Effective communication, teamwork, and interprofessional collaboration, or teams of health and non-health professionals working together, are critical to improving the patient experience of care; improving population health; and reducing healthcare costs (i.e., the Triple Aim). In 2016, the Interprofessional Education Collaborative (IPEC) Expert Panel updated its Core Competencies for Interprofessional Collaborative Practice. As health professionals who collaborate with an extensive network of health and non-health professionals, school nurses embody the aims of interprofessional collaboration (IPC). This article briefly reviews the background of interprofessional collaboration and describes ways that school nurse practice aligns with IPC core competencies to incorporate interprofessional collaboration. We discuss successes, such as case management and care coordination, and include challenges to IPC in the school setting. In conclusion, through case management and collaborative care, school nurse expertise in effective IPC fosters knowledge through which core competencies can be strengthened, with benefits for both patients and other healthcare providers.
Key Words: school nursing, interprofessional collaboration, interprofessional education, health outcomes, school health, chronic disease management, Triple Aim, case management, care coordination.
By a considerable margin, nurses comprise the largest healthcare workforce in the United States (U.S.; Bureau of Labor Statistics, 2016). With 3.6 million registered nurses serving the nation’s diverse healthcare needs (McMenamin, 2016), nurses are prominently placed at a healthcare communication intersection with millions of patients, families, and other healthcare providers and professionals. As such, they develop partnerships upon which patient health outcomes depend.
...school nurses work to provide coordinated and complex care for many of the nation’s 50 million public school students. Working within an education setting, and practicing across multiple healthcare domains, including public health, community agencies, hospitals, and insurance systems, school nurses work to provide coordinated and complex care for many of the nation’s 50 million public school students (McClanahan & Weismuller, 2015; National Center for Education Statistics, 2017). National healthcare changes emphasize effective, efficient, and quality care. As school nurse practice embodies those elements, this new direction in national healthcare positions school nurses as potential and actual leaders in the provision of care coordination and case management for millions of students (McClanahan & Weismuller, 2015).
In recent years, a growing body of research has identified school nurse contributions as necessary to reduce costly and inappropriate use of emergency health services (Wang et al., 2014); to improve economic efficiencies in education and in healthcare (Wang et al., 2014); and to reduce health and academic disparities by serving a disproportionate number of some of the nation’s most vulnerable children (Fleming, 2011). By improving student attendance rates, school nurses help to extend educational and life opportunities for more youth, helping to create a more educated, and healthier, populace (Kocoglu & Emiroglu, 2017). Surveillance, prevention, reporting of communicable disease, and increased population vaccine compliance rates are some examples of critical public health measures mediated by school nurses (Swallow & Roberts, 2016).
Surveillance, prevention, reporting of communicable disease, and increased population vaccine compliance rates are some examples of critical public health measures mediated by school nurses. This article briefly reviews the background of interprofessional collaboration (IPC) and describes ways that school nurse practice aligns with core competencies to incorporate IPC. We discuss successes, such as case management and care coordination, and include challenges to IPC in the school setting.
Interprofessional Collaboration: A Brief Background
It is estimated that 25% U.S. children have a chronic health condition. Increasing rates and complexities of chronic health conditions have shed light on the challenges of care coordination in the United States. In fact, chronic health management has become a key area of focus in many industrialized countries. It is estimated that 25% U.S. children have a chronic health condition (Van Cleave, Gortmaker, Perrin, 2010; van der Lee, Mokkink, Grootenhuis, Heymans, & Offringa, 2007). Coordinated care requires collaboration between and among health and non-health professionals with specialized skills and knowledge to provide comprehensive, coherent, and continuous responses to patients’ unique and changing healthcare needs (Clark, Willgerodt, & Quinonez, 2017; McDonald et al., 2007). Historically, however, healthcare and other professionals have practiced in silos (Rosenthal, 2014). Research is providing increasingly clear evidence that such silos create barriers to the provision of high quality healthcare and improved patient health outcomes (Josiah M. Macy Jr. Foundation, 2013).
Recognition of the importance of interprofessional collaboration, effective communication, and teamwork in healthcare has grown. In 2011, the Interprofessional Education Collaborative (IPEC) Expert Panel produced Core Competencies for Interprofessional Collaborative Practice to promote patient-centered healthcare that improves safety, quality, accessibility, and efficiency. The original IPEC members represented dentistry, nursing, medicine, osteopathic medicine, pharmacy, and public health. The panel updated this report in 2016 in response to national health reforms, such as the Patient Protection and Affordable Care Act (2010) that emphasized the Triple Aim initiative to improve the patient experience of care; improve population health; and reduce healthcare costs (Berwick, Nolan, & Whittington, 2008; IPEC, 2016).
The most significant updates in the 2016 report are the creation of a singular domain of Interprofessional Collaboration (IPC), and revisions of the four core competencies (and their sub-competencies) to better emphasize population health goals and to include non-health professionals as members of the healthcare team in health prevention and maintenance efforts (IPEC, 2016). The core competencies and abbreviated descriptions of them are listed below:
- Values/Ethics for Interprofessional Practice. Explicit maintenance of mutual respect and shared values.
- Roles and Responsibilities. Understanding one’s own and one’s partners’ roles and responsibilities in meeting individual patient and population health needs.
- Interprofessional Communication. Communication with broad partners in health and other fields supports a team approach and helps to ensure timely responses to the promotion and maintenance of health and the prevention and treatment of disease.
- Teams and Teamwork. Apply relationship-building values and principles of team dynamics to effectively plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.
How School Nurse Practice Embodies IPC Aims
The new emphasis of the IPEC competencies... and collaboration with health and non-health professionals is particularly germane to school nursing... The new emphasis of the IPEC competencies on population health, prevention, and collaboration with health and non-health professionals is particularly germane to school nursing, as those elements are embodied in school nurse practice. They also are aligned with the National Association of School Nurses Framework for 21st Century School Nursing Practice (2016), which features five principles: care coordination, leadership, quality improvement, community and public health, and standards of practice. A chief goal of IPC, and an important reason it is embraced by an increasing number of organizations, is that its implementation is believed to better mediate the Triple Aim (Berwick, Nolan, & Whittington, 2008). These aims also are facilitated through the work of school nurses, whose practices provide personalized onsite care, improve population health through multiple means (e.g., immunization, chronic disease management, primary prevention), and reduce healthcare and societal costs (Baisch, Lundeen, & Murphy, 2011; Lineberry & Ickes, 2015; McClanahan & Weismuller, 2015; Swallow & Roberts, 2016; Wang et al, 2014).
The broad scope of school nursing practice requires multifaceted levels of collaboration and communication, including partnerships with non-health professionals such as teachers, school secretaries, and school administrators. School nurses must work seamlessly in the school setting (e.g., with students, parents, teachers, school administrators, coaches, athletic directors, school psychologists and counselors, speech therapists) and at the community level (e.g., with occupational and physical therapists, social workers, primary care physicians and specialists, advanced practice registered nurses, ophthalmologists, dentists, pharmacists, mental health providers, emergency medical technicians and paramedics). They must also be able to navigate complexities in healthcare such as hospital systems and health insurance providers. Successful child health outcomes rely on effective IPC and mutual adherence to its principles in this extensive communication network (Foley, Dunbar, & Clancy, 2014).
The broad and diverse partnerships that characterize the practice of school nurses serve as an exemplar of IPC. Lessons learned from decades of IPC practiced by school nurses can foster knowledge through which IPC core competencies can be strengthened, and through which other healthcare providers and patients may benefit. The following sections of this article will address the strengths of IPC practiced by school nurses, and the barriers and facilitators that influence it.
Successful Interprofessional Collaboration: Care Coordination and Case Management
In a recent survey, 41% of parents recently stated that case management is needed at school for their children. Care coordination and case management and are good examples of how IPC is operationalized. Both of these concepts are practiced frequently by school nurses. In a recent survey, 41% of parents recently stated that case management is needed at school for their children (Toomey, Chien, Elliott, Ratner, & Schuster, 2013).
The Case Management Society of America (2016) defines case management as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost- effective outcomes” (para. 60). Care coordination is defined by McDonald et al. (2007) as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services” (p. 41).
In the school setting, care coordination begins with identification of students with healthcare needs. School nurses plan for and meet student health needs through a well-established process of identification that includes case finding (typically through surveillance activities such as sending home and analyzing student health registration forms) (Educational Service District 105, 2015); conducting health screenings; and by in-person, telephone, or electronic notification (e.g., by parent, school staff, a different school district, healthcare provider, or community agency) (Davis Alldritt, 2006). If there is a school-based health center on site, school nurses also may be notified of student health problems by practitioners working in the clinic.
Once a student health need has been identified, collaboration processes begin. Once a student health need has been identified, collaboration processes begin. Common school nurse partnerships include school-based interdisciplinary teams; teams involving various combinations of school/provider(s)/parents; and school-based health centers. The following sections describe the compositions of these teams and the dynamics that influence IPC within them, and offer recommendations for success.
School Interdisciplinary Teams
An important source of case finding is interdisciplinary teams in schools, which identify and respond to students at academic risk as required by the Individual with Disabilities in Education Act (IDEA) of 2004, and by Section 504 of the Rehabilitation Act of 1973, a federal civil rights law which prohibits discrimination on the basis of disability (Zimmerman, 2013). These federal laws assure students’ rights to access a free and appropriate public education (FAPE). All schools receiving federal funding must comply with these laws. Students referred for a special education evaluation must be assessed by qualified individuals to determine the causes of academic interference, and to develop, if necessary, an Individual Education Plan (IEP) for a student.
Students who do not qualify for special education but who have (or are suspected of having) a disability, must be assessed by a school’s 504 team. Section 504 was amended in 2008, and the interpretation of disability was broadened. The law requires school districts to provide accommodations to students identified as having, or being perceived as having, a disability that limits any major life activity and hence their legal right to receive FAPE (U.S. Department of Education, 2017). If a student is suspected of having a disability, the 504 team must meet to determine whether such disability exists or is suspected of existing, and if so, to put in place accommodations that the team determines necessary to allow the student to receive FAPE. In an analysis of data from the U.S. Office of Civil Rights, the Advocacy Institute found that 1.5% of the K-12 population reported having student plans for accommodations under Section 504. The most common impairment noted was Attention-Deficit/Hyperactivity Disorder (ADHD), followed by diabetes (Holler & Zirkel, 2008).
The composition of interdisciplinary school teams is variable, but federal law requires that at minimum teams include the parent(s)/guardian(s), the child (if appropriate), a member who can interpret the instructional requirements of the evaluation results, and other individual(s) who have expertise in regard to related services necessary to make education accessible to the student (Yonkaitis & Shannon, 2017). Typically, members include school administrator(s); the teacher or staff person making the referral; the school psychologist; the school lead special education or Section 504 staff member; the school nurse; and other staff who have frequent interactions with the student (e.g., music teachers, physical education teachers, librarians). A typical meeting schedule occurs weekly, but frequency of team meetings can vary based on student caseload and staff needs (Department of Defense Education Activity, n.d.).
The school nurse is a vital participant in school interdisciplinary teams because factors that contribute to academic failure can be associated with health problems. The school nurse is a vital participant in school interdisciplinary teams because factors that contribute to academic failure can be associated with health problems. These health concerns may go undetected in the absence of a professional registered school nurse (Yonkaitis & Shannon, 2017). Through communication that educates teachers and staff about implications of health problems and/or needed treatment; and coordinating various aspects of care, the school nurse facilitates IPC. This ensures that if an IEP and/or a 504 plan are prepared for the student, it is informed with appropriate health accommodations as needed. The most recent data (2013-14 school year) from the National Center for Education Statistics (2017) showed that of the nearly 13% of students who received special education services, 50% of them had documented health impairments. Such numbers highlight the importance of including school nurses on the interdisciplinary team.
Hospitals and Community Providers
If the student has or develops comorbidities, the school nurse adds a new partner and integrates new health information into the existing collaborative. In the course of providing daily healthcare for students with chronic health conditions (e.g., asthma, diabetes, seizure disorders, anaphylactic allergies), school nurses frequently collaborate to coordinate care with other healthcare professionals outside of the school setting. Such professionals typically include primary care and/or specialty providers, hospitals, and community health providers. For example, to serve an immigrant student with diabetes, IPC is critical. The school nurse may be required to interface with an endocrinologist, clinic nurse, social worker, and medical interpreter in addition to the student and family and appropriate school personnel. If the student has or develops comorbidities, the school nurse adds a new partner and integrates new health information into the existing collaborative. Other partners may be transient (e.g., in the case of a hospitalization or acute illness or injury) but necessitate communication extensions to hospital or clinic staff to incorporate any changes necessary to alter an ever-dynamic, school-based plan of care.
School-Based Health Centers
According to the School-Based Health Alliance (2017), there are 2,315 school-based health centers (SBHCs) operating in schools in 49 states and the District of Columbia. Most SBHCs are sponsored by hospitals, health departments, and federally qualified health centers. These centers offer primary care, but many offer also mental health and reproductive health services. Some offer dental services (National Association of School Nurses, 2015).
When working with SBHC providers to assure coordinated care for students, school nurses face similar opportunities and challenges as with external entities. School nurses work across systems and navigate privacy laws, but do so with co-located health professional partners. Collaboration between school nurses and school-based health providers can be enhanced with mutual role definition to streamline information exchange, referrals, medication management, and other services (Heuer & Williams, 2016).
...SBHCs should include school nurses as team members who provide health services for shared patients, collaborating to develop a shared case management structure to track care outcomes and coordinate care. The National Association of School Nurses (NASN, 2011) advises school nurses to facilitate student access to SBHC services, an activity that can be accomplished in part by providing referrals and assisting student enrollment in SBHCs. This is common for school nurses, who routinely assist students to access health insurance, community providers, and other services. The NASN (2011) further advises that SBHCs should include school nurses as team members who provide health services for shared patients, collaborating to develop a shared case management structure to track care outcomes and coordinate care. To effectively collaborate and fulfill their independent and shared functions, SBHCs and school nurses should develop well-defined roles and responsibilities; practice mutual respect and support; engage in cooperative planning and implementation of school health services and programs; and share a focus on student academic outcomes (National Association of School Nurses, 2001).
Informal Teams
There are times when student health concerns are managed more informally (i.e. outside the confines of federally mandated teams) with teams that consist of the core professional needed to develop plans of care for the student. Such team members can include parent(s); the student, if appropriate; outside provider(s); and school-based health center provider(s). The school nurse should facilitate and lead these teams (Council of School Health, 2008).
With all teams, an important result, or product, of IPC is the development and maintenance of a student individual health plan. With all teams, an important result, or product, of IPC is the development and maintenance of a student individual health plan (IHP). This document guides health service delivery to students, and is critical to student safety, health, and sound management of chronic disease.
Individual Health Plans
As one of the few types of health providers who do not work within a dedicated healthcare setting, school nurses are practiced in flexibility and versatility as they communicate with a broad range of partners (Wolfe, 2013). School is the place where students spend the majority of their time outside the home. Given this, and the critical contribution of good health to student learning, school nurses who serve as leaders of school-based health teams lead critical care coordination efforts (Council of School Health, 2008). To protect student safety and improve health, part of these efforts include the integration of complex health information from multiple partners to create IHPs.
According to the National Council of State Boards of Nursing ([NCSBN], 2005), preparation of IHPs is a nursing responsibility based on standards of nursing care and regulated by state nurse practice acts. The school nurse also retains responsibility for implementing, evaluating, and updating IHPs as directed by student health outcomes based on frequent assessments of student health status in relation to specified IHP criteria (NASN, 2016).
...the IHP integrates and clarifies student healthcare needs into a single document to promote care management in the school setting. IHPs serve multiple purposes. Zimmerman (2013) noted that the IHP integrates and clarifies student healthcare needs into a single document to promote care management in the school setting. The IHP establishes consistency and continuity of care, especially important for students who are frequently mobile. The clinical elements of the IHP establish care priorities, convey interventions necessary to provide that care, and coordinate services among school-based providers (NASN, 2016).
In addition to the IHP, school nurses also plan and develop Emergency Care Plans (ECPs) to direct lay school staff in providing emergency care for students with potentially life-threatening health conditions. The ECP consolidates and distills important health information in clear language to assure that in a time of crisis, lay staff can better act with direct, clear, and succinct information (Zimmerman, 2013).
The quality of the IHP, as with other care planning, implementation, and health outcomes, depends in part upon the quality of interprofessional communication and collaboration. IHPs are an important product of interprofessional collaboration and offer evidence to support school nurse contributions to navigating and leading the diverse, broad partnerships characteristic of IPC.
Challenges to IPC in the School Setting
Interprofessional collaboration between and among school nurses and primary care and/or other outside healthcare providers is challenged by multiple conditions. Such challenges may include role restriction, privacy laws, conceptual and linguistic differences, and administrative and fiscal pressures (Power, Blum, Guevara, Jones, & Leslie, 2013). These barriers are further explained in this section.
Privacy Laws
Embedded within privacy challenges are the mechanics of communication, particularly as related to electronic health records (EHRs) and sharing of information between entities. Health records maintained by school nurses become part of the school record and are subject to the Family Educational Rights and Privacy Act (Bergren, 2001; [FERPA], 1974). Parents have a right to access such records, regardless of confidentiality laws governing student health privacy. As employees of school districts, school nurses also must abide by these education privacy laws governed by FERPA.
Health privacy laws governed by the Health Insurance Portability and Accountability Act do not govern school health records, but do govern communications between health providers. Health privacy laws governed by the Health Insurance Portability and Accountability Act ([HIPAA], 1996; Public Welfare, 2002), do not govern school health records, but do govern communications between health providers. Although HIPAA allows for communications between health providers for the purposes of coordinating care, some providers are reluctant to share identifiable patient information. Some entities, such as hospitals or clinics, may establish policies that delay the exchange of information.
Timely exchange of student health information is also compromised by the absence of shared electronic health records, in turn impeding the ability to coordinate care for healthcare providers working in or across different health systems (Power et al, 2013). This limitation often requires school nurses to communicate via fax, e-mail, or in writing during face-to-face meetings.
Role Restriction
Many school nurses report exclusion from interdisciplinary school-based teams despite both legal directives for their presence and evidence of the multiple benefits of their participation... Barriers to nurse scope of practice are diverse, widespread, and negatively affect quality and value of care (Institute of Medicine, 2011). Barriers that restrict the role/practice of school nurses reflect persistent silos in education and health. Many school nurses report exclusion from interdisciplinary school-based teams despite both legal directives for their presence and evidence of the multiple benefits of their participation (e.g., reduced duplication of services, improved student outcomes) (Yonkaitis & Shannon, 2017).
While school nurses are expected to demonstrate (or at least be familiar with) knowledge of education, education law, and health law as it pertains to the provision of health services for students at school, the same knowledge about school nursing by educators is not required, or even recommended. The scarce presence of nurses in schools, due to lack of funding, is itself driven by lack of awareness of the powerful ways in which school nurses influence educational outcomes. This lack of awareness makes it difficult for educators to know and/or understand the impact of the school nurse contribution(s) on efforts of both teachers and students. There is a clear need for improvement in understanding roles and responsibilities of interdisciplinary team members and in demonstrating value for unique roles.
Fiscal and Administrative Pressures
The scarce presence of nurses in schools... is itself driven by lack of awareness of the powerful ways in which school nurses influence educational outcomes. Fiscal pressures in schools contribute to the scant and uneven presence of professional school nurses working within. This lack of school nurses imposes severe time constraints on existing nurses, limiting their availability for collaboration (Power et al, 2013). In addition, limited time in school buildings (again, often due to fiscal pressures) exacerbates lack of understanding about the school nurse role, particularly by non-health professionals. In turn, this likely contributes to continued underfunding.
Fiscal pressures in schools contribute to the scant and uneven presence of professional school nurses working within. From an administrative perspective, in terms of case finding, school nurses report some communication barriers with providers and families, evidenced by lack of completed health history forms or timely required release of information forms (Heuer & Williams, 2016; Svavarsdottir et al, 2013). Adaptations to this barrier have been to supplement this surveillance method with additional case finding strategies, such as screenings and outreach through classroom teaching. School nurses also are known to show leadership in IPC by working collaboratively with clinic and hospital system providers to develop streamlined processes for the timely exchange of student health information.
Conceptual and Linguistic Differences
School nurses effectively communicate and collaborate with a broad range of partners, including parents, teachers, coaches, and many health provider types. This is evidenced in part by their creation of a variety of IHPs to improve communication with different audiences. However, there can be both conceptual and linguistic differences that impede communication. Because school nurses routinely serve students with a broad spectrum of chronic diseases, they are often more conversant in the language of multiple health conditions than those who practice with focus on a single specialty. In addition, due to frequent contact and experience with different provider types, school nurses may have a better understanding of the classification systems and language under which different specialists operate (NASN, 2016). Time and intentional effort is required to overcome these barriers as they present.
Conclusion
School nurses identify, treat, refer, and provide case management services for millions of students. School nurses identify, treat, refer, and provide case management services for millions of students (McClanahan & Weismuller, 2015). As healthcare providers whose practices can both help to realize the national level Triple Aim goals and improve education and health outcomes, investment in interprofessional education is necessary.
As community-based healthcare continues to grow, interprofessional and intraprofessional collaborations are becoming increasingly important to ensuring quality and efficient case management and reduce the burden of chronic disease. This may be especially so with potential federal cuts to Medicaid that may increase the quantity and quality of school nurse caseloads. With a long history of collaboration and broad scope of partnerships, school nurses can increase understanding of the strengths and challenges of interdisciplinary communication in practice, thus helping to inform and improve IPC for nursing and other disciplines. As this article has noted, lack of understanding of the school nurse role is an impediment to attain elements of IPC core competencies, particularly the development and maintenance of mutual respect and shared values. Complexities of navigating dual education and health privacy laws; lack of interoperable electronic health records systems; and competition for scarce resources are problems that may be remedied by improvements in education and practice of IPC.
Interprofessional learning and education is necessary to break down isolated silos of practice and facilitate the development of IPEC competencies. As health providers increasingly work with community entities whose primary focus is not health, but whose outcomes are dependent on the health of the populations they serve, the need for IPE for health and non-health professionals grows stronger. For example, in Washington State, health reform efforts have given rise to development of Accountable Communities of Health (ACHs). The purpose of these regional entities is to convene diverse community partners to focus on preventive, community-based solutions to improve population health. Representatives on ACHs include persons from housing, criminal justice systems, education, hospital systems, school nursing, community health workers, environmental experts and others (Washington State Health Care Authority, 2017).
As silos begin to dissolve, IPE for all partners can facilitate effective interprofessional collaboration and communication necessary to improve population health. Through case management and collaborative care, school nurse expertise in effective IPC fosters knowledge through which core competencies can be strengthened, with benefits for both patients and other healthcare providers.
Authors
Robin Fleming, PhD, MN, RN, NCSN
Email: fleming9@uw.edu
Dr. Fleming most recently served as Health Services Program Administrator at Washington State’s education agency, the Office of Superintendent of Public Instruction. While there, she administered a statewide school nursing program, and helped to develop health policy for Washington State. Her interdisciplinary research in health and education, development of education programs for Washington State nurses, and her 13 years of service as a school nurse in Seattle Public Schools have provided rich experience in practicing and refining interprofessional and intraprofessional collaborations. Dr. Fleming received a PhD in Educational Leadership and Policy Studies at University of Washington, Seattle, and an MN and BSN from the University of Washington School of Nursing. She is an affiliate assistant professor in the Child and Family Nursing Department of the University of Washington School of Nursing, Seattle.
Mayumi A. Willgerodt, PhD, MPH/MS, RN
Email: mayumiw@uw.edu
Dr. Willgerodt earned a BSN from Georgetown University and a dual MPH/MS and PhD from the University of Illinois at Chicago. She has held faculty appointments at Rush University, UW Seattle and currently is Professor in Nursing and Health Studies at the University of Washington, Bothell campus. As a certified school nurse, Dr. Willgerodt’s area of scholarship is focused on school-based health promotion research, including care coordination with children with special healthcare needs, and school nursing workforce. Dr. Willgerodt is on the editorial board of Journal of School Nursing, is on the research advisory for the National Association of School Nursing and a member of the School Nurse Organization of Washington. She is a member of numerous professional organizations, provides consultation services and volunteers with the homeless youth population in Seattle.
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