring the Quelitv of Heelth Care Prectices

The ultimate method of ensuring the quality of health care
practices is the collection of data related to outcomes and
participating in research related to the effectiveness of the practices.
The CNS is responsible, in the role of researcher, for collecting data

pertinent to the health care practices of his or her clients to assure

26
that the regimens are correctly administered and appropriately modified,
as well as to determine that the regimens are effective.
i o k-Rol n ie
Health care is a rapidly changing environment. The CNS must stay
thoroughly informed regarding the policy decisions being proposed and
made which relate to the specialty of school health. The competency of
maintaining a flexible stance toward bureaucracy refers to the role
local, state, and national policy-makers on the CNS's practice and role
components. The issues of school health education, school-based
delivery of care, and the funding of programs such as Chapter I will be
discussed and decided on levels outside the community. The CNS must be
informed and politically astute to participate in the debate regarding
these aspects of his/her role.
Summary
The use of Benner's (1984) Domains of Nursing to conceptualize the
actions and interventions of the CNS in the Chapter I program requires
very little modification to be applicable to the school setting. The
domains, conceptually defined, will be used to direct the literature
review necessary to provide the background of previously published
information addressing the concepts contained
in the study.
REVIEW OF THE LITERATURE
Overview
An extensive literature review was conducted specific to the
domains of nursing conceptually defined by Benner (1984) in order to
provide background justification for the importance of the study

question as well as the relevance of the conceptual framework. Since

27
nearly every nursing function, regardless of practice setting, has its
roots in more than one domain, the categorization of literature selected
is somewhat arbitrary, based on the author's determination of the best
fit. The literature reviewed provided an understanding of school
nursing as a specialty in the 1990s, the role of the student's family
and culture in the health status of the child, and the complications
posed by homelessness, poverty, and handicaps. The differing
requirements of school-based health education, school-based health care
delivery, and school-based health care research were also explored. The
important aspect of governmental policy, on local, state, and national
levels is also presented.
n ma'

The literature reviewed under the helping domain was targeted to
the competencies of an expert nurse as related to advocating for a
student, and his or her family, and mediating between the often
conflicting cultures of the health care system, the school system, the
community, and the values and beliefs of the child and his or her
family. Jezewski (1993), as discussed in Chapter 2, derived a model of
advocacy from the field of anthropology, called "culture brokering".
Culture brokering is defined as the act of bridging, linking, or
mediating between groups and persons of differing cultural backgrounds
for the purpose of reducing conflict or producing change (Jezewski,
1993). This model is operationalized in the field of mental health, in
‘Which case managers act as culture brokers by bridging between the
worlds of their mentally ill clients, typically undertreated for
Physical ailments, and medical providers (Schwab, Drake & Burghardt,

1988). Recognizing the important role the student's family plays in the

28
development or modification of health habits, many authors have
attempted to measure the family's influence on child health status, with
a goal of predicting those families whose children are more likely to
have positive health habits.

Using systems theory as a framework, Keltner (1992) used
questionnaires to examine family routines (Family Routines Inventory)
and home environment (Home Screening Questionnaire) for 110 Head Start
enrollees and compared these scores with child health data. The health
data examined, from the school health record, included the results of
the physical examination, hematocrit/hemoglobin, height and weight,
dental inspection, and vision screening (Keltner, 1992). The Family
Routines Inventory (FRI) evaluates the frequency of adherence to 28
family routines common among families with young children, such as
bedtimes and mealtimes, while the Home Screening Questionnaire (HSQ) is
an adaptation of the HOME Inventory which measures the physical and
educational components of a home. The relationship of family routines
and the home environment and child health status were analyzed with
Pearson correlation coefficients to test the significance of the
relationship. Family routines were positively correlated with child
health status (r-.27, p-.004), indicating that families who engaged in
more routines were more likely to have high scores on the health
screening exam. The home environment also had a strong positive
relationship with child health status (r-.40, p-.001). The family
influences on child health data investigated in this study revealed that
both family routines and home environment showed significant common

variances with child health (Keltner, 1992). This focus on pre-school

29
children is considered to be promising in early intervention for both
high risk health issues and facilitation of learning.

Caughy, DiPietro, and Strobino (1994) examined day care
participation as a protective factor in the cognitive development of
low-income children. The study focused on environmental aspects of the
poor learning outcomes experienced by many children from low
socioeconomic groups. The study found that day-care participation
during the first three years of life is positively related to the
subsequent development of mathematics and reading skills for children
from impoverished environments. The socioeconomic status of the child's
family must also be understood as the connection is made between poor
health outcomes and poor learning outcomes.

A study very specific to the importance of a family's ethnic and
cultural heritage was conducted by Okagaki and Sternberg (1993). In
their study, immigrant parents from Cambodia, Mexico, the Philippines,
and Vietnam and native-born Anglo-American and Mexican-American parents
responded to questions about child-rearing, what teachers of first and
second graders should teach their children and what characterizes an
intelligent child. There were specific cultural differences regarding
child rearing, conceptions of intelligence, and school goals. In the
area of child-rearing beliefs, Cambodian, Vietnamese and Filipino
parents placed more importance on problem-solving abilities and
conformity, while Mexican-American and Anglo-American parents placed the
highest value on creativity. Similarly, for educational goals, the
Asian parents scored higher on the importance of academic and social
conformity, while Hispanic and Anglo parents rated academic

individuality and social conformity as being very important. These

30
results speak to the importance of providing health-related information
in a culturally sensitive manner and to knowing the values of a family's
cultural heritage.

Lara (1994) writes about a school centered health education and
services program for rural communities (SCHESRC), which was guided by
the WHO's self-reliance model, to increase access to health education
and health care services by Mexican-American residents. These colonies
were involved in active participation, by disseminating information
through the schools, which were seen as the "authority" in these
communities where there is rarely any other public agency (Lara, 1990).
Mayall (1993) studied the negotiations and relationships between parents
and health staff in regards to child health care and child rearing and
found that these interactions occur in an "intermediate domain" between
work and private life. The nature of the negotiations related very
strongly to the genders of the parent and the health staff, and was most
problematic when the health worker was a female displaying an air of
superiority over the female parent.

Assuring access to the health care system is a strong part of the
Chapter I program. The program designed by Wagner and Menke (1992)
provided case management for homeless families as a way of providing
consistent health care for this at-risk population. Their work combined
individual advocacy, system advocacy, and the four domains of community
health practice as strategies for linking clients to essential services
and for developing the services when they do not exist (Wagner & Menke,
1992). The health problems of sheltered women and their children were
examined by Burg (1994). The study found that the health consequences

were directly related to transitory shelter living, such as higher rates

31
of infectious disease, dietary insufficiency, and possible lead
exposure. The physical environment of shelters causes or exacerbates
the severity of illnesses such as infections and asthma in children
(Burg, 1994).

The psycho-social burdens of homelessness are potentially serious
for children, and include developmental delays in language skills,
cognitive ability, and motor skills (Burg, 1994). School districts must
address the health and academic challenge homeless children bring to
school (Wiley & Ballard, 1993). Wiley and Ballard (1993) provide seven
strategies for school nurses and teachers in dealing with the need for
continuity of both health care services and academic progress. These
strategies dealt with the reality that the child faced significant
barriers in school attendance and that he or she would be moving out of
the system, often within a matter of weeks (Wiley & Ballard, 1993).

In summary, the Helping Domain, as defined by advocacy, early
intervention, and assuring access to health care and community
resources, is well documented in the nursing and research literature.
The advocacy role of the CNS is well-defined by the concept of
culture-brokering, described by Jezewski (1993). The culture-broker
model is particularly relevant when considering the needs of the poor,
the homeless, the handicapped, and children from differing cultural or
ethnic backgrounds.

- h' F ti n

School health education has been widely covered in the literature,
as it is commonly understood that the school is the ideal location to
conduct a curriculum based upon health-related information. The

.American Cancer Society (1993) has developed a National Action Plan for

32
Comprehensive School Health Education, which includes a sequential
Kindergarten through 12th grade program that integrates information
about specific health topics and provides for implementation and
evaluation of the program. Brindis (1993), writing in support of the
Comprehensive School Health Education Plan, pointed out that many of the
nation's major health problems are caused by only six types of
behaviors: l) behaviors that result in unintentional and intentional
injuries; 2) drug and alcohol use; 3) sexual behaviors that cause
sexually transmitted diseases; 4) tobacco use; 5) inadequate physical
activity; and 6) dietary patterns that cause or promote disease. Until
the state or local school district makes a commitment to the funding and
staffing of such a comprehensive program, school health professionals
and educators conduct smaller scale education in the school setting.
Kozlak (1992) writes that school administrators will be seeking the
leadership necessary to design and implement school health concepts of
the future and that school nurses can assume the leadership provided
they are willing to clearly define their role, justify their position,
and develop new skills necessary to become an integral part of the new
school health paradigm.

In summary, the literature related to the school setting as a
location for health education which spans the child's entire school
career is consistently positive. The funding for the comprehensive
programs is not widely available, however, small-scale programs provide
opportunities for professional nurses to assume the leadership for

designing and implementing health education programs.

33
T nos ic and Mon'torin unction

The diagnostic and monitoring function is a key domain in
individualizing the interventions. School nurses must sharpen their
diagnostic and technical skills, as students are coming to school with
more complex health problems (Kozlak, 1992). Teachers are one of the
prime sources of referrals to the school nurse and to the CNS in the
Chapter I program. Schneider and Grimes (1993) conducted a study to
detect the presence of teacher bias in the referral of students to the
school nurse. A chi-square analysis of grouped data in the three
categories of potential bias (race, gender, and socioeconomic status)
showed potential bias in referral patterns related to race and
socioeconomic status. Data were then analyzed by race and gender
simultaneously and it was found that when African-American males were
compared to white males, no difference occurred in the rate of referral,
however African-American females were more likely to be referred than
white females. The differences in referrals when socioeconomic status
and race were combined, probably reflected the greater incidence of
unmet health care needs in children from these groups (Schneider &
Grimes, 1993).

Oda (1992) writes that it is no longer acceptable for school
nursing to be the "invisible practice", because visibility and strength
are needed for effective child advocacy. School nursing will be
required in this era to define itself, as nursing in school settings has
become of intreasing interest throughout the federal government (Salmon,
1994). Collis and Dukes (1989) proposed principles of school nursing
which include the school health nurse as the source of knowledge about

laealth and health services, the school as a health promoting community,

34
and a team approach which acknowledges parents as partners. Desrosiers
(1989) tested a program for readying school nurses to deal with
handicapped children called the School Nurse Achievement Program (SNAP),
in which nurses attended SNAP sessions and took a graduate component of
Advanced School Nursing of the Handicapped Child. As a result of the
implementation of the SNAP curriculum, the Advisory Committee in the New
Hampshire schools recommended additional funding of the program,
implementation of an evaluation component, and application of the SNAP
model to non-nursing groups such as teachers, superintendents, and other'
professionals.

Cowell (1988) developed a school nurse activity tool to compare
nursing time provided to special education students and their
non—disabled peers in general education settings, compare nursing
process activities in traditional settings and special education
settings, and elicit feedback from nurses to improve the validity and
reliability of the time study process. Findings of the study indicated
that 48.2% of school nursing time in the study period was committed to
services for special education students. These students accounted for
37% of the students seen in health services but represented only 9.6% of
student enrollment in the study schools. The findings suggest that the
instrument provides a clear description of quantitative and qualitative
health room services related to the nursing process and distribution of
services among groups of students (Cowell, 1988).

The mainstreaming of handicapped children presents many challenges
to the school health professional. In Pesata's (1994) article, Benner's
model is applied to the school nursing of multiply handicapped children.

The article specifies using the model as a way to guide practice in an

35
ambiguous role or in a non-traditional setting by identifying
competencies required in expert practice, such as that required by
school children with complex health needs (Pesata, 1994). The need for
coordinating a multidisciplinary approach is stated by Reynolds (1994)
as, ”the problems of many children are beyond the understanding and
treatment capacities of single agencies or professionals". In their
analysis of the ethics, values and policy decisions for children with
disabilities, Oberg, Bryant, and Bach (1994) concluded that full
implementation of the laws prohibiting discrimination of those with
disabilities is necessary to remove the barriers that prevent these
children from attaining equity in health care and education. These
children often require attention beyond that which his teacher is
equipped to provide. The training of lay providers by nurses,
respiratory therapists, physical therapists, and occupational therapists
is critical to assure that classroom aides, secretaries, teachers and
child care workers are adequately prepared to handle expected and
unexpected situations (Todaro, et al. , 1993). The school nurse,
because of her knowledge and skills, is the key person to successfully
manage the integration of chronically ill and developmentally disabled
children into the public school system (Joachim, 1989). Information can
be stored by computer, allowing staff to record, report, and obtain
information about the child's school health plan while other school
staff record observations that affect some aspect of the child's care
(Graff & Ault, 1993). This convenience must be tempered by the
awareness that there is a confidentiality concern, particularly with
chronically ill children, large numbers of whom do not wish their

medical and school records merged. A collaborative approach using the

36
school nurse as a case manager enhances the school experience for the
chronically ill child (Joachim, 1989).

In summary, the literature reviewed relevant to the Diagnostic and
Monitoring Function covers the traditional duties of the school nurse,
as well as the additional requirements placed on this specialty by the
mainstreaming of handicapped children. There is also recognition of the
need for the CNS's referral sources, the school nurses and the teachers,
to be skilled in identifying problems requiring intervention and
unbiased in referrals to the CNS. The literature also points to a need
for school nurses to define their own practice and become skilled in
multidisciplinary collaboration of services required for the care of
chronically ill and handicapped children.

v a em of Ra id Ch in Sit

The rapidly changing situations requiring management can refer to
more than a child's medical condition. The previously reviewed
literature regarding the tenuous, unstable lives of homeless families is
an example. This example can be expanded to include children living in
poverty. The living environment of these children and their families
can be one of rapid change, as their economic uncertainty would suggest.
Poor children are frequently un- or under-insured. Children younger
than 18 years of age are the second most likely group to be uninsured,
with one in four uninsured either all or part of the year (Friedman,
1991). Medicaid faces problems in that while families receiving Aid to
Dependent Children constitute between 70 - 75% of the Medicaid
population, three fourths of Medicaid expenditures go to the costs of

care for the aged, blind, and disabled, especially patients in nursing

homes (Friedman, 1991).

37

In their study of the impact of poverty on child health, Newachek,
Jameson, and Halfon (1994), found that not only do poor children
experience a disproportionate number of health problems but, also,
evidence from the study supports that health problems affect poor
children more severely. Children from poor families have been found to
have substantially higher rates of developmental disabilities, chronic
illness, and infectious disease than children from higher income
families (Martin, 1992). Malloy (1992) concludes that the barriers to
health care for poor children include decreasing health insurance
coverage, a critical shortage of health care services in medically
underserved areas and a collapsing public health system.

In summary, the literature relevant to the Effective Management of
Rapidly Changing Situations was reviewed specifically to the tenuous
home life situations of children living in poverty. The literature
clearly indicates the high risk that is placed on a child's health by
living in poverty, both in terms of the barriers experienced by the
group and the increased incidence of illness and morbidity from illness.
The literature does not yet include sufficient documentation of long
term positive impact of programs which increase access and deal with the
social aspects of living in poverty.

Administering and Monitoring Therapeutie Regimens

The school-based delivery of primary health care is seen by many
authors as an integrative solution to the problem of lack of access to
preventive services. The American Medical Association in a 1990 report
from the Council on Scientific Affairs, note that despite all the
identified hazards of this stage of life, school-aged youth do not use

physician services as frequently as do other population groups. Further

38

noted is the tendency of poor inner-city patients to use specialty
clinics and emergency departments as a regular source of care (AMA,
1990). The recommendations put forth include the standard that "On-site
services should be provided by a professionally prepared school nurse..
and that the responsibilities of this professional would include
coordinating the health care of students with the student, the parents,
the school and the student's personal physician, and assisting with the
development and presentation of health education programs in the
classroom” (AMA, 1990, p.90).

Bruininks, Frenzel and Kelly (1994) in their work on designing a
model which links schools to community-based services, make the A
statement that the medical model is used to describe services which are
crisis oriented. An alternative to a deficiency or problem-based model
is a developmental model--one that emphasizes prevention and addresses
the unique strengths as well as the needs of people at various life
stages (Bruininks, et al., 1994). This would lead to the potential for
what Dryfoos (1993) refers to as a "full-service school" which
integrates the education, medical, social, and/or human services that
meet the needs of children and their families on school grounds or in
locations which are easily accessible. School-based primary health
centers are one of the building blocks for full-service schools
(Dryfoos, 1993). Elders (1993), the Surgeon General of the United
States and a strong pr0ponent of school—based health care has the
following philosophy:
. School-based health services provide accessible, affordable and

preventive health services in the schools. The goal of

school-based health services is to improve the overall physical

39

and emotional health of children and adolescents. This is

accomplished by providing good quality, accessible health care to

children when they need it. School-based health services also
promote healthy lifestyles so that youth can have less need for
health care. This is accomplished by enriching classroom
experiences to include teaching about preventive health care and
consumer behaviors and promoting the development of good
decision-making skills in relation to health and other life issues

(p.314).

The expected opposition of physicians to school-based health
clinics has not materialized in response to the perception that the
clinics would be seen as competitive, because they have been developed
primarily in communities that are not being served by individual
providers (Goldsmith, 1991). Elders (1993) states that pediatric
nurses, pediatric nurse practitioners, and public health nurses will be

the backbone of the clinics that provide school-based health services to
hchildren.

SportsPACE is described by Griesemer and Hough (1993) as a health
care partnership program in Springfield, Missouri, which included major
educational initiatives in preventive sports medicine, strength
training, flexibility training, nutrition, and cardiovascular
conditioning for all school—aged children. The philosophy upon which
the SportsPACE program is based is that the lines that formerly
separated the athletic, health education and physical education programs
are becoming less distinct. Although the article describes the
rationale for and implementation of the SportsPACE program, there is no

analysis of the results, in a health outcome sense at this time.

40

Another example of a school-based health promotion program is
presented by Nicholson (1993). This program at Yale Secondary School is
focused on adolescents, as many of the early programs have been, and
utilizes substance abuse prevention workers, peer counseling,
alternative programs for children with behavior problems, public health
nurses, and service projects to be conducted by the adolescents. The
article describing this program is largely descriptive of the
implementation process for such a program and does not include the
health outcomes of the interventions.

Health promotion activities are increasingly seen as the purview
of school-based delivery systems. To be effective, these programs must
impart information, affect attitudes, and change behavior (Igoe &
Giordano, 1992). Lavin, Shapiro, and Weill (1992) conducted a review of
25 reports on school-based health promotion programs and found a growing
consensus for the critical issues, the urgency of the concerns, and
potential strategies for action, which were divided into five common
themes. Those themes are: Education and health are interrelated; the
biggest threats to health are "social morbidities"; a more
comprehensive, integrated approach is needed; prevention efforts are
cost-effective; and health promotion and education efforts should be
centered in and around schools. An urgent and compelling need exists
for more comprehensive and coordinated policies, programs, and services
to make the health and education of children a national priority.

The establishment of school-based clinics has run into community
resistance in many instances, which is primarily spearheaded by
religious groups concerned about the nature of health information being

conveyed, specifically teen-age sexuality issues and contraception

41
(Pacheco, Powell, Kalishman, Benon, & Kaufman, 1991). The controversy
revealed in many communities points to the need to very carefully convey
the services to be provided and the benefit to the community of these
services. The school-based clinics must have strong support from school
administrators, teachers, students, parents, and local community
leaders.

Rienzo and Button (1993) studied the opposition to four selected
school-based clinics to investigate the existence of organized
opposition, how proponents had contended with the opposition, and
effects of organized opposition on school-based clinic approval and
implementation. It was revealed that the opposition consisted of
national conservative organizations, specifically Right to Life, Eagle
Forum, and the Christian Broadcast Network. It once again emphasized
the importance of establishing the need for the program, the content of
the program, and garnering strong, vocal support.

Ross (1994) notes that school-based clinics offer students an
opportunity to discuss such concerns as depression, abuse, chemical
dependency, and family problems. Stone (1990) describes a model of
school health promotion called ACCESS, with five major components:
Administration, Community, Curricula, Environment, and School Services.
The model is conceived as a broad-based organizational structure for
planning, implementing, and evaluating school health promotion, which
has not yet been implemented (Stone, 1990).

In summary, the domain of Administering and Monitoring Therapeutic
Regimens was reviewed in literature relevant to the school-based
delivery of health care services and health promotion activities. The

models of health promotion speak to the advantages of community-linked

42
services that integrate education, medical, social, and/or human
services needs in a convenient location. The coordination of previously
exclusive services is shown repeatedly to yield positive outcomes, while
reducing needless duplication.
WWI“)! of Hialth Cue—mg;

The monitoring and ensuring the quality of health care practices
domain is conceptualized by reviewing literature specific to the use of
research as intervention and health promotion in the school setting.
Simons-Morton, Parcel, Baranowski, Forthofer, and O'Hara (1991)
conducted an intervention study, based on social cognitive theory, which
they called Go For Health Curriculum, Children's Active Physical
Education (CAPE), and the New School Lunch (NSL). This program
consisted of classroom health education, modification of school lunch
content and five, six- to eight-week units of physical conditioning
activities (Simons-Morton, et al., 1991). Two of the four elementary
schools were assigned to this intervention and two to control
conditions. The results show strong positive program effects on
children's diet and activity at school, and is felt by the authors to be
the first US study to demonstrate the potential for altering the school
environment to promote a more healthful diet and more vigorous physical
activity (Simons-Morton, et al., 1991).

Parental involvement with children's health promotion was examined
by Perry, et al. (1989) in the long-term outcomes of the Minnesota Home
Team study. The Minnesota Home Team was a home-based program using 32
schools in four urban school districts in Minnesota and North Dakota to
complement a five week, fifteen session school curriculum on the Healthy

Heart program. The Home Team program was a five-week correspondence

43
course involving third—graders and their parents after random assignment
of their schools to one of four conditions: the school-based Healthy
Heart program, the home-based Home Team program, both programs in
sequence, or a no-treatment control group. After one year, the results
were ambiguous, suggesting a need for longer intervention, booster
sessions, and intervention with different age groups.

The effectiveness of a family-based cardiovascular disease risk
reduction intervention was evaluated in two ethnic groups,
Mexican-American and non-Hispanic white families, by Nader, et al.,
(1989). Half the families were randomized to a year long educational
intervention designed to decrease the whole family's intake of high
salt, high fat foods, and to increase their regular physical activity.
Both Mexican- and Anglo-American families in the experimental group
gained significantly in knowledge of the skills required to change
dietary and exercise habits, and behaviors, than did those in the
control group, and there was evidence that behavior change persisted one
year beyond the completion of the intervention.

The "Know Your Body" intervention trials have been the source of
studies by Walter (1989) and Bush, Zuckerman, Taggart, Theiss, Peleg and
Smith (1989). The program is classroom based and teacher-delivered and
consists of three primary intervention foci: diet, physical activity,
and cigarette-smoking prevention. In the Bush, et al. (1989) study, the
sample consisted of black students in grades four through six at nine
schools in the District of Columbia. These students were randomized
into one control group and two intervention groups, totalling 1,041
students. The two intervention groups differed only in that they were

in different school buildings. In addition to the many physical factors

44
measured before and after the implementation of the study, the teachers
conducting the classroom curriculum were also evaluated. The study
results indicated that intervention students who were judged to have had
the best ”Know Your Body" teachers showed significant favorable net
changes in total serum cholesterol after one year.

Walter (1989) conducted a field trial of the Know Your Body
program using two demographically dissimilar populations of
schoolchildren in New York City. After five years of intervention in
one of the populations, the program was associated with significant
favorable changes in the total blood cholesterol levels, dietary intake
of total fat, carbohydrates, rate of initiation of cigarette smoking,
and was further associated in both groups with significant favorable
changes in knowledge.

Downey et al., (1989) studied the use of Heart Smart curriculum as
a prototype for school-based health promotion, which integrates a
cardiovascular risk—factor screening and health education in grades
kindergarten through sixth-grade, along with modified school lunches and
physical education programs. Risk factors for eventual cardiovascular
disease, which include a family history of heart disease, elevations in
blood pressure and serum lipids and lipoproteins, cigarette smoking,
high dietary fat intake, a sedentary lifestyle, and a complex set of
behaviors called the "Type A" behavior pattern, are established in
childhood. The findings of Downey et al., (1989) regarding the value of
screening school-age children for the presence of these risk factors,
suggest the ability to individualize the program for high-risk children.

A qualitative study by Jacobson (1994) on the meaning of stressful

life experiences in nine-to eleven-year-old children identified

45

seventeen categories of situations concentrated within three dimensions:
feelings of loss, feelings of threat to self, and feelings of being
hassled. Ryan (1988) suggests that there is a need for understanding
the stress-coping process in school-age children in order to design
health promotion programs which include appropriate interventions for
children. The stress-coping inventories and instruments for measuring
coping strategies are adult-focused, and further refinement of
child-specific assessment measures must be developed.

McClowery, Giangrande, Tommasini, Clinton, Foreman, Lynch and
' Ferketich (1994) studied the effects of child temperament, maternal
characteristics, and family circumstances on the maladjustment of
school-age children. Mothers and their school-age children, living in a
mid-size New England city that is predominately Caucasian and middle
class, were the subjects of the study. Instruments were used to measure
child maladjustment, parental distress, maternal psychiatric symptoms,
temperament of the child, temperament of the mother, major life events,
maternal daily hassles, and socioeconomic status. In terms of
correlating maladjustment of children with the other factors under
study, the internalizing (overcontrolled, anxious) child was directly
affected by maternal hassles and child negative reactivity, measured by
temperament of the child. The externalizing (undercontrolled,
aggressive) child was directly affected by maternal hassles, high child
negative reactivity, and child low task persistence, and indirectly
affected by aspects of the maternal hassles, which were broken down by
maternal psychiatric symptoms, major life events, and maternal

intensity. This is also important information for individualizing

46
health promotion strategies, based upon the child and family's
adjustment.

Farrand and Cox (1993) looked at the determinants of positive
health behavior in middle childhood to determine the contributions of
sociodemographic variables, health experiences, family functioning,
self-esteem, intrinsic motivation, and health perception to the health
behaviors of preadolescent children. Health behaviors were found to be
gender-specific and formed partially through a set of background
variables, that included, for girls, mother's health, family size, and
health perception and, for boys, income, mother's education, and
father's education, which affected self-esteem.

In summary, the domain related to Monitoring and Ensuring the
Quality of Health Care Practices was reviewed in the literature specific
to research-based intervention and health promotion programs. The
programs were both school-based, with collaboration among food service
workers and physical education staff, and home-based, with efforts
directed at the involvement of the family in the child's health
promotion. All the studies indicate a need for longitudinal
interventions with "booster" sessions for maintenance of positive gains
experienced by the participants. All the programs require additional
research to further demonstrate their effectiveness.
ngepizetippal and Wort-Role Competencies

The organizational and work-role competencies domain are
operationalized in this study as the requirement for the CNS in the
school health setting to remain politically aware and astute regarding
the local, state, and national policies affecting the role and practice

of the CNS. Healthy People 2000 (US Public Health Service, 1990)

47
contains many initiatives which are specific to the school setting.
Former Surgeon General, Novello (1991) developed the ready-to-learn
initiative, directed to child and family health, as an
operationalization of the goal ”By the year 2000, all children in
America will start school ready to learn“. More than 170 of the 300
Healthy People 2000 objectives relate to maternal and child health,
including behavioral objectives relevant to school health promotion
(McGinnis, 1992).

McGinnis and DeGraw (1991) took the goals which were specific to
the school setting, and formulated Healthy Schools 2000, stating that
"Successful school health programs represent a key to attaining the year
2000 objectives" (p.292). School health programs are seen to contain
the elements of care delivery, health education, and developing the
attitudes, behaviors and skills necessary to make informed health and
life decisions. By the year 2000, many students passing through the
educational system will have reached adulthood; for this reason, and
because of health programs for faculty and staff and integrated school
and community health promotion efforts, school health programs will have
far-reaching effects on many more objectives related primarily to adults
(US Public Health Service, 1990).

The Department of Education is an important source of funding and
support for health-related school programs, including Chapter I. The
Comprehensive School Health Education Program, previously discussed, has
taken the lead in coordinating all health-related programs in the
Department of Education (Ravitch, 1992). Policies regarding health care
reform, although currently stalled, must be continually reviewed and

followed. School health specialists must continually assure that in the

48
debate regarding program design for health care reform the needs of
uninsured, poor children and their families, homeless children and
families, handicapped children and families, and other vulnerable
children be kept in the foreground.

In debates about costs, it has been shown that a number of
preventive expenditures are dramatically cost-effective (Oberg, 1990).
For children with chronic illness and disability, the current health
care reform process holds both promise and uncertainty in regard to the
proposed benefit package (which could be limiting), the issue of
provider choice (which could limit access to specialists) and investment
in research (Palfrey, Samuels, Haynie & Cammisa, 1994). If those
concerned with school health education take a lead in working with
education reformers, they can help shape schools into places where
health is integral to education (Sullivan & Bogden, I993). The current
state of policy flux in the education arena across the nation offers a
unique opportunity for dynamic schools to push ahead and integrate
health into their basic education program and draw the attention of
state policymakers to schools with demonstrated effectiveness in
promoting health (Sullivan & Bogden, 1993).

In summary, the literature relevant to the domain of
Organizational and Work-Role Competencies was reviewed specific to the
public policy realm. The literature contains several examples of the
interest in modifying the delivery of health care services to school age
children. The rapidly changing environment related to both education
and health care require the CNS to remain politically aware of changes
in policy, as well as be astute regarding the need for professionals to

be part of proposed changes in the regulatory process.

49
Summary

The use of Benner's (1984) Domains of Nursing provide a relevant
background for conceptualizing the role of the CNS in the school
setting. This information regarding the role of the CNS then can be
used to inform the interventions which are used to manage the problems
presented by students identified by teachers, school nurses, and the
student's family as having a learning difficulty potentially based on an
unmet health need. The literature supports the importance of the focus
on the health needs of the school-age child, and provides several
examples of creatively designed strategies for assuring that we meet the
immediate needs of the child and also prepare him or her for future
health related decisions based on information from well designed health
education and promotion programs. The literature is quite comprehensive
in covering the need for a multidisciplinary approach to health
promotion and health education, which includes other professionals and
community human services agencies. A review of literature indicates the
increasing complexity of the school nursing specialty, as shown by the
mainstreaming of handicapped children, chronically ill children,
homeless children and children from diverse cultural and ethnic
backgrounds. The literature does not cover in great detail the
interventions used for children who are not yet in the health care
system; those with unmet health care needs. It is in this area that the
interventions employed by a CNS in all the domains of nursing can have a
visible impact.

The indication for these interventions needs to be described in
order to provide a foundation for future research which focuses on the

outcomes of specific interventions. There is also a need to quantify

50
the frequently made statements regarding the link between unmet health
needs and poor school performance, as this obviously is a relationship
in which many other variables could be considered as significant. The
need to establish that certain interventions can be correlated with
probable outcomes is another component which concerns all of health
care, as the time is near when all reimbursement will be tied, if not to
actual outcomes, then at least to utilizing interventions which have
been shown to be effective. The first step in the process of correlating
interventions and outcomes, is identifying interventions, describing
them, and using that information to establish desired outcomes for an
intervention.
METHODS

The problem addressed with this research study was the type and
frequency of interventions employed by a Clinical Nurse Specialist for
cases referred to the Chapter I program with multiple identified
problems.

Description of Research Design

The design for this study was a non-experimental,
exploratory/descriptive design with a retrospective review of data
collected by the Clinical Nurse Specialist working in the Chapter I
program of the Lansing School District, on forms adapted from the Omaha
System. The study design, a Level I descriptive study, was felt to be
most appropriate as data have only been collected using the Omaha System
for one full school year, the 1993-94 session. There are no external
studies published in which the Omaha System has been used as a data
collection tool in order to determine its reliability and validity.

With little known about the specific variable under study, the most

51
appropriate initial research is that in which factor
identification/isolation is the intent.
Sample Techniques
The sampling for this research study was a non-probability,
convenience sample drawn from the cases of children who were referred to

the Chapter I program in the Lansing School District during the 1993-94

school year. The children served by this program are grade school

students, ranging in age from five years old to twelve years old. Many
referrals request the assistance of the Chapter I CNS for relatively
uncomplicated situations, such as the child who needs a vision exam and
glasses. In some cases, the school performance issue may be secondary
to absenteeism related to the student's disadvantaged social situation.

In order to assure that the cases examined were relevant to the intent

of the study, which was to examine CNS interventions for cases referred

with multiple problems, there needed to be specific criteria for those
cases to be analyzed. The criteria for inclusion were:

- The cases selected were those of children referred to the Chapter
I program for a health or school performance-related problem
related to unmet health care needs;

. Those cases selected were children who, upon evaluation by the
Chapter I staff, were found to have three or more problems
requiring intervention, and for which they received interventions.
Lansing School District is located in Lansing, Michigan, the

state's capital. Lansing is a community of 131,000, with a school

enrollment of 20,152, of which 10,939 are elementary school students.

The racial composition of the Lansing school enrollment includes 10,076

(50%) Caucasian, 6,574 (33%) African-Americans, 2,345 (12%) Hispanic,

52
993 (5%) Asian, and 226 (1%) Native American. Major employers in the
surrounding area of Lansing include General Motors, state government and
Michigan State University. With very active church involvement, as well
as the university's influence, Lansing has become an immigration entry
point, with an increasing level of ethnic diversity.
Data Collection Procedures and Recording
The data collected by the CNS from the cases referred to the
Chapter I program over the course of the 1993-94 school year were the
source of the analysis for this study. Upon referral of a case to the
program from the variety of referral sources, data collection begins by
the CNS. This data collection includes information provided by the
referring party, as well as the child's school health record. Appendix
A is a copy of the Lansing School District Chapter I Health Service
Nursing Form. The initial data collected include the student's name and
student number, the building in which the student attends school, the
student's grade, parent's name, address, telephone number, and the
student's date of birth. In addition to these demographic data, the
name of the referring party, the reason for the referral, and the method
of payment, if known, are collected and recorded. The rationale for
collecting information regarding the existence of a payment source is
that there may be coverage for the interventions proposed by the CNS,
such as referral to a specialist physician. A limited budget is
provided to the Chapter I program for the provision of uncompensated
care, however, an attempt is first made to identify other sources of
payment.
At this point, the CNS will initiate communication with the

family. This communication is either a telephone call or, if necessary,

53
an appointment for a home visit will be made to further evaluate the
student's home setting, resources and additional problems which may
affect the treatment plan. With the data collected, the CNS will
document a codified problem, a rating of the problem, the category of
the problem, the target, and an action plan. Each additional contact is
documented in the same manner. The data collection process is ongoing
for as long as the case is considered active. A case is considered
inactive or closed when the CNS's action plan is completed and evaluated
as having met the targeted goals. Other reasons for closing a case
would include a child's moving out of the school district or the child's
death.

These codified data have been entered into a Lansing School
District computer, by school district information specialist staff, and
used to create a database which sorts and reports data by referral
source, reason for referral, method of payment, method of communication,
summary of problem classification, and then categorized by the clinical
codes assigned by the CNS. The types of interventions utilized and the
frequency of the interventions also are collected and recorded in a
codified manner. Appendix C is the Categorization of Interventions,
developed by the CNS, used to document the interventions by code. In
addition to a code for each intervention employed, there is further
categorization of the broad type of intervention. These data can be
sorted in such a way to select those cases in which there were three or
more problems identified by the CNS for which interventions were
employed.

From the original school district data set, the aggregate data,

with the identifiers removed, were obtained by the researcher following

54
the appropriate approvals from the Lansing School District (Appendix B)
and Michigan State University's UCRIHS application approval (Appendix
D).

The categorization of interventions assigned by the CNS were
examined and reassigned to the Domains of Nursing, as categorized by
Benner (1984). To assure that this assignment occurred in an objective,
systematic manner, three individuals, including the researcher, the
Lansing School District CNS, and a Michigan State University Associate
Professor in the College of Nursing, independently recategorized the
interventions. These three recategorizations were examined for
agreement, and only those categorizations in which two of the three
individuals agreed were accepted.

Protecting Human Subjects

As this study was retrospective and non-intervention, the primary
risk was that of inappropriately disclosing a student's confidential
medical information. The cases are assigned identifying numbers by the
Lansing School District CNS, and subsequent data are reported by ID
number only. All identifiers were removed prior to the researcher's
review and analysis. As the research involved the study of existing
data in which the subject could not be identified, there was no risk
associated with human rights violations.

Operational Definitions of the Variables

The independent variable in this study was the sample group of
cases representing school-age children with multiple identified
problems. The dependent variable in the research question was the type
and frequency of the interventions employed by the CNS, which classified

the research as a univariate descriptive study. Children with multiple

55
identified problems are defined as those students who have been
determined by the Chapter I program to have three or more separate,
coded problems requiring intervention. Types of interventions were
grouped by Benner's (1984) Domains of Nursing, as described in the
previous section, to further define the type of competency demonstrated
by the expert nurse. The interventions are the actions taken by the CNS
in response to a referral, including the actions that are taken in
follow-up. These actions include, but are not limited to, referral to a
primary care physician or pediatrician, home visits for an assessment of
the environment or to provide educational information, community
advocacy on behalf of a child, counseling and consultation with school
nurses and teaching staff. Appendix E is an outline of the
Categorization of Interventions as defined by the Chapter I program. As
previously described, these codes were re-assigned to the defined
Domains of Nursing. Frequency of interventions were listed and grouped,
by the type described above, according to the Domain of Nursing
represented. Frequency was counted as individual contacts resulting in
an intervention. If a child is referred to three different specialist
physicians, for example, that was one intervention type with a frequency
count of three.
Instrumentation

The data on the cases handled by the CNS in the Chapter I program
have been compiled on a form adapted by the CNS from the Omaha System.
The Omaha System was developed during a series of three research
contracts between the Visiting Nurses Association of Omaha and the
Division of Nursing, Public Health Service, US Department of Health and

Human Services. The initial work focused on the development and

56
preliminary testing of the Problem Classification Scheme (PCS), the
second phase was field testing of the PCS and development of an Expected
Outcome-Outcome Criteria Scheme (EO-OC) and the third phase was testing
and revision of the PCS, as well as the development and testing of the
Problem Rating Scale for Outcomes and Interventions Scheme (Martin &
Scheet, 1992). Many agencies have used this data collection tool,
including the Public Health Nursing Association of Des Moines (IA), the
Division of Public Health, Bureau of Nursing, State of Delaware, and the
VNA of Dallas, among others.

The PCS was subject to testing following each revision in which
records were reviewed and problem lists generated, using the PCS
guidelines. In addition to high consistency in the use of the
instrument (98% problems supported by data, 100% of modifiers used
correctly), staff agreed that the tool promoted understanding of one
another's records, encouraged nurses to consider the entire family,
helped organize care, and distinguished between medical and nursing
diagnoses (Martin a Scheets, 1992). The PCS classifies problems as
falling into one of four domains: environmental, psychosocial,
physiological, and health related behaviors. From that point modifiers
are assigned to-the problem. The first set of modifiers describe the
problem as either health promotion, potential deficit, or deficit. The
second set of modifiers indicates if the problem is a family or
individual one. From there, specific signs and symptoms are coded for
the problem (Martin & Scheets, 1992).

The EO-OC Scheme was tested in a similar way, by record review
with 77-100% agreement between evaluators. The staff stated that the

Schemes provided a starting point, were useful in developing specific

57
plans, provided guidelines for evaluation, and helped measure the
client's progress (Martin & Scheets, 1992). The result of this was an
Outcome Model which was based on the assumption that interactions of a
community health nurse and a client in relation to a problem affect what
the client knows (knowledge), does (behavior), and is (status).
Nurse-client interactions lead to changes or various possible outcomes
(Martin & Scheets, 1992).

The Intervention Scheme, designed to classify nursing activities
and actions was tested by field testing and interrater agreement. The
percentages of agreement ranged from a low of 42.2% to a high of 96.9%;
8 of 12 percentages of agreement were above 80%. The Intervention
Scheme is intended to describe a series of functions or actions
organized into three levels of abstraction: categories, targets, and
client-specific information (Martin & Scheets, 1992). These levels also
have lists of codes for customizing a client's record with minimal
verbiage.

Although this tool has been subjected to rigorous testing,
significant modifications have been made by the Lansing School District
CNS, which may have made it less reliable in this context. However, as
the data were recorded and coded by one CNS for the entire timeframe
under study, the stability of the use of the instrument should be
enhanced. This is, however, a limitation of the use of secondary data
and an untested instrument which will be acknowledged in a report of the
findings. An additional limitation of the instrument may be the extent
to which modifications were made to the data collection procedure as the
CNS became more familiar with it, or identified a need to collect

additional data. These limitations will also be acknowledged.

58
Data Summarizing Procedures

It was expected that many of the cases were intervened with in
more than one way. It was necessary to indicate the cases as having
differing levels of complexity, based on the problem requiring
intervention at each contact, and numbers of different contacts. The
interventions were sorted by the Domains of Nursing into which they
fall, which was the first level of hierarchy of the "type”. The second
level of the hierarchy of "type" was the intervention itself.

The frequency of each intervention used was tallied, the frequency
of each identified problem was tallied, and separately, the Domains of
Nursing were rank-ordered according to the frequencies of the
interventions employed in each Domain. Correlation coefficients were
calculated between problems with intervention domain, as well as with
specific interventions. The cases analyzed by frequency distribution
are described by age of the student, gender of the student, by school
grade of the student, and socioeconomic status as defined by health
insurance coverage.

Plans for Data Processing and Analysis

The data collected were analyzed by quantifying the types and
frequencies of interventions used by the CNS, by both the Domain of
Nursing represented by the intervention and the intervention itself, as
described above. Analysis included an accounting of those cases in
which the CNS in the Chapter I program implemented interventions for
children with three or more identified problems. The nature of the
problems identified were tallied. There was a preliminary analysis of
the consistency with which interventions are utilized for children with

similar identified problems. The relationships between the identified

59
problem, intervention used, and status of the case at the end of the
school year are described. It was possible to determine outcomes for
many of the cases, although these data will be of interest for future
correlational study, as many cases are ongoing from one school year to
the next. It was possible to obtain the status of the case from end of
the year data and to do preliminary analysis of the relationship between
the interventions used for specific problems and the status of the case
at the end of the year. There was also the ability to control for age
and gender in this relationship, which added a degree of interest to the
findings. There are also data collected on the socioeconomic status of
the family, relative to insurance coverage, which provided interesting
data related to a relationship between socioeconomic status and degree
of complexity of identified problems for intervention. The findings
from this study will be applicable to identical or very similar
populations and will provide information and direction for future
research questions.
RESULTS

The problem addressed by this research study was the types and
frequency of interventions employed by a Clinical Nurse Specialist (CNS)
for cases referred to the Chapter One program of the Lansing School
_ District with multiple identified problems.

Overview

In order to research the problem, data collected by the CNS of the
Lansing School District, from the 1993-94 school year, as described in
the Methods section of this paper, were analyzed. Data collected by the
CNS included student demographics, the age and grade of the student, the

nature of the identified problem(s), and the interventions employed.

60

Additionally, the interventions employed were sorted by the Domains of
Nursing in which they were determined to fall, as conceptualized by
Benner (I984). The assignment of interventions to one of the seven
Domains of Nursing was done independently by three individuals; the
author, the CNS in the Lansing School District, and a professor of
Pediatric Nursing at Michigan State University. Consensus was achieved
in the assignment of the interventions to the Domains of Nursing prior
to analysis of the findings. The study design was a retrospective Level
I descriptive analysis, for the purpose of factor identification.

Sample Description

The convenience sample of all cases referred to the Chapter One
program in the 1993-94 school year was used to select those cases in
which there were three or more problems requiring the intervention of
the CNS. Several variables from the resulting sample (n=86) were then
examined. '

As Table 1 shows, the sample consisted of 43 females (50%) and 43
males (50%). The children ranged in age from 6 years old to 12 years
old (mode-9.00, mean-8.78, sd 1.78), as shown in Table 2. The children
were in grades kindergarten through fifth (mode=3.00, mean-2.24, sd
1.60) (Table 3).

The Chapter One program and its staff are centralized, serving 26
schools in the district. In Table 4 the breakdown, on a school-specific
basis, of the 17 schools responsible for referrals to the program during
the time period under study is represented. Three of the schools, Post
Oak, Allen, and Bingham, all showed much higher rates of referral than

the others (16, 11, and 12, respectively). It may be of interest, in

61

 

 

 

 

 

Table 1.

Mindset;

Gender Frequency Percent

Female 43 50

Male 43 50

Table 2.

Age pf Students

Years of Age Frequency Percent
6 8 9.3
7 18 20.9
8 11 12.8
9 21 24.4
10 13 15.1
11 6 7.0
12 .2 _l.Q_-5

86 100.0

mode-9.0

 

62

 

 

 

 

 

Table 3.
W
School Grade Frequency Percent
Kindergarten 16 18.6
First Grade 15 17.4
Second Grade 16 18.6
Third Grade 19 22.1
Fourth Grade 11 12.8
Fifth Grade _s 10.5
86 100.0
mode-3.0
Table 4.
Sepppl Building
Name of Building Frequency Percent
Allen 11 12.8
Bingham 12 14.0
Cumberland 2 2.3
Gier 7 8.1
Grand River 5 5.8
Gunnisonville 3 3.5
Dendon 3 3.5
Lyons 5 5.8
Maplewood 2 2.3
Moores Park 3 3.5
Mt. Hope 5 5.8
Northwestern 4 4.7
Post Oak 16 18.6
Reo l 1.2
Riddle 3 3.5
Walnut 2 2.3
Willow __; 2.3

CD
01
t—l
O
O
O

 

63
future study, to more closely examine this distribution to determine the
source of any significant variations.

The school district itself qualifies for Chapter One funding based
on the percentage of families within the district living at, or below,
federally-established poverty limits, as determined by the United States
census. The child referred to the program for evaluation and
intervention, however, is not means tested. The source of payment for
each case was determined to be of interest, in order to draw any
possible impressions of the role a child's socioeconomic status plays in
his health status. In Table 5 the payment source documented for each
case is shown. The payment sources ranged from none required,
indicating the intervention was provided solely by the Chapter One CNS,
to Medicaid coverage for services, Chapter One monies, which are used
for such purposes as purchasing eyeglasses for children with an economic
need, or Children's Special Health Care Services (CSHCS), formerly known
as the Crippled Childrens' Program. The breakdown of the 86 cases
showed CSHCS (n-3, 3.5%), Medicaid (n- 27, 31.4%), Chapter One funds (n-
15, 17.4%), and no payment required (n-41, 47.7%). This indicates that
over half (52.3%) of the cases referred had payment sources that were
indicative of economic need; in other words, the program is serving
children and families living in poverty. As there are no clarifying
data collected relative to the category in which no payment was
required, it was not possible to determine if there were cases referred
to the program with private payment sources, such as a parent's
employer-funded health insurance. As the Chapter One program does not
bill for its services, there is no current ability, from the present

data, to compute outcomes based on cost-effectiveness. It would be

64
Table 5.

P men 0 r e

 

 

Type Available Frequency Percent
None required 41 47.7
Medicaid 27 31.4
Chapter One 15 17.4
CSHCS __; __3t§

86 100.0

 

feasible, with additional research, to obtain fee schedule information
from sources such as Medicaid, to establish the value of services
provided by the program, and to use this information to establish the
comparative cost-effectiveness of its services. The data collection
method was not sufficiently specific to draw conclusions relative to the
role of the student's socioeconomic status in either the nature of the
intervention employed for the problem or the status of the problem
before and after intervention, however it does indicate that economic
need is a factor in over half of the cases referred to the program.

Another area of interest was the status of the child's identified
problem prior to the intervention of the Chapter One staff, as well as
after the intervention. The children referred to this program have
often been found to have unmet health care needs and many have

experienced access barriers to the health care system. The presumption

65
was that these children would display problems whose initial status
would be rated relatively poorly. Each identified problem (Na345) was
given an initial status rating of one to five (Table 6), from poor to
excellent, specific to the problem for which the referral was generated.
This rating was assigned by the CNS as a result of her initial problem
assessment. Following the interventions employed by the CNS for the
management of the identified problem, the CNS again assigned a ranking
to the status of the problem. On Table 6, the initial status was shown
to have a mean- 1.57, sd .50, indicating that the average problem
identified for cases referred to the Chapter One program was initially
rated between "poor" condition and "fair" condition. Following the
interventions of the CNS for the management of the problem, the case was
given a subsequent rating, by the CNS, again from one to five, or poor
to excellent.

Table 7 represents these ratings showing a mean of 2.04, with a
standard deviation of .94, indicating that a later evaluation of the
average problem, resulted in a rating of just above "fair". Table 8
reveals that for 156 (45.2%) of the problems there was an improved
status rating, for 152 (44%) there was no change in the rating, and for
37 (10.7%) the status of the problem worsened. To test for the
significance of the difference between the Status 1 condition and the
Status 2 condition, a t-test of the paired sample was conducted (Table
9). The mean of the paired difference was -.47, with a standard
deviation of .86, and a 95% confidence interval of -.56 to -.38. The
t-value is -10.21, with a two-tailed significance of .000. The results

of the t-test indicate a significant difference between the initial

66

 

 

 

Table 6.

Initiel Stetgs of the Problem

Assessed Status Frequency Percent

Poor 151 43.8

Fair 193 55.9

Average 1 .3

Good 0 O 0

Excellent __9 9.9
345 100.0

Table 7.

Stetus of PrOblethollowing Intervention

 

 

Assessed Status Frequency Percent
Poor 115 33.3

Fair 134 38.8

Average 64 18.6

Good 32 9.3

Excellent

- E

 

67
Table 8.

P o l S

 

Comparison Frequency Percent

 

Status I > Status II

 

(problem worse) 37 10.7
Status I - Status 11
(problem same) 152 44.1
Status I < Status 11
(problem better) 15g 55,2
345 100.0
Table 9.
r' n of Mean nit' l St tus and S a ol 0 'n t v

 

t-tests for Paired Samples

 

Number of 2-tail SE of Mean
Variable Pairs Corr Sig Mean SD
STATUS l 1.57 .502 .027
345 .427 .00
STATUS 2 2.04 .944 .051

 

Paired Differences
Mean SD SE of Mean t-value df 2—tail Sig

 

-.47 .859 .046 -10.21 344 .000
95% CI (-.563, -.381).

 

68
status of the problems and the status of the problems following
intervention.

Although it was not the purpose of the study to measure the
effectiveness of the CNS's interventions in improving the status of the
problem, this is an area in which additional hypotheses could be tested.

Finally, as the total numbers of identified problems (N-345)
exceeded the sample size criteria, which would have been the 86 cases
with three distinct problems each (Na258), there were clearly cases for
which there were more than three identified problems. To get a sense of
the actual impact these 86 cases had on the resources of the Chapter One
program, information regarding the numbers of encounters per case is
displayed on Table 10. This information reveals that for the 86 cases,
there were 933 encounters, with a mean number of encounters per case of
10.85, with a standard deviation of 6.76. As the standard deviation
would indicate, there were several outlier cases on the high end, with
one case each representing 24, 25, 26, 29, and 42 encounters. When
these five cases are dropped, the mean number of encounters per case is
9.72, with a standard deviation of 4.85. It would seem clear that the
actual impact each case has upon the resources of the Chapter One
program requires a more comprehensive description than the focus of this
study would allow.

Findings

In order to determine the types and frequencies of interventions
employed by the CNS for cases referred to the Chapter One program with
Inultiple identified problems, data were reviewed relevant to the
specific problems. Table 11 represents the 36 different problems

identified for the 86 cases in the sample, representing 345 total

69

 

 

Table 10.
F n n ercent e o ncoun er b h N e
# encounters/case Frequency Percent
3 3 3.5
4 3 3.5
5 11 12.8
6 6 7.0
7 5 5.8
8 15 17.4
9 4 4.7
10 7 8.1
11 4 4.7
12 4 4.7
13 5 5.8
14 2 2.3
15 1 1.2
16 2 2.3
18 1 1.2
19 3 3.5
21 3 3.5
22 2 2.3
*24 l 1.2
*25 1 1.2
*26 l 1.2
*29 I 1.2
*42 __t 1.2

‘0
w
w
H
O
O
O

Mean-10.85
SD- 6.76

*Without the
last five values 928

Mean-9.72
SD-4.85

 

70
Table 11.

Prpblem, Freguency and Percentage by Omahe System Domain Categorizetion

 

Problem by Omaha System Domain Frequency Percent

 

I. Epvipppmeptel Domein

Income 26 7.5
Sanitation 3 .9
Residence 2 .6
Neighborhood Safety 2 .6
11.151911952231me
Community Resources 11 3.2
Role Change 1 .3
Interpersonal Relation 4 1.2
Spiritual Distress 1 .3
Grief 1 .3
Emotional Stability 9 2.6
Human Sexuality 1 .3
Caretaking/parenting 11 3.2
Neglected child/adult 2 .6
Abused child/adult 3 .9
Growth & Development 10 2.9
III. Physiplogic Domain
Hearing 16 4.6
Vision 41 11.9
Speech & Language 9 2.6
Dentition 59 17.1
Cognition 16 4.6
Pain 11 3.2
Level of consciousness 1 .3
Integument 6 1.7
Neuro-musculo-skeletal function 7 2.0
Respiration 20 5.8
Circulation 4 1.2
Digestion/hydration 5 1.4
Bowel Function 4 1.2
Genitourinary function 6 1.7
IV. Health-Related Behaviors Domain

Nutrition 6 1.7
Sleep and rest patterns 7 2.0
Physical activity 2 .6
Personal hygiene 2 .6
Health care supervision 35 10.1
Prescribed medication regimen __t .3

345 100.0

 

71
problems, sorted in descending frequency of the Omaha problem code, to
allow visualization of the most frequently identified problems. The
problems are sorted by the Omaha problem domain, as assigned by the CNS,
which provides a further breakdown of the nature of the problems. The
greatest numbers were grouped in the areas of basic health care and
screening, such as dentition problems (N-59, 17.1%), vision problems
(N-4l, 11.9%), and health care supervision (N=35, 10.1%).

As previously stated, the examination of the payment source was
not a definitive indicator of the role a child's socioeconomic status
plays in the referral to the Chapter One program. Additional
examination of the problems identified by the referral sources and the
Chapter One staff, reveals that problems from the Environmental Domain,
indicating income, residence, sanitation, and neighborhood safety
issues, represented 33 (9.6%) of the problems identified. Problems
identified in the Psychosocial Domain can also often be associated with
disadvantaged lifestyles, such as the need to be linked with community
resources. The Health-Related Behaviors Domain shows problems that
include nutrition and personal hygiene, which are associated with
poverty.

The 35 different interventions which were tallied, representing
345 total interventions, are displayed on Table 12, in descending order
of frequency by the Domains of Nursing, to allow visualization of the
most frequently employed interventions. The interventions most
frequently employed were referral for dental services (Ns59, 17.1%), CNS
communication with the parent (N254, 15.7%), and CNS to physician
consult (Ns39, 11.3%), referral to a pediatrician (N-33, 9.6%),
provision of food and/or clothing (N=17, 4.9%), a school consult (N-IG,

72
Table 12.

interventions by Benner's Domains of Nursing

 

Intervention by Domain Frequency Percent

 

I. HELPING ROLE
Parent Communication
Food/Clothing
School Consult
MSU Nursing Referral
Glasses
Prescription
MichCare
Social Work Consult
Communication
Supplies
Public Health Nursing Ref.
Crippled Childrens' (CSHCS)
Probate Court/Protective Serv
Support System
Wellness
Pre-primary referral
Cooperative Extension

N-F-b-FU'I

HHS—I'm
r—u—u—oNNNNNwwwm-bmflh
ubummmmmooowwaxow

b—l
(a)
N
GIL
on
w

11. TEACHING-COACHING FUNCTION
Caretaking/Parenting
Education
Medical/Dental Care Info

mIHP-‘a‘

III. DIAGNOSTIC & PATIENT MONITORING
None

0
O
C

IV. EFFECTIVE MANAGEMENT OF RAPIDLY
CHANGING SITUATIONS
None 0 0.0

V. ADMINISTERING & MONITORING
THERAPEUTIC REGIMENS
Medication Action/Side Effects

73
Table 12 (cont.)

 

Intervention by Domain Frequency Percent

 

VI. MONITORING & ENSURING QUALITY OF
HEALTH CARE PRACTICES

Dental Referral 59 17.1
Nurse/Physician Consult 39 11.3
Pediatrician Referral 33 9.6
Family Practitioner Referral 16 4.6
Opthamologist Referral 13 3.8
Mental Health Referral 10 2.9
Ingham Co. Health Dept. 7 2.0
Specialist Physician Referral 7 2.0
ENT Referral 5 1.4
Optometrist 5 I. 4
Lab/XRay/CT Scan 5 1.4
Imunization 3 .9
Hospital Visit 1 .3
Emergency Room _1 .
204 59 1
VII. ORGANIZATION & WORK-ROLE COMPETENCIES
None __0 0,9
TOTALS 345 100.0

 

4.6%), MSU nursing referral (N-lfi, 4.6%), which refers to the practice
of assigning follow-up of some cases to an undergraduate nursing
student, referral to an ophthalmologist (Na-13, 3.8%), and referral to
mental health (ii-10, 2.9%). The remaining interventions represent
frequencies of eight or fewer. This table shows that the CNS is
employing interventions which serve to achieve or optimize access to the
health care system in 204 (59.1%) of the total interventions, and
conlnunicating information and education to parents in 62 (18.0%) of the

total interventions.

74

The'hnerventions employed, in Table 12, are sorted by the Domains

of Nursing represented by the interventions. The greatest number of

interventions employed (204, 59.1%) were in the domain labelled,
Monitoring and Ensuring Quality of Health Care Practices, in which
interventions involving referrals to specialist physicians, dentists,
and telephone conversations between the CNS and other professionals were

The next most frequently employed domain was the Helping Role,
These

coded.
in which 132 (38.3%) of the interventions were coded.

interventions included conversations and home visits between the family

of the student and the Chapter One staff, provision of food and
clothing, consultation with school staff, such as teachers and school
nurses on behalf of the student, and referral to Michigan State

University student nurses, in their Community Health rotation for

intensive follow-up. Also represented was the Teaching-Coaching

Function, a domain in which eight (2.3%) of the interventions are coded.
This domain represents interventions in which the CNS works with the

family of the student on issues involving caretaking and parenting, and

providing education and information. Administering and Monitoring

Therapeutic Regimens had one (0.3%) intervention coded, for which there

was intervention for medication action or side effects. Three of the

domains, the Effective Management of Rapidly Changing Situations, the

Diagnostic and Patient Monitoring, and the Organizational and Work-Role

Competencies, had no coded interventions from this sample. All of the

possible interventions, sorted by the Domains of Nursing, are sumarized

in Appendix C.
Correlation coefficients were computed in an attempt to reveal

relationships among the variables in the data set (Table 13). There

75

 

 

Table 13.
i e m V l
Age Payment Sex Status 1
Age 1.00 .19 .10 -.O6
(86) (86) (85) (86)
-. P-.37 P-.59
Payment .19 1.00 -.21 -.11
(86) (86) (86) (86)
P=.O9 P-.06 P-.32
Sex .10 -.21 1.00 .02
(86) (86) (86) (86)
P=.37 P-.06 P-.83
Status 1 -.06 -.11 .02 1.00
(86) (86) (86) (345)
P-.59 P-.32 P-.83

 

were no significant or meaningful correlations among age, sex, payment

source, and the initial status of the problem. An apparent negative

correlation between sex and payment source does not, in fact, exist due
to the lack of specificity in the data collection, previously described,
related to payment source.

There was a correlation found between intervention employed and

the identified problem of .27, with a p-.OOO (Table 14). There was no

correlation found between the problem and the number of encounters.

There was also no correlation between the intervention employed and the

number of encounters.

76

 

 

 

Table 14.
C ° C f’ 'e t o Pr e d V ria l
Encount Interv Prob
Encount 1.00 -.06 -.OO
(86) (86) 86)
P-.61 P-.99
Interv -.06 1.00 .26
(86) (345) (345)
P-.61 P-.OO
Prob -.OO .26 1.00
(86) (345) (345)
P-.99 P-.00
Summary

The data collected by the CNS in the Chapter One program of the
Lansing School District were analyzed to determine the types and
frequency of interventions employed for cases referred with multiple
problems. The problems and the interventions were further categorized
as falling within the Domains of Nursing, as categorized by Benner
(1984). To better understand the types and frequencies of interventions
employed, the author first examined characteristics of the sample in
relation to age, gender, grade, socioeconomic status. For targeting
future research or systems education, information was collected on the
specific school buildings from which referrals were being received. The
nature of the problems identified in the referred cases was of primary

importance in understanding the types of interventions selected as well.

77

The results of the data analysis indicate that the cases (ti-86)

contained 36 problems and 35 interventions, representing an overall

frequency of 345, with 933 total encounters. The types and frequencies

of the interventions are displayed in Table 12, and reveal that the

interventions most commonl y used were the referral for dental services

(Na-59, 17.1%), parent communication with the CNS (N—54, 15.7%),
CNS/physician consult (ti-39, 11.3%), referral to a pediatrician (ti-33,
9.6%), provision of food and/or clothing (N-17, 4.9%), referral to a
family practitioner (N216, 4.6%), a school consult (Na-16, 4.6%), MSU
nursing referral (ii-14, 4.1%), referral to an ophthalmologist (Na-13,
3.8%), referral to a mental health agency (Na-10, 2.9%), and 25 other

interventions representing frequencies of eight or fewer.

The Domains of Nursing (Benner, 1984) represented by the

interventions are displayed in Table 12, with 204 (59.1%) of the

interventions grouped into the domain, Monitoring and Ensuring the

Quality of Health Care practices. This domain includes such

interventions as screening services, referrals to health care providers,

consulting between the CNS and physician referral, and other specialty
The Helping Domain had 132 (38.3%) of the

service referral.
The Helping Domain represents such

interventions grouped into it.

interventions as financial assistance, referral to cormnunity agencies,
The

transportation, prescription filling, and support system access.
Teaching—Coaching Function was the grouping for eight (2.3%) of the
This domain included education,

interventions employed by the CNS.
Administering

nutrition, safety, and stress management interventions.
and Monitoring Therapeutic Regimens was the Domain of Nursing assigned

to only one (0.3%) of the interventions. This domain represents such

78
interventions as bowel care, cast care, feeding procedures, and
bronchial hygiene. Three of the Domains of Nursing were not represented
in the findings of this study. The domain of Effective Management of
Rapidly Changing Situations had only one intervention code assigned to
it, the domain of Organizational and Work-Role Competencies had no
intervention codes assigned, and the domain of Diagnostic and Patient
Monitoring had only three assigned intervention codes, making it much
less likely that interventions employed would derive from these domains.
In the following section a detailed interpretation of these
findings will be outlined which will include an assessment of the
research conducted, as well as implications for advanced nursing
practice and future research.
DISCUSSION
Interpretation of Findings
The children who represent the "cases" in this study were found to
be equally likely to be of either gender, as the selection criteria
resulted in a chance sample of 43 boys and 43 girls. There was no
gender bias evident in referral of students to the Chapter One program,
based on these data. The mean age of the child was 8.78 years (mode-9
years) and the mean school grade was 2.24 (mode-grade 3). These figures
are of interest, as the age is approximately one year older than the
average child's, in the general population, at that grade level. This
finding may be related to the child's unmet health care needs, family
mobility, socioeconomic status, or for reasons unknown. The child's age
and grade at the time of the recognized need for referral to the program
may be a function of his or her growth and development and verbal

skil‘ls, as opposed to recognition earlier in the child's school career.

79

Most (76.7%) of the cases referred to the program represent children in

grades kindergarten through third grade.
As the Chapter One program has been in place for a number of

years, it is likely that by the time a child has reached fourth and
fifth grade, problems related to unmet health care needs will have been

recognized. The problems identified having to do with the child's

environment are potentially very dynamic and may not have been a factor

earlier in the child's life. The school population is also dynamic,

with children moving in and out at different ages and grades, with the

referral occurring when the child comes into the school system at an

older age. The significance of age and grade to the referral bias, or
the nature of the identified problems or outcome, would be of interest

in a controlled study to demonstrate the positive impact of the Chapter

One program in early identification and intervention on

cost-effectiveness and outcomes.
As discussed in the previous section, there was an attempt to

determine the impact a child's socioeconomic status, as determined by

payment source, had upon the nature of the problems identified, the
interventions employed and the outcome of the case. The data show that

52.3% of the children had payment sources that could indicate an
economic need, such as Medicaid, the use of Chapter One funds for

services required and, potentially, the Children's Special Health Care

Services (CSHCS) program. The information collected in this area was

not sufficiently specific to adequately determine the impact of a
child's socioeconomic status on his or her referral to the Chapter One

program. There was, however, adequate information in the problem
identification data to determine that at least 9.6% of the identified

80
problems were specifically related to the Environmental Domain, which
included income, housing, sanitation and residence, with additional
cases in the Psychosocial Domain, the Physiologic Domain, and the

Health-Related Behaviors Domain, with problems that were at least
indirectly related to poverty and lack of access to health care. The

Psychosocial Domain accounted for 15.8% of the identified problems, and
included caretaking/parenting problems, the need for conlnunity

resources, and growth and development problems, among others.

The Physiologic Domain accounted for 59.3% of the problems,

including hearing, vision, dental problems, as well as several other

categories which, if not specifically related to socioeconomic status,

certainly are related to a lack of access. The implications from the

problem identification of the problems for which students were referred
to the Chapter One program, are that a significant proportion of the
children have a lack of access to primary care, and are at risk for the

development of long term problems or unnecessary complications of their

problems.
The Chapter One program does not submit reimbursable bills for the

As a federally funded program, the necessary

services it provides.
In the case of an

funds are provided for administration of the service.

available source of payment, such as Medicaid, any outside services

provided, such as consultation by a specialty physician, will be paid

through that source. Of interest for future study may be the actual

dollar value of services provided free of charge to students by the

Chapter One program, that would otherwise be reimbursed if available

externally. Fee schedules from the Medicaid program, HMOs, and other

third-party reimbursement sources could be utilized to establish the

 

81
tangible value of the services provided by the program. Assigning a
financial value to the interventions of the CNS may provide outcomes
data related to the cost-effectiveness of this program, especially
valuable at a time when all expenditures are being closely evaluated.

Data were collected regarding the school building which the
student attended. This information may be useful for revealing any
differences in problems identified related to the demographic status of
the student population in specific buildings, levels of attention to the
identification of problems by referral sources, and any need for
outreach education regarding appropriate referrals to the Chapter One
program. Three of the schools, Post Oak, Allen, and Bingham schools had
very high referral rates (16, 11, and 12, respectively). With the
exception of Post Oak, which is one of the largest elementary schools in
the district, there was no single, unique feature relative to special
programs or the characteristics of the student body that would serve to
explain this difference. In the absence of detailed data regarding the
composition of the Lansing School District, however, further analysis is
beyond the scope of this study.

The information collected regarding the assignment of a rating to
the status of the identified problem initially and following
intervention was challenging to interpret. The difference between the
means in the paired sample, before and after intervention (Table 9), is
significant and indicates improvements in the status of problems
following the intervention of the CNS. The primary concern regarding
this information was a lack of clearly defined criteria for the
assignment of ratings, for example, what was the difference between fair

and average? There was a potential for bias in the direction of

 

 

82

assigning relatively low ratings initially and relatively higher rating
following intervention for the purpose of demonstrating an effectiveness
that may not be objective. There was no ability, retrospectively, to
evaluate the consistency of the rating assignment across the sample. To
address this issue, the CNS could provide specific definitions of and
criteria for the assignment of these ratings. Records could then be
retrospectively reviewed, with ratings to be assigned by another CNS to
establish inter-rater reliability. Agreement in the rating given in 90%
or more of the cases, would establish the objectivity of this process.

There was no general or overall status rating for the case. Each
rating was specific to the problem, and, therefore, the same child could
have one problem for which the intervention had resulted in an
improvement and another problem which worsened. The study was not
designed to examine the effectiveness of individual interventions and
there were not sufficient controls established to determine that the
final status of a problem was related to the interventions, as opposed
to external factors. A comparison of the problems was made to the
initial status and the status following intervention (Table 8), and it
was found that 45.2% of the problems were better following intervention
than initially, with the other 44.1% rated the same, and 10.7% rated
worse. The logical inference is that not all the interventions are
equally effective, however, it is also necessary to account for the
severity of the problem, the interaction of multiple problems, and a
myriad of uncontrolled external factors.

Another element of the data analysis which was not initially
available was the actual impact of an individual case on the time and

resources of the Chapter One program. Of the 86 cases reviewed, it was

83

found initially that 345 problems and interventions could be identified.
liowever, when this was examined for actual encounters, this number
jumped to 933. The mean number of encounters for a case was 10.85, with
a minimum of three to a maximum of 42. Clearly, this factor must be
taken into account when actually measuring the impact of an intervention
on a problem's outcome, and the program's resources. There was no
acuity rating to the individual problems or any weight for the relative
complexity of the interventions. In recognition of this, the selection
criteria included the requirement that cases be selected in which three
or more problems had been identified, with the intent that the cases
selected would be relatively more complex in nature. In the data
analysis, however, it was apparent that many of the problems required
repeated interventions, both different interventions or the same
intervention repeatedly. For example, in analyzing the numbers of
encounters per case, it was found that five cases represented outliers,
in that the actual number of encounters far exceeded the mean. These
five cases consisted of 24, 25, 26, 29, and 42 encounters respectively.
These cases would be of interest to examine more closely, to determine
the nature of the problems, the interventions employed, and the cost to
the program in terms of resources and time. In order to measure the
consistency with which specific interventions were applied to specific
problems, the numbers of encounters and their sequence would need to be
collected. The same problem was frequently identified by the CNS, over
time, and the same intervention was often repeated, as well as different
interventions.

The data set did not include dates or encounter numbers to clarify

at which point of involvement certain interventions would be deemed most

84
appropriate. The ongoing nature of most of the problems, and their
inherent uniqueness and complexity, necessitated several different
interventions, frequently from different domains, for the same problem.
The consistency of the employment of interventions could be further
studied by categorizing the interventions by encounter numbers. In that
way, one could compare the consistency with which specific interventions
are applied to a problem at key encounter points.

The findings of the study suggest that children are being referred
to the Chapter One program with multiple identified problems. The
problems themselves are divided into the four domains of the Omaha
System, the environmental, the psychosocial, the physiologic, and the
health-related behaviors domains. The assignment of a problem by the
CNS to a particular domain required the use of non-specified criteria.
There was difficulty establishing any consistency for this assignment
process retrospectively. It was also impossible to establish the
weighing given to different components of the same problem. In other
words, it is possible that a given problem could have components from
all four domains affecting the severity and manifestation of symptoms.
The process which is used to determine the relative significance of any
one domain would benefit from clarification.

These cases frequently required interventions and management over
the entire school year, and for subsequent years. The interventions
employed were as varied as the initial problems, however, it was evident
that many of the interventions were for health screening and health care
access issues. The interventions were divided into the Domains of

Nursing described by Benner (1984). These domains depict the action of

85

the CNS in a more specific way relative to the direction of the plan of

care.
The domain labelled Monitoring and Ensuring Quality of Health Care

Practices represented 204 (59.1%) of the interventions coded for these

cases. This domain includes interventions such as referral to a

dentist, specialist physician, and communication between the CNS and the
other health care professionals. The next most frequently employed

group of interventions was found in the domain, the Helping Role, with

132 (38.3%) of the coded interventions. Interventions in this domain

include comnunication between the CNS and the family, providing food and

clothing, and communication with school staff, such as teachers and

school nurses, on the student's behalf. The Teaching-Coaching Function

domain had eight (2.3%) of the interventions coded, which included

caretaking and parenting instruction, education, and providing specific

medical and dental information. Finally, the domain, Administering and

Monitoring Therapeutic Regimens, had one (0.3%) intervention coded,

dealing with medication action or side effects. The other three

domains, Diagnostic and Patient Monitoring, Effective Management of
Rapidly Changing Situations, and the Organizational and Work-Role

Competencies, had no coded interventions from this sample.

The problem experienced in the data analysis related to certain
domains being unrepresented was a result of the use of retrospective

data. Although the CNS performs a diagnostic function with the

assessment of every referred case, this has not been captured as an

_ intervention. Similarly, the aspects of the CNS's role in which she

participates in community groups, attends policy and planning meetings

and similar work-related responsibilities, are not recorded as

 

 

86
interventions for any individual case and are, therefore, also not
captured. A potential way of accounting for these important components
of the CNS's role would be to establish a percentage of her time which

is spent in the Organizational and Work-Role competency and assign a

proportionate amount to each case handled. The Diagnostic and

Monitoring domain should be consistently represented as part of the
initial assessment and follow-up functions of the CNS in every case.
The third domain which was unrepresented, the Effective Management of

Rapidly Changing Situations is, by definition, an acute instance in

which a child's immediate need is handled. As the CNS functions in a

centralized role, outside the classroom and building, these situations

would be handled by personnel more immediately available.

The most relevant domains, in analyzing the retrospective data,

are the Helping Role and the Monitoring and Ensuring Quality of Health

Care Practices. There was a great deal of overlap between these two

areas, with a similar lack of defined criteria in intervention

assignment as there was in problem assignment. The domain of Monitoring

and Ensuring Quality primarily referred to interventions which served to

provide entry into the health care system. The Helping Role was more

utilized for providing linkages with community, social, and other
The Helping Role also included all the contacts

supportive agencies .
The domain of Teaching-Coaching

between the CNS and the family members.

function only represented eight interventions, however, it seems quite
likely that this is underrepresented as a result of the intervention
being counted as a parent communication under the Helping Role. It is

probable that there was an element of Teaching-Coaching in virtually

every parent communication, so there is, again, overlap and lack of

87

The most unexpected underrepresentation was in the

clear distinction.
There is a

domain Administering and Monitoring Therapeutic Regimens.
similar logic of the CNS's central location in accounting for her
inability to actually give medications and/or treatments to a student,
however, in a very real sense, she monitors ongoing cases, and their

regimens, by communicating with the family, the health care provider,

the teachers, and the school nurses. These activities are recorded in

the other two well-represented domains, however, the function of this

domain and its competencies are not captured. It is also possible that

the components of this domain which are psychomotor ”tasks" are not part
of the role of the Advanced Practice Nurse (APN) in the school health

setting, and would not be an efficient use of this resource.
The model of the nurse as a culture broker becomes relevant in all
Some patients enter the health care system much

of these situations.
The result may be culture

like imigrants entering a foreign country.

shock for such patients as they enter a system with a set of values,

beliefs, behaviors, and language unlike their own (Jezewski, 1993). The

CNS in the school health setting is called upon to broker two different

cultures for the student and his or her family, the school system's

culture and the health care system's culture. As a culture broker in

anthropology makes understandable the language, customs, and currency of
an unfamiliar nation or tribe, the CNS assists the family and the

student to understand unfamiliar medical terminology, treatment
Additionally, the family may

requirements, and options for care.
Families

require an advocate within the community or the school system.
which perceive that they are powerless in a situation, whether due to

economics, educational level, or ethnic/cultural background, often

 

88
require the CNS's assistance in building trust in institutions from
which they have felt alienated. The Helping Role domain provides a
specific description of the competencies involved in strategies portion
of the culture broker's function (Figure 2). School health nurses must
possess a broad and deep, interdisciplinary knowledge base that allows
them to serve as a bridge, translator, link, and health expert among all
parties (Salmon, 1994).

The second most common intervention found, parent communication,
supports the role of the CNS as an advocate working within the school
and family systems. This role, which has been described by many as case
management, requires additional skills of the school nurse. As case
manager, the nurse coordinates the efforts of the child, parents,
physician, and all segments of the school system (Joachim, 1989). In
the revised Culture Broker model (Figure 2), this is shown as the both
the intervention phase and the resolution phase, which incorporates
reassessment. Parent communication is also a key component of the
assessment phase, in which all of the lntervening Conditions are
assessed by the CNS. The domain most specific to the case management
aspect, or the coordinator role, is the Monitoring and Ensuring Quality
of Health Care Practices, which involves communication and consultation
with the interdisciplinary team.

The Culture Broker model and the Domains of Nursing are compatible
concepts in describing the role characteristics of the CNS in a school
health setting and in defining the types and frequencies of the

interventions employed by that professional.

89
Study Limitations

The study was limited initially by its design. As a
non-probability, convenience sample, the findings are not generalizable
to all school children. Additionally, the instrument used for data
collection was modified from the Omaha System and had not been subjected
to any testing for reliability or validity. The reliability of the
modified instrument would be enhanced by defining the criteria for the
assignment of status ratings, diagnostic codes, and the other components
of the assessment of the problem and the evaluation of the outcome
following intervention. Records could then be retrospectively reviewed
by another CNS to test inter-rater reliability. Agreement of 90% or more
would be strong evidence of the accuracy of the instrument.

The Omaha System was well-suited to problem identification,
however, was less specific in the area of interventions, as the
interventions were not problem—specific. There was significant overlap
and lack of sensitivity with regard to interventions. The categories of
some interventions were overly broad and resulted in high numbers of
occurrences in a very few categories. The most commonly employed
interventions could be further defined for greater specificity, which
would allow all the components of the CNS's interactions with a case to
be appreciated.

The data collection and assignment of codes was made more
consistent by the fact that the CNS was the only individual recording
the information. It is necessary to note that she may have refined her
assignment of problem and intervention codes as the school year
progressed, thus affecting the consistency of application. Another

limitation to the tool, or the reports derived from it, was the

90
inability to assess the link between the problem and the chronology of
interventions employed. The interventions were reported by the code in
ascending order, so an intervention which was tried first may be
reported last. The limitations experienced are those normal to analysis
of data retrospective to their collection.

It was not possible to determine the status of a case at the end
of the school year. There was information collected on the status of
the problem itself, following the CNS's intervention, but that may or
may not accurately reflect the status of the entire case, or child.
There was no ability, retrospectively, to control for extraneous
variables which may have affected the status of the case following
intervention by the CNS. The deficiencies of the assignment of status
ratings, related to objectivity and consistency, before and after
intervention, were previously described.

Another study design issue may be the criterion for selection,
limiting the sample to cases with three or more identified problems.
Although this served to identify the greatest number and types of
problems and interventions, it does not reflect a comprehensive
representation of the cases referred to the Chapter One program. To the
extent that some students are encountered repeatedly for the same one or
two problems, this information was not captured, and may underreport
cases which account for significant portions of the CNS's time and/or
system resources.

In relationship to the categorization of the interventions into
the Domains of Nursing, there were no identified interventions in the
domain of Organizational and Work-Role Competencies. Although the

competencies of this domain are a significant portion of the CNS's role

91
in the school health setting, this information could not be collected as
a problem-based intervention. Similarly, there was only one
intervention coded as the domain of Effective Management of Rapidly
Changing Situations, and it was never collected in this sample as an
intervention which was employed. Presumably, the nature of a crisis
situation is one which would be handled by personnel on the scene,
whereas the CNS's role is more specific to ongoing situations. There
were also no interventions collected in the domain, the Diagnostic and
Monitoring Function, although as previously described, this is part of
the initial assessment and continuous follow-up of every case. The
Domains of Nursing, as adapted for this study, were not sensitive and
specific enough to capture the interventions in a meaningful way. The
usefulness of this categorization would be enhanced by prospectively
defining the interventions in such a way that captures the subtler
aspects of these competencies.

Given unlimited resources to conduct this study, it would have
been ideal to establish the consistency with which the modified Omaha
System instrument was completed. Definitions and criteria for the
assignment of codes would have been established and complete records,
which included the CNS's narrative, would have been recoded by two or
three similarly prepared individuals to establish an inter-rater
reliability of at least 90%. The interventions employed would have been
examined closely to identify subcomponents of the competency. These
factors would have then been used to further recode records for
additional clarity and accuracy. Additional variables of interest, such
as socioeconomic status based on eligibility for free or reduced price

school lunches, and ethnic characteristics of each child would have been

92
collected. With a reliable instrument, it would have been more feasible
to conduct factor relating calculations and to test hypotheses regarding
these relationships.
Implications for Advanced Nursing Practice

The findings of this study and the related literature offer many
implications for the role of the Advanced Practice Nurse (APN) in the 9
school health setting. The potential contribution of the school nurse
towards a goal of the school as a health promoting community is
considerable (Collis & Dukes, 1989). In order to effectively meet our
nation's challenges and best safeguard the health of its students,
school nurses must have an expanded scope of practice, manage diverse
client needs as well as students with more complex health problems, and
become key players in the integration of various health care delivery
models into the school setting (Passerelli, 1994). The new skills
required to operationalize comprehensive school health programs are
leading to development of an expanded role for nurses (Kozlak, 1992).
The findings of this study show the many role characteristics of the APN
in practice. The Domains of Nursing encompasses the assessor, advocate,
collaborator, coordinator, educator, change agent, consultant,
counselor, and planner roles.

The school is recognized as the location in which the needs of
children, especially those with geographic and financial barriers to
access, can be effectively met. The school-based clinic concept is a
primary care delivery mechanism which provides care to children who may
otherwise receive none. The APN in the school-based clinic can work
collaboratively with the CNS in the Chapter One program to meet the

needs of children with identified problems. Referrals to family

93
physicians and pediatricians were interventions used 49 times (14.2%) in
this study. Many of those referrals may have been appropriate for an
APN in the school health setting, which would be an efficient use of the
health care system's resources. Additionally, an established
school-based clinic, with an established mechanism for reimbursement may
be permitted, in a reformed health care system, to contract with managed
care organizations, including the Medicaid Physician Sponsor Plan, to
provide care to qualified children routinely.

The changing character of school health nursing increases the need
for the APN to use nursing theory to guide nursing decisions (Pesata,
1994). The nursing paradigm, which incorporates a patient's environment
into a holistic philosophy of providing care is evident in the
interventions employed by the CNS in this study. Intangible components
of the CNS's role include establishing relationships with families that
enhance their trust in the school system, as well as the health care
system. Further definition and refinement of the categorization process
could lead, not only to the ability to quantify the interactions, but
also the ability to "uncover the knowledge embedded in clinical
practice” as Benner (1984) describes the process of recognizing
interventions and decisions which seem to have no definite cognitive
process. As many of the CNS's activities serve to enhance access to
services and the quality of the services, it would be useful to define
more completely the role her activities play in the health outcomes of
these cases.

Benner (1984), described the organizational and work-role
competency as important when working with teachers and staff in the

school district, as well as occupational, physical, hearing and speech

94
therapists, doctors, and community health nurses (Pesata, 1994). The
results of this Study, and the CNS's recurring intervention of contact
with an interdisciplinary team, reveal this, in spite of the inability
to quantify this under the domain of the Organizational and Work-Role
competencies.

As the second most employed intervention, parent communication is
a pivotal aspect of the APN's role in the school setting. Parents
should be recognized for their important role as experts on their child-
experts in maintaining their child's health and conducting activities
that promote health (Graff & Ault, 1993). Health promotion and disease
prevention are goals which cannot be addressed until basic health care
needs are met. To the extent that the school setting is the place to
begin long term health promotion, the unmet health care needs of these
children will need to be addressed first. This is especially true of
the chronically ill or developmentally disabled student. In this study,
there was not a specific focus on chronically ill and disabled children;
it may be that such children are already established in the health care
system and are less likely to be identified by the school referral
sources.

Research, theory, and practice should incorporate consideration of
family routines and home environment when concerned about the health
status of the child (Keltner, 1992). Once again, a significant number
of the CNS's interventions center around communication with the family
and providing support and information that serves to customize a more
generic plan of care. This function is specific to an APN with the

knowledge base sufficient to modify a treatment plan in such a way that

95
the client will find it possible to integrate within his or her
resources and environment.

Any health problem--hunger, poor vision or hearing, increased
blood lead levels, dental caries, and child abuse- can interfere with
learning (Lavin et al., 1992). Through education and demonstration,
teachers and administrators must be helped to realize how school health
programs complement their own efforts to meet the educational needs of
their students (McGinnis & DeGraw, 1991). Developmental and behavioral
problems have been shown to be more prevalent among children who reside
in environments where biological insults are more prevalent, family
relationships are more volatile and less supportive, and basic nutrition
is questionable (Newacheck et al., 1994). The degree to which children
identify the frequency and stressfulness of the events in their lives
suggest there is much to learn about how these chronic, enduring
situations affect them (Jacobson, 1994). This information is not
captured in the data available for this study, but is often uncovered as
a component of the CNS's assessment and interaction with the family.
Providing a mechanism for coding and quantifying this aspect would
contribute to the body of knowledge in these areas, and allow the CNS to
target interventions that address these needs.-

The critical role that lack of access play's in a child's ability
to enter the primary care system can be directly impacted by the
presence of primary care providers, such as APN's, in the school
setting. This addresses several of the aspects of lack of access which
include such factors as lack of or type of insurance coverage, the
geographic location or hours of operations of clinics, and the lack of

availability of certain providers or services. The CNS in the Chapter

96
One program frequently intervenes with identified problems by referring
the child to some form of primary care. This intervention requires a
subsequent series of steps which may include establishing a payment
source, finding transportation and/or child care for siblings, and
follow-up conversations with the family and the provider. Direct
referral to a school district's school-based clinic, staffed by an APN,
could eliminate or compress several of these steps. By providing entry
into the health care system through the school-based clinic referral,
the APN establishes a primary care relationship which is accessible and
continuous over time. By establishing communication among the child's
caregiver, other medical providers and school personnel, the APN helps
assure consistency in the application of the therapeutic regimen and a
thorough appreciation of the need and resources of the child and his
family. Comparative cost data from these efforts can be utilized to
establish the cost-effectiveness of the program.

Additionally, the providing primary care access in a school-based
clinic could integrate theeducation needs related to health promotion
directly into the classroom setting. The APN could use his or her
knowledge regarding the needs of the students to become involved in
multi-disciplinary school-based projects focused on health promotion,
such as those which advocate for food service and physical education
modifications.

The role of the APN as related to policy development and political
involvement, also relates to the implications in the literature.
Political involvement on a local level can occur when the APN uses
information to change school curricula to include health teaching in

important areas (Pesata, 1994). The information gained from this study

97
and others similar to it, can be a starting point for educating school
administrators and public officials regarding the depth of the need and
the informed deployment of resources. By becoming informed on facts and
issues, and through active involvement in the policy process, nurses can
be a positive force in moving toward the attainment of Healthy People
2000 goals and objectives (Malloy, 1992). Quite obviously, changes in
children's health care will need to be considered as part of the total
package of reforms in health care, but there is a critical need to move
children's issues high on the priority list (Martin, 1992).

One of the most important underlying themes in both the
comprehensive school education and health care reform movements is the
issue of health outcomes, whether associated with improving the health
status of children and families through a more cost-effective service
delivery system, or through health education that fosters the adoption
of positive health behaviors, thus reducing the need for expensive
medical resources (Brindis, 1993). Nursing in the acute care setting
has been forced to cost out services and measure outcomes by current
reimbursement mechanisms and restrictive health policies (Oda, 1992).
Nursing in community agencies and schools is now catching up as funding
becomes increasingly stringent and educational monies dwindle (Oda,
1992).

Implications for Research

Several implications for research are suggested by the results of
the data analysis for this study. Additional research needs to be
conducted relative to problems identified in students with relationship
to age, gender, and socioeconomic status. Ethnic and cultural

variations were not part of the data collected for this study, but would

98
be an interesting variable of study, both in terms of the types of
problems experienced and to examine potential bias in referral patterns.
Correlating identified problems with a student's absenteeism may also
provide an area of study for the interested researcher.

Research related to the APN's advocacy role, as conceptualized by
the Culture Broker model, would also be of interest. Research can also
be a tool of advocacy (Burg, 1994). The findings of any research which
adds to the body of nursing knowledge can be seen as having the
potential for being used to advocate on behalf of a client and his or
her family.

AMA (1990) recommends that further objective research into the
potential benefits and problems associated with school-based health
services be undertaken by credible organizations in the public and
private sectors. Once national standards for school health education
are established, research should be conducted to show the effectiveness
of different program designs in achieving national objectives (American
Cancer Society, 1993).

There is a need for research regarding interventions which
specifically include the input and participation of the child's family.
The literature review performed for this study provided several examples
of health promotion studies which were conducted with school-age
children. The lack of extensive literature related to the interventions
which are most successful in meeting children's previously unmet health
care needs, most probably is due to the need to involve the family in
any intervention plan. The identified needs of the family are then,
appropriately, a major focus of the intervention. The reality of the

need to involve the family in any intervention with the child may mean

99
that the intervention is researched as a "family" issue. In recognition
of that, research that explores effective interventions for a child's
specific problems should incorporate the family's input and
participation. In the Chapter One program, the CNS could begin, as part
of the initial assessment, to collect information utilizing the Family
Routines Inventory and the Home Screening Questionnaire. Information
from these instruments has been shown by Keltner (1992) showed
significant common variances with child health in pre-school children.
This information could be the basis of hypotheses related to the outcome
of an intervention plan given the strength of the home environment
and/or the adherence to family routines.

Given the findings of this study, which were limited to
descriptions of the types and frequencies of interventions employed by
the CNS, there are many directions future research could take. The
relationship between a child's socioeconomic status and his or her
health care deficits has been often expressed, but less often
quantified. The outcomes of particular problems based on the
interventions or series of interventions employed, and the
cost-effectiveness, would be of interest. The first step in additional
data analysis for this particular group would be refinement of the data
collection instrument, based on the findings of this study. The Omaha
System has not adequately captured information specific to the child's
socioeconomic status, ethnic or cultural background or a sense of the
timing of interventions in a sequence of encounters. As the payment
source information collected was not a sensitive indicator of the

child's socioeconomic status, another method of making this

100
determination could be the child's eligibility for free or reduced price
school lunch.

This research study showed a significant improvement in the
overall status of problems following intervention. Research which
controls the variables which may have contributed to this result should
be conducted to establish the extent to which the intervention was
responsible for the problem's improved or unchanged status. The
significance of maintaining a problem's status, in certain conditions,
should not be minimized.

The Domains of Nursing, as a way of uncovering the competencies of
the CNS in this role, would be more useful with a consistent and
thorough documentation of CNS actions not specifically case-related.
Establishing criteria that define the status of the health problem
identified would provide demonstrated objectivity to the rating of
problems, pre— and post-intervention.

Research into interventions which include the family are most
likely to promote long range health promotion goals. The outcomes of
such interventions will need to be measurable and objectively
demonstrated. Outcomes are both cost-related and quality related. The
”best" intervention is one which provides the optimum quality of service
at the most cost-effective price. Possible research question in this
area should address the outcomes of specific interventions for specific
problems, based on quality and cost. This study makes an initial
contribution in describing the frequently used interventions. Those
interventions, such as parent communication, which are frequently
employed, would be key components of health promotion intervention, as

well as problem-focused interventions.

101

The next logical research question is, Are the interventions
employed by the CNS responsible for the improved or unchanged status of
the problem in these cases?

Conclusion ,

The role of the CNS in the school health setting is one in which
all of the skills for which he or she is trained are called upon. The
diversity and the complexity of the problems of the students, which
include poverty, homelessness, chronic illness, and developmental
disabilities, challenge the APN's abilities and creativity. Added to
that, is the need to document the effectiveness of the interventions
employed. The first step, identifying the interventions, has been
undertaken by this research. Further research will be needed to fully
understand the efficacy and cost-effectiveness of the interventions

employed by the CNS, in the Chapter One program, and other school health

settings.

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Jacobson, G. (1994). The meaning of stressful life experiences in
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Keltner, B.R. (1992). Family influences on health status.
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105

McGinnis, J.M. (1992). The role of the federal government in
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106

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107

Todaro, A.W., Failla, s., & Caldwell, T.H. (1993). A model for
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Congressional Quarterly Weekly Report, 51(19), 1150.

APPENDIX A

Lansing School District
Chapter 1 Health Service Nursing Form

108

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APPENDIX 8
Letter of Support

110

LANSING
SCHOOL

DISTRICT
Committed to Quality

 

January 5, 1995

Sara A. Daniel
13844 Blue Point Drive, NE
Kalkaska, MI 49646

Dear Ms. Daniel:

In regard to the proposed study, "What are the Types and Frequency of
Interventions Employed by a Clinical Nurse Specialist for Cases Referred to
the Chapter One Program with Multiple Identified Problems?", the request to
conduct the study in the Lansing School District has been approved.

The following comments apply to the study:

It is my understanding that there will be no student or staff
involvement .

If you have any questions or need additional information, please contact me
(325-6460).

Thank you.
‘W/WW

Marian Phillips

MP/mlc

cc: Research Review Committee Members

Research & Evaluation Services Office
500 W. Lenawee St.
Lansing, Michigan 48933

An Equal Opportunity District

APPENDIX C
Chapter 1 School Nurse Strategies

111

CHAPTER 1 SCHOOL NURSE STRATEGIES

HELPING ROLE COMPETENCIES

98

Durable Medical Equipment
Social Work/Counseling
Day Care/Respite
Employment

Finances

Food

Housing

Legal System

Spiritual Care

Substance Abuse

Support System

Wellness

Supplies

Glasses

Prescriptions
Communications
Interactions

School consult

Parent Communication
School Visit

Social Work/Service
Nutritionist

Other Community Resources
Support Group
Transportation

Coop Extension

MSU Nursing Referral
Public Health Nursing Ref.
Michcare

Crippled Children

Probate Court/Protective Serv.
Police Department

Social Services

Open Arms
Preschool/Preprimary

Red Cross

.Building Strong Families

ADMINISTERING & MONITORING
THERAPEUTIC REGIMENS

Bladder Care

Bowel Care

Bronchial Hygiene

Cardiac Care

Cast Care

Dressing Change/Wound Care
Feeding Procedures

Medication Action/Side Effects

TEACHING-COACHING FUNCTION

Ol - Anatomy/Physiology

19 - Exercises

24 - Gait Training

02 - Behavior Modification
O4 - Bonding

08 - Care Taking/Parenting
11 - Coping Skills

13 - Discipline

16 - Education

18 - Environment

20 - Family Planning

25 - Growth/Development

26 - Homemaking

37 - Nutrition

41 - Personal Care

45 - Rest/Sleep

46 - Safety

55 - Stimulation/Nuturance
S6 - Stress Management

31 - Medical/Dental Care

DIAGNOSTIC a pang mm

48 - Sickness/Injury Care

49 - Signs/Symptoms - Mental
lEmotional

50 - Signs/Symptoms - Physical

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99 - Crisis Intervention

ORGANIZATIONAL & WORK-ROLE

COMPETENCIES

112

ADMINISTERING & MONITORING
THERAPEUTIC REGIMENS - Continue

33 - Medication Administration
34 - Medication Setup

35 - Mobility Transfers

36 - Nursing Care

39 - Ostomy Care

42 - Positioning

43 - Rehabilitation

51 - Skin Care

53 - Specimen Collection

MONITORING & ENSURING QUALITY OF
HEALTH CARE PRACTICES

47 - Screening

64 - Pediatrician

65 - Family Practitioner
66 - ICHD

67 - Specialist

68 - ENT

69 — Ophthalmologist

70 - Optometrist

71 - Dental

73 - Lab, X-ray

74 - Mental Health

77 - Speech & Hearing

82 - Immunization

89 - B.R./Radicare

94 - Surgery

76 - Hospital Visit

78 - Nurse/Physician Consult
83 - Follow up on Care

APPENDIX D

Human Subject Approval

 

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RESEARCH
AND
GRADUATE
STUDIES

Univcmity Committee on
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(UCRIHS)

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East Lansmg. Mrhngan

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113

MICHIGAN STATE

UNIVERSITY

January 10, 1995

To: Sara A. Daniel
13844 Blue Point Dr. NE
Kalkaska, HI 49646

RE: IRBI: 94-597

TITLE: wHAT ARE THE TYPES AND FREQUENCY OF
INTERVETNIONS EMPLOYED BY A CLINICAL NURSE
SPECIALIST FOR CASES REFERRED TO THE CHAPTER ONE
PROGRAM WITH MULTIPLE IDENTIFIED PROBLEMS?

REVISION REQUESTED: N/A

CATEGORY: -H

APPROVAL DATE: 01/02/95

The University Committee on Research Involving Human Subjects°(UCRIHS)
review of this project is complete. I am pleased to adVise that the
rights and welfare of the human suhjectn appear to be adequately
proteCteu and methoos to obtain informed consent are appropriate.

herefore, the UCRIHS approved this project including any revision
listed above.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original a proval letter or when a.
project is renewed) to seek ugdate certification. There is a
maximum of four such expedite renewals ssible. Investigators
wishing to continue a project beyond tha time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving_human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at aha other time during the year
send your written request to the CRIHS Chair, requesting reVised
approval and referencing the prOject's IRB I and title.. Include
in our request a description of the change and any reVised
ins ruments, consent forms or advertisements that are applicable.

PROBLEMS]

CHANGES: Should either of the followin arise during the course of the
work, investigators must noti UCRIHS promptly: {1) problems
(unexpected side effects, comp aints, etc.) involVing uman
subjects or ‘2) changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we_can be of any future help, please do not hesitate to contact us
at {Eiofidbb‘éidU or FMA (aixpaso-illi.

Sincerely,

avid E. Wrig
CRIHS Chair

DEW:pjm

cc: Barbara A. Given

APPENDIX E

OHAHA System
Categorization of Interventions

114

OMAHA System
Categorization of Interventions

ir h sical care 11 Family Issues
01 Anatomy/Physiology 02 Behavior Modification
03 Bladder care 04 Bonding
05 Bowel care 08 Care taking/Parenting
06 Bronchial Hygiene 11 Coping skills
07 Cardiac care 12 Day care/respite
08 Cast care 13 Discipline
l4 Dressing change/wound care 16 Education
15 Durable medical equipment 17 Employment
19 Exercises 18 Environment
21 Feeding procedures 20 Family planning
24 Gait training 22 Finances
29 Lab findings 23 Food
32 Medication action/side effects 25 Growth/development
33 Medication administration 26 Homemaking
34 Medication setup 27 Housing
35 Mobility transfers 30 Legal system
36 Nursing care 37 Nutrition
39 Ostomy care 41 Personal care
42 Positioning 45 Rest/sleep
43 Rehabilitation 46 Safety
48 Sickness/injury care 54 Spiritual care
49 Sign/symptoms--mental/emotional 55 Stimulation/nuturance
50 Signs symptoms--physical 56 Stress management
51 Skin care 57 Substance abuse
53 Specimen collection 60 Support system

62 wellness

111 Health Care Providers Su i
31 Medical/dental care 58 Supplies
47 Screening 72 Glasses
52 Social work/counseling 75 Prescriptions

64 Pediatrician

65 Family practitioner
66 ICHD

67 Specialist

68 ENT

69 Ophthalmologist

70 Optometrist

71 Dental

72 Lab, X-ray

74 Mental health

77 Speech and hearing
82 Immunization

89 E.R./Redicare

94 Surgery

115

W

Communications
Interactions

Hospital visit
Nurse/physician consult
School consult

Follow up on care
Parent communication
School visit

Social work/service

MW];

98

Nutritionist

Other community resources

Support group

Transportation

MSU Nursing referrals
Public health nursing ref

Michcare

Crippled children

Probate court/protective
services

Police department

Social services

Open Arms
Preschool/preprimary

Red Cross

Cooperative Extension

Building strong families

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