The Journal of School Nursing2023, Vol. 39(2) 103-104© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231158450journals.sagepub.com/home/jsn
This past year, The Journal of School Nursing issued a call for evidence-based practice and quality improvement manuscripts. Many papers have been submitted in response to the call, predominantly Doctor of Nursing Practice (DNP) projects. Unfortunately, the majority of the submissions have not been accepted for publication. The most common reason for these manuscripts to be rejected is that the authors only provided an educational offering and the only outcomes measured were knowledge and attitude. Some authors reported participants already had a high level of knowledge of best practices prior to the educational intervention, yet still only provided educational intervention to improve documented substandard practices.
Within health care and in industry, we have long known that education alone is not sufficient to change health and behavior outcomes (Beer et al., 2016; ISMP, 2020; Soong & Shojania, 2020; Vogus & Hilligoss, 2016). Whether we aim to change students’ and families’ health and behavior or if we are implementing quality initiatives for improved school nurses’ assessment or interventions, even the most comprehensive trainings and workshop sessions occurring over weeks and months are effective in only changing knowledge and attitudes, but not behavior.
Evidence-based practice or quality improvement initiatives involve a needs assessment, engagement with the target population or community, a review of the literature, program design, outcome measure selection, implementation, and evaluation. From start to finish, that involves a tremendous amount of effort, time, and expense. Maximizing the return on that investment and closing the Knowing-Doing gap requires choosing an intervention that has support in the literature to make measurable differences in the desired outcomes (Bergren, 2022). It is crucial to implement a program that is most likely to change school nurse practices and improve the health and education of students.
DNP-prepared nurses are educated to be implementation scientists. The key to changing behavior is to alter the environment or processes to make it easier to adopt the new practice or procedure than to continue old habits (Duhigg, 2012; Thaler & Sunstein, 2008 Vogus & Hilligoss, 2016). Some examples of altering the care environment that could prompt nurses to adopt the standard of care for medication in schools are changing forms and electronic health records to only record students’ weights in kilograms; purchasing scales that only measure student weight in kilograms; stocking only medication measuring devices designed for liquid medication dosing (Bergren, 2021). Audits and self-audits of school health offices, activities, and students’ records are also an effective strategy for quality improvement (Bergren, 2021; Cross et al., 2021; Spina et al., 2012). Checklists for screenings and referrals are trusted tools for reinforcing best practices (Gawande, 2009; School-Located Vaccination: School Nurse Planning Checklist, 2022). Real-time prompts for changing behaviors for both providers and students increase recommended behaviors (Swallow & Roberts, 2016).
These are just a few examples of alternatives to trainings and educational sessions that are more efficient and less costly than face-to-face or online teaching. Often education is a necessary component of a multifaceted intervention. However, any “one and done” strategy will not change human behavior. A combination of interventions layered on top of education is necessary to disrupt and unlearn poor practices (ISMP, 2020).
Evidence-based nursing requires evidence-based implementation (van Achterberg et al., 2008). It is time to end the default of providing education as a sole remedy for quality improvement and translation of evidence into practice in any setting, including schools.
Martha Dewey Bergren, PhD,RN,NCSN,PHNA-BC,FNASN FASHA,FAAN
Executive EditorThe Journal of School Nursing
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Swallow, W., & Roberts, J. C. (2016). An evidence-based project demonstrating increased school immunization compliance following a school nurse–initiated vaccine compliance strategy. The Journal of School Nursing, 32(6), 385–389. https://doi.org/10.1177/1059840516665216
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