Millie Makes Her Mark

Call her a late bloomer. Millie had already made quite a name for herself around here after starring in several scenarios in the Center for Technology-Enhanced Nursing, Cooper Hall’s state-of-the-art simulation suite. But now, at the age of 90, she is set to break onto the national scene thanks to a four-part gerontological simulation package developed by Clinical Assistant Professor Kari Hirvela MS ’07, RN, and Clinical Instructor Paula Woywod, MSN, RN.

The simulation series follows Millie through various stages of health and transitions from home care to a hospital stay and eventually into a skilled nursing facility. Millie is a fictional patient with a thorough health and personal history, and she is represented in simulations by a high fidelity manikin.

Although Millie is not a “real” patient, she enables students to follow her health over time and get to know her as an individual and not simply a case study for a specific exercise or an example of a certain illness or condition. As a result, Millie presents a unique learning opportunity that students seldom, if ever, encounter in their clinical rotations.

“Millie’s our star,” Hirvela says. “She has the backstory of having a dog and losing her husband and enjoying gardening. Students talk quite a bit about her social history in their interviews with her. That’s really important, so students don’t focus too narrowly on what her problem is right now.”

Hirvela and Woywod developed the series with support from the Helen Daniels Bader Fund, and they worked with the school’s Center for Aging Research and Education to make the series freely available to other schools and colleges of nursing. Woywod is pleased that students in nursing school across the country may soon meet Millie and learn about the intricacies and the joys of gerontological practice.

“Developing students’ critical thinking skills is essential to ensuring that our graduates are prepared to address the complexities of older adult needs, including transitions in care, out in the real world, ” Woywod says. “Millie makes that learning more personal, more authentic and, we expect, more successful.”

A Heart and Mind for Home Health

photo of Troy Lawrence

While many of his classmates gravitated toward the adrenaline rush of the emergency room or the intensity of surgery, Troy Lawrence ’10, found himself pulled in a different direction. Lawrence, a current DNP student, found his calling in home health.

Home health is unique. It is a practice that enables visiting nurses like Lawrence to care for patients, mostly older adults, where they live. That, he says, gives him an unfiltered view into his patients’ lives and any challenges they may face in caring for themselves or family members.

“When you sit down with someone at the kitchen table, the reasons why they might be noncompliant or non-adherent become really obvious, and sometimes they are really legitimate reasons,” he says.

The in-home perspective enables Lawrence, and other home-health nurses, to better tailor communication and education to individual patient circumstances.

Lawrence believes home health is a better alternative to clinic-based care for many older-adult patients. Plus, it captures the essence of nursing—of meeting patients where they are—in both the literal and figurative sense.

“There’s something really poetic about sick people not needing to leave their homes to get the healthcare they need,” he says. “They face mobility, pain and cognitive challenges, and yet we typically make them make all the effort to come to us.”

Lawrence discovered home health during a clinical rotation as an undergraduate student. Initially skeptical about the assignment, the intimacy of the practice quickly changed his mind. He has never worked as an RN in any other capacity.

“Before undergrad, I didn’t know home health was a thing,” he says. “As luck would have it … I fell in love with the model.”

Troy Lawrence, RN, works for UW Home Health. He is also pursuing his DNP at the University of Wisconsin–Madison School of Nursing. He currently serves on the steering committee for the Center for Aging Research and Education (CARE).

 

Read the full story, “Leading the Way,” in ForwardNursing, Fall/Winter 2016.

Teaching Teamwork

"Teaching Teamwork" headline from ForwardNursing magazine Fall/Winter 2016
by Jennifer Garrett, photography by Alexander André

Millie is lying in bed, and four University of Wisconsin students—two nursing, two occupational therapy—are tending to her. One nursing student asks about her diet.

Do you eat any fruits or vegetables?
Yes, Millie responds. She does. She usually buys canned produce because it lasts longer. She especially loves fruit cocktail.

The nursing student is satisfied with the answer and makes a note to talk about sugar intake. Then an OT student chimes in.

How do you open the can?
“I start with a can opener,” Millie answers, “but sometimes I have trouble getting it all the way around because of my arthritis.”

So what do you do then?
“I jab at it with a knife,” she says.

It was an important moment.

“That single exchange nailed the objective of this exercise and underscored the value of interprofessional education,” says School of Nursing Clinical Professor Paula Jarzemsky, MS, RN.

The exercise was a simulation in the School of Nursing’s Center for Technology-Enhanced Nursing, or CTEN, which is outfitted with an apartment designed to help students practice home health visits. Millie is the manikin voiced by different instructors behind a two-way mirror who prompt students with comments designed to drive home learning objectives. In this case, the goal was to help nursing students recognize the unique and valuable input that OT students bring to home health visits and vice versa.

And it worked.

“In the debrief, the OT student said she would never have asked about Millie’s diet, and the nursing student said she would never have asked how Millie opened the can of fruit cocktail,” Jarzemsky says. “Both pieces of information were crucial because they exposed a real safety risk, and neither student would have discovered it without the other.”

Nursing faculty members Paula Woywod, Kari Hirvela and Barbara J. King, along with Debbie Bebeau, a clinical assistant professor in the UW–Madison Occupational Therapy Program, developed the simulation last summer with a Bader Foundation grant. Interprofessional educational experiences like this one are growing more common as scientific evidence points to the benefits of improved communication and collaboration among members of healthcare teams.

Jarzemsky originally grew interested in interprofessional collaborations nearly a decade ago. She heard from colleagues in practice that new nurses often struggled with determining their roles and responsibilities with respect to other providers. They eventually figured out how to work alongside each other but not necessarily together.

That was not a surprise. At that time, future nurses learned primarily with other future nurses. Physical therapy students learned with other physical therapy students. While some students from different disciplines interacted in programs and projects outside the classroom, most of their formal learning occurred in discrete silos.

Jarzemsky reached out to Bebeau to explore the possibility of teaching students together in an exercise designed to clarify roles and, as in the apartment simulation with Millie, show how collaboration could lead to better outcomes for patients. Bebeau thought it was a great idea from the start.

“I didn’t have any interprofessional education as a student,” Bebeau says. “My first job was in a level-one trauma center, and we operated minute to minute. That was my first experience working directly with nurses, and it took me a while to learn how we came together, where we overlap, where we didn’t and how we view patients and situations with different lenses.”

Bebeau credits Jarzemsky for spearheading many interprofessional learning opportunities for UW health professions students. “She has been a real igniter and she’s still going,” Bebeau says. “Just today we found two more places where we could intersect.”

Jarzemsky and Bebeau also work together every autumn at a fall-prevention workshop that brings together UW–Madison nursing, OT, physical therapy and pharmacy students to provide free screenings for older adults. Nursing students take blood pressures and conduct vision tests. The OT students conduct home safety assessments. Pharmacy students look for
drug interactions that might lead to dizziness, and PT students assess mobility. Results are tabulated to generate a fall-risk score at the end.

The project also provides a valuable community service with real impact. A follow-up survey conducted a month after the event reveals that 77% of participants had initiated their individualized action plans. Jarzemsky says a 25% implementation
rate is typical. “We need to do more research, but we believe the interprofessional nature of the workshop contributes to that high initiation rate,” she says. “Those improved outcomes really speak to the value of this kind of learning.”

That is a big part of what motivates Jarzemsky to identify and offer other interprofessional learning opportunities. Another of her favorites involves second-year nursing and third-year pharmacy students working together to respond when a patient’s condition deteriorates. The scenario takes place in the CTEN hospital suite and calls for medication reconciliation,
anticoagulation therapy and discharge teaching—all situations that require pharmacists and nurses to work closely together in real life.

“The pharmacy students, who typically have had less exposure to clinical settings, see that it is the nurses who recognize and respond when a patient’s condition changes,” Jarzemsky says. “Nursing students begin to appreciate the value of their experience, and that’s a real boost for them. They see that they’ve come a long way in just a year.”

Jarzemsky says that while coursework explores the roles of other health professionals, some insights into how they practice together come only from interaction. And those insights, she notes, are important not only for the health professionals but also for the patients. Research has shown that when providers break down perceived hierarchies and function well as a team, they deliver better care. That improves patient satisfaction and outcomes.

Indeed, it is widely accepted that highly collaborative interprofessional practice is good for patients. In 2001 the Institute of Medicine called on academic institutions to begin teaching health professionals to work more collaboratively because of evidence pointing to increased healthcare quality and safety. Eight years later, six national health profession education associations, including the American Association of Colleges of Nursing, formed the Interprofessional Education Collaborative (IPEC) and promulgated standards and core competencies for interprofessional education. Funders, too, such as the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services, frequently look for interprofessional collaboration during research and discovery.

The UW–Madison School of Nursing identified the expansion of interprofessional education as one of its strategic initiatives for 2016–2020, and it will be home to the new UW Center for Interprofessional Practice and Education. Led by School of Pharmacy Dean Emerita Jeanette Roberts, CIPE will foster and facilitate interprofessional learning opportunities for students and professionals.

“The stars and moon are aligning,” Jarzemsky says. “I hate to think of it as a stick, because once people start doing these activities, they realize there’s a more of a carrot at the end. It is valuable, and some of these concepts are hard to teach in any other way. And, it really is a lot of fun to work with people from other disciplines.”

School Nurses—The Big-Impact Practice

School nurse at work in middle school

Keeping kids healthy and ready to learn

School nurse at work in middle school
Sennett Middle School nurse Anna Melville with eighth grader

School Nursing

The School of Nursing offers a certification program for bachelor’s-prepared RNs as well as a school nursing course for RNs with aassociate degree.

Learn more

The bell rings, launching a constant flow of teens streaming in and out of the health offices. It’s a group of three small rooms, two of which have windows looking into a courtyard, a chair-lined hallway that doubles as a waiting room, a tiny bathroom and an alcove with a narrow refrigerator. It’s a tight space crammed with chairs and desks, the walls lined with artwork and inspirational quotes, corners filled with loosely rolled posters.

One student walks in from the hallway and announces that she’s there for a Band-Aid. She grabs it and leaves. Other students don’t stop to talk; they head straight to the bathroom, which is stocked with tampons and Clearasil, and return to the halls without a word. Others get medicine from the nurse, brush their teeth in the office sink or heat their lunches in the small microwave on top of a file cabinet. Some are there for a reprieve from the pressure of the school day. They recline in loungers, close their eyes and drift off while opera music plays softly in the background beneath the sounds of the slamming door, chorus of voices, and ringing phones.

For Madison’s West High School students, this is an enclave, a peaceful if not exactly quiet place where they seek out a variety of services and supports. The busy lunch period sees the highest traffic during the school day.

On this Thursday, dozens of kids—some alone, some in pairs or groups turning sideways or hugging the wall to let others pass—move through the health offices just off the main entrance to West High School. There is constant motion but not commotion—despite the volume of students, there is a rhythm to it all. What outsiders might expect to devolve into chaos is actually a predictable, familiar and well-managed level of activity.

In other words, this is a normal day.

Lynne Svetnicka (MS ’82), a lead nurse for Madison Metropolitan School District, worked as the West High school nurse four years ago before assuming her current role as a districtwide school nurse mentor. “When I left West High School, we were seeing well over 80 students a day,” Svetnicka says. “We were nonstop.”

There are an estimated 70,000 nurses working in similar health offices across the United States. It is an independent practice, as most schools are lucky to have a single nurse in the building some of the time. Immediate colleagues are health aides, social workers, psychologists, counselors and, of course, teachers—but generally not other nurses.

The work covers a broad health territory, too. In addition to the lice checks, ice pack distribution and thermometer readings that most people associate with them, school nurses perform an encyclopedic list of services for students and school staff.

They administer first aid. They perform vision and hearing screenings. They develop health plans. They pick up medication for students. They teach health classes (the human growth and development lesson frequently brings school nurses into fourth- and fifth-grade classrooms in Wisconsin). They perform mental health and addiction screenings. They train teachers and other school staff on medication administration. They monitor hallways. They report potential outbreaks of infections like norovirus or influenza.
“The jobs are a lot bigger than they were 20 years ago,” says Sara Parrell, another lead nurse for MMSD. “I had one epi-pen in my office in the 90s. When I left in 2011 I had 28 epi-pens, five students with diabetes, and other children with significant pain and suffering in their lives.”

A Twofold Challenge

School nurses confer at work in middle school
Sennett Middle School nurse Anna Melville (right) and Sara Parrell, a lead nurse for Madison Metropolitan School District

Parrell’s heath office wasn’t an outlier. School nurses across the country have been seeing increasing numbers of students for serious and potentially life-threatening chronic health conditions. The U.S. Centers for Disease Control and Prevention reports that the number of individuals (children and adults) with asthma increased by 28% between 2001 and 2011. The CDC reports that in another ten-year period from 1997 and 2007, the prevalence of food allergies increased 18% among children under 18 years. And diabetes, too, is a growing problem. A study reported in the Journal of the American Medical Association found that in just eight years between 2001 and 2009, the prevalence of Type 1 diabetes in children increased by 21% and Type 2 by 30%.

Overall, more than 25% of school-aged children now have some kind of chronic health condition—up from 1.8% in the 1960s, according to the National Association of School Nurses (NASN).

Complicating things is the fact that many school nurses are managing larger numbers of students overall. The NASN formerly recommended a 1:750 nurse-to-student ratio, but that ratio was set in the 1970s before the proliferation of chronic health conditions among student populations. And many schools did not come close to hitting that target anyway.

Now NASN is revisiting its recommendations to develop a formula that accounts for factors that impact actual workload, such as prevalence of chronic health conditions, special education status and poverty levels. Parrell says MMSD already uses its own formula to determine nurse staffing in its schools.

“It’s a privilege to work with kids and their families and to be in the kind of role to be able to help.”
—Anna Melville

School nurse in the hallway of schoolFor Anna Melville, who is finishing up her first year as a school nurse at Sennett Middle School on Madison’s East Side (where she works a 70% schedule), that formula results in 648 students under her care. Of those, 346—more than half—have one or more health conditions noted in their files.

With just a year of experience, Melville can’t make historical comparisons about shifting workloads. She does agree that her days are often filled with complex health issues, few of which are resolved over the course of a school year and almost never with an ice pack or bandage. For example, she has conducted full neurological assessments after head injuries, and she regularly works with students whose families face the consequences of living in poverty, which contributes to and exacerbates health conditions like asthma and diabetes.

She recalls talking to students who were distraught about the dialog that emerged during and after the A Day Without Latinos rally in February. “You’d be surprised at what kids are willing to tell you if you’re willing to sit down and listen,” she says. “Kids are worried about their parents getting deported, and it does happen.”

Growing Mental Health Responsibilities

Worry and stress are common among students regardless of their backgrounds. Middle school can be a battlefield for preteens and teens who are trying to both fit in and stand out. Now, social media broadcasts and amplifies the angst, insecurity and awkwardness inherent in coming of age. It’s a frenzied loop that plays 24/7. Many students feel pushed to excel in everything—academics, sports, extracurriculars—and manage unrelenting schedules of activities, lessons and studying. Still others face difficult challenges at home or struggle with full-blown anxiety or mental illness.

In fact, there are almost 5 million children in the United States with a serious mental health condition, and every year nearly 20% of children are diagnosed with a mental illness, such as anxiety, ADHD, depression or eating disorders. By middle school, substance abuse and addiction are not uncommon. School nurses like Melville encounter all of it and spend, on average, nearly a third of their time on mental health issues.

In the Face of Challenge, Optimism

Despite the challenges she faces—workload, complex conditions, limited resources—Melville sees more opportunities than limitations, and she is quick to point out that that is why she’s here.

“I really like this age group. They look to adults for guidance and still have that childlike spark, but they are also starting to think critically,” she says. “The environment of being in the school is really positive. The laughter, the band, the singing in the hallways—you just don’t hear that in the hospital.”

Melville knows. She worked in the UW Hospital neuro ICU as a student nursing assistant, and she was offered a residency upon graduation. Melville does not disclose the details, yet she acknowledges that the money would have been significantly better than what she is making now. That’s fairly common for all school nurses, who earn, on average, around $55,000 a year. Their peers in other nursing practices average closer to $70,000, and nurses working in critical care settings tend to make even more.
But for Melville, there was more to the math than the starting salary. Melville grew up with a passion for community service, she developed an interest in public health nursing while in school.

“There is this huge community piece,” Svetnicka says of the school nurse practice. “For nurses who want to work in the community, schools are smack-dab in the middle of that.”

Melville adds that she enjoys her independence and the relationships she forges with students. “It’s a privilege,” she says, “to work with kids and their families and to be in the kind of role to be able to help.”

eSchoolCare | Supporting a Hidden Healthcare System

Unlike their peers in hospitals and clinics, school nurses frequently practice alone. There is no one down the hall to consult, no one with greater insight. Nurses are the healthcare experts in the school.

This gives school nurses a great deal of independence in their practice, which many want and enjoy. Yet Lori Anderson, a clinical professor in the UW–Madison School of Nursing and former school nurse, says there is a flip side to that independence.

“There is an isolation to the practice,” she says. “That feeling stuck with me, of being out in a school, the only healthcare person, and people were counting on me to know a lot of things.”

Complicating things is the fact that the numbers of chronically ill students continues to rise while their conditions grow increasingly complex. Anderson says that for most school nurses, it is difficult to keep their professional development on pace with the rapid expansion of the school nursing practice. Many are left feeling underprepared to handle the health conditions, particularly mental illness, that they face in their student populations.

That is why Anderson developed eSchoolCare, a digital tool that connects school nurses with expertise from the School of Nursing and the American Family Children’s Hospital. With modules on asthma, diabetes, severe allergies, cancer, epilepsy and mental health disorders, eSchoolCare provides school nurses with health plan templates for various conditions, videos on medication administration and links to nurse- and doctor-vetted professional development opportunities.

Anderson notes that children with chronic health conditions miss more school than their healthy peers and are three times more likely to repeat a grade. While eSchoolCare is designed to keep school nurses current in their skills, confident in their practice and connected to each other and valuable resources, the ultimate goal is to maintain and even improve children’s health to keep them learning in the classroom as much as possible.

“Kids are in school more than they are anywhere else except home, and a lot of care is delivered within school walls. That’s why we call school, and school nurses, a hidden healthcare system,” Anderson says. “For parents of children with chronic health conditions, a school nurse can be a wonderful ally. By supporting school nurses and giving them resources they need, we are supporting children and their families.”