The Journal of School Nursing2023, Vol. 39(4) 276–284© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211000683journals.sagepub.com/home/jsn
States have key roles and responsibilities in protecting and promoting the health of all of school-age youth. Though assessment and planning instruments exist to support quality school nursing service delivery at individual school building, community, and district levels, no comparable measure was available to assess state-level support for the delivery of quality school nursing. This project, conducted in three phases, resulted in the development of a novel measure to identify state-level infrastructure supports for school nursing services delivery. The State School Health Infrastructure Measure is comprised of seven domains with 24 indicators and demonstrated initial content validity and test–retest reliability. States can use this measure to self-assess, identify, benchmark, prioritize, and address state-level infrastructure strengths and gaps related to supporting the delivery of high-quality, equitable school nursing services.
Keywordsschool nursing, school health services, state-level infrastructure, domains, indicators, quality measure, equity
All children and youth should have opportunities to grow, develop, learn, and lead healthy lives regardless of family socioeconomic status, race, or zip code (Braveman et al., 2017). Substantial evidence confirms that school nursing services, provided by full-time professional registered nurses knowledgeable in this specialty area, have significant positive impacts on student health and learning (Basch, 2011; Best et al., 2018; Ickovics et al., 2014; Lineberry & Ickes, 2015; Maughan et al., 2018; Michael et al., 2015; Murray et al., 2015; World Health Organization [WHO], 2014). However, approximately half of school children in the United States lack adequate school nursing services (Willgerodt et al., 2018; Zimmerman & Woolf, 2014). Additionally, great variations in access, quality, and policies related to school nursing services delivery exist within and across states (Chriqui et al., 2019; Knauer et al., 2015; Praeger & Zimmerman, 2009).
States have key roles and responsibilities in protecting and promoting the health of all of school-age youth. Though federal and state laws, regulations, and statutes set school health standards, policies, procedures, and funding, states lack accountability for assuring that systematic structures and processes are in place to support the provision of quality school nursing service in each community (Chriqui et al., 2020). High minority population enrollment schools in lowincome communities typically have fewer health-related resources, services, or programs as compared to schools in communities with higher socioeconomic status (Pearlman et al., 2005). These differences lead to disparities in both health and achievement outcomes (Agency for Healthcare Research and Quality, 2017; Annie E. Casey Foundation, 2017; Braveman et al., 2010; Centers for Disease Control and Prevention [CDC], 2017; Gracy et al., 2017; Maughan et al., 2018; Wasserman et al., 2019). The COVID-19 pandemic has exacerbated health disparities among school-age youth (Kodzis, 2021; Padilla & Thomson, 2021). This health calamity has also highlighted states’ roles, amplified the importance of public health, and broadened the need for school nursing leadership, expertise, and care in every school.
It is critical to monitor and set priorities for effective, equitable, quality health care, and these standards must also be upheld in school nursing. Frameworks exist for individual school building, community, and district-level assessment and planning for school nursing service delivery that promotes continuous quality improvement (Aspen Education & Society Program & Council of Chief State School Officers, 2017; Klassen et al., 2010; Lewallen et al., 2015; National Association of School Nurses [NASN], 2015; QSEN Institute, 2019; WHO, 2014). Additionally, the CDC (2019a) School Health Index and the CDC (2019b) School Health Policies and Practices Study are tools that provide selfassessment and planning guidance for school health services delivery.
However, an extensive literature review did not yield an instrument that addressed state-level self-assessment in supporting high-quality, equitable school nursing services delivery (Doremus, 2019; see also Kazemitabar et al., 2020). This deficit, coupled with an increasing societal call to address equity issues, illuminated a gap. This need directed the purpose of this project to develop a valid and reliable evidence-based measure for state-level selfassessment of infrastructure supports for school nursing services delivery. For the purposes of this project, the term school health is used synonymously with school nursing.
Donabedian’s (1966) structure-process-outcome (S-P-O) theory explained that structure and process components of health care systems must be in place for expected health care outcomes to occur. Donabedian (1966, 1988) described structure components of care as the materials, policies, settings, and human and organizational resources associated with the provision of quality health care. Process components of care pertain to the capacities of individuals or systems to conduct, coordinate, and deliver services and programs. Outcomes are the health results that are dependent on a foundation of sufficient effective structures and processes. The S-P-O theory serves as a relevant model to examine interrelated health care system factors to improve health care delivery and ultimately, health care outcomes. Donabedian’s constructs of structure and process aptly apply to the purpose of this project to develop a measure that identifies structure and process indicators for state-level infrastructure supports associated with quality school nursing services delivery (see Figure 1).
A three-phase, mixed methods design was used. This project employed an iterative process in which revisions were made using results from each previous phase. Phase 1 focused on the selection of a set of evidence-informed quality measure structures and processes, as guided by Donabedian theory (1966), that embodied state-level supports for school nursing service delivery. These structures and processes informed the development of the proposed domains and indicators for the final product, the State School Health Infrastructure Measure (SSHIM).
Phase 2 involved the preparation and administration of a web-based content expert (CE) survey to assess the content validity of the proposed domains and indicators and to incorporate the CEs’ qualitative input to improve the overall content of the proposed SSHIM. Revisions to the SSHIM domains and indicators were made using the CE survey data results.
In Phase 3, a single-group pilot trial run of the SSHIM was conducted with cross-sector, state-level leaders in health and education as participants. The SSHIM pilot test–retest sought to determine repeat reliability, and an SSHIM pilot questionnaire collected information from the participants about the ease and feasibility of using the SSHIM.
The Rhode Island College Institutional Review Board approved this project. Human participant protection steps for human subjects included obtaining consents for voluntary participation in the CE survey, SSHIM pilot test–retest, and SSHIM pilot questionnaire. Participant anonymity of the web-based CE survey was assured by masking the participants’ computer internet protocol (IP) identity. CE survey data were compiled in aggregate form and did not include any potential personal identifiers of the participants. Risks to any participants, including the SSHIM pilot test–retest and SSHIM pilot questionnaire were deemed low, as participation did not differ from that which was required in normal work activities.
Phase 1. An extensive literature review included examination of the best available research evidence, white papers, models, and theories related to selecting and developing quality domains and indicators. Key health system frameworks were identified and concepts were compared (see Table 1). The frameworks domain and indicator examples served as models to generate a parallel set of evidence-informed quality domains and indicators pertinent to state-level supports for school nursing services delivery. The domain and indicator selections were guided by Donabedian’s concepts of structure and process dimensions of quality measurement (1966), as elaborated upon by Derose et al. (2002). This work formed the preliminary SSHIM domains and indicators.
Phase 2. For the CE survey, a national sample of school nursing and school health experts was sought through purposive recruitment of state school nurse consultants (SSNCs) and other state school nurse leaders and experts such as State School Health Directors from all regions of the United States. These individuals were recognized as CEs by virtue of their state-level positions of responsibility, expertise, and experience in school nursing and school health services delivery (Broussard et al., 2011; McComb, 2005; NASN, 2013; National Association of State School Nurse Consultants [NASSNC], 2008; Young-Jones, 2011). The investigator contacted the NASSNC organization and collaborated with the Data and Research Committee chairperson for the recruitment of NASSNC members as potential CE survey participants.
The investigator provided the NASSNC Data Committee chairperson with a formal recruitment request that included a description of the project, informed consent information, and confidentiality assurances for participation. To maintain participant anonymity, the NASSNC Data Committee chairperson forwarded the online CE survey link, powered by Qualtrics software by email to 43 members on the NASSNC organization listserv. This included 36 actively employed SSNCs and seven retired former SSNCs. One email to an active member was returned. The CE survey link was also forwarded to one other school health expert who expressed interested in participating. The survey reached a total of 43 potential participants.
The CE survey requested participants to anonymously provide nonidentifiable demographic information about their age, role, years of school health experience, and regional location (CE survey Items #1–5). Potential participants over the age of 65 were instructed to opt out of completing the survey, to avoid involving individuals in a potentially vulnerable age category. CE survey instructions included specific written guidelines for providing quantitative ratings and qualitative feedback on the relevance, acceptability, and feasibility of each proposed measure domain related to state support/provisions for school health services and each indicator item related to the relevance and feasibility of documenting specific indicators for state support for school health services. Participants were instructed to indicate on a Likert-like scale the extent to which they agreed or disagreed with the statements where 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree. Open-ended questions sought input about the overall content, design, and readability of the proposed measure. These procedures followed methodological guidelines set forth by Gray et al. (2017).
Phase 3. The SSHIM pilot test–retest was conducted in one state and purposive participant recruitment targeted school nursing and school health professional leaders employed by the State Department of Health, State Department of Education, and other state-level school or child health agencies with responsibilities for oversight of school-age youth health care services. Four state-level health and education leaders met face-to-face in a state office to take part in the initial SSHIM pilot test (T1) of the proposed measure, with the investigator present to oversee administration. In this single-group trial run, participants jointly completed one hard copy of the proposed SSHIM, as it was designed to be implemented. To arrive at consensus on a score for each SSHIM item, participants exchanged cross-sector information about their collective knowledge of state-level infrastructure support for each item. The participant group rated each item on a 4-point Likert-like scale indicating the extent of the presence of state-level infrastructure supports for school nursing services delivery where 0 = not in place, 1 = under development, 2 = partly in place, and 3 = fully in place.
Immediately following the first SSHIM pilot test administration (T1), each of the four participants individually completed a hard copy of the SSHIM pilot questionnaire which was comprised of a set of 10 questions with yes or no and open-ended response options regarding the ease and feasibility of completing the proposed SSHIM (see Supplemental Table 1).
For the SSHIM pilot retest (T2), the same four participants requested to reconvene by conference call instead of in person, for the sake of convenience. T2 was conducted 17 days later by phone conference, with the investigator again present during the conference call to oversee the SSHIM pilot retest administration. The participants followed the same consensus discussion and scoring procedures as the T1 SSHIM pilot test administration.
Demographic information about the age ranges, role titles, years of school health or school nursing experience, and regional location of the CE survey participants was compiled. The SSHIM pilot questionnaire yes/no responses were tallied, and the open-ended feedback was applied to make minor revisions to the SSHIM.
In Phase 2, CE survey data were analyzed for content validity of the individual items (item content validity index [I-CVI]) and of the overall measure (Scale Content Validity Index [S-CVI/Ave]). The I-CVI expressed the proportion of rating agreement among the CEs on the relevance, acceptability, and feasibility of each of the proposed measure’s individual domains and indicators. According to content validity standards, items with I-CVI scores >0.79 are appropriate; items with scores >0.70 and <0.79 need revision; and items with scores <0.70 should be eliminated (Polit & Beck, 2017). The S-CVI/Ave calculation was derived from the average of the I-CVI scores (Polit & Beck, 2017). The qualitative and quantitative CE survey data results directed modification and refinement of the proposed measure.
The Phase 3 SSHIM pilot test–retest applied the intraclass correlation coefficient (ICC) statistical test to examine repeat reliability of the SSHIM by calculating variations between two different administrations of the same measure. ICC calculates the ratio of true variance over true variance plus error variance with a value range from 0 to 1. Stronger reliability values approach 1 and represent both correlation and agreement between measures (Koo & Li, 2016; Polit & Beck, 2017). The ICC statistical analysis for test–retest reliability was applied to T1 and T2 results, using a single measurement, absolute agreement, two-way mixed-effects model on 24 indicator items. These model parameters were used because the participants were not randomly selected (Koo & Li, 2016).
The findings from the literature search for key frameworks directed the development of interdependent and nonhierarchical domains and related indicators. Domains identified as critical components of state infrastructure for supporting school nursing were:
These domains and the related indicators were organized into a proposed measure, modeled on the format of the School Health Index (CDC, 2019a) culminating in the SSHIM.
Nineteen of 43 CE surveys were completed and returned electronically by school health and school nursing expert participants from across the United States, for a response rate of 44%. All participants reported having at least 10 years of school health experience and identified their roles (with some listing more than one role) as State School Nurse Consultant or Director (n = 17), State School Health Services Consultant or Director (n = 3), and other: former SSNC (n = 1) and state program manager (n = 1). The U.S. geographic distribution of CE survey participants were as follows: Northeast (n = 9), Midwest (n = 4), West/Northwest (n = 3), and South (n = 3).
The average number of responses per CE survey question was n = 18 of 19 total participants; not every participant entered a response for every question. See Supplemental Table 2 for CE survey I-CVI scores. Of a total of 43 survey question items, the number of items considered appropriately relevant, acceptable, and feasible based on I-CVI scores was n = 36. The number of items considered in need of revision based on I-CVI scores was n = 7. The number of items considered in need of elimination based on I-CVI scores was n = 0. Modifications were made to the seven items indicated for revision based on the CEs’ qualitative input.
The overall S-CVI/Ave, determined by the average of I-CVIs = 0.887, represented the standard of excellent content validity, demonstrating that the content of the measure was relevant, acceptable, and feasible (Polit & Beck, 2017).
The SSHIM pilot test–retest (T1 and T2) data (see Supplemental Table 3) were used to calculate the ICC using SPSS statistical package Version 23 (IBM Corp., 2015) based on a single-measure, absolute-agreement, two-way mixed-effects model (see Supplemental Table 4). The ICC = 0.728, in the range between 0.5 and 0.75, represented a significant positive correlation between T1 and T2 with a 95% confidence interval across 24 indicator items (Koo & Li, 2016; Polit & Beck, 2017). This represents test–retest repeat reliability.
The tally of the yes/no and qualitative data from the SSHIM pilot questionnaire results indicated overall ease and feasibility with completing and using the SSHIM (see Supplemental Table 1). Feedback from the SSHIM pilot questionnaire narrative responses was used to make minor revisions to the proposed SSHIM.
The final version of the SSHIM was composed of seven domains with 24 indicators and sections for documentation and scoring (see Supplemental Figure).
This project, developed in three phases, produced the SSHIM, a valid and reliable set of evidence-informed domains and indicators that measure state-level infrastructure capacity for quality school nursing service delivery. Designed for formative assessment, the SSHIM should be conducted on a regular basis to account for state-level structures and processes affecting school health services provision. The SSHIM is not intended to be utilized for summative performance evaluation of school health services on local levels. Additionally, there should not be inferences drawn that school nurses provide inferior care where state-level support is underresourced. The purpose of this novel measure is for proactive quality improvement. The data should be applied to develop, implement, and evaluate actionable plans to improve state-level infrastructure supports for the delivery of school nursing services.
While each state is unique in needs, priorities, and laws, the SSHIM was generated using a national sample, and thus the use of the measure is applicable and broadly generalizable within the United States for identifying, prioritizing, and using the data to address state infrastructure issues that impact quality and equity in school nursing services delivery.
The domains and indicators identified in the SSHIM are not all-encompassing. They represent essential, yet minimum standards for state system-level infrastructure necessary to support the delivery of quality school nursing services to meet student health needs. Because the SSHIM was designed to be completed through the process of statelevel self-report, this data collection strategy may inherently result in biased information. To counter this, when completing the SSHIM, each response to an indicator requires related documentation of supporting evidence such as a web URL address or a link to an existing policy, procedure, program, report, or document to verify the status of the indicator standard.
School health CE participants in the CE survey provided perspectives unique to their varying state-level leadership roles, responsibilities, and the needs of their state. However, some participants stated in their qualitative feedback that their state employment was funded in part or wholly by grants, which may have limited the scope of their role and perhaps their perspectives. In addition, nearly half (nine of 19) of the CE survey participant respondents hailed from the northeast area of the United States, so overrepresentation of this region may have skewed certain perspectives. Further, not every state employed a state school nurse or school health consultant, so the CE survey lacked input from areas with potentially the greatest needs for state infrastructure supports. A methodological limitation of this research was that participants over the age of 65 were excluded to avoid the involvement of a possibly vulnerable age population, thus reducing the sample size and limiting input from potentially very experienced individuals.
The initial Phase 3 SSHIM pilot test (T1) was conducted in person. However, at the request of the participants who lived and worked in various locations throughout the region, the retest (T2) with these same individuals was conducted 2.5 weeks later via conference call. This was a departure from standard procedures that specify that the retest be conducted under the same conditions (Gray et al., 2017). This irregularity may have contributed to differences between the results of the two test administrations. In any case, the ICC indicated a significant positive correlation between T1 and T2.
Though the SSHIM demonstrated acceptability for use in its final form, additional testing of the domains and indicators with a larger sample and factor analysis would strengthen validity. Further development of a web-based SSHIM tool kit with detailed administration guidelines including guidance on scoring, and online access to a fillable form would make this measure widely available and usable across the United States.
Research using the SSHIM could contribute to evidence about opportunities and challenges that impact school nursing practice. Specific topics to explore might include using findings from the SSHIM to determine if changes in statelevel support have an impact on the quality of school health services delivery and student outcomes at local and district levels. Researchers could examine the effect of using the SSHIM on promoting cross-sector collaboration among governmental, educational, and health sector leaders. Other investigations could study specific changes in access, equity, or quality of aspects of school nursing services within and across states as a result of conducting and applying SSHIM findings. Additional research could analyze the return on investment of state-level infrastructure support on student health and related academic outcomes or an analysis of the relationship between quality and the availability of support and resources.
States have the responsibility to assure equitable, quality school health services. The SSHIM is a resource for statelevel leaders in health and education as well as legislators to identify and map state assets, gaps, and inequities and to use that data to analyze policies, set priorities, and enhance support for quality school nursing services delivery. The SSHIM also provides a means to monitor, evaluate, and track the progress of state improvement efforts over time toward promoting healthy outcomes for all students. States must address school health infrastructure inadequacies, including policies that drive inequities, in order to improve health outcomes. The SSHIM establishes benchmarks for state-level accountability for the delivery of quality school health services. Though the SSHIM is designed to be applied at the state level, school nurses can use this measure to gather data and advance research to aid state leaders and policy makers in understanding and addressing infrastructure support needs.
State-level health and educational systems often are not aligned on efforts. Intentional formation and strengthening of state-level interprofessional partnerships among public, private, and governmental leaders in educational and health professions and agencies are critical for systems-level improvement in child health and academic achievement (Doremus, 2012; Shaw et al., 2006). The SSHIM compels a partnership approach for state leaders to reach across health and education sectors to ensure that effective practices, programs, and policies are in place.
Strengthening state-level supports for school nursing services infrastructure is key to advancing school-age youth population health and educational achievement for all students (NASEM, 2019). State leadership, expertise, and advocacy are vital for effective and equitable education and health care policy and regulatory decisions that support healthy development and positive life course trajectories for all school-age youth. The SSHIM equips leaders to identify needed state-level infrastructure support for incorporation as health and educational improvement goals in state strategic plans.
This project resulted in the development of a novel measure, the SSHIM, comprised of a set of valid and reliable evidence-informed domains and indicators to assess statelevel support for school nursing service delivery. This measure identifies strengths and gaps in state-level infrastructure which can lead to prioritizing, planning, and implementing high-quality, equitable school nursing services delivery. The SSHIM provides a practical and sustainable pathway for interprofessional collaborative work to translate and disseminate evidence to advance school nursing practice, influence health and educational policy development, and enable capacity-building and evaluation to improve the health and educational outcomes of all school-age youth.
The SSHIM can propel state-level support toward systematically improving school nursing services delivery in the areas of evidence-based practice, professional school nursing workforce development, population health interventions, management of the needs of students with chronic conditions, equity and accessibility, information technology for data-driven and cost-effective decision making and policy development, coordination and collaboration across sectors, effective leadership, and sustainable funding. These efforts can significantly and positively impact school-age youth on both individual and population health levels. This approach is also an essential component of ongoing quality improvement, health care transformation, and educational reform efforts and has the potential to contribute to accelerating progress toward health equity and closing academic achievement gaps for school-age youth.
The author acknowledges the Rhode Island College School of Nursing faculty for their assistance including DNP project advisors Dr. Marie Wilks and Dr. Joanne Costello and public health advisor Patricia Raymond, RN, MPH, of the Rhode Island Department of Health. In addition, the author is grateful to the National Association of State School Nurse Consultants for their survey participation and to Linda Mendonca, DNP; Kathy Hassey, DNP; Jenny Gormley, DNP; and other National Association of School Nurse colleagues for their guidance, support, and encouragement.
Wendy A. Doremus contributed to conception or design, contributed to acquisition, analysis, or interpretation, drafted the manuscript, critically revised the manuscript, gave final approval, and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
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.
Wendy A. Doremus https://orcid.org/0000-0001-7584-0192
Supplemental material for this article is available online.
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Wendy A. Doremus, DNP, APRN, NP-BC, PHNA-BC, is an adjunct professor in the School of Nursing, Rhode Island College, RI.
1 School of Nursing, Rhode Island College, Providence, RI, USA
Corresponding Author:Wendy A. Doremus, DNP, APRN, NP-BC, PHNA-BC, 62 Beachwood Drive, East Greenwich, RI 02818, USA.Email: wendydoremus@gmail.com
