The Journal of School Nursing2025, Vol. 41(4) 502–515© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241289243journals.sagepub.com/home/jsn
Abstract
Childhood homelessness is increasing and is associated with negative health and academic outcomes. The goal of this quality improvement project was to improve access to healthcare and health outcomes for students experiencing homelessness through a school nurse-led comprehensive health assessment. The multilevel intervention included identifying students experiencing homelessness, conducting a standardized health assessment, and making referrals to care. This 8-month project was conducted in an urban school district. Feasibility and acceptability data were collected to guide sustainability. Student health and referral data were analyzed using descriptive statistics. At the project start, 688 students were identified as experiencing homelessness. More than half (67%) had a partial or fully completed health assessment during the project. Of the students assessed, most had a primary care provider, some had a health condition, and half had a dental home. Students experiencing homelessness would benefit from systematic school-based health assessments to identify unmet health needs.
Keywordsschool nurse, homelessness, student, health assessment, outcomes, access
Approximately 1 in every 30 children in the United States experience homelessness each year (American Institutes for Research, 2023; Family Gateway, 2023). The national percentage of public school students experiencing homelessness during the 2020–21 school year was 2.2%, a 63% increase since the 2004–05 school year (National Center for Homeless Education [NCHE], 2022). The McKinney-Vento Homeless Assistance Act defines homeless children and youth as individuals who lack a fixed, regular, and adequate nighttime residence (National Conference of State Legislatures [NCSL], 2023). Under McKinney-Vento, schools must provide an equal education to all students regardless of their housing status, ensure privacy of youth experiencing homelessness and appoint a liaison to ensure the identification of students experiencing homelessness in coordination with other agencies (NCHE, 2022; NCSL, 2023).
Evidence shows there are multiple adverse effects for children experiencing homelessness. School-aged children are at risk for academic consequences such as chronic absenteeism, increased school mobility, and lower academic performance (National Alliance to End Homelessness, 2023; NCHE, 2022; NCSL, 2023). Additionally, studies show that child health and housing security are closely intertwined (Briggs, 2013; Gultekin et al., 2020). Children experiencing homelessness have a greater incidence of illness and injury and greater prevalence and severity of chronic conditions such as asthma, diabetes, and obesity (America’s Health Rankings, n.d.; Briggs, 2013; Gultekin et al., 2020). Further, children experiencing homelessness have higher rates of sexually transmitted infections, unplanned or unwanted pregnancy, mental health problems, substance use, and are at increased risk of poor nutrition (America’s Health Rankings, n.d.; Briggs, 2013; Damron, n.d.; Gultekin et al., 2020). Not only does this population experience disparate health outcomes, but they also have higher use of emergency healthcare and hospitalizations, fragmented health care resulting in disruption of care especially for chronic conditions, and encounter significant barriers to access to high quality, consistent health care (Briggs, 2013; Gultekin et al., 2020).
To address the problem of unmet health needs of children experiencing homelessness and improve health and wellbeing, a comprehensive multilevel intervention is required. One possible approach is the increased use of school-based health centers (SBHCs) which provide health services in schools for students from disadvantaged populations and those experiencing barriers to regular healthcare access and are known to improve health outcomes (Arenson et al., 2019; Kjolhede & Lee, 2021; Knopf et al., 2016). While there is limited literature specific to the impact of SBHCs on students experiencing homelessness, it is likely the population would benefit from this service. However, SBHCs are resource intensive and often function interpedently from school nurses.
Studies show nurses in other healthcare settings such as hospitals, clinics and the public health sector are highly effective at engaging and producing positive health outcomes for people experiencing homelessness (Weber, 2018). In alignment with their role and scope of practice, school nurses are in a key position to influence the health of students experiencing homelessness and translate the positive outcomes produced by nurses in other settings to the school setting (American Academy of Pediatrics, 2023; Barnes et al., 2021; Council on School Health, 2008; Gultekin et al., 2020). However, solutions in the literature specific to students experiencing homelessness and school nurse intervention are limited. Regardless, important first steps are identifying these students and educating school nurses about their needs (Anidi, 2023; Lilliston & Mincemoyer, 2014).
The goal of this quality improvement project was to improve access to healthcare and health outcomes for students experiencing homelessness by achieving three objectives: (a) creating, implementing, and evaluating a process for a school nurse-led, comprehensive health assessment of students experiencing homelessness, (b) describing the health needs of students experiencing homelessness, and (c) exploring an early framework to facilitate referrals to care and community resources. This project was guided by Brofenbrenner’s Ecological Systems Theory, which views child development in a complex multilevel system of relationships and has been used extensively in research on student health and well-being (Andrade et al., 2017; Lewallen et al., 2015). Specifically, this project employed the school nurse as a liaison to facilitate interactions between the child’s family (microsystem) and the healthcare system (exosystem) to improve access to healthcare and ultimately health outcomes for these students.
The project was implemented at a metropolitan school district located in the upper Midwest. This school district served over 25,000 students in 52 schools (blinded citation). During the 2021–22 school year, this district’s total student enrollment decreased, yet the percentage of students experiencing homelessness increased to 3.1% (790 students), higher than both the state and national average and higher than that of multiple nearby school districts (America’s Health Rankings, n.d.; Euseary & Girard, 2022; Wisconsin Department of Public Instruction, n.d.). Following McKinney-Vento guidelines, this school district had a liaison appointed to help identify students experiencing homelessness and a district-wide program to support them. Enrollment in this program was continuous and occurred throughout the school year as students’ statuses changed and/or were identified. School-based social workers received automatic notification when a student at their school was identified as experiencing homelessness and enrolled in the district-wide program. The social workers then worked closely with these students and families to reduce barriers to school enrollment and achievement.
In the context of school nursing, current state protocols did not include a standardized process for communicating this status of homelessness to the school nurse. Consequently, school nurses were often not involved in the care of these students, resulting in missed opportunities for health assessment and intervention. Frequently, the school nurse was only notified when students had a known medical condition and therefore were not able to help connect students experiencing homelessness with basic primary or preventative care if they did not have medical conditions. Together, these critical gaps threatened the district’s ability to ensure access to comprehensive health care and prevention of the negative health and academic outcomes shown to impact students experiencing homelessness.
The project team, led by a school nurse and the Director of Health Services, included ten school nurses with varying levels of leadership roles and experience working with students experiencing homelessness. District social workers, two district data engineers, and Health Services Information Technology (IT) staff were also team members. To support all project objectives, the team created a new health roster report for nurses to identify eligible students. This included students identified as experiencing homelessness and enrolled in the district-wide program. In addition to student names, the health roster report also included health information pulled from the district student database entered either by nurses or by parents on enrollment (Table 1).
To support the first objective, the team conducted a 5-item pre-survey to collect data on current processes and nursing care for students experiencing homelessness, nurse perceptions and ideas for this project, and nurses’ anticipated challenges and worries for this project. The team also created a health assessment checklist, as part of a district guideline, for nurses to use when performing the comprehensive health assessment. The questions in the health assessment were guided by evidence as well as data already available from the school district (Table 2). All nurses received training on the new guideline and process at a required, paid Professional Development Day. The team also communicated with district school social workers. To evaluate the new process, the team assessed nurse perceptions, including facilitators and barriers, four months post-implementation using a 20-item survey.
The project lead ran the health roster report at the start of project implementation to assess the number of eligible students. The new nurse-led workflow (Figure 1) was designed by the project team and included the following steps: (a) identify their students experiencing homelessness using the health roster report filtered for their school; (b) conduct a records review to assess for health gaps; (c) collaborate and coordinate health assessments; (d) perform the comprehensive health assessment using the approved form; (e) submit the completed health assessment form for centralized tracking; (f) make referrals to healthcare or community resources for identified health needs using the referrals resource guide; and (g) follow-up with the family to ensure the referral had been completed or the health need had been met.
To support the second objective, nurses were instructed to send all completed health assessment documents to the project lead. The project lead tracked the percentage of students with completed health assessments and reviewed de-identified data collected from the health assessments to characterize the health status and needs of eligible students.
To support the third objective, the team mapped the health assessment form to existing referral mechanisms and resources within the school district and community and created a referral resource guide for nurses to utilize when making referrals to healthcare based on the health assessment findings. Types of referrals and referral completion were assessed via the nurse post-survey.
The Plan-Do-Study-Act (PDSA) method was used as the implementation framework for this project. The PDSA method, also known as rapid cycle improvement, is an iterative, four-stage problem-solving model used for improving a process or carrying out change (Minnesota Department of Health, 2022). For this project, one cycle of PDSA was conducted with the team engaging in each step of the process, allowing for implementation of the new process, studying of the results, and intervening to make changes as needed. Future PDSA cycles will be conducted to evaluate and refine the new process.
Quantitative data from the nurse pre-survey (month 1) and post-survey (month 4) responses were analyzed using descriptive statistics. Qualitative data from the free text open-ended questions were evaluated for themes. Descriptive statistics were used to report the student population experiencing homelessness at the start (month 1) and end (month 8) of implementation; completion rates of health assessments; baseline health data; and types and completion rates of referrals.
This project was determined to be Quality Improvement by the [blinded institution] institutional review board. The data collected and presented are de-identified and are intended to be shared for educational purposes.
Fifty-four school nurses were invited to complete the presurvey. The response rate was 91% (n = 49). Only one school nurse reported their school had a process to notify the nurse of which students were experiencing homelessness prior to project implementation. Only 16.3% (n = 8) nurses reported providing healthcare interventions for students experiencing homelessness. Table 3 includes all pre- and post-survey results. Further, school nurses identified a system for notification and collaboration with other school staff as priorities in the new process. They also identified potential challenges to the new process including time, resources, stigma, and confidentiality.
A total of 25,420 student records were reviewed for eligibility. At the start of the project, 2.7% (n = 688) students were identified as experiencing homelessness via the health roster report. At the end of the project (8-months), 67% (n = 458) initial assessments were received by the project lead. Of the 458 students with completed initial assessments, 70% (n = 319) students did not need a comprehensive health assessment by the school nurse because the results of their record review showed no health needs. The remaining 30% (n = 139) students received either a partial or complete health assessment beyond the record review by the school nurse. In the final sample of 458 students, 71% (n = 323) were elementary level, 14% (n = 66) were middle school level, and 15% (n = 69) were high school level). Throughout the project period, an additional 482 students were newly identified as experiencing homelessness. It is possible that some of these students received initial assessments and associated follow up as they were identified. However, this was not tracked by the project team.
Student records from the record reviews (N = 458) revealed 34% (n = 154) students had a documented health condition, 80% (n = 367) had health insurance, 76% (n = 348) were compliant with school-required immunizations, 72% (n = 330) had a primary care provider (PCP), and 74% (n = 340) had seen their PCP in the last year. A total of 35% (n = 160) students met criteria for chronic absenteeism and 29% (n = 133) met criteria for chronic tardiness. Only 59% (n = 268) students had an established dentist, and only 40% (n = 185) students had seen a dentist in the past. Record review student health data is summarized in Table 4.
For the 139 students who received either a partial or full health assessment beyond the record review by the school nurse, 29% (n = 34) students had a known health condition, 75% (n = 98) had health insurance, 68% (n = 88) were up to date on immunizations, 68% (n = 81) had a PCP, and 58% (n = 61) had seen their PCP in the last year. Relating to dental care, 57% (n = 68) students had seen a dentist in the past and 25% (n = 27) had a current dental concern. Additionally, 28% (n = 31) students had a mental health concern. Of note, 40% (n = 40) families were agreeable to signing a release of information for communication between the school nurse and medical team. Student health assessment data is summarized in Table 5.
A total of 78.8% (n = 26) nurses reported making referrals to care following the assessments. As self-reported by nurses, 85.7% (n = 24) made referrals for dental care, 71.4% (n = 20) made referrals for health insurance, 57.1% (n = 16) made referrals for immunizations, 57.1% (n = 16) made referrals for vision/glasses, and 46.4% (n = 13) made referrals for establishing with a PCP. When asked about referral completion, 68.8% (n = 22) nurses reported that about 50% or less of referrals they made were completed by the student/family.
Fifty school nurses, representing each school, were invited to complete the post-survey. The response rate was 66% (n = 33). Of the responding nurses, 24 (72.7%) nurses reported providing interventions for students experiencing homelessness. Nurses reported on the number of their students needing health assessments completed and the average amount of time it took to partially or fully complete an assessment. See Table 3 for detailed results. Of the responding nurses, 75.8% (n = 25) nurses reported having assessments they attempted but were unable to complete, and barriers to completing assessments were further reported to include difficulty contacting the family, having other competing priorities, not having enough time, difficulty with family’s willingness to participate, and difficulty collaborating with other school staff. Nurses reported liking the increased awareness and focus on this student population, the new process itself, the assessment checklist, and new health roster report. Nurses shared more time, improved collaborative process, and improved identification/automatic notification as ideas for improvement. Of the responding nurses, 57.6% (n = 19) nurses agreed the process was easy to use, and 81.8% (n = 27) nurses agreed this project was meaningful to their work as a school nurse.
This project addressed a critical gap of assessing and addressing the health of students experiencing homelessness in a single metropolitan school district. The need for this work was confirmed by the pre-survey results, indicating that almost all schools in the district did not have a system in place for notifying the school nurse of which students were experiencing homelessness. Most school nurses were not providing interventions to support these students prior to project implementation, which is concerning given the known negative health outcomes for this population and the prime position school nurses are in to intervene and prevent negative sequelae (Gultekin et al., 2020).
On the pre-survey, school nurse ideas for improvement included a notification system and collaboration, both of which have been identified as facilitators to nursing intervention for people experiencing homelessness (McWilliams et al., 2022). The reported worries of stigma and confidentiality reflect literature that demonstrates stigma is commonly reported by people experiencing homelessness and is known to have a negative effect on health (Reilly et al., 2022). Additionally, nurses expressed concerns about time and resources needed to adequately support students experiencing homelessness, which is consistent with other literature surrounding barriers to school nurses providing care to students, such as those with chronic diseases (Uhm et al., 2020). All of these factors were considered when implementing this project. This was especially important for success as the school nurses included in this project were not actively aware of and were not supporting the health needs of this student population. Thus, when creating new processes, it is essential to understand the perceptions of those carrying out the implementation to promote adoption and fidelity of new protocols.
According to the Centers for Disease Control and Prevention (2021), more than 40% of school-aged children have at least one chronic health condition. Additionally, one study found that children experiencing homelessness were 2.5 times more likely to have health problems and three times more likely to have severe health problems than children with homes (Berti et al., 2001). However, only about one third of students in this project reported a known health condition. This is likely related to underreporting of conditions rather than improved health status. Reasons for this disparity are not clear and should be explored to ensure that students who experience homelessness and have health conditions receive adequate care and resources. Despite the lower rate of documented health conditions in this student population, identification of these students led to an increase in the number of students with health conditions for school nurses to manage. This increase in workload should be monitored to ensure sufficient staffing to meet health needs of students experiencing homelessness.
While most students in this sample were identified as compliant with vaccines, this must be interpreted carefully because only vaccinations required for school compliance were reviewed and the presence of a vaccine waiver was noted as being compliant with district policy. For example, this school district did not require Hepatitis A, Human Papillomavirus, Influenza, or COVID-19 vaccinations although these are recommended by the Centers for Disease Control and Prevention for school-aged children (Centers for Disease Control and Prevention, 2024). In addition, families have the option to sign a personal, medical, or religious waiver to be compliant. Together, a student that is identified as compliant could be one that has received only required vaccines or no vaccines at all. Because of this, compliance cannot be used as a measure of overall immunization status. Also, while most students were compliant, this percentage was still below that required for herd immunity for some diseases. For example, the percentage of vaccination needed for herd immunity for measles is 95% and in this population only 76% of students were compliant with school-required vaccinations, signaling that the herd immunity for this population may not be adequate (Desai & Majumder, 2020). This finding is consistent with and can help explain literature showing that children experiencing homelessness have higher rates of vaccine-preventable infectious diseases (Gultekin et al., 2020). Because this student population may experience challenges with health care access, future improvements could include offering immunizations in a school setting. Further, in future PDSA cycles, the team could investigate students’ immunization status for all recommended vaccines instead of solely assessing compliance with only school-requirements as a way to further protect the health of the population.
It is concerning that only about half of students in this sample reported having an established dentist or having seen a dentist in the past, especially when taken in combination with a quarter of students reporting a current dental concern. This is consistent with findings reported by the U.S. Department of Health and Human Services (2023), that families experiencing homelessness may face barriers to meeting their child’s oral health needs, and children experiencing homelessness are less likely to visit a dentist compared to children from families with low incomes who have stable housing. This is concerning given the many negative effects dental disease can have on health, academics, and overall development (Centers for Disease Control and Prevention, 2022). In future PDSA cycles, the team should continue to prioritize ensuring this student population receives dental care through the schoolbased dental program to hopefully mitigate barriers families face in meeting their child’s oral health needs.
Mental health is a growing public health concern, and about one third of parents reported a mental health concern for their child. According to the U.S. Department of Health and Human Services (2022), nearly 20% of children ages 3 to 17 in the United States have a mental, emotional, developmental, or behavioral disorder. One study found that the proportion of homeless school-age children with mental health problems was two to four times higher than poor children who were stably housed (Bassuk et al., 2015). While the team expected the percentage of students in this sample with a mental health concern to be higher and more aligned with the aforementioned studies, the prevalence of this concern among this sample cannot be dismissed. It will be important to prioritize mental healthcare for students in need for future PDSA cycles. Improvements could focus on ensuring students have access to school-based mental health services as well as available community resources. It could also be helpful to further assess what types of mental health concerns are most prevalent among this student population to compare to existing literature and further tailor appropriate school-based interventions.
In the context of academics, about one third of students met criteria for chronic absenteeism and chronic tardiness, similar to findings by the National Center for Homeless Education (2022), which found that 37% of students experiencing homelessness were chronically absent during the 2018–19 school year. While this project’s findings appear slightly lower, it is important to remember that these measures require 10 or more absences or episodes of tardiness. Therefore, assessments completed earlier in the school year would be less likely to have met these criteria. Nonetheless, this has important implications because chronic absenteeism and tardiness result in students missing substantial amounts of learning time in the classroom, further exacerbating negative academic outcomes of homelessness (Treglia et al., 2023). In future PDSA cycles, assessing these measures later in the school year would likely yield more accurate data.
An encouraging finding of this study was that about half of families were willing to sign release of information for the school nurse to communicate with the student’s medical team. This shows promising implications for future work as school nurses work to intervene and assist this population in accessing health services. This aligns with current literature stating that school nurses are in a key position to influence the health of students experiencing homelessness and are highly effective at engaging and producing positive health outcomes in this population (Gultekin et al., 2020; Weber, 2018).
At the end of the 8-month project implementation, an additional 482 students were identified as experiencing homelessness via the health roster report. This substantial increase reflects the dynamic nature of this population and suggests that health rosters should be generated more frequently to identify new students in the district throughout the school year, or perhaps automatic notification would be a more efficient means to notify the school nurse. Consequently, there were many students identified as experiencing homelessness who did not receive a health assessment from the school nurse. While their data could not be included in this study, it is important to consider how having a more complete set of health data could influence the results and conclusions and likely discover more unmet health needs. To ensure a more sustainable process, the team plans to employ a system that will automatically notify the school nurse when a student is newly identified as experiencing homelessness at their school and enrolled in the district-wide program. Automated systems will improve the timeliness of notification to the school nurse and reduce delays to increase the number of students receiving health assessments and referrals to health services.
Following the School Nurse Practice Framework, providing care coordination by connecting students and families to available health resources is an essential component of school nursing standards of practice (National Association of School Nurses, 2024). In this sample, most nurses made at least one referral to care, with the most common referral being for dental care followed by health insurance and immunizations, again demonstrating the importance of school nurse involvement to ensure access to basic primary care services. It is concerning that most nurses reported half or less of referrals being completed by the student or family, which unfortunately correlates with current literature. A study by Daughtry and Engelke (2018) found that, while school nurses could provide information and make referrals, the success of referral completion was largely dependent on parent follow-up, and this did not always occur. The low referral completion rates signal further research needed as to the best way to support these students and families in accessing health services to ensure health needs are met.
The sample size for the nurse post-survey was smaller, which could be attributed to many factors including the timing and length of the survey. Despite the smaller sample size, it was encouraging that the number of nurses providing interventions to students experiencing homelessness increased. Most nurses reported the new process was easy to use and the project was meaningful to their work as a school nurse. Nurses reported liking the increased awareness, nursing focus, and involvement in the care of this student population, as well as the process itself and resource documents. These findings demonstrate success of this project, especially when considering findings from a scoping review of the literature by McWilliams et al. (2022) which found that a lack of awareness about homelessness amongst healthcare professionals acted as a barrier to the appropriateness of service provision, and nursing attributes, skills, and knowledge can serve as facilitators for achieving increased access to care for this population.
Commonly reported barriers were time and competing priorities, aligning with a study by Davis et al. (2021) which found that most school nurses identified time, workload, and caseload as top impacts on their ability to practice as they would like. Nurses suggested an improved collaborative process that includes an automatic nurse notification as an idea for change, which might help to streamline communications and contact with families when they are first identified as experiencing homelessness. This could also potentially address the barriers of contacting families and their willingness to participate. Unfortunately, some nurses reported difficulty in collaborating with other school staff, which reflects previous documentation of lack of school nurse role clarity and consequent barriers to collaboration in interprofessional school teams (Reutersward & Hylander, 2017). Additionally, the results for the student health assessment responses were found to be highly variable. After investigating and conducting the nurse postsurvey, the variability was attributed to some nurses not always asking the complete list of health assessment questions, resulting in different sample sizes for each health assessment question. The lack of reliability with the nursing assessment was identified as a future focus for intervention.
When considering the workload for nurses and sustainability of this new process, the number of assessments, time to complete, incomplete assessments despite nursing attempts, and barriers faced signify the complexity in providing this level of nursing care to students experiencing homelessness. A study by Daughtry and Engelke (2018) argued that including social determinants of health in staffing formulae recognizes what most school nurses know intuitively: nursing care takes more time when families are disadvantaged and do not have the resources for optimal health care. This has important considerations for district budgeting and allocations.
Only some health information was required to be filled out on student enrollment, which made it difficult for school nurses to interpret while doing the record review if an item had no response. Additionally, the information in the record review may have changed since enrollment. This potentially could have led to some students not having health needs accurately represented in the record review, and thus not receiving a needed health assessment. Further, nurses were instructed to periodically re-run their health roster report to assess for newly identified/eligible students, but compliance with this was not directly assessed.
This project took place in a large, urban school district, with many resources already in place, and so conclusions might not be generalizable to other districts. Importantly, this school district already had a system in place to identify students experiencing homelessness, which is a critical first step that needs to be addressed prior to implementing further nurse-led interventions.
To support long-term sustainability, the new guideline and associated documents were uploaded to the district health services website, where other nursing guidelines are located. The team plans to continue to integrate this process into workflows that school nurses are expected to do monthly. This will support identification of eligible students throughout the continuous enrollment period for the program. Additionally, the multidisciplinary nature of this work should continue to promote teaming and inclusion of the nurse role in the care for these students. In the future, the team hopes to automate the notification to school nurses when students are identified as experiencing homelessness, like the notification that social workers receive. After successful and sustainable systems are in place, the team will shift focus from completed assessments to completed referrals.
Students experiencing homelessness have unmet health needs. Without this new process, school nurses would not have been able to identify their students experiencing homelessness, and many of these students would not have received a health assessment by the school nurse or potentially any health care professional. Evidence shows students experiencing homelessness are at risk for poor academic and health outcomes, but sustainable solutions to address this are limited in the literature (America’s Health Rankings, n.d.; Briggs, 2013; Damron, n.d.; Gultekin et al., 2020; National Alliance to End Homelessness, 2023; NCHE, 2022; NCSL, 2023). While school nurses are in a key position to intervene, they face many barriers in providing the care and assistance these students and families need. School nurses should be empowered to advocate for appropriate allocation, resources, and involvement in the care of these students. With appropriate systems in place, school nurses can intervene to ultimately improve health and academic outcomes for these students and help negate some of the negative effects of insecure housing.
The authors would like to thank Dr. Kathleen Montgomery, PhD, RN, PCNS-BC, for her contributions and mentorship throughout the project.
Samantha Starkey: Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Writing – original draft; Writing – review & editing.
Kari Stampfli: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Supervision; Writing – review & editing.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.
This project was determined to be Quality Improvement by the University of Wisconsin-Madison institutional review board. The data collected and presented are de-identified and are intended to be shared for educational purposes.
Samantha Starkey https://orcid.org/0009-0008-9054-4154
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Samantha Starkey, DNP, RN, CPNP-PC, is a School Nurse at Madison Metropolitan School District, Wisconsin.
Kari Stampfli, MS, RN, APNP, CPNP, is a Health Services Coach/ Lead Nurse at Madison Metropolitan School District, Wisconsin.
1 Madison Metropolitan School District, Madison, WI, USA
Corresponding Author:Samantha Starkey, DNP, RN, CPNP-PC, Madison Metropolitan School District, Madison, WI, USA.Email: samanthastarkey94@gmail.com
