M. J. Lineberry

The role and impact of nurses in American elementary schools: a systematic review of the research.

School nurses are tasked with the critical job of keeping students safe and well. Due to competing demands for resources in schools, the impact of school nurses must be demonstrated to secure their jobs. A systematic review of the literature from 1937 to 2013 was conducted to show the efficacy of school nursing activities in American elementary schools. While some studies of immunization compliance, attendance rates, body mass index screening, vision screening, and follow-up are promising, results are mixed and additional evidence is needed. The impact of school nurses on educational and health outcomes must continue to be evaluated and more rigorous evaluation methods should be explored. Suggestions for future research and collaborations are discussed.

A needs assessment of complementary and alternative medicine education at the University of Kentucky College of Medicine.

Introduction: Complementary and alternative medicine (CAM) encompasses a wide variety of increasingly popular therapies not generally taught in allopathic medical schools but of apparent interest to medical trainees. However, little is known about the learners’ specific needs for improving their CAM clinical skills. Methods: Third-year medical students and internal medicine resident-physicians at the University of Kentucky were invited to participate in a voluntary questionnaire to assess CAM knowledge, skills, attitudes as well as their desired learning methods. Results: Medical students (n = 22) and resident-physicians (n = 39) generally hold favorable attitudes toward CAM but admit to significant knowledge deficits and do not feel adept at counseling their patients about CAM. Students indicate observation and hands-on experiences as their preferred pedagogy while residents favor textbooks, articles, and lectures to learn about CAM. Nevertheless, one resident noted, “any information in any format would be helpful as we get no teaching in this area”. Conclusions: In our sample, learner-driven CAM education at undergraduate and graduate levels is indeed necessary and wanted. In constructing CAM education interventions, attitudes, perceived knowledge deficits, and preferred learning strategies should be considered for the trainees and thus ultimately responsive to the needs of their patients.

A Randomized Controlled Trial Using Insinuated Standardized Patients to Assess Residents' Domestic Violence Skills Following a Two-Hour Workshop

Background: Residents feel inadequately trained to treat domestic violence victims. Purpose: The purpose was to assess clinical skills of residents participating in a domestic violence workshop. Methods: Twenty-seven internal medicine residents were randomized to receive one of two workshops (domestic violence or control workshop). Standardized patients were trained to two domestic violence cases (depressed; injured). The two cases were randomized and insinuated into each residents continuity clinic at either 1 to 3 months or more than 3 months after the workshops. Results: The domestic violence workshop residents did not identify the standardized patients as domestic violence victims any more often than residents participating in the control workshop; 16/25 (64%) versus 13/23 (56%), p = .86. However, domestic violence workshop residents were more likely to score 75% or higher on the domestic violence checklist items compared to control workshop residents; 9/25 (36%) versus 2/23 (9%), p = .04. Conclusions: Once a standardized patient was identified in clinic as a domestic violence victim, domestic violence workshop participating residents demonstrated better clinical skills than a control group.

Is time spent with the physician associated with parent dissatisfaction due to long waiting times

The objectives of this study were to assess the relationship between wait time and parent satisfaction and determine whether time with the physician potentially moderated any observed negative effects of long wait time. Data were collected from parents in a pediatric outpatient clinic. Parent satisfaction with the clinic visit was significantly negatively related to wait times. More time spent with the physician was positively related to satisfaction independent of wait times. Furthermore, among clinic visits with long wait times, more time with the physician showed a relatively strong positive relationship with parent satisfaction. Therefore, although long wait times was related to decreased parent satisfaction with pediatric clinic visits, increased time with the physician tended to moderate this relationship.

The Role of School Nurses, Challenges, and Reactions to Delegation Legislation: A Qualitative Approach:

Passage of new laws, national standards regarding delegation, and the recommendation for at least one full-time nurse in every school have provided more visibility to the role of school nurses. Recent legislative amendments in Kentucky presented an opportunity to examine how the role of the school nurse is changing. Aims were to describe the (1) role of school nurses in Kentucky, (2) impact of school nurses, (3) challenges faced by school nurses, and (4) impact of budget cuts and legislation. Three focus groups were conducted. School nurses faced challenges of limited time and resources, communication barriers, and multiple documentation requirements. Nurses’ greatest impacts were their availability, recognition of psychosocial problems and health concerns, and connection with resources. Nurses had not yet encountered many changes due to new legislation that expanded delegation of diabetes-related tasks to unlicensed school personnel, but some had concerns about possible negative effects while others expressed support.

THE ROLE AND IMPACT OF SCHOOL NURSES AND INTENTIONS TO DELEGATE DIABETES-RELATED TASKS AMIDST BUDGET CUTS AND LEGISLATIVE CHANGES

OF DISSERTATION THE ROLE AND IMPACT OF SCHOOL NURSES AND INTENTIONS TO DELEGATE DIABETES-RELATED TASKS AMIDST BUDGET CUTS AND LEGISLATIVE CHANGES As the percentage of school children with chronic conditions such as diabetes continues to rise, funding for school nurses to keep those students healthy and safe is decreasing. This dissertation includes three studies: (1) a systematic review of the literature on the role and impact of American elementary school nurses, (2) a focus group study that further examined the role of Kentucky school nurses and described their reaction to a new regulation that necessitates delegation of diabetes-related nursing tasks to unlicensed assistive personnel (UAP), and (3) a quantitative study that examined Kentucky school nurses’ past behaviors and future intentions regarding the delegation of diabetes-related tasks. A systematic review of the literature revealed that activities of school nurses can be conceptualized into four major areas: (a) health promotion and disease prevention; (b) triage and treatment of acute issues (e.g., injuries and infectious diseases); (c) management of chronic conditions; and (d) psychosocial support. School nursing activities are associated with increased attendance, higher quality schools, and cost savings. Focus groups in three regions of Kentucky found that Kentucky school nurses fulfill the same major roles as their counterparts across the nation, and face similar challenges such as lack of time, limited resources, language barriers, and communication issues with families. School nurse participants described their biggest impact on students as identifying and addressing students’ physical and psychosocial barriers to learning. While recent legislation was passed in Kentucky necessitating the delegation of insulin administration to UAP, school nurses had not experienced many changes at the time of the focus groups. However, some nurses said that their districts were not planning to delegate insulin administration and intended to keep a nurse in every school. Others appreciated the prospect of having more trained staff in schools to recognize signs of distress in chronically ill students. A statewide survey of 111 Kentucky school nurses indicated that nurses’ past delegation behaviors and future intentions related to delegation are rooted in the level of skilled decision-making that must occur and the risk to the student if the wrong decision is made. Unfortunately, school nurses’ intentions to delegate higher-stakes tasks (e.g. carbohydrate counting, insulin dose verification, and insulin administration) were significantly stronger than their support for (attitude related to) delegation of those tasks, which is disconcerting both for the safety of students as well as for the liability retained by delegating nurses. This disparity between support and intentions indicated that school nurses anticipate that they will have to delegate certain tasks to UAP despite their discomfort with delegating them, most likely due to high workload and lack of resources. Additional studies should be undertaken to determine the impact of legislative changes on the delivery of school health services in Kentucky and other states, particularly once school districts and nurses have had adequate time to adjust to new laws. Such studies should investigate to whom nurses are delegating health services, what tasks are being delegated, and the extent and process of training that UAP receive. Future surveys should utilize perceived behavioral control items that assess situational control (e.g. policy, workload) over delegation rather than, or in addition to, efficacy of individual skills required for delegation of nursing tasks. Researchers must further explore the discrepancies between attitude and intentions; that is, why are nurses planning to delegate tasks to UAP if they do not support the delegation of those tasks? Kentucky school nurses are champions of health promotion for children, not only in their provision of health services and health education, but also in the area of school health policy. School nurses should train UAP so that more school staff can recognize signs of distress in students with diabetes, but at the same time should continue to advocate and seek funding for a nurse in every school with the help of the Every Student Succeeds Act.

A COMPLEMENTARY AND ALTERNATIVE MEDICINE WORKSHOP USING STANDARDIZED PATIENTS INCREASES KNOWLEDGE AND IMPROVES SKILLS.: 370

ended written scores of WS participants and nonparticipants were analyzed by means and multiple regression approaches solving for performance on a preventive medicine station and USMLE Step 1. Results: The NPWB WS was delivered to 12 of the 24 rotation groups during the 2004–2006 academic years. Ninety-four students participated in the WS and 92 did not. WS participants performed significantly better than nonparticipants on the post-SP encounter written exercise (4.7 6 1.8 vs 2.8 6 1.4, F 5 60.5, p , .0001) and the NPWB written examination items (5.7 6 1.0 vs 4.9 6 1.2, F 5 24.0, p , .001). There was a trend toward a significant difference on the NPWB-specific SP checklist items (23.8 6 3.8 vs 22.4 6 5.3, F 5 3.4, p 5 .066). Conclusions: Students participating in a 4-hour SP WS exhibit superior NPWB knowledge as assessed by open-ended and multiple-choice questions, and there is a trend toward better clinical skills as assessed by an SP checklist.

A NUTRITION AND PHYSICAL WELL-BEING WORKSHOP USING STANDARDIZED PATIENTS INCREASES KNOWLEDGE AND IMPROVES SKILLS.: 369

age confirmed that the post-FCM group scored significantly higher than the pre-FCM group. The test group parameter estimate was 4.02 (p , .001). In this model, the step 1 score was also a significant predictor of step 2 score: parameter estimate 0.699 (p , .001). The model’s adjusted R was 0.5375. Conclusions: Both step 1 scores and the FCM course were independent and significant predictors of step 2 performance for medical students. A centrally developed curriculum integrating clinical and basic sciences is feasible for the third year of medical school and is associated with an improvement in standardized testing.

AN ADOLESCENT MEDICINE WORKSHOP USING STANDARDIZED PATIENTS INCREASES KNOWLEDGE AND IMPROVES SKILLS.: 368

age confirmed that the post-FCM group scored significantly higher than the pre-FCM group. The test group parameter estimate was 4.02 (p , .001). In this model, the step 1 score was also a significant predictor of step 2 score: parameter estimate 0.699 (p , .001). The model’s adjusted R was 0.5375. Conclusions: Both step 1 scores and the FCM course were independent and significant predictors of step 2 performance for medical students. A centrally developed curriculum integrating clinical and basic sciences is feasible for the third year of medical school and is associated with an improvement in standardized testing.

335 DOES A NUTRITION AND PHYSICAL WELL-BEING WORKSHOP USING STANDARDIZED PATIENTS INCREASE KNOWLEDGE AND IMPROVE SKILLS?

Background Only about 20% of Americans consume the recommended proportions of fruits and vegetables and achieve the recommended level of physical activity. Also, only about 40% of patients report receiving dietary or exercise advice from their doctor. Therefore, nutrition and physical well-being (NPWB) knowledge and counseling skills should be part of the medical student curriculum. The purpose of this study is to determine the impact of a NPWB workshop (WS) using standardized patients (SP) on knowledge and clinical skills of third-year medical students. Methods A 4-hour NPWB WS was developed as part of a new curriculum for a required third-year 4-week primary care internal medicine clerkship. The NPWB WS and three other novel WS were randomized for delivery to half of the rotational groups. The NPWB WS incorporates four SP cases representing different clinical challenges (exercise prescription, diabetic dietary counseling, stress reduction strategies, and low-carbohydrate diet counseling). A faculty preceptor facilitates group discussion of sensitive approaches to the problems. Participating students are also provided a 17-page NPWB reference. All students in every rotation group are assigned NPWB readings. At the end of the 4 weeks, all students take a 100-item written exam (seven NPWB questions) and nine-station SP exam (one NPWB station) including a post-SP encounter open-ended written exercise. Scores on the written exam NPWB items, NPWB SP checklist, and NPWB open-ended written exercise of workshop participants and nonparticipants were analyzed with simple means, standard deviations, and multiple regression approaches controlling for USMLE Step 1 scores and preventive care SP station checklist scores. Results The NPWB WS was delivered to 6 of the 12 rotation groups during the 2004-2005 academic year. Forty-nine students participated in the workshop and 48 did not. Workshop participants performed significantly better than nonparticipants on the NPWB written exam items (5.7 6 1.0 vs 4.9 6 1.2, F = 13.9, p < .001) and the post-SP encounter written exercise (86.9% 6 6.7 vs 78.9% 6 5.8, F = 36, p < .001). There was no significant difference (p = .55) between the groups on the SP checklists. Conclusions Students participating in a 4-hour SP workshop exhibit superior NPWB knowledge as assessed by open-ended and multiple-choice questions. NPWB attitudinal and supportive counseling skills are easily integrated into basic interviewing while practice with SPs assists in acquisition of knowledge.