The Journal of School Nursing2024, Vol. 40(2) 231–236© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221085682journals.sagepub.com/home/jsn
School-Based Health Centers (SBHCs) often serve vulnerable populations who have been exposed to adverse childhood experiences (ACEs) which have been tied to an increase in adult health risk factors. At an urban SBHC serving adolescent students, 75% of patients reported three or more ACEs. This SBHC also had multiple practitioner students. A multicomponent onboarding was created to implement the Patient Interaction Standard of Care, addressing the SBHC model, adolescent care, and ACEs. Practitioner students that completed the onboarding demonstrated 97% adherence to the Patient Interaction Standard of Care “Always” or “Most of the Time.” By onboarding frequent practitioner students, care provided to this vulnerable patient population was more consistently aligned to evidenced-based care appropriate for the SBHC model, adolescent care, and ACEs. This demonstrates the importance of mandatory onboarding completion compliance and further implementation across other SBCHs.
high school, preceptor for students, school-based clinics, communication, evidence-based practice, standardized nursing languages, standards of care, abuse
School-Based Health Centers (SBHCs) aim to expand access to healthcare for children by providing a place to receive preventative and basic care supplementary to primary care providers (PCP) (Health Resources & Services Administration [HRSA], 2017). Because these centers serve children of various ages, it is important for providers to deliver age-appropriate care. Additionally, these SBHCs often serve vulnerable populations who have been exposed to adverse childhood experiences (ACEs), which have been tied to an increase in health risks (Felitti et al., 1998). Given the nature of SBHCs and their patient population, specific training for practitioner students such as nurse practitioner (NP), physician assistant, and medical students is imperative to deliver consistent and safe care.
SBHCs are a unique model that increase access of care for children by reducing barriers that they cannot control such as travel or missed parental work time. They “often are operated as a partnership between the school and a community health organization, such as a community health center, hospital, or local health department” (HRSA, 2017). While SBHCs are not meant to replace the child’s PCP, studies have found that this collaboration can increase compliance rates for metrics such as influenza vaccinations and nutrition/physical activity counseling for shared patients when compared to those only seen by their PCP (Riley et al., 2016). The literature suggests that frequent patients have visits often related to behavioral, sexual, reproductive, and acute care visits (Koenig et al., 2016).
Organically, patient populations at SBHCs depend on the student population served. Thus, a high school SBHC needs to be prepared to treat adolescences with age-appropriate considerations. The World Health Organization (WHO) identifies three domains that guide practice when working with this patient population in Core Competencies in Adolescent Health and Development for Primary Care Providers (WHO, 2015). These include: “Domain 1. Basic concepts in adolescent health and development, and effective communication; Domain 2. Laws, policies and quality standards; Domain 3. Clinical care of adolescents with specific conditions” (WHO, 2015). Each domain has several competences that are broken down by knowledge points and demonstratable skills (WHO, 2015). These guidelines were developed from synthesized literature findings.
Another important component to consider at SBHCs is the impact of ACEs. The first documented study on ACEs was published in 1998 by Felitti et al. This study examined associations between self-reported ACEs, defined as differing types of abuse, and current adult health morbidities in a large cohort of participants in San Diego (Felitti et al., 1998). They found that higher presence of cumulative ACEs correlated with an increased risk of negative health outcomes (Felitti et al., 1998). Another landmark study, Giovanelli et al. (2016), found the prevalence of ACEs linked to an increased risk of poor health outcomes as well as a decrease in high school graduation rates and an increase in juvenile arrests and felony charges.
Recent studies have expanded on the definition of trauma and incorporated those experiences when evaluating the impact of ACEs. Participants in a study conducted by Wade et al. (2014) generated their own examples of traumatic elements of childhood. Their list included ACEs like violence in the community and bullying that were not originally recognized (Wade et al., 2014). Mersky et al. (2017) found that the number of ACEs were related to a higher likelihood of negative health outcomes rather than specific ACEs like death of a family member. Evidence also suggests that the number of ACEs exposures are also linked to level of participation in risky behaviors such as the being violent, delinquent, and misusing substances in children as young as nine to eleven years old (Garrido et al., 2018).
The prevalence of ACEs is common among the general population. Per the Behavioral Risk Factor Surveillance System (BRFSS), an annual, nationally representative telephone survey, 61.55% of respondents reported at least one ACE and 24.64% reported three or more ACEs (Merrick et al., 2018). Due to the high prevalence of ACEs, the American Academy of Pediatrics (AAP) recommends that primary care providers implement trauma-informed care (TIC) (AAP, 2014). Additionally, the WHO outlines specific competencies when caring for adolescents (WHO, 2015). SBHCs then should incorporate TIC and adolescent care principles.
Training is imperative to ensure practitioner students with differing clinical and education experiences are providing consistent evidenced-based care in SBHC. In one study, Green et al. (2015) found that patient-centeredness composite scores increased during standardized-patient encounters in a primary care setting after residents completed a TIC curriculum. While there are examples of formal curriculum provided through educational programs, the literature has limited studies of practitioner student trainings in specific clinical rotations. Sobolewki et al. (2016) found a multimedia unit specific orientation to a rotation in emergency room better prepared residents for the roles and responsibilities of their rotation. Successful elements of the training included the ability to complete the orientation online before the rotation, the accountability of evaluation during the rotation based on the contents of the orientation, and the involvement of key stakeholders (Sobolweki et al., 2016). While these examples provide valuable insight into the effectiveness of training, there is a gap in the literature regarding onboarding for practitioner students applying the intersectionality of the SBHC model, adolescent care, and TIC principles.
The setting for this pilot project was an urban SBHC located inside a high school that served patients grades 9–12. About 400 students were enrolled in the high school and were the only individuals with access to the primary care services within the SBHC. Per an assessment given by the school’s social workers, 75% of patients reported three or more ACEs. This SBHC also had multiple practitioner students monthly for varying rotation lengths. There was not a multicomponent onboarding that established a standard of care addressing the SBHC model, adolescent care, and ACEs. By onboarding frequent practitioner students, care provided to this vulnerable patient population can be more consistently aligned to evidenced-based care.
The purpose of this pilot project was to create, implement, and evaluate a Patient Interaction Standard of Care (PISC) Education Training Module for practitioner students in a SBHC. The PISC Training Module was developed by using the Core Competencies in Adolescent Health and Development for Primary Care Providers (WHO, 2015), the principles and prevalence of ACES, and the AAP’s recommendations for Trauma-Informed Care as a framework to practically apply a PISC in SBHC setting. Practitioner students were asked to complete the training before interacting with patients in order to standardize care provided to this vulnerable population. The training included an evaluation to determine competency and a self-assessment to ascertain implementation adherence after each clinical day.
The project outcome objectives were: 100% practitioner students would complete the PISC Training Module from October-December 2019; 100% practitioner students would demonstrate understanding of the material by scoring 80% or higher on post-assessment; practitioner students would follow Patient Interaction Standard of Care after completing the PISC Training Module as evidenced by marking “most of the time” or “always” on 80% of their self-assessment.
A practitioner student PISC Training Module PowerPoint, 61 slides in length, presenting the intersectionality of the SBHC model, adolescent care, and ACEs/TIC was created by the project manager. The PISC Training Module began by introducing the SBHC including the clinic team and the associated high school. Next, information relating to SBHCs’ role and reach throughout the specific urban area were provided. Then, guidelines for Adolescent Care outlined by the WHO addressing key health-related behaviors and conditions, age-appropriate healthcare laws, and STI prevalence were used to compare national and local data. Subsequently, ACEs and their correlation to poor health outcomes were explained linking the high prevalence of both at this SBHC. After the foundational elements of this clinical environment were explained, a ten-step PISC was introduced combining guidelines for SBHC, adolescent care, and ACEs/TIC. In the training, each step provided rationale of alignment, action items, and an example dialogue of a possible patient encounter. The PISC Training Module was then submitted to and approved by SBHC’s medical director, NP, and social worker. The Practitioner Student Orientation Content Summary can be found in Table 1. The PISC can be found in Figure 1.
From October-December 2019, emails were collected from practitioner students ideally on their first day of their clinical rotation to this SBHC. Instructions were also placed around the SBHC for new practitioner students to contact the project manager via email or complete a hard copy of the PISC Training Module provided. Once practitioner students had completed their PISC Training Module, they then had to demonstrate proficiency by scoring 80% or higher on a 26-question basic comprehension assessment. Each day the practitioner students were in the SBHC, they were expected to complete an anonymous self-assessment measuring how often they implemented each part of the Patient Interaction Standard of Care on a scale that ranged from “Never, Rarely, Sometimes, Often, or Always.” This self-assessment was available via email and hard copy and was expected regardless of PISC Training Module completion.
Many practitioner students came to the SBHC each Monday; thus, the project manager made an effort to be physically present on Mondays to aid the PISC Training Module completion. If the practitioner students did not finish the PISC Training Module the same day they began their rotation, reminder emails were sent to them, their preceptor, and the medical director. Once the PISC Training Module was complete, the practitioner students were sent an email describing how to submit their daily selfassessment. Data, including the post-assessment and the selfassessment, were imputed into REDCap, a secure database used to manage online surveys, throughout the project.
Prior to its initiation, the project was sent to the collaborating university’s Institutional Review Board and it was determined that this was non-human subject research. Since the adolescent patients were not asked to be involved in the PISC Training Module or either assessment, there was not risk of Health Insurance Portability and Accountability Act (HIPAA) violation nor were there any necessary considerations concerning minors. Practitioner students needed to disclose their identity for the PISC Training Module assessment to ensure a competent score. However, the selfassessment was anonymous.
The objective of 100% of the practitioner students to complete the PISC Training Module was not met. Over a threemonth period, 80% or 12 of the 15 practitioner students completed the PISC Training Module. Six practitioner students completed their PISC Training Module before interacting with patients as intended. Three practitioner students saw patients before and after completing their PISC Training Module. Two practitioner students completed their PISC Training Module only after interacting with patients. Three practitioner students never completed the PISC Training Module. See Table 2. The 12 practitioner students who completed the PISC Training Module scored 80% or higher on the 26-question post-assessment. A total of 16 self-assessments were submitted from 9 practitioner students who had completed the of the PISC Training Module prior to patient interaction as intended. Eight self-assessments were done prior to practitioner students completing the PISC Training Module. All 15 practitioner students completed at least one self-assessment after interacting with patients. Overall, 24 self-assessments were completed with practitioner students reporting on between one to four clinical days. Amounts of self-assessments varied because each practitioner students had different lengths of their rotation. See Table 3.
Based on the 16 self-assessments submitted after completion of the PISC training, practitioner students self-reported 97% adherence to the Patient Interaction Standard of Care “Always” or “Most of the Time” each clinical day. The objective that practitioner students would adhere to the PISC 80% of the time after completing the PISC Training Module was met. The step of the PISC Training Module that was least implemented according to the self-assessments was: Asked the patient if they felt comfortable with the door closed or slightly cracked.
All data was intended to evaluate patient interactions post-completion of the PISC Training Module. However, some practitioner students performed self-assessments pre- and post- PISC Training Module completion. Two of the practitioner students who originally reported “Never” asking the patient if they felt comfortable with the door closed or slightly cracked later reported that they “Always” and “Most of the time” completed this step on a specific clinical day after completing the PISC Training Module. Due to the small sample size the results were not statistically significant.
This project aimed to create a PISC Training Module for short-term practitioner students assigned to work with a vulnerable SBHC population. Practitioner students completed a post-assessment demonstrating knowledge of the SBHC model, Adolescent Care Competencies, ACEs/TICs and the PISC. This intervention aligned with other findings in the literature as Sobolewski et al. (2016) also found that practitioner students undergoing short-term rotations had increased knowledge of the clinical setting, expectations, and patient population after completing a unit specific orientation. To evaluate this project, each clinical day, practitioner students were supposed to report their implementation of the PISC via a self-assessment.
Majority of the practitioner students completed the PISC Training Module, but only six of 15 completed it before interacting with all patients, demonstrating that even though the PISC Training Module was intended to be mandatory before patient interaction, this did not occur. Practitioner students that submitted their self-assessment prior to completing the PISC Training Module provided unanticipated pre-intervention data. For care consistency, ideally each encounter would be aligned to the PISC. Thus, this project did not aim to collect pre-data at the expense of the patients not being treated according to the PISC. However, this did occur and allowed for analysis of selfassessments before and after completion of the PISC Training Module. This data showed that the PISC was followed at an increased rate after practitioner students completed the PISC Training Module. The literature also suggests that training increases practice modification. Green et al. (2015) found that residents who underwent training for TIC received it well and had improved patient-centeredness composite scores after performing a medical interview.
The strengths of this project included the quality of the PISC Training Module materials and their alignment with current literature and guidelines. It was also effective when the project manager was present to reinforce the PISC Training Module completion. Additionally, PISC adherence after the PISC Training Module was self-reported at 97%. The limitations of this PISC Training Module included the lack of enforcement from those in supervisory positions to ensure that the PISC Training Module was completed prior to patient interaction. The project manager did not have the authority to implement this stipulation. Also, self-assessments results can be inflated so the data are inherently biased.
Recommendations for the future include a more thorough commitment from supervisory staff to require practitioner students to complete the PISC Training Module prior to initiation of this rotation and a project manager that can be present more frequently. For this project to be sustainable, the NP and medical director need to continue to provide the PISC Training Module to new practitioner students. While buy-in from stakeholders was achieved at the beginning of this project from the medical director, the NP, and the social worker, more check-ins throughout the implementation may have increased support. All parties supported the topic, but logistically the PISC Training Module was not incorporated into their workflow. One of the key takeaways discussed in Sobolewski et al. (2016) emphasizes the involvement of key stakeholders including those taking the orientation themselves.
Next steps to enhance this quality improvement project should be determined through an establish systematic approach like Plan-Do-Study-Act (Institute for Healthcare Improvement, 2022.) The results of this pilot found that many practitioner students were not completing the PISC Training Module prior to beginning their rotation. Future attempts of implementation might be to provide the training with the original communication to the students about the other logistics of the rotation as those were provided separately. Additionally, while leadership was engaged as a stakeholder when formulating the intervention, practitioner students were not. A post-rotation survey could be used as a tool to allow practitioner students to provide suggestions and to evaluate aspects of the project’s implementation such as timing of delivery of content, content medium, and usefulness of content. Finally, increasing the sample size to include more SBHCs and practitioner students would provide more data regarding the level of effectiveness of the PISC Training Module.
A PISC Training Module for frequent short-term practitioner students was initiated to provide consistent care to a vulnerable patient population addressing the SBHC model, adolescent care competencies, and ACEs/TIC. However, not all practitioner students completed this PISC Training Module prior to patient interactions. Additionally, the quantity of the results could not generate enough data for statistical significance so this data is not generalizable. Nonetheless, adherence to the PISC was reported at higher levels after the PISC Training Module completion, demonstrating the importance of mandatory onboarding completion compliance and further implementation across other SBHCs.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Amanda LaMonica-Weier https://orcid.org/0000-0002-8998-0863
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Amanda LaMonica-Weier, DNP, APRN, FNP-BC, MAT, CNL, CMSRN, is an Instructor at Rush University College of Nursing.
Margaret Perlia Bavis, DNP, APRN, FNP-BC, is an Assistant Professor at Rush University College of Nursing.
Rush University College of Nursing, Chicago, IL, USA
Corresponding Author:Amanda LaMonica-Weier, DNP, APRN, FNP-BC, MAT, CNL, CMSRN, Rush University College of Nursing, 600 S. Paulina, Suite 1063, Chicago, IL 60612, USA.Email: amanda_m_lamonica-weier@rush.edu