monograph 2007 annual report of children’s health and nursing service in alabama… ·...

MONOGRAPH 2007

Annual Report of Children’s Health and Nursing Service in Alabama’s Public School Systems

Principal Investigator Allison J. Terry, PhD, RN Alabama Board of Nursing Montgomery, Alabama January 2007

Acknowledgements

Principal Investigator Allison J. Terry, PhD, MSN, RN Director, Center for Nursing Technical and Administrative Support Richard Boyette Programmer Analyst Initial Planning and Development N. Genell Lee MSN, RN, JD Executive Officer Consultants Jean B. Lazarus, EdD, RN Martha Holloway, MHSA, RN State School Nurse Consultant State Department of Education Melanie Sharpton, RN President, Alabama Association of School Nurses Alexander City School System

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Table of Contents

Acknowledgements p. ii List of Tables p. iv List of Figures p. v List of Appendix items p. vi Glossary p. vii Introduction p. 1 Literature Review p. 1 Procedure p. 3 Findings p. 3 Limitations p. 15 Implication of Findings p. 16 Recommendations p. 17 Conclusion p. 18 References p. 294

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List of Tables Table 1: Identifying Information p. 4 Table 2: Personnel Information p. 5 Table 3: Medication Information p. 7 Table 4: Medication and Procedure Information p. 7 Table 5: Chronic Condition Information p. 8 Table 6: Acute Condition Information p. 8 Table 7: Physician’s Order Information p. 8 Table 8: Reported Barriers or Challenges to the Provision of Health Services p. 9 Table 9: Comparison of Data From 2005-2006 and 2006-2007 Academic Years (Personnel Information) p. 9 Table 10: Comparison of Data From 2005-2006 and 2006-2007 Academic Year (Medication Information) p. 11 Table 11: Comparison of Data From 2005-2006 and 2006-2007 Academic Years (Procedure Information) p. 14 Table 12: Comparison of Data From 2005-2006 and 2006-2007 Academic Years (Condition Information) p. 24

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List of Figures

Figure 1: Personnel Information from 2005-2006 and 2006-2007 p. 10 Figure 2: Medication Information from 2005-2006 and 2006-2007 p. 12 Figure 3: Procedure Information from 2005-2006 and 2006-2007 p. 14 Figure 4: Condition Information from 2005-2006 and 2006-2007 p. 15

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List of Appendix Items

Appendix A: School Nurse Allocations p. 19 Appendix B: Reports Per Individual School Systems p. 23 Appendix C: School Nurse Survey-Academic Year 2006-2007 p. 294

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Glossary

1. Attention deficit disorder-syndrome of disordered learning and disruptive behavior that has several subtypes characterized primarily by symptoms of inattentiveness and/or hyperactivity and impulsive behavior. 2. Automatic external defibrillator-an electronic device used to defibrillate a heart by applying an electric shock. 3. Asthma-a chronic lung disorder that is marked by recurring episodes of airway obstruction manifested by labored breathing accompanied especially by wheezing and coughing and by a sense of constriction in the chest, and that is triggered by hyperreactivity to various stimuli. 4. Autism-a developmental disorder that appears by age three and that is recognized and diagnosed by impairment of the ability to form normal social relationships, impairment of the ability to communicate with others, and by stereotyped behavior patterns. 5. Cardiopulmonary resuscitation (CPR)-emergency first aid procedure for a victim of cardiac arrest. 6. Cellulitis-inflammation of the connective tissue underlying the skin. 7. Central line-a central venous catheter (CVC or central (venous) line) is a catheter placed into a large vein in the neck, chest or groin 8. Diabetes- a disorder of carbohydrate metabolism caused by a combination of hereditary and environmental factors; usually characterized by inadequate secretion or utilization of insulin, excessive urine production, excessive amounts of sugar in the blood and urine, and by thirst, hunger, and weight loss. 9. Epinephrine- used medicinally especially as a heart stimulant, to treat open-angle glaucoma and life-threatening allergic reactions, to prolong the effects of local anesthetics, and as a bronchodilator. 10. Gastric tube- medical device inserted through a small incision in the abdomen into the stomach; used to provide nutrition to patients who cannot obtain nutrition by swallowing. 11. Glucagon- hormone that promotes an increase in the sugar content of the blood. 12. Glucose monitoring- measures the amount of glucose in the blood right at the time of sample collection.

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http://en.wikipedia.org/wiki/First_aid

http://en.wikipedia.org/wiki/Cardiac_arrest

http://en.wikipedia.org/wiki/Inflammation

http://en.wikipedia.org/wiki/Connective_tissue

http://en.wikipedia.org/wiki/Skin

http://en.wikipedia.org/wiki/Catheter

http://en.wikipedia.org/wiki/Vein

13. Hemophilia- hereditary blood defect that occurs almost exclusively in males and is characterized by delayed clotting of the blood and consequent difficulty in controlling hemorrhage even after minor injuries. 14. Hickman catheter- an indwelling central venous line which provides direct access to the heart. 15. Human immunodeficiency virus- causes acquired immunodeficiency syndrome (AIDS), a condition in which the immune system begins to fail, leading to life-threatening opportunistic infections. 16. Immunization- process by which an individual is exposed to an agent that is designed to fortify his or her immune system against that agent. 17. Inhaler- a device designed to deliver medication via inhalation. 18. Nebulizer- an atomizer equipped to produce an extremely fine spray of medication for deep penetration of the lungs. 19. NO CODE-physician’s order meaning “do not resuscitate”. 20. Ostomy- surgically created opening in the body for the discharge of body wastes. 21. Pediculosis-infestation of head or body lice. 22. Pressure ulcer-skin breakdown caused by pressure or friction. 24. Scoliosis-curvature and deformity of the spine. 25. Seizure- convulsions, sensory disturbances, or loss of consciousness resulting from abnormal electrical discharges in the brain. 26. Sickle cell anemia-genetic disorder in which red blood cells change shape, assuming a “sickle”-shape. 27. Solu-Cortef- medication that may be used to treat bladder problems such as frequent need to urinate or loss of control of urinary function as well as other conditions. 28. Standard precautions-practice of avoiding contact with another person’s bodily fluids. 29. Tracheostomy- the surgical formation of an opening into the trachea through the neck especially to allow the passage of air.

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http://en.wikipedia.org/wiki/AIDS

http://en.wikipedia.org/wiki/Immune_system

30. Urinary catheterization- insertion of a catheter into a patient's bladder in order to drain urine from the bladder into an attached bag or container.

31. Vagal nerve stimulator- device implanted in the brain in an attempt to decrease seizure activity. 32. Ventilator-a device for maintaining breathing. (Merriam-Webster Incorporated, 2003)

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Annual Report of Children’s Health and Nursing Service in

Alabama’s Public School Systems

Introduction Like society in general and healthcare nationally, school nursing in Alabama is in a state of flux. The profession is challenged to a greater degree than ever before by an overwhelming number of students who have healthcare needs and conditions of a higher level of acuity than have previously been seen in public school systems. In an attempt to meet the healthcare needs of students, Alabama allows the delegation of procedures such as assistance with medication to unlicensed assistive personnel. The Alabama Board of Nursing (the Board) is accountable for both the enforcement of regulations that allow for delegation to occur and assuring that the licensed nurses providing the delegation are competent in their practice. Rule 610-X-6-.06 of the Alabama Board of Nursing Administrative Code specifically addressed delegation by school nurses and stipulated that a report would be submitted to the Board upon request by either the State School Nurse Consultant or the School Nurse Administrator. Since implementation of the regulations in 2001, the Board has requested a yearly report which addressed the current state of student populations as well as the nursing care provided by licensed and supervised, unlicensed personnel. The initial school health report was requested and compiled for academic year 2003-2004, with a more detailed report being compiled for the subsequent school year. A Monograph for each year has been printed and distributed to the State Department of Education, Governor Bob Riley, legislators, school superintendents, and interested stakeholders. The current report reflects data gathered during academic year 2006-2007 and is a comparison of the changes which have evolved in Alabama’s delivery of healthcare to students from one year to the next. Literature Review The importance of the school nurse in providing healthcare services to public school students has been well established in the literature. Changes in society, the provision of healthcare, education, and the family structure have all combined to increase both the need and the demand for school health services. Furthermore, the public school systems must now cope with the ramifications of legal and illegal immigration, homelessness, divorce and blended families, violence, and substance abuse associated with every type of drug from alcohol to prescription pills to methamphetamine produced in homemade laboratories. The school nurse must have the central management role in the implementation of the school health services program and often must function as the team coordinator. Frequently, the healthcare team will include licensed practical nurses, unlicensed personnel such as clerical staff, guidance counselors, and

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various physicians who will be consulted as necessary. As leader of the school health team, the school nurse must assess each student’s health status, identify health problems that could potentially create a barrier to educational progress, and develop a health care plan for management of these problems in the school environment (Taras, Frankowski, McGrath, Mears, Murray, and Young, 2001). Once the importance of school nurses in the provision of healthcare is established, an adequate number of licensed nurses to provide health services must be obtained. Wolfe and Selekman (2002) noted that the National Association of School Nurses has recommended that the school nurse to student ratio should be 1:750 in the general school population, 1:225 in the mainstreamed student population, 1:125 in the severely chronically ill or disabled population, and possibly even lower for medically fragile students. This ratio is not being met in some of Alabama’s more rural counties, as is shown in Appendix A, which provides a report of data collected on a system-by-system basis. Furthermore, despite federal recommendations regarding the ratio of nurses to students, the U.S. Department of Education believes that state and local official determine staffing needs, according to Susan Asprey, press secretary for the Department. School districts frequently struggle to find the financial resources needed to hire nurses. Also, many nurses balk at the salary deficit experienced by many school nurses. A 2004 survey by the National School Nurses Association revealed that the median salary for a school nurse was approximately $36,000 annually, considerably less than the pay for a hospital-based nurse (Horovitz and McCoy, 2005). School nurse allocations for Alabama’s school systems for both the 2005-2006 and 2006-2007 academic years are shown in Appendix A (Alabama School Journal, 2006). In reviewing data presented in Appendix A, it should be noted that the data are reflective of the 1995 passage of the Foundation Program by then-Governor Fob James Jr. The law was designed to promote educational opportunity for all children attending Alabama’s public schools. In order to participate in the Foundation Program and therefore receive state funding, each local school system was required to pledge a portion of its local revenues to be included in the funding requirements of the program. All school systems chose to participate. The primary focus of the funding process is the provision of state funds to cover the salaries and benefit packages of the personnel who are known as “foundation units”. This group consists of principals, classroom teachers, assistant principals, librarians, and counselors. In order to calculate the number of foundation units to be funded for a specific fiscal year, each school system must accurately report its student enrollment during the first 20 days after the Labor Day holiday. This constitutes the Average Daily Membership report, which figures prominently in Appendix A. This means that students who enroll or withdraw from school after the 20th day following Labor Day have no effect on the state foundation funding process for the succeeding year. The Average Daily Membership calculations for one year form the basis of the funding calculations for the following academic year (Alabama Education Association, 2007).

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Procedure The instrument for data compilation consisted of a survey which was distributed to 134 Alabama public school systems and 1451 public schools. The survey instrument is shown in Appendix C. Questions were validated for appropriate wording and content by Board members and staff as well as the State School Nurse Consultant in the State Department of Education. Detailed instructions for completion of the survey were sent to each nurse via electronic mail. The survey was placed online on the Board’s website and was intended to be completed by responders between November 1 and November 20, 2006. Response rate was 100%, with the registered nurses assigned to the schools being required to complete the report. Some school systems failed to meet the required timeframe for survey completion, with the final participant providing data on December 21st, 2006. In the case of some school systems which have a Lead Nurse or Nurse Administrator overseeing the School Health Program, these personnel chose to be accountable for the completion and submission of reports for each school in their system. Findings Once data had been compiled, it became clear that a longitudinal comparison of the calculations derived from the current year’s report and the calculations from the previous year’s report could be determined. A compilation of the data derived from the 2006-2007 academic year’s survey is included in Tables 1-8, with Table 8 being a report of nurses’ comments regarding barriers or challenges to the provision of health services in Alabama public school systems. Calculation of descriptive statistics was performed on data submitted by each school system. Compilation of identifying information on each school system presented in Table 1 revealed that 1,324 of the systems have a lead nurse or Nurse Administrator who is accountable for the system’s School Health Program (91.25%). When the Registered Nurse (RN) of each school was asked on the survey how many days per week students in that particular school had access to an on-site licensed nurse, the overwhelming response was daily access. However, the fact that 118 nurses completing the survey reported that the students being served in that specific school system did not have access to a licensed nurse raises concerns. It is recommended that when the survey is administered for academic year 2007-2008, terms utilized such as “access to a licensed nurse” be clarified. This would increase the knowledge base of the respondents completing the survey and also increase the validity and reliability of the findings reported. Nurses were also questioned regarding the frequency with which a supervising RN conducts on-site supervision of Licensed Practical Nurse (LPN) employed by the school system. Although 649 (49.35%) of school systems reported that this question was not applicable to them, 666 (50.65%) systems responded that on-site supervision occurred as often as daily (2.74%) and as often infrequently as less than once monthly (3.12%). Furthermore, nurses were

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also questioned regarding the frequency with which a licensed nurse monitors unlicensed school personnel who are delegated the task of assisting with medications. To this question, school systems reported frequency of supervision ranging from daily (1.12%) to less than once monthly (24.3%). The variance in the amount of supervision of unlicensed personnel is a concern in light of the intense nature of the procedures being performed, medications being administered, and conditions being monitored in Alabama’s public school systems. Review of personnel information compiled revealed that 893 licensed nurses are now employed full-time in Alabama’s public school systems. The knowledge base of the respondents completing the survey again becomes questionable when the 893 full-time nurses reported is compared with the 1451 public schools completing the survey. Although the number of full-time nurses is a significant decrease from the previous year (26.92%), it is believed that school systems during the previous year may have combined full-time and part-time nurses employed into one number. A comparison of personnel information from the two academic years may be seen in Table 9. It should be noted that nurses assigned to one classroom as well as nurses assigned to one student both increased. The number of substitute nurses increased to such a degree that it is believed that school systems either over reported this number during the current academic year or underreported it during the previous year. A comparative graph showing data derived from the two academic years is shown as Figure 1. Table 1: Identifying Information

Criteria Schools Responding Number of schools reporting 1,451 (each school reporting did not complete all

sections of survey) Number of school systems reporting 134 No. of schools with lead nurse or Nurse Admin. 1,324 No. of schools w/o lead nurse or Nurse Admin. 127 Days students have on-site access to a licensed nurse No access: 118

1 day/week: 91 2 days/week: 63 3 days/week: 29 4 days/week: 17

Daily access: 997 Frequency with which a supervising RN conducts on-site supervision of an LPN

Daily: 36 Three times per week: 23

Twice weekly: 42 Once weekly: 178

Once biweekly: 129 Once monthly: 217

Less than once monthly: 41 Not applicable: 649

Frequency with which a licensed nurse monitors unlicensed school personnel who assist with medications

Daily: 130 Three times per week: 31

Twice weekly: 43 Once weekly: 146

Once biweekly: 136 Once monthly: 330

Less than once monthly: 262 Not applicable: 238

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Table 2: Personnel Information

Criteria Schools Responding Licensed nurses employed full-time 893 total Licensed nurses employed full-time per school 1 nurse: 786

2 nurses: 87 3 nurses: 14


>6 nurses: 1 Licensed nurses employed part-time 249 total Licensed nurses employed part-time per school 1 nurse: 202


Licensed nurses employed as substitutes 940 total Licensed nurses employed as substitutes per school 1 nurse: 213

2 nurses: 89 3 nurses: 44 4 nurses: 12 5 nurses: 11 6 nurses: 6



Health career teachers/licensed nurses 107 total Health career teachers who are licensed nurses employed per school

1 teacher/nurse: 79 2 teacher/nurses: 11 3 teacher/nurses: 2

Volunteers who are licensed nurses 50 total Volunteers who are licensed nurses per school 1 volunteer nurse: 32

2 volunteer nurses: 7 3 volunteer nurses: 1

>3 volunteer nurses: 10 Nurses assigned to one classroom 106 total Nurses assigned to one classroom per school 1 nurse: 86


Nurses assigned to one student 64 total Nurses assigned to one student per school 1 nurse: 52

2 nurses: 4 >3 nurses: 1

Number of unlicensed personnel employed by the school who are delegated the task of assisting the students with medications per school

1: 170 2: 397 3: 226 4: 102 5: 77 6: 51 7: 37 8: 30 9: 19

10: 17 11: 13 12: 14 13: 3

14: 10 15: 14 16: 7 17: 4 18: 1 19: 5 20: 3 21: 1 22: 2 23: 1 25: 1 35: 1 43: 1

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45: 1 49: 1 50: 1

Number of hours nurses spent on field trips 1-5 hrs during 1st 3 mos. of school yr: 149 6-10 hrs during 1st 3 mos. of school yr: 37

11-15 hrs during 1st 3 mos. of school yr: 57 16-20 hrs during 1st 3 mos. of school yr:109

>20 hrs/mth during 1st 3 mos. of school yr: 26 Number of hours nurses spent riding the school bus with students

1-5 hrs during 1st 3 mos. of school yr: 61 6-10 hrs during 1st 3 mos. of school yr: 29

11-15 hrs during 1st 3 mos. of school yr: 16 16-20 hours during 1st 3 mos. of school yr: 12

>20 hrs/mth during 1st 3 mos. of school yr: 56 Number of hours nurses spent in individualized health-related teaching



>20 hrs/mth during 1st 3 mos. of school yr: 131 Number of hours nurses spent counseling students & parents regarding need to obtain follow-up medical care



>20 hrs/mth during 1st 3 mos. of school yr: 130 Number of hours nurses spent attending student extracurricular activities



>20 hrs/mth during 1st 3 mos. of school yr: 26 Types of health promotional activities initiated Vision/hearing screenings:110

Handwashing: 98 Scoliosis screening: 54 Influenza prevention clinics: 44 Health fairs: 42 Hygiene: 31 Smoking Prevention: 7 ALL KIDS Insurance: 16 CPR: 13 Diabetes: 20 Health Education classes: 17 HIV: 15 Immunizations: 12 Pediculosis screening: 19 Drug awareness: 30 Wellness program: 13 Breast cancer awareness: 10 Dental screenings: 9 Standard precautions: 27 Other miscellaneous topics: 281

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Table 3: Medication Information

Criteria Schools Responding Method for maintaining privacy of a student receiving assistance with medication

Yes: 1298 No: 52

Method for medication security Yes: 1308 No: 43

Area for refrigerating medications Yes: 1121 No: 230

Number of times students have experienced side effects of medication (last 3 months)

0: 1248 1: 43 2: 25 3: 8

>3: 29 Number of unusual occurrence reports specific to medications completed

0: 1143 1-10: 206 11-20: 2

2 Type of medication error occurring in the last 3 mths None: 1000

Other: 106 Out of Medication: 181

Wrong Time: 33 Failure to Document: 15

Overdose: 11 Wrong Medication: 3

Wrong Student: 6 Incidents in which unauthorized persons have provided medication assistance (may not necessarily have been delegated by licensed nurse)

Yes: 26 No: 1320

Table 4: Medication and Procedure Information

Medication or Procedure Numbers of Students

access to automatic external defibrillator 7,917 central line care 26 gastric tube care 359 fingerstick glucose monitoring 1,587 monitoring of implanted defibrillator 33 monitoring of insulin pump 422 medication administration via central line 7 nebulizer care 852 oral suctioning, including bulb syringe 7,357 ostomy care 127 skin assessment 506 tracheostomy care, including suctioning 48 urinary catheterization 168 vagal nerve stimulator care 66 care of ventilator 9 wound care for pressure ulcers 29

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Table 5: Chronic Condition Information

Chronic Conditions Numbers of Students severe allergies 7,706 ADD/ADHD 18,381 asthma 35,025 autism 1,892 autoimmune diseases 424 cancer 208 cardiac conditions 2,274 diabetes (Type I or Type II) 1,849 gastrointestinal diseases 1,873 genetic disorders 1,087 hemophilia 98 mental disorders 2,299 mental retardation 4,534 more than one chronic illness 4,142 obesity 18,197 orthopedic disorders 1,455 seizure disorder 4,115 sickle cell anemia 556 other conditions 4,406

Table 6: Acute Condition Information

Acute Conditions Numbers of Students

acute wound care 6,838 cellulitis or other acute infections 1,453 concussions 369 diarrhea 8,266 first aid 115,379 fractures 1,579 headaches 46,253 influenza 1,909 pain 54, 574 (primary location: abdominal) vomiting 24,145

Table 7: Physician’s Order Information

Ordered Medications or Treatments Numbers of Students

automatic external defibrillator 1,035 blood products 31 breathing treatments 2,186 NO CODE 82 ear drops 73 Epi-Pens (injectable epinephrine) 2,481 eye drops 252 Glucagon 1080 injectable pain medication 9 injectable psychiatric medication 1 insulin 1,324 self-administered inhalers 8,809 inhalers requiring assistance 5,713 oral antibiotics 853 ADD/ADHD medications 5,803 oral psychiatric medications 658 oral seizure medications 610 rectal medications 417 Solu-Cortef 26 topical medications 496 Nurses can access students’ medical information Yes : 970

No: 313

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Table 8: Reported Barriers or Challenges to the Provision of Health Services

1. Being supervised by a non-nurse 2. Knowledge deficit of parents related to health concerns of their children a. Lack of parental concern, involvement, and willingness to comply b. Parents will not always bring in medication from home. c. Parents will not respond to nurses’ notes or to phone calls. d. Telephone numbers change frequently or are disconnected 3. Students’ negative behavior 4. Lack of funding, lack of necessary equipment and supplies 5. Sharing a nurse with other schools 6. Lack of emergency services available in the area 7. Families with no insurance as well as language barriers 8. Difficulty with responses from specific hospitals 9. Lack of supplies in nurse’s office (includes running water) 10. No on-site nurse on a regular basis 11. Lack of physician cooperation 12. Lack of administrative support 13. Health Insurance Portability and Accountability Act Requirements Table 9: Comparison of Data From 2005-2006 and 2006-2007 Academic Years (Personnel Information)

ITEM TOTAL RESPONSES

FROM 2005-2006 TOTAL RESPONSES FROM

2006-2007 Full-time Licensed Nurses 1,222 893 Nurses Assigned to One Classroom 86 106 Nurses Assigned to One Student 57 64 Health Career Teachers/Nurses 101 92 Substitute Nurses 454 940 Volunteer Nurses 30 50 Unlicensed School Personnel Receiving Delegation

5,411 5,202

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Figure 1: Personnel Information from 2005-2006 and 2006-2007

Personnel Information

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TOTAL RESPONSES FROM 2005-2006TOTAL RESPONSES FROM 2006-2007

Further review of personnel information compiled from the survey revealed that most nurses responding reported spending one to five (149 nurses) and ten to twenty (109 nurses) hours per month on field trips with students. Also, 35.06% of the nurses who were required to accompany students on buses reported spending between one and five hours on this task. An additional one to five hours per month was reported to have been spent by 47.26% of nurses who were required to attend student extracurricular activities. In addition to their regularly scheduled healthcare activities, nurses in Alabama provide a great deal of individualized health-related teaching to students, with 45.39% of nurses reporting between one and five hours spent per month. Also, 48.42% of responding nurses reported that one to five hours per month was spent counseling students and, in some cases, parents regarding the need to obtain follow-up medical care. A wide variety of health promotional activities are occurring as a result of the presence of nurses in the public school systems. These include vision and hearing screenings, health fairs, scoliosis screenings, and influenza prevention clinics.

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Review of medication information revealed that most responding nurses (96.15%) have a method in their public school for maintaining the privacy of students who are receiving assistance with their medication as well as a method for maintaining the security of medications being administered (96.82% of responding nurses). Also, 82.98% of responding nurses reported having an area available for the refrigeration of medications. Interestingly, 84.48% of nurses responded that they had not completed a single unusual occurrence report specific to medications since the beginning of the academic year. This is in sharp contrast to a study conducted by the National Association of School Nurses (NASN) which assessed practices and concerns associated with medication administration in schools. Among respondents to the NASN survey, 48% reported that at least one medication error had occurred within the past year, with the primary type of error occurring being a missed dose of medication (McCarthy, 2000). A comparison of medication information from the 2005-2006 and 2006-2007 academic years may be seen in Table 10. A comparative graph showing the data derived from the two academic years is shown as Figure 2. It should be noted that the number of breathing treatments being administered in Alabama’s public school systems increased 307.45%, the number of medications used to treat Attention Deficit Disorder increased 354.37%, and the number of oral antibiotics being administered increased 498.83% from one academic year to the subsequent year. Table 10: Comparison of Data From 2005-2006 and 2006-2007 Academic Years (Medication Information)



2006-2007 Breathing Treatments 711 2,186 Epi-Pens 2,164 2,481 Glucagon 974 1,080 Inhalers (Self-Administered) 11,229 8,809 Injectable Insulin 1,136 1,324 Inhalers with Assistance 8,004 5,713 ADD/ADHD medications 5,187 18,381 Oral Antibiotics 171 853 Psychiatric Medications 458 658 Oral Seizure Medication 411 610

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Figure 2: Medication Information from 2005-2006 and 2006-2007

Medications Ordered by Physicians

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Review of procedure information compiled from the survey revealed that the most frequently performed procedures were access to an automatic external defibrillator as well as oral suctioning. The numbers were so high for these procedures (7,917 and 7,357, respectively) that it is believed that a few nurses misinterpreted access to an external defibrillator to be synonymous with use of the defibrillator, with a similar interpretation existing for oral suctioning. These large numbers were only reported by twelve schools out of the 1,451 schools reporting data. A comparison of procedure information from the 2005-2006 and 2006-2007 academic years may be seen in Table 11. A comparative graph showing the data derived from the two academic years is shown as Figure 3. It should be noted that the procedure of administration of blood products increased 29.03% from one academic year to the next, while the number of ventilators in

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use and requiring care increased 44.44%, from five in use throughout the public school systems to nine in use. A review of information on various conditions compiled from the survey revealed that the most prevalent conditions experienced by students in the public school systems were asthma, attention deficit disorder, and obesity as chronic disorders. In terms of acute disorders, more than 115,000 students required first aid since the beginning of the 2006-2007 academic year. Over 54,000 students were treated by school nurses for pain, with abdominal pain being the primary location of the discomfort, and more than 46,000 students were treated for headaches. A comparison of condition information from the 2005-2006 and 2006-2007 academic years may be seen in Table 12. A comparative graph showing the data derived from the two academic years is shown as Figure 4. It should be noted that there was no significant increase in the number of students diagnosed with diabetes, hemophilia, mental illness, or seizure disorder from one academic year to the subsequent year. Review of information compiled on physician’s orders revealed that 970 (75.60%) of responding nurses reported having access to all of the necessary medical information of students served. The remaining 313 nurses responded that they were functioning daily in the school setting without having adequate medical information on each child served. This is particularly problematic when considered in light of the documentation of Individual Health Plans which are required from the U.S. Department of Education for students receiving special services. Furthermore, the main medications or treatments which were found to be ordered by physicians for students were self-administered inhalers (27.58%), medications for attention deficit disorder (18.17%), and inhalers requiring assistance (17.89%). It should be noted that 82 students in the state have physician’s orders for “Do Not Resuscitate” if the students appear to require resuscitation. Nurses were not queried regarding such orders in the previous year’s survey. Finally, nurses were asked to report barriers or challenges to the provision of health services in their specific school system. Of particular concern was the challenge of “being supervised by a non-nurse”. Many nurses in Alabama are supervised by Department of Education personnel who are in charge of the system’s provision of health services but who are not necessarily nurses and have no medical knowledge. Communication between medical and non-medical personnel can become strained if tensions are allowed to escalate. Other challenges center around parents. Nurses noted that some parents are not consistently concerned about their children’s health, frequently fail to become involved in the Individual Health Plan for each child, and often do not comply by bringing medication from the home environment so that it can be administered at school. When nurses attempted to involve parents in the health plan for their children, they found that the home telephone number had changed and the school was never notified, or that parents did not always respond to notes sent home from school. Furthermore, nurses noted that families frequently were without health insurance and often had a language barrier as well.

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Table 11: Comparison of Data From 2005-2006 and 2006-2007 Academic Years (Procedure Information)



2006-2007 Blood Products 22 31 Gastric Tube care 337 359 Glucose Monitoring 1,671 1,587 Tracheostomy Care 55 48 Urinary Catheterization 193 168 Ventilator Care 5 9

Figure 3: Procedure Information from 2005-2006 and 2006-2007

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Table 12: Comparison of Data From 2005-2006 and 2006-2007 Academic Years (Disorder Information)

CONDITION TOTAL RESPONSES FROM 2005-2006

TOTAL RESPONSES FROM 2006-2007

ADD/ADHD 18,534 18,381 Asthma 35,721 35,025 Diabetes 1,919 1,849 Hemophilia 117 98 Mental Illness 2,732 2,299 Seizure disorder 4,240 4,115

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Figure 4: Conditions Information from 2005-2006 and 2006-2007

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ber of Students Experiencing Disorder

2005-2006 Year2006-2007 Year

Limitations The limitations of this research project are those associated with the implementation of any survey. The lack of random sampling involved in this type of survey research can lead to poor external validity. This means that, although the survey instrument utilized appears to measure what it was intended to measure, the results received may not be generalizable to school nurse populations outside of Alabama. Sources of error can result from sampling errors, question characteristics, and interviewer influences (Bigger, 2003). A limitation specific to the administration of this survey was the respondents’ interpretation of questions. Many nurses contacted the researcher requesting clarification on the timeframe utilized in each question, even though instructions e-mailed to all participants specified that nurses were to use the beginning of the academic year as the beginning of the timeframe for calculating numbers of students with various conditions, medications, or procedures. Furthermore, many nurses, though the only practitioner in their school system, counted themselves as being full-time for each school in that system, thereby causing the system to appear to have multiple nurses employed in its schools rather than only one. This required the researcher to spend additional man hours in scrutinizing each school system’s entry in an attempt to determine duplicate entry of nurses.

15

Implication of Findings

As previously mentioned, nurses were questioned regarding the frequency

ss e

ing

ditional numbers of registered nurses in the public school

field

ivities

rise. f

g

e

bing

n should

with which a licensed nurse monitors unlicensed school personnel who are delegated the task of assisting with medications. To this question, school systems reported frequency of supervision ranging from daily (1.12%) to lethan once monthly (24.3%). The vast difference in the amount of supervisionwhich unlicensed personnel receive must be weighed against the intense naturof the procedures being performed, medications being administered, and conditions being monitored in Alabama’s public school systems. The varyamounts of supervision must inevitably have an effect on the quality of health care being delivered. The need for adsystems is underscored by the additional hours which many nurses spent monthly providing healthcare to students which en route on buses, while ontrips, and while participating in extracurricular activities. Also, nurses are spending a considerable amount of time monthly in health promotional actas well as in counseling both students and parents, when applicable, regarding the need for follow-up medical care. Furthermore, many nurses commented on the need to provide basic food and clothing for some students, particularly in the elementary schools. One nurse noted that she maintains a pantry with clothing in it for students who are sent to school inadequately clothed against inclement weather. The increasing incidence of child abuse was also commented upon by nurses. This speaks to the need for social workers to be available for collaboration with public school nurses when such problematic issues a Another finding which has long-term implications is that of the failure omany nurses to complete a single unusual occurrence report since the beginninof the academic year. Although nurses may erroneously equate completion of such a document with failure to provide adequate healthcare to the student, theimplication of such failure to document is a reduced amount of data which will beavailable for risk management purposes. However, the greatest concern is that nurses may not be documenting all aspects of student incidents or injuries, thus negating the opportunity for appropriate follow-up care and long-term monitoring. Review of the findings on medications and procedures also produced implications for future practice of school nurses. The significant increase in thnumber of breathing treatments, medications to treat attention deficit disorder, aswell as oral antibiotics being administered in the public school system should be further investigated. As part of the Individual Health Plan for students who are receiving an increased number of any of these medications than previously prescribed, the nurse should speak with the parents and possibly the prescriphysician to determine the rationale behind the significant increase in medications. The large number of students receiving treatment for paialso receive follow-up. Nurses who recognize that particular students frequentlycomplain of pain should attempt to isolate the area of discomfort and maintain a symptom journal in an effort to determine the existence of a pattern. Again,

16

follow-up should occur in the form of contact with parents and/or the primary physician. A major concern is the 313 nurses who specified that they did not have access to adequate medical information on each of the students that they served. This means that the nurse is not prepared with sufficient information to implement a reasonable assessment and will not be able to document a complete Individualized Health Plan which addresses all of the health concerns of each student. As previously mentioned, this does not allow for adequate monitoring of student acute or chronic conditions nor for appropriate follow-up to incidents or evaluation of interventions. Recommendations Once the findings of the 2006-2007 school nurse survey are compiled and tabulated, recommendations which will affect the future practice of school nurses begin to emerge. Regarding the survey itself, it is recommended that both terms utilized and the timeframe in question be clarified in each succeeding year. Nurses who had answered the survey for a previous academic year were asked to provide data in certain sections for a typical day in their practice. The timeframe used in the 2006-2007 survey, the beginning of the academic year, despite being clearly provided in instructions sent to all participants, required clarification on a frequent basis. The major recommendation resulting from the research involves documentation on the part of school nurses. Many nurses contacted the researcher to report that they did not know the exact number of students in a particular school that they served who had a specific disorder or received a certain medication and would try to provide an estimate. A uniform method of documentation which is followed by each school nurse will decrease the nurses’ level of frustration and could potentially decrease the amount of time spent on paperwork. Public school nurses also should be annually retrained on the Health Insurance Portability and Accountability Act requirements and the process for acquiring necessary medical information on students. Although undoubtedly nurses are initially trained on all such requirements, periodic retraining would be helpful since the Health Insurance Portability and Accountability Act requirements were listed by nurses as a barrier to their provision of care to students. Fisher, Hunt, Kann, Kolbe, Patterson, and Wechsler (2007) discussed eight priority actions that states can implement which will improve the health and academic outcomes of their young people. Their top priority action is the monitoring of critical health-related behaviors among young people and the effectiveness of school policies and programs in promoting health-enhancing behaviors and an increased level of health. Such monitoring cannot occur without implementation of a uniform system of statewide documentation that is used conscientiously by each public school nurse. As alluded to in a previous section, nurses also cited their frustration regarding the knowledge deficit of parents in relation to the health concerns of their children, lack of parental involvement, and failure to comply with

17

18

medical regimens. Fisher et al. (2007) recommended the formation of school health councils that would include parents and community representatives. This would be a natural forum for providing education to families as well as a method of involving professionals such as physicians, law enforcement officers, the media, as well as faculty from local community colleges in the process of being a resource for the school system. Conclusion It is clear from the content of this monograph that the health services provided in the public school system in Alabama are constantly evolving. It is the intent of the Center for Nursing to assess the provision of school health services on an annual basis and to develop a longitudinal view of the data provided each year. Although the services required by public school students are becoming more comprehensive and the acuity levels greater each year, the dedication of school nurses to the children that they serve continues to be evident. Many expressed great satisfaction with their ability as a school nurse to provide children with the nursing time that they had not been able to provide as acute care hospital-based nurses. It is hoped that Alabama’s young people may continue to be served by these dedicated professionals.

Appendix A: School Nurse Allocations for 2005-2006 and 2006-2007

ADM= Average Daily Membership of Students

System ADM* Amount/ Nurse Allocation/ Allocation: State Funded RNs: State Funded RNs: RNs Hired: Avg. Salary Nurse ADM 06-07 06-07 05-06 05-06 05-06 Totals: 742,976.80 $19,880,780 $26,637,596 520.39 140.00 409.84 $33,510.47 Autauga County 9,438.00 $51,188 $252,545 $303,733 5.93 1 10.5 $28,535.43 Baldwin County 25,825.20 $51,188 $691,038 $742,226 14.50 2 13 $46,018.27 Barbour County 1,123.85 $51,188 $30,072 $81,260 1.59 1 1 $47,341.00 Bibb County 3,687.20 $51,188 $98,663 $149,851 2.93 1 1 $34,728.00 Blount County 7,905.60 $51,188 $211,540 $262,728 5.13 1 1 $40,437.00 Bullock County 1,771.65 $51,188 $47,406 $98,594 1.93 1 1 $37,212.00 Butler County 3,514.10 $51,188 $94,031 $145,219 2.84 1 4.9 $34,506.89 Calhoun County 9,029.65 $51,188 $241,618 $292,806 5.72 1 2 $41,562.00 Chambers County 4,328.70 $51,188 $115,829 $167,017 3.26 1 2 $40,528.00 Cherokee County 4,199.40 $51,188 $112,369 $163,557 3.20 1 3 $28,348.00 Chilton County 7,278.45 $51,188 $194,759 $245,947 4.80 1 5.27 $27,730.06 Choctaw County 2,027.75 $51,188 $54,259 $105,447 2.06 1 1 $35,948.00 Clarke County 3,510.25 $51,188 $93,928 $145,116 2.83 1 2 $25,597.56 Clay County 2,103.70 $51,188 $56,291 $107,479 2.10 1 0 Cleburne County 2,573.65 $51,188 $68,866 $120,054 2.35 1 1 $37,092.00 Coffee County 2,077.20 $51,188 $55,582 $106,770 2.09 1 2 $20,739.50 Colbert County 3,115.15 $51,188 $83,356 $134,544 2.63 1 1 $41,895.00 Conecuh County 1,816.65 $51,188 $48,610 $99,798 1.95 1 1 $30,120.00 Coosa County 1,456.95 $51,188 $38,985 $90,173 1.76 1 1 $28,614.00 Covington County 3,206.50 $51,188 $85,800 $136,988 2.68 1 1 $38,428.32 Crenshaw County 2,344.00 $51,188 $62,721 $113,909 2.23 1 3 $30,331.75 Cullman County 9,924.30 $51,188 $265,557 $316,745 6.19 1 3 $35,874.00 Dale County 2,840.60 $51,188 $76,010 $127,198 2.48 1 2 $27,020.94 Dallas County 4,484.35 $51,188 $119,993 $171,181 3.34 1 1 $38,220.42 DeKalb County 8,539.80 $51,188 $228,510 $279,698 5.46 1 1 $51,956.42 Elmore County 10,901.65 $51,188 $291,709 $342,897 6.70 1 7 $33,712.73 Escambia County 4,533.45 $51,188 $121,307 $172,495 3.37 1 4 $28,903.26 Etowah County 9,048.50 $51,188 $242,122 $293,310 5.73 1 10 $26,734.20 Fayette County 2,592.10 $51,188 $69,360 $120,548 2.36 1 1 $35,947.78 Franklin County 3,060.35 $51,188 $81,890 $133,078 2.60 1 2 $25,499.43 Geneva County 2,662.75 $51,188 $71,251 $122,439 2.39 1 1 $37,313.00 Greene County 1,576.35 $51,188 $42,180 $93,368 1.82 1 1 $40,084.00 Hale County 3,229.30 $51,188 $86,411 $137,599 2.69 1 1 $39,910.44 Henry County 2,741.55 $51,188 $73,359 $124,547 2.43 1 3 $30,646.67 Houston County 6,308.50 $51,188 $168,805 $219,993 4.30 1 0 Jackson County 6,046.65 $51,188 $161,798 $212,986 4.16 1 4.5 $28,669.56 Jefferson County 35,973.15 $51,188 $962,580 $1,013,768 19.80 3 10 $36,340.20

19

Lamar County 2,382.75 $51,188 $63,758 $114,946 2.25 1 1 $34,440.00 Lauderdale County 8,862.80 $51,188 $237,153 $288,341 5.63 1 2 $49,676.00 Lawrence County 5,612.35 $51,188 $150,177 $201,365 3.93 1 1 $30,787.00 Lee County 9,712.50 $51,188 $259,890 $311,078 6.08 1 12 $33,786.25 Limestone County 8,395.00 $51,188 $224,636 $275,824 5.39 1 3 $25,643.00 Lowndes County 2,206.55 $51,188 $59,043 $110,231 2.15 1 1 $31,310.00 Macon County 3,516.45 $51,188 $94,094 $145,282 2.84 1 1 $39,131.00 Madison County 18,280.10 $51,188 $489,144 $540,332 10.56 1 17.5 $35,045.26 Marengo County 1,593.35 $51,188 $42,635 $93,823 1.83 1 1 $29,522.27 Marion County 3,717.45 $51,188 $99,473 $150,661 2.94 1 1 $31,310.00 Marshall County 5,467.45 $51,188 $146,300 $197,488 3.86 1 4 $33,102.81 Mobile County 65,686.25 $51,188 $1,757,651 $1,808,839 35.34 5 26 $37,539.88 Monroe County 4,309.25 $51,188 $115,308 $166,496 3.25 1 1 $37,881.00 Montgomery County32,520.40 $51,188 $870,190 $921,378 18.00 1 30 $34,824.91 Morgan County 7,755.90 $51,188 $207,535 $258,723 5.05 1 8 $29,691.88 Perry County 2,016.90 $51,188 $53,969 $105,157 2.05 1 1 $45,933.00 Pickens County 3,180.25 $51,188 $85,098 $136,286 2.66 1 1 $40,280.00 Pike County 2,173.85 $51,188 $58,168 $113,195 2.21 1 1 $35,949.00 Russell County 3,716.15 $51,188 $99,438 $150,626 2.94 1 3 $39,572.00 St Clair County 7,908.35 $51,188 $211,614 $262,802 5.13 1 1 $31,576.20 Shelby County 24,891.70 $51,188 $666,059 $717,247 14.01 2 4 $44,035.62 Sumter County 2,545.70 $51,188 $68,119 $119,307 2.33 1 1 $40,585.00 Talladega County 7,865.30 $51,188 $210,462 $261,650 5.11 1 3 $36,480.53 Tallapoosa County 3,249.85 $51,188 $86,960 $138,148 2.70 1 3 $29,212.67 Tuscaloosa County 16,372.15 $51,188 $438,091 $489,279 9.56 1 6 $32,034.77 Walker County 8,462.60 $51,188 $226,445 $277,633 5.42 1 2 $69,734.14 Washington County 3,600.05 $51,188 $96,331 $147,519 2.88 1 2 $33,100.27 Wilcox County 2,291.60 $51,188 $61,319 $112,507 2.20 1 3 $34,345.67 Winston County 2,782.90 $51,188 $74,466 $125,654 2.45 1 0 Albertville City 3,720.70 $51,188 $99,560 $150,748 2.94 1 2 $38,167.50 Alexander City 3,636.55 $51,188 $97,308 $148,496 2.90 1 2 $43,048.56 Andalusia City 1,688.40 $51,188 $45,179 $96,367 1.88 1 1 $32,000.04 Anniston City 2,537.80 $51,188 $67,907 $119,095 2.33 1 1 $31,310.00 Arab City 2,523.70 $51,188 $67,530 $118,718 2.32 1 1 $27,872.00 Attalla City 1,879.75 $51,188 $50,299 $101,487 1.98 1 3 $21,859.00 Auburn City 5,247.15 $51,188 $140,405 $191,593 3.74 1 3 $26,669.24 Bessemer City 4,223.95 $51,188 $113,026 $164,214 3.21 1 0 Birmingham City 31,064.90 $51,188 $831,243 $882,431 17.24 2 9.98 $42,102.61 Boaz City 2,149.85 $51,188 $57,526 $108,714 2.12 1 2 $38,024.79 Brewton City 1,376.65 $51,188 $36,837 $88,025 1.72 1 1 $30,800.00 Cullman City 2,712.45 $51,188 $72,580 $123,768 2.42 1 2 $29,796.17 Daleville City 1,462.80 $51,188 $39,142 $90,330 1.76 1 1 $31,769.00 Decatur City 8,830.75 $51,188 $236,296 $287,484 5.62 1 0 Demopolis City 2,422.60 $51,188 $64,825 $116,013 2.27 1 1 $32,241.00 Dothan City 8,811.85 $51,188 $235,790 $286,978 5.61 1 8 $26,380.38 Elba City 904.80 $51,188 $24,211 $75,399 1.47 1 1 $35,463.00

20

Enterprise City 5,778.40 $51,188 $154,620 $205,808 4.02 1 5 $31,343.60 Eufaula City 2,840.80 $51,188 $76,015 $127,203 2.49 1 1 $28,225.20 Fairfield City 2,360.25 $51,188 $63,156 $114,344 2.23 1 2 $34,938.00 Florence City 4,027.20 $51,188 $107,761 $158,949 3.11 1 1 $42,699.12 Fort Payne 2,827.90 $51,188 $75,670 $126,858 2.48 1 1 $30,628.00 Gadsden City 5,434.55 $51,188 $145,419 $196,607 3.84 1 5 $31,059.80 Geneva City 1,257.40 $51,188 $33,646 $84,834 1.66 1 1 $41,895.00 Guntersville City 1,865.00 $51,188 $49,904 $101,092 1.97 1 0.11 $36,098.82 Haleyville City 1,688.75 $51,188 $45,188 $96,376 1.88 1 2 $26,128.50 Hartselle City 3,105.70 $51,188 $83,103 $134,291 2.62 1 5 $19,490.60 Homewood City 3,372.65 $51,188 $90,246 $141,434 2.76 1 5 $40,004.00 Hoover City 11,766.10 $51,188 $314,841 $366,029 7.15 1 9 $29,029.22 Huntsville City 22,971.90 $51,188 $614,688 $665,876 13.01 1 24 $27,371.00 Jacksonville City 1,682.50 $51,188 $45,021 $96,209 1.88 1 2 $31,504.00 Jasper City 2,698.50 $51,188 $72,207 $123,395 2.41 1 2 $24,113.00 Lanett City 1,003.55 $51,188 $26,853 $78,041 1.52 1 1 $37,092.00 Leeds City 1,338.40 $51,188 $35,813 $87,001 1.70 Linden City 523.40 $51,188 $14,005 $65,193 1.27 1 1 $31,712.00 Madison City 7,774.25 $51,188 $208,026 $259,214 5.06 1 10 $22,978.60 Midfield City 1,211.60 $51,188 $32,420 $83,608 1.63 1 2 $26,378.50 Mt Brook City 4,335.00 $51,188 $115,997 $167,185 3.27 1 1 $51,836.00 Muscle Shoals City 2,605.35 $51,188 $69,715 $120,903 2.36 1 2.6 $41,228.52 Oneonta City 1,424.00 $51,188 $38,104 $89,292 1.74 1 1 $30,035.00 Opelika City 4,289.05 $51,188 $114,768 $165,956 3.24 1 2.7 $32,382.22 Opp City 1,395.20 $51,188 $37,333 $88,521 1.73 1 1 $32,257.19 Oxforf City 4,014.50 $51,188 $107,421 $158,609 3.10 1 2 $34,999.50 Ozark City 2,627.90 $51,188 $70,318 $121,506 2.37 1 1 $44,757.00 Pell City 4,113.05 $51,188 $110,058 $161,246 3.15 1 1 $36,431.00 Phenix City 5,377.00 $51,188 $143,879 $195,067 3.81 1 3 $31,361.80 Piedmont City 1,049.50 $51,188 $28,083 $79,271 1.55 1 1 $34,440.00 Roanoke City 1,450.20 $51,188 $38,805 $89,993 1.76 1 1 $31,310.00 Russellville City 2,411.95 $51,188 $64,540 $115,728 2.26 1 2 $33,427.50 Scottsboro City 2,712.40 $51,188 $72,579 $123,767 2.42 1 1 $50,588.00 Selma City 4,023.30 $51,188 $107,657 $158,845 3.10 1 1 $34,257.00 Sheffield City 1,250.00 $51,188 $33,448 $84,636 1.65 1 1 $35,247.00 Sylacauga City 2,471.50 $51,188 $66,133 $117,321 2.29 1 1 $31,600.00 Talladega City 2,789.85 $51,188 $74,652 $125,840 2.46 1 1 $28,333.72 Tallassee City 1,868.55 $51,188 $49,999 $101,187 1.98 1 1 $32,850.00 Tarrant City 1,470.00 $51,188 $39,335 $90,523 1.77 1 1 $35,211.00 Thomasville City 1,614.35 $51,188 $43,197 $94,385 1.84 1 1 $28,955.00 Troy City 2,347.30 $51,188 $62,810 $113,998 2.23 1 1 $34,440.00 Tuscaloosa City 10,483.55 $51,188 $280,522 $331,710 6.48 1 6 $40,203.83 Tuscumbia City 1,558.50 $51,188 $41,703 $92,891 1.81 1 1.5 $26,300.64 Vestavia Hills City 5,692.50 $51,188 $152,321 $203,509 3.98 1 1.28 $30,663.99 Winfield City 1,325.55 $51,188 $35,469 $86,657 1.69 1 1 $35,768.00 Trussville City 4,145.95 $51,188 $110,938 $162,126 3.17 1 1 $36,816.00

21

Al. School 358.90 $51,188 $9,604 $60,792 1.19 of Fine

22

Appendix B: Reports Per Individual School Systems

AUTAUGA COUNTY SCHOOL SYSTEM REPORT

No. of Schools in System: 14

NURSES:

Avg. No. of Days/Week Students Have Access to a Nurse

Average of 1 day/week

No. of licensed nurses in School System (full-time)

8

No. of licensed nurses part-time in School System 4 No. of Licensed Nurses Assigned to a Specific Classroom

1

No. of Licensed Nurses Assigned to a Specific Student

1

No. of Health Career Teachers who are Nurses 2 No. of Volunteers who are also Licensed Nurses 0 No. of Substitute Licensed Nurses 11 No. of Unlicensed Personnel who can Receive Delegation from Licensed Nurse

87

TOTAL NUMBER OF STUDENTS WITH ORDERS FOR THE FOLLOWING MEDICATIONS:

Injectable Insulin 19 Injectable pain medication 0 Insulin via insulin pump 9 Eardrops 0 Eyedrops 3 Glucagon 18 SoluCortef 0 Blood Products 0 Epi-Pen or Injectable Epinephrine 46 Rectal Medications 4 Inhaler with Assistance 35 Inhalers per self 275 ADD Medications 37 Antibiotics 13 Psychiatric Medications 4 Injectable psychiatric medications 0 Asthma Medications 51 Seizure Medications 1 Breathing Treatments 16 Topical Medications 1 Vaginal Medications 0

23

AUTAUGA COUNTY SCHOOL SYSTEM REPORT

TOTAL NUMBER OF STUDENTS WITH ORDERS FOR THE FOLLOWING PROCEDURES:

Urinary Catheterization or Assistance 5 Tracheostomy Care 2 Gastric Tube Care, Including Feeding 6 Glucose Monitoring 27 Ventilator Care 0 External Defibrillator 1 Central Line 0 Implanted defibrillator 0 Medication administration via central line 0 Nebulizer 11 Oral suctioning 1 Ostomy care 2 Skin assessment 1 Vagal nerve stimulator care 0 Wound care (chronic) 0 Wound care (acute) 505 First Aid 3936 Do Not Resuscitate 0

TOTAL NUMBER OF STUDENTS WITH THE FOLLOWING DISORDERS:

ADHD 519 Allergies 118 Asthma 636 Autism 22 Autoimmune disease 3 Cancer 6 Cardiac 68 Cellulitis 96 Diabetes 33 Gastrointestinal disorders 100 Genetic 25 Mental Illness 24 Mental retardation 39 Multiple illnesses 395 Obesity 395 Orthopedic disorders 54 Hemophilia 2 Seizure Disorder 80 Sickle Cell 7 Diarrhea 655 Concussion 11 Fracture 23 Headache 2066 Influenza 27 Pain 1674 Vomiting 1079

24

BALDWIN COUNTY SCHOOL SYSTEM REPORT


NURSES:


< 1 day/week


12

No. of licensed nurses part-time in School System

4

No. of Licensed Nurses Assigned to a Specific Classroom

13


8

No. of Health Career Teachers who are Nurses

2

No. of Volunteers who are also Licensed Nurses

1

No. of Substitute Licensed Nurses 6 No. of Unlicensed Personnel who can Receive Delegation from Licensed Nurse

439



25

BALDWIN COUNTY SCHOOL SYSTEM REPORT





26

BARBOUR COUNTY SCHOOL SYSTEM REPORT


NURSES:




1


0


0


0


0


0


7



27

BARBOUR COUNTY SCHOOL SYSTEM REPORT





28

BIBB COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


4


3


0


0


0


18



29

BIBB COUNTY SCHOOL SYSTEM REPORT





30

BLOUNT COUNTY SCHOOL SYSTEM REPORT



< 1 day/week


11


0


2


1


1


2


31



31

BLOUNT COUNTY SCHOOL SYSTEM REPORT





32

BULLOCK COUNTY SCHOOL SYSTEM REPORT





1


1


0


0


0


0


5



33

BULLOCK COUNTY SCHOOL SYSTEM REPORT





34

BUTLER COUNTY SCHOOL SYSTEM REPORT



Average of 4.5 days/week


7


0


0


0


0


0


18



35

BUTLER COUNTY SCHOOL SYSTEM REPORT





36

CALHOUN COUNTY SCHOOL SYSTEM REPORT



< 1 day/week


2


1


1


0


1


0


54



37

CALHOUN COUNTY SCHOOL SYSTEM REPORT





38

CHAMBERS COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average of 5 days/week


3


14


0


0


1


0


19



39

CHAMBERS COUNTY SCHOOL SYSTEM REPORT





40

CHEROKEE COUNTY SCHOOL SYSTEM REPORT


NURSES:


< 1 day/week


4


0


0


0


1


0


20



41

CHEROKEE COUNTY SCHOOL SYSTEM REPORT





42

CHILTON COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


3


2


0


0


1


0


9



43

CHILTON COUNTY SCHOOL SYSTEM REPORT





44

CHOCTAW COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


0


1


1


0


0


11



45

CHOCTAW COUNTY SCHOOL SYSTEM REPORT





46

CLARKE COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


3


1


1


0


1


0


4



47

CLARKE COUNTY SCHOOL SYSTEM REPORT





48

CLAY COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


2


0


0


0


0


1



49

CLAY COUNTY SCHOOL SYSTEM REPORT





50

CLEBURNE COUNTY SCHOOL SYSTEM REPORT

NUMBER OF SCHOOLS IN SYSTEM: 6

NURSES:


< 1 day/week


1


0


2


1


0


1


7



51

CLEBURNE COUNTY SCHOOL SYSTEM REPORT





52

COFFEE COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


2


0


1


1


0


0


7



53

COFFEE COUNTY SCHOOL SYSTEM REPORT





54

COLBERT COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


9


0


1


0


0


56



55

COLBERT COUNTY SCHOOL SYSTEM REPORT





56

CONECUH COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


2


2


0


0


0


0


12



57

CONECUH COUNTY SCHOOL SYSTEM REPORT





58

COOSA COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


0


0


0


1


0


6



59

COOSA COUNTY SCHOOL SYSTEM REPORT





60

COVINGTON COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


2


3


0


0


0


0


8



61

COVINGTON COUNTY SCHOOL SYSTEM REPORT





62

CRENSHAW COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 5


3


0


0


0


1


0


7



63

CRENSHAW COUNTY SCHOOL SYSTEM REPORT





64

CULLMAN COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


9


0


4


4


0


2


8



65

CULLMAN COUNTY SCHOOL SYSTEM REPORT





66

DALE COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


1


0


0


0


0


30



67

DALE COUNTY SCHOOL SYSTEM REPORT





68

DALLAS COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


4


0


2


0


26



69

DALLAS COUNTY SCHOOL SYSTEM REPORT





70

DEKALB COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 2 days/week


6


0


2


0


2


0


179



71

DEKALB COUNTY SCHOOL SYSTEM REPORT





72

ELMORE COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 4.5 days/week


10


0


0


0


0


0


42



73

ELMORE COUNTY SCHOOL SYSTEM REPORT





74

ESCAMBIA COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


4


6


3


1


2


0


26



75

ESCAMBIA COUNTY SCHOOL SYSTEM REPORT





76

ETOWAH COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


11


0


0


0


0


1


126



77

ETOWAH COUNTY SCHOOL SYSTEM REPORT





78

FAYETTE COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


0


0


0


0


36



79

FAYETTE COUNTY SCHOOL SYSTEM REPORT





80

FRANKLIN COUNTY SCHOOL SYSTEM REPORT


NURSES:


.5 day/week


4


2


0


0


2


0


32



81

FRANKLIN COUNTY SCHOOL SYSTEM REPORT





82

GENEVA COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


6


0


0


0


0


56



83

GENEVA COUNTY SCHOOL SYSTEM REPORT





84

GREENE COUNTY SCHOOL SYSTEM REPORT


NURSES:


1 day/week


1


0


0


0


0


0


5



85

GREENE COUNTY SCHOOL SYSTEM REPORT





86

HALE COUNTY SCHOOL SYSTEM REPORT


NURSES:


<5 day/week


1


0


1


0


1


2


32



87

HALE COUNTY SCHOOL SYSTEM REPORT





88

HENRY COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


0


0


2


3


0


37



89

HENRY COUNTY SCHOOL SYSTEM REPORT





90

HOUSTON COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


3


1


0


0


0


0


26



91

HOUSTON COUNTY SCHOOL SYSTEM REPORT





92

JACKSON COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


2


1


0


2


1


33



93

JACKSON COUNTY SCHOOL SYSTEM REPORT





94

JEFFERSON COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


17


9


2


3


4


3


358



95

JEFFERSON COUNTY SCHOOL SYSTEM REPORT





96

LAMAR COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


3


1


0


1


1


14



97

LAMAR COUNTY SCHOOL SYSTEM REPORT





98

LAUDERDALE COUNTY SCHOOL SYSTEM REPORT


NURSES:


< 1 day/week


8


0


2


1


2


1


22



99

LAUDERDALE COUNTY SCHOOL SYSTEM REPORT





100

LAWRENCE COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


4


0


0


0


1


0


71



101

LAWRENCE COUNTY SCHOOL SYSTEM REPORT





102

LEE COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 5 days/week


11


2


0


0


2


1


76



103

LEE COUNTY SCHOOL SYSTEM REPORT





104

LIMESTONE COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


5


1


3


0


2


0


2



105

LIMESTONE COUNTY SCHOOL SYSTEM REPORT





106

LOWNDES COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


1


1


0


1


0


12



107

LOWNDES COUNTY SCHOOL SYSTEM REPORT





108

MACON COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 5 days/week


6


3


0


0


1


0


0



109

MACON COUNTY SCHOOL SYSTEM REPORT





110

MADISON COUNTY SCHOOL SYSTEM REPORT


NURSES:




18


3


0


0


3


8


162



111

MADISON COUNTY SCHOOL SYSTEM REPORT





112

MARENGO COUNTY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


0


0


0


5



113

MARENGO COUNTY SCHOOL SYSTEM REPORT





114

MARION COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


3


6


3


3


0


0


58



115

MARION COUNTY SCHOOL SYSTEM REPORT





116

MARSHALL COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


4


0


1


0


0


0


89



117

MARSHALL COUNTY SCHOOL SYSTEM REPORT





118

MOBILE COUNTY SCHOOL SYSTEM REPORT


NURSES:


< 1 day/week


27


21


4


4


11


1


188



119

MOBILE COUNTY SCHOOL SYSTEM REPORT





120

MONROE COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


1


1


0


1


1


10



121

MONROE COUNTY SCHOOL SYSTEM REPORT





122

MONTGOMERY COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


36


6


1


5


3


1


64



123

MONTGOMERY COUNTY SCHOOL SYSTEM REPORT





124

MORGAN COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


9


2


0


0


2


2


55



125

MORGAN COUNTY SCHOOL SYSTEM REPORT





126

PERRY COUNTY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


0


0


0


4



127

PERRY COUNTY SCHOOL SYSTEM REPORT





128

PICKENS COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


0


0


1


0


14



129

PICKENS COUNTY SCHOOL SYSTEM REPORT





130

PIKE COUNTY SCHOOL SYSTEM REPORT


NURSES:




4


0


0


0


1


0


8



131

PIKE COUNTY SCHOOL SYSTEM REPORT





132

RANDOLPH COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


0


0


0


0


0


12



133

RANDOLPH COUNTY SCHOOL SYSTEM REPORT





134

RUSSELL COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average 3 days/week


2


9


2


1


1


0


25



135

RUSSELL COUNTY SCHOOL SYSTEM REPORT





136

ST. CLAIR COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


4


1


0


0


3


0


35



137

ST. CLAIR COUNTY SCHOOL SYSTEM REPORT





138

SHELBY COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


11


2


5


3


2


4


213



139

SHELBY COUNTY SCHOOL SYSTEM REPORT





140

SUMTER COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


6


1


0


2


0


16



141

SUMTER COUNTY SCHOOL SYSTEM REPORT





142

TALLADEGA COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


4


0


3


2


1


1


38



143

TALLADEGA COUNTY SCHOOL SYSTEM REPORT





144

TALLAPOOSA COUNTY SCHOOL SYSTEM REPORT


NURSES:


Average .5 day/week


3


2


0


0


0


0


40



145

TALLAPOOSA COUNTY SCHOOL SYSTEM REPORT





146

TUSCALOOSA COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


6


0


1


2


4


3


78



147

TUSCALOOSA COUNTY SCHOOL SYSTEM REPORT





148

WALKER COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


5


4


2


0


0


46



149

WALKER COUNTY SCHOOL SYSTEM REPORT





150

WASHINGTON COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


7


3


5


0


0


1


13



151

WASHINGTON COUNTY SCHOOL SYSTEM REPORT





152

WILCOX COUNTY SCHOOL SYSTEM REPORT


NURSES:


Aveage 2 days/week


3


3


0


0


2


0


16



153

WILCOX COUNTY SCHOOL SYSTEM REPORT





154

WINSTON COUNTY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


0


0


0


0


13



155

WINSTON COUNTY SCHOOL SYSTEM REPORT





156

ALBERTVILLE CITY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


0


1


0


16



157

ALBERTVILLE CITY SCHOOL SYSTEM REPORT





158

ALEXANDER CITY SCHOOL SYSTEM REPORT


NURSES:


Average 5 days/week


5


0


1


0


1


0


16



159

ALEXANDER CITY SCHOOL SYSTEM REPORT





160

ANDALUSIA CITY SCHOOL SYSTEM REPORT


NURSES:


Average 2 days/week


1


2


0


0


0


0


22



161

ANDALUSIA CITY SCHOOL SYSTEM REPORT





162

ANNISTON CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


6


0


0


1


0


10



163

ANNISTON CITY SCHOOL SYSTEM REPORT





164

ARAB CITY SCHOOL SYSTEM REPORT


NURSES:




2


1


1


0


2


4


10



165

ARAB CITY SCHOOL SYSTEM REPORT





166

AUBURN CITY SCHOOL SYSTEM REPORT


NURSES:




4


5


0


0


2


0


69



167

AUBURN CITY SCHOOL SYSTEM REPORT





168

ATTALA CITY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


0


1


0


25



169

ATTALA CITY SCHOOL SYSTEM REPORT





170

ATHENS CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


0


0


0


2


16



171

ATHENS CITY SCHOOL SYSTEM REPORT





172

BESSEMER CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


4


1


1


0


0


13



173

BESSEMER CITY SCHOOL SYSTEM REPORT





174

BIRMINGHAM CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


15


2


2


0


1


6


170



175

BIRMINGHAM CITY SCHOOL SYSTEM REPORT





176

BOAZ CITY SCHOOL SYSTEM REPORT


NURSES:




2


4


0


0


0


0


46



177

BOAZ CITY SCHOOL SYSTEM REPORT





178

BREWTON CITY SCHOOL SYSTEM REPORT


NURSES:




1


0


1


0


0


0


8



179

BREWTON CITY SCHOOL SYSTEM REPORT





180

CULLMAN CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


0


1


0


0


0


8



181

CULLMAN CITY SCHOOL SYSTEM REPORT





182

DALEVILLE CITY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


0


0


0


17



183

DALEVILLE CITY SCHOOL SYSTEM REPORT





184

DECATUR CITY SCHOOL SYSTEM REPORT


NURSES:


Average 3 days/week


6


2


0


1


2


0


43



185

DECATUR CITY SCHOOL SYSTEM REPORT





186

DEMOPOLIS CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


2


0


0


0


0


10



187

DEMOPOLIS CITY SCHOOL SYSTEM REPORT





188

DOTHAN CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


5


7


1


2


1


0


85



189

DOTHAN CITY SCHOOL SYSTEM REPORT





190

ELBA CITY SCHOOL SYSTEM REPORT

No. of Schools in System: 2 NURSES:




1


0


0


0


0


0


1



191

ELBA CITY SCHOOL SYSTEM REPORT





192

ENTERPRISE CITY SCHOOL SYSTEM REPORT


NURSES:




4


0


1


0


0


0


21



193

ENTERPRISE CITY SCHOOL SYSTEM REPORT





194

EUFAULA CITY SCHOOL SYSTEM REPORT


NURSES:




2


4


0


0


1


0


33



195

EUFAULA CITY SCHOOL SYSTEM REPORT





196

FAIRFIELD CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


0


0


0


1


1


10



197

FAIRFIELD CITY SCHOOL SYSTEM REPORT


Urinary Catheterization or Assistance 1 Tracheostomy Care 0 Gastric Tube Care, Including Feeding 0 Glucose Monitoring 3 Ventilator Care 0 External Defibrillator 2,302 Central Line 0 Implanted defibrillator 0 Medication administration via central line 0 Nebulizer 1 Oral suctioning 2,302 Ostomy care 0 Skin assessment 1 Vagal nerve stimulator care 0 Wound care (chronic) 2 Wound care (acute) 0 First Aid 47 Do Not Resuscitate 0



198

FLORENCE CITY SCHOOL SYSTEM REPORT


NURSES:


< 1 day/week


1


0


1


0


1


0


31



199

FLORENCE CITY SCHOOL SYSTEM REPORT





200

FORT PAYNE CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


0


0


0


0


0


8



201

FORT PAYNE CITY SCHOOL SYSTEM REPORT





202

GADSDEN CITY SCHOOL SYSTEM REPORT


NURSES:




8


11


1


0


0


4


44



203

GADSDEN CITY SCHOOL SYSTEM REPORT





204

GENEVA CITY SCHOOL SYSTEM REPORT


NURSES:




1


0


0


0


0


0


4



205

GENEVA CITY SCHOOL SYSTEM REPORT





206

GUNTERSVILLE CITY SCHOOL SYSTEM REPORT


NURSES:


Average 3.75


3


0


1


0


0


0


16



207

GUNTERSVILLE CITY SCHOOL SYSTEM REPORT





208

HALEYVILLE CITY SCHOOL SYSTEM REPORT


NURSES:


Average 5


2


0


1


0


0


0


37



209

HALEYVILLE CITY SCHOOL SYSTEM REPORT





210

HARTSELLE CITY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


0


1


4


42



211

HARTSELLE CITY SCHOOL SYSTEM REPORT





212

HOMEWOOD CITY SCHOOL SYSTEM REPORT


NURSES:


Average 5 days/week


5


1


0


0


0


0


15



213

HOMEWOOD CITY SCHOOL SYSTEM REPORT





214

HOOVER CITY SCHOOL SYSTEM REPORT


NURSES:


Average 4 days/week


12


0


2


1


0


8


79



215

HOOVER CITY SCHOOL SYSTEM REPORT





216

HUNTSVILLE CITY SCHOOL SYSTEM REPORT


NURSES:




35


6


3


4


2


12


328



217

HUNTSVILLE CITY SCHOOL SYSTEM REPORT





218

JACKSONVILLE CITY SCHOOL SYSTEM REPORT


NURSES:


Average 5 days/week


2


0


1


2


0


0


0



219

JACKSONVILLE CITY SCHOOL SYSTEM REPORT





220

JASPER CITY SCHOOL SYSTEM REPORT


NURSES:




3


2


0


0


0


0


9



221

JASPER CITY SCHOOL SYSTEM REPORT





222

LANETT CITY SCHOOL SYSTEM REPORT


NURSES:




1


0


0


0


0


0


11



223

LANETT CITY SCHOOL SYSTEM REPORT





224

LEEDS CITY SCHOOL SYSTEM REPORT


NURSES:


Average 3 days/week


2


0


0


0


0


0


3



225

LEEDS CITY SCHOOL SYSTEM REPORT





226

LINDEN CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


2


1


0


1


0


2



227

LINDEN CITY SCHOOL SYSTEM REPORT





228

MADISON CITY SCHOOL SYSTEM REPORT


NURSES:


Average 5 days/week


9


0


0


0


1


0


77



229

MADISON CITY SCHOOL SYSTEM REPORT





230

MIDFIELD CITY SCHOOL SYSTEM REPORT

No. of Schools in System: 4 NURSES:


Average 1 day/week


1


4


0


0


0


4


8



231

MIDFIELD CITY SCHOOL SYSTEM REPORT





232

MOUNTAIN BROOK CITY SCHOOL SYSTEM REPORT


NURSES:




5


4


0


0


0


1


16



233

MOUNTAIN BROOK CITY SCHOOL SYSTEM REPORT





234

MUSCLE SHOALS CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


2


0


0


0


1


0


28



235

MUSCLE SHOALS CITY SCHOOL SYSTEM REPORT





236

ONEONTA CITY SCHOOL SYSTEM REPORT


NURSES:




1


0


0


0


0


0


0



237

ONEONTA CITY SCHOOL SYSTEM REPORT





238

OPELIKA CITY SCHOOL SYSTEM REPORT


NURSES:




3


0


0


0


1


0


38



239

OPELIKA CITY SCHOOL SYSTEM REPORT





240

OPP CITY SCHOOL SYSTEM REPORT


NURSES:




1


1


0


0


0


0


6



241

OPP CITY SCHOOL SYSTEM REPORT





242

OXFORD CITY SCHOOL SYSTEM REPORT


NURSES:


Average 5 days/week


6


0


0


0


0


1


11



243

OXFORD CITY SCHOOL SYSTEM REPORT





244

OZARK CITY SCHOOL SYSTEM REPORT


NURSES:


< 1 day/week


1


4


0


0


1


0


21



245

OZARK CITY SCHOOL SYSTEM REPORT





246

PELL CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


4


0


0


0


0


32



247

PELL CITY SCHOOL SYSTEM REPORT





248

PHENIX CITY SCHOOL SYSTEM REPORT


NURSES:




6


4


0


0


1


0


20



249

PHENIX CITY SCHOOL SYSTEM REPORT





250

PIEDMONT CITY SCHOOL SYSTEM REPORT


NURSES:




1


0


0


0


0


0


5



251

PIEDMONT CITY SCHOOL SYSTEM REPORT





252

ROANOKE CITY SCHOOL SYSTEM REPORT


NURSES:




2


2


0


0


0


3


15



253

ROANOKE CITY SCHOOL SYSTEM REPORT





254

RUSSELLVILLE CITY SCHOOL SYSTEM REPORT


NURSES:




3


0


0


0


1


0


17



255

RUSSELLVILLE CITY SCHOOL SYSTEM REPORT





256

SCOTTSBORO CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


2


1


2


0


15



257

SCOTTSBORO CITY SCHOOL SYSTEM REPORT





258

SELMA CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


0


0


1


0


31



259

SELMA CITY SCHOOL SYSTEM REPORT





260

SHEFFIELD CITY SCHOOL SYSTEM REPORT


NURSES:




3


0


2


0


0


0


20



261

SHEFFIELD CITY SCHOOL SYSTEM REPORT





262

SYLACAUGA CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


1


0


0


0


0


0


13



263

SYLACAUGA CITY SCHOOL SYSTEM REPORT





264

TALLADEGA CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


0


0


0


1


0


14



265

TALLADEGA CITY SCHOOL SYSTEM REPORT





266

TALLASSEE CITY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


1


0


0


15



267

TALLASSEE CITY SCHOOL SYSTEM REPORT





268

TARRANT CITY SCHOOL SYSTEM REPORT


NURSES:




1


0


0


0


0


0


7



269

TARRANT CITY SCHOOL SYSTEM REPORT





270

THOMASVILLE CITY SCHOOL SYSTEM REPORT


NURSES:




1


0


0


0


0


0


13



271

THOMASVILLE CITY SCHOOL SYSTEM REPORT





272

TROY CITY SCHOOL SYSTEM REPORT


NURSES:




3


5


0


0


0


0


23



273

TROY CITY SCHOOL SYSTEM REPORT





274

TRUSSVILLE CITY SCHOOL SYSTEM REPORT


NURSES:




3


0


0


0


0


0


5



275

TRUSSVILLE CITY SCHOOL SYSTEM REPORT





276

TUSCALOOSA CITY SCHOOL SYSTEM REPORT


NURSES:


Average 1 day/week


5


2


1


0


1


0


115



277

TUSCALOOSA CITY SCHOOL SYSTEM REPORT





278

TUSCUMBIA CITY SCHOOL SYSTEM REPORT


NURSES:


<1 day/week


1


2


0


0


0


0


11



279

TUSCUMBIA CITY SCHOOL SYSTEM REPORT





280

VESTAVIA HILLS CITY SCHOOL SYSTEM REPORT


NURSES:




6


0


1


0


0


0


76



281

VESTAVIA HILLS CITY SCHOOL SYSTEM REPORT





282

WINFIELD CITY SCHOOL SYSTEM REPORT


NURSES:




2


0


0


0


0


0


4



283

WINFIELD CITY SCHOOL SYSTEM REPORT





284

ALABAMA SCHOOL OF FINE ARTS SCHOOL SYSTEM REPORT


NURSES:


Average 5


1


0


0


0


0


0


0



285

ALABAMA SCHOOL OF FINE ARTS SCHOOL SYSTEM REPORT





286

Appendix C School Nurse Survey

Academic Year 2006-2007

Registered nurses or licensed practical nurses who provide nursing care in the school setting through the twelfth grade may delegate specific tasks to unlicensed assistive personnel. The school nurse shall provide periodic and regular evaluation and monitoring of the individual performing the delegated tasks. The School Nurse Consultant or School Nurse Administrator shall submit a report(s) to the Alabama Board of Nursing in a format specified by the Board upon request (Alabama Board of Nursing Administrative Code, Chapter 610-X-6, Standards of Nursing Practice, Section 610-X-6-.06, Delegation by School Nurses). The survey should be completed between November 1 and November 20, 2006. Section 1-Identifying Information 1. Name of registered nurse completing survey as listed on ABN license card ________________________ 2. License number 1-_________________________ 3. County of school (drop-down menu) 4. Name of school system (drop-down menu) 5. Name of school (use drop-down menu to check the school to which you are assigned) 6. Which grade or grades of students are served in this school? (use the drop-down menu to select all that apply) 7. What is the total enrollment of students in this school?

o 1. 101-200 o 2. 201-300 o 3. 301-400 o 4. more than 400 o

8. What is the total number of students enrolled in this school? o 1. preschool _____ o 2. kindergarten _____ o 3. elementary _____ o 4. intermediate or middle _____ o 5. senior high _____

9. If you are an RN supervisor, please check all of the schools which you supervise: (use the drop-down menu to select all schools that apply). Otherwise, please proceed to the next question.

287

10. Does this school system have a Lead Nurse or Nurse Administrator who oversees the School Health Program?

o Yes o No

Section 2-Personnel-Related Questions 1. How many days per week do students in this school have access to at least one licensed

nurse? o 1. Every day/all day/5 days o 2. 4 o 3. 3 o 4. 2 o 5. 1 o 6. Less than 1 day

2. How often does a supervising RN conduct on-site supervision of LPNs?

o 1. daily o 2. three times per week o 3. twice weekly o 4. once weekly o 5. once biweekly o 6. once monthly o 7. less than once monthly o 8. Not applicable

3. How often does a licensed nurse monitor unlicensed school personnel who assist with medications?

o 1. daily o 2. three times per week o 3. twice weekly o 4. once weekly o 5. once biweekly o 6. once monthly o 7. less than once monthly o 8. Not applicable

4. How many licensed nurses are employed full-time (36-40 hours/week) in this school? _____ 5. How many licensed nurses are employed part-time (< 36 hours/week) in this school? _____ 6. How many licensed nurses currently function as a substitute school nurse in this school? (drop-down menu) 7. How many health career teachers in this school are also licensed nurses?

o 1. 1 o 2. 2 o 3. none

288

8. How many volunteers who are licensed nurses assist in this school? o 1. 1 o 2. 2 o 3. 3 o 4. more than 3 o 5. none

9. How many licensed nurses in this school are assigned full-time to one classroom?

o 1. 1 o 2. 2 o 3. 3 o 4. none

10. How many licensed nurses in this school are assigned full-time to one student?

o 1. 1 o 2. 2 o 3. 3 o 4. more than 3 o 5. none

11. How many unlicensed school personnel are employed by this school that are delegated the task of assisting students with medications? _____ 12. How many hours in the past three months have nurses spent on field trips with students who require health services?

o 1. none o 2. 1-5 o 3. 6-10 o 4. 11-15 o 5. 16-20 o 6. more than 20 hours per month

13. How many hours in the past three months have nurses spent riding the school bus with students who require health services?


14. How many hours in the past three months have students required individualized health- related teaching?


15. How many hours in the past three months have students and/or parents been counseled regarding follow-up health care appointments, health insurance, or the need to obtain other types of medical care?

o 1. none o 2. 1-5 o 3. 6-10

289

o 4. 11-15 o 5. 16-20 o 6. more than 20 hours per month

16. How many hours in the past three months have nurses attended or participated in extracurricular activities (football games, band trips, cheerleading) with students who require health services?


17. What types of health promotion activities have nurses participated in within the past three months? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section 3-Medication Questions 1. Is there a method in place at this school to maintain the privacy of a student who receives assistance with his/her medication?

o 1. Yes o 2. No

2. Is there a method in place at this school to maintain security for medications,

such as a double-locked area in which to secure medications? o 1. Yes o 2. No

3. Is there an area at this school where medications which must be refrigerated

can be kept separate from food? o 1. Yes o 2. No

4. How many times in the past three months have students experienced side effects of

medication? o 1. 1 o 2. 2 o 3. 3 o 4. more than 3 o 5. none

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5. How many unusual occurrence reports specific to medications have you received or completed in the past three months?

o 1-10 o 2. 11-20 o 3. 21-30 o 4. 31-40 o 5. 41-50 o 6. more than 50 o none

6. The type (s) of medication error that occurred at this school in the past three months

consisted of: (select all that apply) o 1. Out of medication o 2. Overdose o 3. Wrong medication o 4. Wrong time o 5. Wrong student o 6. Failure to document o 7. Other

7. Have incidents been reported in which unauthorized persons have been delegated to provide assistance with medications?

o 1. Yes o 2. No

Section 4-Medication and Procedure Questions 1. Provide the number of students at this school who require the following procedures:

o Access to automatic external defibrillator _____ o Central line care, including care of Hickman or Groshong catheters or PICC lines

_____ o Gastric tube feedings, insertion, or replacement ______ o Glucose monitoring (finger sticks) ______ o Implanted defibrillator_____ o Insulin pump care _____ o Medication administration via central line _____ o Nebulizer care _____ o Oral suctioning, including bulb syringe_____ o Ostomy care_____ o Skin assessment for prevention of pressure ulcers _____ o Tracheotomy care, including suctioning ______ o Urinary catheterization, clean or sterile (self or assisted) ______ o Vagal nerve stimulator care_____ o Ventilator care _______ o Wound care for pressure ulcers_____ o Other (please specify the procedure and the number of students who require it)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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2. Provide the estimated number of students at this school who have the following chronic conditions and who required school nurse interventions:

o Allergies (severe) _____ o ADD/ADHD ______ o Asthma ______ o Autism _____ o Autoimmune diseases _____ o Cancer _____ o Cardiac conditions _____ o Diabetes (Type I or II) ______ o Gastrointestinal diseases (e.g. irritable bowel syndrome) _____ o Genetic disorders (e.g. Down Syndrome, Fragile X Syndrome) _____ o Hemophilia ______ o Mental disorders (e.g. bipolar disorder) _____ o Mental retardation _____ o More than one identified chronic illness_____ o Obesity _____ o Orthopedic disorders (e.g. hip contractures) _____ o Seizure disorder ______ o Sickle cell anemia _____ o Other (please specify the condition and the number of students who have it)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Provide the estimated number of students at this school who have the following acute conditions and who required school nurse interventions:

o Acute wound care (wound is < 3 days old)_____ o Cellulitis or other acute infections_____ o Concussion_____ o Diarrhea_____ o First aid_____ o Fracture_____ o Headache_____ o Influenza_____ o Pain_____ Location_________ o Vomiting_____ o Other (please specify the condition and the number of students who have it)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Provide the estimated number of students at this school who have physician’s orders for the following:

o Automatic External Defibrillator_____ o Blood products _____ o Breathing treatments _____ o Do Not Resuscitate_____ o Ear drops_____ o Epi-Pens or other injectable epinephrine _____ o Eye drops_____ o Glucagon_____

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o Injectable pain medication _____ (please specify the medication and the number of students who require it) ________________________________________________________________

o Injectable psychiatric medication _____ (please specify the medication and the number of students who require it) ________________________________________________________________

o Insulin ______ o “On-person” inhalers which student can self-administer _____ o Oral antibiotics _____ o Oral medications for the treatment of ADD/ADHD _____ o Oral medications for the treatment of psychiatric/mental illness _____ o Oral medication for the treatment of seizures _____ o Rectal (e.g. Diastat) _____ o Solu-Cortef ______ o Topical medications_____ o Vaginal _____ o Other (please specify the medication or procedure and the number of students

who require it) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Do you have access to all medical information needed on each student who receives health services?

o 1. Yes o 2. No

If not, what barriers exist that prevent you from receiving this information? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. Identify any barriers or challenges to the provision of health services for students in your school(s)._________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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REFERENCES

Alabama Education Association. (2007). K-12 Foundation Program. Retrieved January 22, 2007 from http://www.myaea.org/FoundationK12.htm.

Bigger, M. (2003). The Uses and Limitations of Survey Methods Within Primary Care Practice. Journal of Community Nursing. Retrieved January 17, 2007 from www.jcn.com. Fisher, C.,Hunt, P.,Kann, L., Kolbe, L., Patterson, B., and Wechsler, H. (2007). Building a Healthier Future Through School Health Programs. Retrieved January 23, 2007 from www.cdc.gov. Horovitz, B., and McCoy, K. (2005). Nurse Shortage Puts School Kids at Risk. USA Today. Retrieved January 17, 2007 from http://usatoday.com/news/nation/2005-12-13-school-nurses_x.htm. Merriam-Webster Incorporated. (2003). Merriam-Webster Medical Dictionary. Retrieved January 23, 2007 from http://www.nlm.nih.gov/medlineplus.html. McCarthy, A. (2000). Medication Administration Practices. Journal of School Health, 70 (9), 371-376. . State of Alabama. (1975). Code of Alabama. Taras, H, Frankowski, B., McGrath, J., Mears, C., Murray, R., and Young, T. (2001). The Role of the School Nurse in Providing School Health Services. Pediatrics, 108 (5), 1231-1232. Wolfe, L. and Selekman, J. (2002). School Nurses: What It Was and What It Is. Pediatric Nursing, 28, 403-407.

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http://www.cdc.gov/

http://www.nlm.nih.gov/medlineplus.html

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