These days I open all of my correspondence with “I hope you and yours are well,” which has never meant so much as it does as I open this message to all of you. I have seen media reports of healthcare workers and first responders succumbing to COVID elsewhere but I am not aware that this has happened yet in Delaware. Although they have not drawn much public or media attention, there have, however, been healthcare workers and first responders in Delaware that were sickened by the virus. Our thoughts and prayers go out to them and their loved ones and wish for them a speedy and full recovery.

I want to discuss holidays and recognition.We honor the military with three holidays. I

write this just after the last Monday in May; the national holiday to honor those members of the military members who were killed in defense of our country. However, most people recognize Memorial Day more as the unofficial first day of summer. I might add in that regard that because of COVID we just concluded one of the strangest Memorial Day weekends ever.

Every year on November 11th we honor those who have served with Veterans’ Day. The third and lesser-known holiday often gets overlooked due to its proximity to Memorial Day and its similarity to Veterans’ Day. Armed Forces Day honors those who are still in the military and is observed on the third Saturday of May.

Much wholly-deserved credit has been given recently to the essential members of our retail and commercial supply chains. Arguably, those retail and commercial workers already have a holiday – Labor Day – observed nationally on the first Monday of September. Intended to pay tribute to the contributions and achievements of American workers, especially those who are members of organized labor (unions), that holiday enjoys more fame as the unofficial end of summer.

Volume 45 • Issue 3 August, September, October 2020

Reporter The Official Publication of the Delaware Nurses Association

School Nursing History in Delaware

Page 4

Trauma-Informed Care in School Nursing

Page 7Megan S. Fioravanti, BSN, RN, NCSN

Denise Bradley Buffin, RN, MEd, FNP, NCSN

current resident or

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InsideDNA

REPORTER

Guest Editor

Constituent member of ANA

The mission of the Delaware Nurses Association is to improve healthcare in Delaware by the advancement of nursing.Quarterly publication distributed to approximately 12,000 RNs and LPNs in Delaware.

Beth received her BSN and MSN from the University of Delaware and in 2017, was inducted into the University of Delaware Wall of Fame. She is a Nationally Certified School Nurse and a Fellow in the National Academy of School Nursing. Beth is currently the lead nurse in the Brandywine School District and the school nurse for the 18-21-year-old SITE Community Program. Prior to this role she served as the school nurse at Mt. Pleasant High School for 16 years. She is also the Co-Lead of the Delaware Nurses Action Coalition as part of the Future of Nursing: Campaign for Action. She is a Past President of the National Association of School Nurses. You can reach Beth via email at Elizabeth.mattey@bsd.k12.de.us

Beth Mattey

School Nursing in the 21st Century

Beth Mattey, MSN, RN, NCSN, FNSN

This issue of the DNA Reporter comes to you six months after a devastating virus interrupted our way of life. The extraordinary courage and dedication of nurses and our fellow health care providers on the front line fighting the coronavirus is truly remarkable and they have our utmost gratitude. The Year of the Nurse in 2020 will forever be remembered as the year nurses modeled for the world why we are the most trusted profession. See Figure 1 The Definition

Guest Editor continued on page 2

President’s MessageGary W. Alderson, RN, Esq.

Gary W. Alderson

President’s Message continued on page 3

School Nursing History in Delaware . . . . . . . . . .4

A Different Type of Critical Care:

The Transition from ICU to School Nursing . . .5

Comprehensive Induction Program for School

Nurses – A Mentoring Experience . . . . . . . . . .6

Trauma-Informed Care in School Nursing . . . . .7

School-Based Intervention to Reduce

Admissions for Diabetic Ketoacidosis . . . . . . 8-9

Welcome New & Renewing Members. . . . . . . . . .9

LPN Membership Activation Form . . . . . . . . . . 10

DNA Membership Activation Form . . . . . . . . . . 11

Page 2 • DNA Reporter August, September, October 2020

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Reporter

of School Nursing. School nurses worked early on as the alarm sounded to prepare for potential cases of COVID-19 in our schools and in our community. See Figure 1 The Definition of School Nursing.

We had frequent conversations with our partners at the Division of Public Health and reviewed information from CDC and WHO for guidance. We met with administrators and collaborated with staff members. Could the little boy whose mother was sick two weeks after returning from Italy attend school? What about the staff member who went to church in NYC where there was a large outbreak of coronavirus but was not showing symptoms? We sought supplies for our staff and helped to answer questions from the community. We were alert to student symptoms and planned our response if the first case of COVID-19 in Delaware occurred in one of our schools.

Suddenly, the schools were closed on March 16, 2020. A new set of concerns reared up. What about our students whose meals are provided at school, those students who eat both breakfast and lunch at school and are not always sure there will be enough food at home for dinner? What about our students with chronic health conditions needing ongoing management? That includes the young girl who doesn’t have the asthma medication she needs at home. What about the young man who doesn’t have his own bed or the student who worries about the safety of his mother at home? What about the students who are homeless?

School nurses volunteered to help, ferrying food back and forth from the food pantries so our students would have food. School nurses checked in on students with chronic health conditions who have difficulty managing their illness. School nurses helped distribute chrome books and iPads and followed the big yellow school bus to hand out meals in our communities. This gave school nurses an opportunity to interact with students – a valuable opportunity where seeing familiar faces reassured students and nurses alike. School nurses planned and presented health education for online learning while others participated in statewide meetings via Zoom to examine healthcare access and equity in our communities.

School nurses continued to develop Individual Health Plans and attend online Individual Education Planning meetings for students in special education. School nurses mined data to examine trends and

developed procedures and policies to keep our students healthy and safe. They worked with administrators to plan for staff screening and an eventual return-to-school. School nurses across the state volunteered in the community, helping to screen staff and clientele at State Service Centers.

Throughout the stay-at-home orders, school nurses demonstrated the broad role that defines school nursing. The National Association of School Nursing Framework for 21st Century School Nursing PracticeTM describes the five core principles of school nursing as: Standards of Care, Care Coordination, Public & Community Health, Quality Control and Leadership (NASN, 2016). See Figure 2 The Framework.

While the hands-on care and care coordination school nurses provide daily might fit the commonly held vision of school nursing, the true impact made by school nurses encompasses a much larger canvas. School nursing recognizes and addresses the multitude of factors that influence the health and well-being of all of our students. It is developing connections within the community that provide support to students to address the needs of the whole child. It is the leadership school nurses demonstrate as the only health care provider in the school setting. It is collecting and analyzing data to affect positive change so our students are able to develop to their fullest potential. It is the advocacy school nurses provide for our students both in the education setting and in the policy arena, working at the local and state level making sure the health needs of our students are heard. It is the on-going education school nurses pursue to inform clinical practice so that students are healthy and ready to learn. All of these actions ultimately lead to educating students in an environment of wellness, creating a culture of health in our community.

School nurses are the “boots on the ground” in the community and the Chief Wellness Officer in the school (Cogan, 2020). Like the canary, they may be the first to see the issues that affect our students and families. They then work tirelessly to meet the needs of our students and advocate for the change that is needed.

The authors in this issue of the DNA Reporter will highlight the varied, complex, and extremely rewarding practice that is school nursing. Megan Fioravanti, BSN, RN, NCSN writes about early school nurses who were tireless advocates for student health care in schools. A new school nurse, Jacquelyn Kimball, MSN, RN, CCRN shares her experience transitioning from the ICU to school nursing. Patricia Guilday, MSN, RN, NCSN discusses the mentor program to support nurses new to school nursing. Experienced school nurses, Denise Buffin, RN, MEd, FNP, NCSN, and Heidi Bamonte-Hildick, MSN, RN, CPN, and her co-writer Patrick Hanley, MD describe the diverse skill set demanded of nurses in the school setting.

ReferencesCogan, R. (2020) Future of Nursing 2020-2030 Philadelphia

Town Hall: Lessons Shared From a Relentless School Nurse. NASN School Nurse, 35(1). pp. 74-78. DOI: 10.1177/1942602X19896836

National Association of School Nurses, (2016) Framework for 21st Century School Nursing Practice. NASN School Nurse, 31(1). 45-53. doi:10.1177/1942602X15618644

National Association of School Nurses/American Nurses Association, (2017). School Nursing: Scope and Standards of Practice, 3rd ed. American Nurses Association. Silver Spring MD. Author

School nursing, a specialized practice of nursing, protects

and promotes student health, facilitates optimal

development, and advances academic success. School

nurses, grounded in ethical and evidence-based practice, are the leaders who bridge health care and education, provide care coordination, advocate for quality student-centered

care, and collaborate to design systems that allow individuals and communities to develop

their full potential. Adopted by the NASN Board of Directors,

February, 2017. (National Association of School Nurses/American Nurses Association,

NASN/ANA, 2017)

Figure 1: The Definition of School Nursing

Figure 2: The Framework

(Reprinted with permission by the National Association of School Nurses)

Guest Editor continued from page 1

Advancing Nurses today for tomorrow

• MSN – Family Nurse Practitioner

• MSN – Nursing Education

• Post Masters Certification – Family Nurse Practitioner

• Post Masters Supervisory Certification School Health

• Doctor of Nurse Practice

https://www.millersville.edu/nursing

August, September, October 2020 DNA Reporter • Page 3

It is time we were given equal recognition.It may not be popular to suggest yet another paid

holiday as our country struggles with our economic recovery from the pandemic. Be that as it may, most citizens recognize that the debt owed to our healthcare workers and first responders is every bit as important as that owed to our military, our workers, and our members of organized labor, who already have their respective holidays.

Apparently the events of 9/11/2001, when hundreds of first responders gave their lives; the scores of police who are gunned down every year; and the fire fighters and medics who die every year in service to others is not enough to justify a national day of recognition. But now we have nurses, physicians, and other healthcare workers dying from an unseen enemy as they go about their work to help others.

COVID has certainly driven home the point that it is now time to establish a national holiday to commemorate and honor healthcare workers and first responders. We more than deserve our very own national holiday.

Yes, we already have National Nurses Week which begins each year on May 6th and ends on May 12th, Florence Nightingale's birthday. We observe National Student Nurses Day on May 8th and National School Nurses’ Day on the Wednesday between May 6th and May 12th. We even observe National Doctors’ Day on March 30th! Ostensibly, each year we also celebrate National First Responders’ Day on October 28th but I doubt most people even know that (I didn’t).

So, I say it is time we bond with our first responder brothers and sisters to demand a national day of recognition. It has been suggested before, but seemingly the most obvious choice of days for that holiday would be September 11th. Or perhaps it should be observed on February 28th which appears to be the date of the first COVID death in the United States.

Unlike most wars, or discrete events such as a hurricane or even a terrorist attack, there is

simply no way to establish a date to celebrate closure or “victory” over COVID. Depressingly, it appears as though the virus will be with us for a while because it seems to stay a step or two ahead of the researchers by morphing into different strains to wreak even more morbidity and mortality upon different segments of the population. It also remains a threat because we have not done everything we can to eradicate it or at least control its spread. Picture the crowded scenes from beaches and lakes over the Memorial Day weekend.

Even more hideous is the thought that somewhere right now another “super virus” may be vectoring from the animal world to infect even more of us.

As I wrote in my last column, we remain solidly locked in the throes of what has indeed turned out to be the greatest challenge of our lifetimes: an existential threat to our healthcare system, our way of life, and our economy; and a very real threat of morbidity and mortality to ourselves, our families, our loved ones, our friends, and our neighbors around the world. But for many, patience for self-quarantine and social distancing has run out. And for some, venturing out into the world is a matter of desperation as we watch jobs evaporate and our economy crumble.

And yet, there remains that shining beacon amidst the ocean of anxiety – the local hospital or healthcare facility. In certain locations, such as New York City, the healthcare system was pushed to and beyond its breaking point. So why didn’t it break? Because EMT’s, medics, firefighters, police officers, nurses, physicians, and the myriad of other disciplines in healthcare rose to the challenge. But for the dedication of those healthcare workers and first responders who knows what would have happened in the Big Apple?

So, it is really not much to ask for a single day a year for all of us to honor and celebrate that this great country has such a cadre of dedicated individuals to protect us. Arguably, every day should be dedicated to healthcare workers and first responders. But that is, of course, not possible.

In closing, two things should happen from now on.

First, the public should show its appreciation to healthcare workers and first responders every day by respecting them, listening to them, and heeding their warnings. They are not here to scare you or restrict your liberty – they are here to protect you. Unfortunately, however, that message is not heard universally and we need to redouble our efforts to push back the borders of ignorance and intolerance.

Second, we need that national holiday. That one day when everyone turns his or her attention to our self-sacrificing healthcare workers and first responders. Just as our military and members of organized labor have done at other times, our healthcare workers and first responders are proving yet again why we are the greatest country in the world.

My hope is that all of you continue to stay safe, stay strong, and stay well. God bless you and yours.

President’s Message continued from page 1

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Page 4 • DNA Reporter August, September, October 2020

School Nursing History in Delaware

Megan S. Fioravanti, BSN, RN, NCSN

Megan earned her BSN from Widener University and is a Nationally Certified School Nurse. Additionally, Megan is a graduate of the School Health Leadership Fellowship at Rutgers University. She has worked as an emergency, critical care, and post anesthesia care nurse prior to becoming a school nurse 23 years ago. Megan is currently a school nurse for Red Clay Consolidated School District at North Star Elementary and works part-time at The University of Delaware in Student Health Services. Megan was the Delaware School Nurse of the Year in 2016 and is currently the Delaware Director for the National Association of School Nurses. She has served on the Delaware School Nurse Association Executive Board for the past four years. Megan can be reached by email at megan.fioravanti@redclay.k12.de.us or at her office at (302) 234-7200.

Megan S. Fioravanti

Delaware school nurses have a long legacy of supporting children, their families, and communities. School nurses are the hidden healthcare system for many children and strive through evidence-based practices to keep children healthy, safe, and ready to learn. School nursing has a rich history and school nurses stand on the shoulders of the many great leaders who have blazed a path before them.

The first mention of school nurses in Delaware was in 1919 when there was a notation in public records of two school nurses, Elizabeth MacLaughlin RN and Elizabeth Rogers RN who served in Wilmington Public Schools. Both were public health nurses assigned to the schools. In 1930 another nurse, Mary Miller RN, was added to cover the northern Claymont area, with Ruth Webb RN to follow in 1931. By early 1940, several other nurses were added to the schools throughout Delaware.

In 1946, Title 14 of the Delaware Legislative Code passed, requiring every school district in Delaware to have a full-time school nurse. In 1949-1950 school year regulations were expanded requiring that school nurses be certified in order to practice. Also, in that year, school nursing became a separate

division in the Delaware Nurses Association. Feeling marginalized, school nurses joined the Delaware State Education Association (DSEA) in the late 1950’s and formed a separate school nurse section.

In 1960, a certification overhaul required that all school nurses in Delaware have a bachelor’s degree. By 1964, school districts were having difficulty finding a nurse to employ who had a bachelor’s degree and the regulation was softened. A licensed RN became the standard for employment. In 1974, a new regulation passed requiring school nurses to have a bachelor’s degree and later amended to require that school nurses have a Bachelor Degree in Nursing.

Pearl Ake RN became a school nurse in 1945 and described how she would hold up a watch for hearing screenings and used a Snellen chart for vision screenings. School nurses supplied clothing through the Needlework Guild and fed children at school. She explained, “They were hungry, so we fed them.” (Vincent, 2005, p.4). She also said that school nurses regularly took children home when they were sick because “nobody had cars or phones in those days.” (Vincent)

In 1956 the Delaware School Health Advisory Committee was organized. This committee included the State Board of Health, State Department of Public Instruction (now the Department of Education), Administrators, the State PTA, Delaware Dental Association, University of Delaware, AI DuPont Hospital and school nurse representatives. This group looked at school health issues and worked together to dictate priorities and policies. In 1962, the Delaware School Health Advisory Committee recommended hiring a school nurse supervisor, but the State Board of Education did not fund the position. By the 1963-64 school year, 126 school nurses were working in Delaware Schools. Two years later, The School Nurse: A Guide to Responsibilities and Duties was released. It was the first formal manual that delineated school nurse practice in Delaware.

Finally, in 1968 Edith Vincent, RN, M.A., B.S. was hired as the State Supervisor of Health Education and School Nurses. Edith practiced school nursing in Delaware from 1947 until her retirement in 2005. Her energy and commitment to school health was a driving force for school nursing in Delaware. The School Nurse Advisory Committee (SNAC) was formed in 1968 to focus on issues such as school nurse image and the acceptance of school nurses as professional team members. SNAC did a formal job analysis of the school nurse’s role which led to the development of screening protocols, school nurse certification, and unit count in funding for school nursing positions.

Twenty years later, Jean Allen, Vice President of the State Board of Education drafted, and Senator Dave Sokola introduced legislation, requiring one school nurse in every school. It passed and was entered into the Delaware Legislative Code.

Delaware School Nurse Association (DSNA) minutes and newsletters dating back to January 1975 show that the organization (then called Delaware School Nurses – DSN) was a part of Delaware State Education Association. The dues to join the organization were $5. DSN paid $15 a year to be an organizational member of the National Education Association and paid $2 to Delaware Nurses Association as a donation. The treasurer’s report showed that the organization had $758 in assets and had 34 active members.

Throughout the 70s and 80s, Delaware school nurses were very active legislatively. The Legislative Committee of the Delaware Association of Superintendents and Administrators introduced a bill to change the language in the regulations from “school nurse” to “school health personnel” in an effort to hire non-nurses to cover the health offices. Delaware School Nurses lobbied and testified, and the change did not take place. DSN also weighed in on nurse-student ratios, K-12 Family Life Curriculum – which included reproductive and teen pregnancy regulations, and national certification pay equity. Delaware school nurses continue to shape health policy serving on numerous governor’s task forces and are active volunteers in health promotion agencies and organizations throughout the state.

In 2017, school nurse Sue Smith, M.Ed., RN testified before the senate subcommittee on professional regulations. As a result, school nurses now have the option of using the NCLEX as the test to measure competency in lieu of the Praxis exam required for other educators. Mrs. Smith is currently a board member on the Professional Standards Board at the Department of Education.

Many of the health topics we see today are the same issues reflected throughout the archived minutes:

• Substance Abuse• Stress management • Chronic illnesses• Dental Health• Immunizations • Infectious disease• School Funding

Issues such as Reyes Syndrome, the “new role” of nurse practitioners, and “no-nits” lice policies are no longer debated.

The Delaware School Nurse Association (DSNA) was officially established in 1983 and the yearly dues were $7.50. The following year, DSNA formed a Family Health Committee and had the foresight to set the goal of having school nurse representation in many community organizations throughout Delaware. In 2004, DSNA became a unified affiliate of the National Association of School Nurses (NASN).

Delaware is proud of the school nurse leaders who have made superior contributions to school nursing and the NASN. Two of our school nurses have risen to the position of President of NASN. Dr. Linda Wolfe served from 2001-2003 and most recently, Beth Mattey, MSN, RN, served from 2015-2017. In addition, five Delaware school nurses have been inducted into as a Fellow in the National Academy of School Nursing including: Madalyn Schultz Petit (2005), Linda Wolfe (2007), Elizabeth “Libby” Thomas (2007), Janice Selekman (2012), and Beth Mattey (2018).

The Delaware School Nurse Association eagerly looks to the future and aspires to continue with our mission of empowering school nurses through advocacy, community, and leadership. It is our vision to have exceptional school nurses, supportive communities, and students who are healthy and ready to learn.

ReferenceVincent, E. (2005). Remembering. The Influence of School Nurses on Delaware’s School Health

Services. Greenwood, DE: Author.

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August, September, October 2020 DNA Reporter • Page 5

A Different Type of Critical Care: The Transition from ICU to School Nursing

Jacquelyn N. Kimball, MSN, RN, CCRN

Jacquelyn received her BSN from West Chester University and her MSN in Nursing Leadership with a focus in nursing education from Wilmington University. She has worked in Critical Care in the Medical Intensive Care Unit at Christiana Care Health System for over five years. She is currently a School Nurse for the Brandywine School District at Talley Middle School in Wilmington, Delaware. She is a member of the Delaware School Nurse Association and National Association of School Nurses. Jacquelyn can be reached by email at Jacquelyn.kimball@bsd.k12.de.us or by her office phone 302-475-3980.

Jacquelyn N. Kimball

Many would say that transitioning from critical care nursing to school nursing is a complete 180. However, I can say now that this statement is not completely true. I loved the fast pace of the intensive care unit (ICU) and the adrenaline rush that came with mixing and administering life-saving mediations, assisting with critical procedures, running to codes and other emergencies and caring for patients suffering from cardiac arrest, drug overdoses, renal failure and respiratory failure. I truly felt as though I helped to save lives and provided the best care possible, which was always my philosophy as a nurse. However, after working with such an intense population for five years, I began to feel emotionally and physically depleted. I was seeking a change. I was finishing my MSN in Nursing Leadership with a focus in nursing education when I began talking with a colleague who had recently left bedside nursing to become a school nurse.

I have to admit, at first, I thought it seemed it would be an easy, dare I say boring, job that consisted of stomach aches and skinned knees. I had always wanted to work with children and thought school nursing would be a great opportunity for me to utilize my education degree. I took a leap of faith and applied for a float nurse position in a local school district. If I knew then what I know now I would tell myself that I would be in for the most eye-opening, rewarding and humbling experience of my nursing career.

My days as a school nurse do not consist of crashing patients, procedures, and emergent medications – it is a different type of critical care. I never know what is going to walk through the door and having accurate and detailed critical thinking and assessment skills is imperative as a critical care and school nurse. The family trauma, depression, bullying, and anxiety experienced by our students can manifest as a stomachache or a headache. My job is to build relationships in order to recognize the slight details that may lead me to believe there are deeper issues other than the common ailment reported.

School nursing began in the early 1900s. Lina Rogers, the first school nurse, began her role in 1902. Her initial goal was to reduce absenteeism in relation to communicable diseases in New York City (National Association of School Nurses, 2016). Since then, school nursing has become much more than what Rogers set out to accomplish, but our goal remains the same: keep children healthy, safe, and in school (National Association of School Nurses). With an increase in the medically complex needs of students as well as a rise in mental health needs, school nurses are often faced with difficult caseloads. “…Rates of children with chronic conditions that interfere with their daily life have increased 400% between 1960 and 2010. Today’s children come to school with more complex daily health needs…” (Johnson, 2017, para. 15). Students with severe asthma and allergies, epilepsy, type 1 and type 2 Diabetes Mellitus, feeding tubes, rare genetic disorders, cancer, organ transplants, and many other acute and chronic conditions are coming to school and need to be cared for in a way to foster a healthy environment and contribute to effective learning.

Working in the ICU, I cared for countless patients in diabetic ketoacidosis (DKA) and the knowledge I acquired helps me to proactively support my students with diabetes. Throughout this year, many of my students with diabetes presented to my office with hyperglycemia and positive ketones. Often, these students are able to be managed with hydration and insulin administration and could go back to class. However, sometimes these students teeter on the threshold of DKA and were unable to keep fluids in their system and a trip to the emergency department was needed. This required effective communication with the student and their families. We also review blood glucose and carbohydrate logs with the student and their families to better understand why frequent high’s or low’s may be happening and collaborate with the student’s endocrinology team to help the student have less variability in their blood glucose readings.

As a critical care nurse, one has the support of other floor nurses, the charge nurse, respiratory therapists,

advanced practice providers and physicians on a daily basis. School nurses are the sole medical professional in the school and must practice independently and autonomously. We focus on continuity of care and take a holistic approach when caring for students. We act as case managers and actively follow up with students and their families in regard to illnesses, injuries, immunizations, vision, hearing and postural screenings and chronic conditions. We are also educators and teach our students about current and vital health promotion and illness prevention topics. In addition to caring for our student’s physical health, we also address their mental health and emotional needs. Often, when a student presents to my office, their mental and emotional distress manifests as physical symptoms, which is not always immediately apparent. A school nurse must build trusting relationships with his or her students to investigate the underlying issues. Frequent visits for stomach aches, headaches, and fatigue can be somatization of depression, anxiety, and family trauma. It is imperative that we communicate effectively with the entire interdisciplinary team, such as our guidance counselors, school psychologists, special education teachers and education diagnosticians to minimize barriers to learning.

“School nurses are an important link in the continuum of care for children with chronic conditions, a critical component of illness prevention, and a safety net for those children who are outside the traditional medical system. They bridge the gap between health and education…” (Johnson, 2017, para. 44). School nurses are a safety net. We provide medical care, but also offer compassion, empathy, and understanding in order to support the psychosocial needs of our students. We care for their physical, mental and emotional health in order to help them stay in school, stay healthy and stay safe. In my first year as a school nurse I know I made a positive impact on my students helping them manage their physical and emotional health, as well as their social and family situations. Our days as school nurses are above and beyond stomach aches and skinned knees. We play a pivotal role in the lives of our students and I hope to continue to make a positive impact on my students for many more years to come.

ReferencesJohnson, K. (2017). Healthy and ready to learn: School nurse

improve equity and access. http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-22-2017/No3-Sep-2017/Healthy-and-Ready-to-Learn.html

National Association of School Nurses. (2016). The role of the 21st century school nurse (Position statement). Retrieved from https://www.nasn.org/advocacy/professional-practice-documents/position-statements/ps-role

Page 6 • DNA Reporter August, September, October 2020

School nursing in Delaware is a unique practice. Delaware is one of the few states that mandate a nurse be present in the school, all day, every day. In Delaware public schools, registered nurses with a minimum of a bachelor’s degree in nursing and three years of supervised nursing experience are employed under the teachers’ contract.

In compliance with the Department of Education regulation 1503 Educator Mentoring (Delaware General Assembly, n.d.), Delaware school nursing initiated a mentoring program for new school nurses beginning in 2005. At the time the mentoring program was instituted, only 12 nurses were enrolled with a 1:1 mentee who was an experienced school nurse. Today that program has grown to include public and charter school nurses with approximately 74 school nurse mentees partnered with 38 mentors in 19 public school districts and 21 charter schools – a startling number when you consider that there are only a total of 275 Delaware public school nurses.

School nursing in Delaware is reflective of the new millennial job market. Historically, nurses came to school nursing later in their careers and it became

a terminal career position; rarely did nurses leave until it came time to retire. Today, we see nurses come to school nursing earlier in their careers, but we also see nurses leaving for other positions after only a few years as a school nurse.

One primary goal of any mentoring program is staff retention. As stated on the Department of Education (2019) website:

The purpose of the Comprehensive Induction Program is to provide new educators with the support necessary to become familiar with school and district policies, hone their professional skills, help them evaluate and reflect on their own professional performance and develop an individualized growth plan to improve their effectiveness.

Since very little data exists relating to retention and mentoring in school nursing, school nurses have had to model the educator programming in designing and implementing the program. However, nursing education and teacher education are not designed in the same way. Prospective teachers spend the last year or two of their baccalaureate educations as a “student teacher,” supervised in the classroom. There is no such specialty track for school nursing in most BSN programs. Although nurses are familiar with orientation and preceptorships from other occupational settings, a challenge remains in distinguishing mentoring in a school nursing setting from orientation or preceptorship. The practice of school nursing is an independent practice requiring special skills since the nurse is practicing outside of a medical setting and is integrated into an education community.

At its inception, the comprehensive induction program provided mentoring support to new professional staff in the public-school system (teachers, nurses, psychologists, and counselors) over a three-year period. In 2017, this support was expanded to four years. Years one and two provide the support necessary to develop the skills related to school nursing practice. Years three and four focus on nursing leadership, advocacy, and outreach in the school and the community.

Every newly hired school nurse is provided with a mentor who works within the same district or within the charter system. That mentor-mentee relationship is a 1:1 relationship for the first two years. During those two years, the mentor makes regular visits to the mentee both during and after the school day. The nurse is observed in practice and guided discussions follow each observation experience. The novice school nurse also spends at least one day in the office of an experienced school nurse. During those visits, the novice nurse is guided to observe how the school health office is managed, how the nurse communicates with students, staff and families, how special needs students are served, and how the nurse fulfills the mandatory obligations of immunization compliance, disease surveillance. and health screenings. At the beginning and end of the second year of employment the mentee (novice school nurse) completes a self- assessment based on the Framework for 21st Century School Nursing PracticeTM (National Association of School Nurses [NASN] 2015). The nurse is asked to rate his/her strengths in skills and knowledge based on the Framework’s key principles: leadership, care coordination, community/public health, and quality improvement. Some of the areas for self-reflection are: effective health education, legal issues related to school nursing and risk management, role of the school nurse as first responder in a crisis/disaster, and the nursing process for management of children with special needs. The self-assessment document is then reviewed with the mentor and assists both the mentee and mentor to design activities in the third and fourth year of the program that will bolster strengths that were identified as well as increase proficiency in areas that were identified as weaknesses.

The last two years of the induction program are more self-directed, and the nurses then fall under the responsibility of the lead mentor. Each school district has one experienced nurse who functions as the lead mentor, coordinating mentoring services and disseminating information related to the program. Depending on the needs of the district, there may be additional mentors involved. The recommendation is that each mentor partner with no more than three mentees at a time. Mandatory activities in years three and four include participation in a book club utilizing either the NASN/ANA School Nursing: Scope and Standards of Practice or the Code of Ethics for Nurses. These book clubs and discussions related to issues identified by the novice nurses are held both in face-to-face meetings and online formats. The novice nurse is also asked to complete a personalized five-year growth plan and submit a document to the program reflecting on their participation. As a capstone to the four years, each nurse develops and presents a project that reflects an area of particular interest to them within the scope of school nursing. The project’s focus must relate to advocacy, leadership, or outreach. It can take many forms, such as an online blog, posting specific health content on the school website, a poster presentation at a professional conference, or a presentation to parent groups, faculty, or school boards.

Successful completion of all segments of the Comprehensive Induction Program are a requirement for licensing as a School Nurse by the Delaware Department of Education. This is a dynamic program that is regularly reviewed and updated to reflect the needs of the participants.

References: American Nurses Association and National Association of School Nurses. (2017). School

nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: ANA & NASN.Delaware Department of Education, (2019) Mentoring and Induction Home Page. https://

www.doe.k12.de.us/domain/185Delaware General Assembly, Administrative Code, §14 §1503. Educator Mentoring. https://

regulations.delaware.gov/AdminCode/title14/1500/1503.shtmlComprehensive Induction Program for School Nurses (n.d.). https://www.doe.k12.de.us/

domain /524National Association of School Nurses. (2015). Framework for 21st century

school nursing practice. NASN School Nurse, 30(4), 218-231. https://doi.org/10.1177/1942602X15589559

Comprehensive Induction Program for School Nurses – A Mentoring Experience

Patricia Guilday, RN, MSN, NCSN

Patricia Guilday is currently the developer and trainer for the Comprehensive Induction Program for School Nurses at the Delaware Department of Education. Pat has a background in pediatric nursing and was a school nurse in the Brandywine School District until her retirement in 2016. Pat received her BSN from Neumann College and an MSN from the University of Delaware and is a nationally certified school nurse. Pat served as a past president of the Delaware School Nurse Association and was a recipient of the Carol Costante Research Award from the National Association of School Nurses (NASN). Pat was also a trainer and contributor to the School Emergency Triage Training for NASN. You can reach her at: pat.guilday@doe.k12.de.us

Patricia Guilday

August, September, October 2020 DNA Reporter • Page 7

Trauma-Informed Care in School Nursing

Adverse childhood experiences (ACEs) are traumatic experiences that occur before the age of 18 years that have an impact on long-term health and emotional well-being. ACEs include:

• experiencing violence, abuse, or neglect• witnessing violence in the home or community• having a family member attempt or die by suicide• substance misuse• mental health problems• instability due to parental separation or household members being in jail

or prison (Centers for Disease Control and Prevention [CDC], 2020a).

More than half the U.S. population reports having experienced at least one ACE. One out of six people report having had experienced four or more ACEs (CDC, 2020a). Continued and extended exposure to trauma and toxic stress in childhood causes a prolonged release of stress hormones, including cortisol, which may cause changes in brain development. These changes may affect things such as attention, decision-making abilities, learning, and responses to stress. This toxic stress can also suppress the body’s immune response leaving the person vulnerable to a variety of infections and chronic health problems (Middlebrooks & Audage, 2008). ACEs have been shown to be proportionally related to health outcomes. Persons with a higher number of ACEs have an increased risk of injury, an increase in sexually transmitted infections, and an increase in maternal and child health risks. A wide range of chronic diseases and leading causes of death such as cancer, diabetes, heart disease, and suicide are also associated with a higher ACE score (CDC, 2020b).

Fortunately, there is hope for individuals and communities affected by ACEs. Trauma-informed care (TIC) is a model for organizational change in health and behavior that promotes resilience. This is accomplished by promoting organization safety, trustworthiness, transparency, cultural sensitivity, collaboration, and empowerment in the school community. School nurses are in a position to make improvements on problem outcomes and negative impacts on long-term health. Nurses achieve this by changing their focus from “what’s wrong with you” to “what happened to you” (Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration [SAMHSA-HRSA], n.d.).

Resilience is a skill set that can be learned and built over a period of time and can help a person adapt well in the face of adversity. School nurses assess for and can teach and provide protective factors that build resilience, which may help offset the long-term damage done by growing up in extended periods of trauma. The basic ingredient in building resilience is in helping clients to meet their fundamental needs. Nurses help their students and families build

resilience by recalling Maslow’s Hierarchy of Needs – food, shelter, safety, love, esteem and self-actualization. Do clients, whether they be an individual, family or community: have their basic needs met, have a supportive family or social network, feel safe when they go home, have access to healthcare and social services, have a caring adult in or out of their family who can act as a mentor?

Protective factors can help lower the likelihood of problem outcomes or reduce the negative impact that risk factors may have on problem outcomes. Social support is a major protective factor for children, families, and communities. School nurses are in a unique position to spend time with students and ask questions about their lives to make sure their needs are met. The nurse can be a safe, caring person in a student’s life. They can empower families to identify and fulfill their needs by providing resources and referrals to agencies that will help meet life’s basic demands.

Caring for others experiencing trauma can bring a return of physical and emotional responses from one’s own ACEs. It is important that nurses provide support and understanding toward each other and themselves to prevent secondary trauma, compassion fatigue, and burnout. Feelings of anxiety, irritability, depression or intrusive memories are all potential signs that a nurse needs some self-care.

School nurses practice self-care through meditation, physical exercise, reading, or taking time for a hobby. Nurses may organize and participate in support groups, or seek counseling with a professional, colleague, or friend. Additional options for self-care include awareness exercises and spiritual activities such as writing a daily gratitude list or prayer. Many employers offer resources such as Employee Assistance Programs, meditation rooms, and reimbursement for joining a gym. Self-care should not be seen as selfish. Self-care helps keep nurses compassionate, and emotionally and physically available for their students.

At Mt. Pleasant Elementary in the Brandywine School District, the school nurse, several teachers, and the school counselor shared a vision of building resilience for students, families, and the school community. The team found that change can be a challenge in a large group of overwhelmed and burned-out people, but the team persisted by modeling evidenced-based, resilience-building interventions beginning with mindful meditation and awareness education for the school community.

Each team member designated an area of their space as a “peace-corner” with a centrally located poster that provides instruction and choices for students needing time to regulate their emotions. An ottoman/container full of mindful activities was included in the “peace-corner.” Putty for tactile mindfulness, deep-breathing exercise instructions, postcards for coloring, and a space for the student to express their feelings in writing all helped to calm students. Successes in emotional regulation and self-care were promoted among the building staff and the team noticed others emulating the same resilience-building activities. Administrators began mindful breathing and meditation in the daily morning announcements for all students and staff to practice.

The ideas that started with the small team of like-minded individuals has grown exponentially throughout the school community. The team received the Delaware Governor’s Compassionate Champion Award recognizing trauma-informed care in education. A large grant was awarded and used to provide programming and resources to build community resilience. The latest initiative of this team of champions is to institute restorative practices to improve relationships among students and teachers to reduce disciplinary problems and build community resilience.

ReferencesCenters for Disease Control and Prevention (2020a). Prevention of adverse childhood

experiences https://www.cdc.gov/violenceprevention/childabuseandneglect/aces/fastfact.html

Centers for Disease Control and Prevention (2020b). Violence Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Fabout.html

Middlebrooks, J. S. and Audage, N. C. (2008). The Effects of Childhood Stress on Health Across the Lifespan. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration (SAMHSA-HRSA). (n.d.). Trauma. https://www.integration.samhsa.gov/clinical-practice/trauma-informed

Denise Bradley Buffin, RN, MEd, FNP, NCSN

Denise earned her BSN at Neumann University and FNP degree at Wilmington University. She earned her MEd with a certificate in School Nursing at Widener University and is a board certified in school nurse. Denise has been a School Nurse since 1997, working for the Brandywine School District. She is currently working at Mt. Pleasant Elementary and a member of the team receiving the Delaware Governor’s Compassionate Champion Award recognizing trauma-informed care in education. The best way to reach Denise is by email at denise.buffin@bsd.k12.de.us or call her office at (302) 762-7110. Denise Bradley

Buffin

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Page 8 • DNA Reporter August, September, October 2020

The National Association of School Nurses (NASN) Framework for the 21st Century School Nursing PracticeTM identifies five key principles that provide structure and focus to the complex practice of school nursing (NASN, 2015). One of these principles is Quality Improvement, using data to improve the health and wellness of students. Data analysis serves to guide and improve practice as demonstrated in this project. A second principle of the framework is care coordination. As you read through the details of the project described in this article, several components of care coordination, including chronic disease management, collaborative communication, and direct care, will be evident.

Diabetic ketoacidosis (DKA) is a severe complication that can arise in patients with both type 1 diabetes mellitus (T1DM), as well as type 2 diabetes mellitus (T2DM). DKA is the leading cause of morbidity and mortality in children with T1DM, with a fatality rate ranging from 0.15 percent to 0.31 percent in the United States (Poovazhagi, 2014). Compliance with insulin therapy is an essential component of the prevention of DKA (EL-Mohandes & Huecker, 2019). Recognizing the significance of this information is the basis of this project.

The focus of the study was to concentrate on insulin adherence through a school-based intervention. School nurses have the knowledge and skills to be leaders of diabetes management and prevention in the school setting. The student’s healthcare provider writes the diabetes medical management plan, which the school nurse then coordinates and implements throughout the school day. The school nurse is essential in helping to manage the student with diabetes effectively. Effective diabetes management helps ensure an environment of safety and wellness for the student. Successful management of diabetes allows the student to be ready to learn and to be an active member of the student body (NASN, 2016).

The project hypothesis was that if students received their basal insulin in school, they would have a lesser chance of admission with DKA as a result of missed insulin dosing. The objective was to decrease future preventable DKA admissions for children with known T1DM and T2DM admitted with DKA to Nemours Alfred I DuPont Hospital for Children (AIDHC). The collaborative school-based intervention with school nurses administering basal insulin at school began in May 2019. There were sixteen schools involved in the partnership throughout three states (Delaware, Pennsylvania, and New Jersey). Schools served students in elementary, middle, and high school.

When a student was admitted with DKA, the medical team, after discussing and getting approval from the student’s guardian, changed the basal insulin to degludec (Tresiba) and altered the timing of the basal insulin to lunchtime so the school nurse could administer it. Changing the basal insulin to degludec was based on the fact that basal insulins such as glargine (Lantus) or determir (Levemir) last approximately 18-24 hours. Degludec lasts up to 40 hours and can reduce rates of ketosis in pediatric patients versus other basal insulins in the setting of similar rates of hyperglycemia (Thalange et al., 2019). The medical team called the student’s school nurse to discuss the change, sent an explanatory cover letter, and sent a daily log sheet. At the end of each month, the school nurse was asked to fax the log sheet documenting lunchtime basal insulin administration to the healthcare provider. Communication between the school nurse and the healthcare provider was encouraged to discuss barriers to care.

School-Based Intervention to Reduce Admissions for Diabetic Ketoacidosis

Heidi Bamonte-Hildick, MSN, RN, CPN &Patrick C. Hanley, MD

Heidi earned her BSN from the University of Delaware and her MSN from Wilmington University in nursing education. She is a Certified Pediatric Nurse (CPN). Heidi has been working as a pediatric nurse for more than 20 years and is currently the Lead School Nurse for the Colonial School District. A strong advocate for school-based intervention to promote the health and wellness of students, she is her organization’s super user for Nemourslink, as well as a member of the Readmission Summit for Nemours Alfred I duPont Hospital for Children. Her passion lies in advocating for medically complex students to be successful in the school setting by promoting the importance of school nursing services. Her current projects include co-authoring a case study on epi-pen administration in schools and serving on the board of Live Like Lil Bill Inc, a non-profit promoting advocacy and inclusion. Heidi can be reached by email at heidi.hildick@colonial.k12.de.us or at her office at (302) 429-4055.

Heidi Bamonte-Hildick

Patrick earned his medical degree from the Sidney Kimmel Medical College at Thomas Jefferson University. He holds board certification from the American Board of Pediatrics in both Pediatrics and Pediatric Endocrinology. After medical school, Patrick completed his pediatric residency and chief residency training at Rainbow Babies and Children’s Hospital in Cleveland, OH. He then completed his pediatric endocrinology fellowship training at the Children’s Hospital of Philadelphia. After completing his fellowship at the Children’s Hospital of Philadelphia, Patrick began working at Nemours Alfred I DuPont Hospital for Children in Wilmington, DE. He is a staff pediatric endocrinologist there in the Division of Endocrinology. He has an appointment as an Assistant Professor of Pediatrics at the Sidney Kimmel Medical College of Thomas Jefferson University. Patrick can be reached at Patrick.hanley@nemours.org

Patrick C. Hanley

August, September, October 2020 DNA Reporter • Page 9In 2018, there were 82 DKA admissions for

known diabetic patients at AIDHC. In 2019, there were 65 DKA admissions to AIDHC. Since the project began in May 2019 through January 2020, there were 44 admissions for DKA. Of the 44 admissions for known diabetic patients, 13 patients were changed to degludec from another basal insulin and transitioned to lunchtime school administration. Another three patients who had already been receiving degludec were changed to school-based administration at lunchtime. Figure 1 below shows a run chart of DKA admissions and the overall decrease in the rate of admissions since the project began.

Overall, the initial results are favorable for the intervention using degludec for school-based administration in reducing DKA readmissions. The benefit occurred with no unintended

negative consequences from the intervention. The school nurse and provider collaboration proved beneficial. School nurses noted positive changes and more accountability in some students after the shift to lunchtime basal insulin. School nurses did report there were barriers to care. Specifically, students did not bring their degludec to school, or the student was frequently absent from school for reasons not identified.

After reviewing the results of this project, a short-term goal to improve the efficacy of a school-based intervention was developed. The creation of an assessment tool to identify the causes and barriers for student and/or parent participation, will help address the barriers identified by the school nurses. School nurses can then establish appropriate interventions in collaboration with the student’s healthcare

provider and the student. Moving forward, school nurses can use their interactions with students to empower them to independently manage their diabetes as they move into adulthood to promote long term health and wellness.

The results support the benefit of a school-based intervention in the management of diabetic students to reduce future DKA admissions. It also highlights the critical role of the school nurse in the management of chronic disease in schools. This project provides a framework to support school-based intervention to manage students with chronic medical conditions. Continued expansion of school nurse and provider collaboration for children with chronic medical conditions is vital to promote health and wellness both inside and outside the school environment. Selekman and Ness (2019, p. 498) summarize the importance of school nurse and provider collaboration best stating, “School nurses provide direct care to students with chronic conditions and are integral multidisciplinary team members to optimize health, safety, learning, and well-being at school for these students.”

ReferencesEL-Mohandes N, and Huecker MR. (2019) Pediatric

Diabetic Ketoacidosis. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK470282/

National Association of School Nurses (2015). The Framework for 21st Century School Nursing Practice. ht tps://w w w.nasn.org/nasn/nasn-resou rces/professional-topics/framework

National Association of School Nurses. (2016). Diabetes management in the school setting (Position Statement). Silver Spring, MD: Author. https://www.nasn.org/nasn/advocacy/professiona l-pract ice-documents/position-statements/ps-diabetes

Poovazhagi, V. (2014). Risk factors for mortality in children with diabetic keto acidosis from developing countries. World Journal of Diabetes, 5(6), 932–938. doi:10.4239/wjd.v5.i6.932

Selekman, J., and Ness, M. (2019). Students with chronic conditions. In J. Selekman (Ed.), School nursing: A comprehensive text (3rd ed.) (pp.480-502). Philadelphia, PA: F.A. Davis Company.

Thalange, N., Deeb, L., Klingensmith, G., Franco, D., Bardtrum, L., Tutkunkardas, D., & Danne, T. (2019). The rate of hyperglycemia and ketosis with insulin degludec- based treatment compared with insulin detemir in pediatric patients with type 1 diabetes: An analysis of data from two randomized trials. Pediatric Diabetes, 20, 314–320.

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We offer competitive wages in a Christian environment.

Resume can be emailed to bekatroyer@aol.com or faxed to 302.349.5009

Country Rest Home12046 Sunset Lane, Greenwood, DE 19950

Phone: 302.349.4114

We’re looking for all areas, including behavioral health, med/surg and more!