The Journal of School Nursing2021, Vol. 37(6) 532–541© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519877436journals.sagepub.com/home/jsn
As numbers of culturally diverse students rise, struggles with language, cultural differences, and health care create challenges for school nurses. The focus of this quality improvement project was to utilize the National Standards for Culturally and Linguistically Appropriate Services (CLAS) as a framework to initiate cultural competency development among school nurses. Eighteen public school nurses attended programming that began with the webinar “CLAS is in Session,” an introduction to the standards as applicable to school nursing practice. Outcome measures included self-report of cultural awareness and sensitivity (CAS) and culturally competent behaviors (CCB). A greater percentage of nurses reported feeling “somewhat competent” after program completion, though CAS and CCB scores did not significantly change. Despite lack of measurable improvement in CCB, implementation of the CLAS Standards created an important starting point for CC programming.
school nurse, cultural competency, culturally diverse students, National CLAS Standards
The increasingly diverse population of the United States has created a rising number of English language learner students in public schools across the country (Whitman, Davis, & Terry, 2010). In 2016, an estimated 37,500 children were designated as refugees, with nearly 3 times as many arriving without legal status (Murphey, 2016). These students pose unique cultural and linguistic challenges for school nurses who must address health needs to promote school attendance and educational achievement. Unfortunately, most school nurses do not collectively reflect the diversity of their students, nor do they report receiving adequate ongoing cultural competency (CC) education to confidently provide care for the students at the level they prefer (Matza, Maughan, & Barrows, 2015). This widespread national challenge is exemplified in a midsize Midwestern school district experiencing significant growth in culturally diverse students with a strong presence of immigrant and refugee families. The students and families within the school system face language and cultural challenges such as understanding school exclusion and attendance policies. Oftentimes, they may have difficulty navigating the health-care system and delay seeking care, which can lead to increased absenteeism and decreased academic performance.
District school nurses recognize these health-related barriers to learning but often struggle to address them while experiencing busy health offices, language barriers, and a lack of ongoing CC education. The increased diversity in this geographical area is relatively new, with no longstanding programs or policies in place within the school district to address specific issues related to the health care of culturally diverse students. A recent community assessment reported the county is growing rapidly and projected to increase by 28% in the next 30 years, with racial and ethnic groups increasing faster than the state average (Carver County, 2017). A district needs assessment completed in 2017 revealed significant concern regarding the health of culturally diverse students from district school nurses and intercultural specialists (ICSs), whose role includes helping school staff connect with diverse students and families (Eastern Carver County Schools {ECCS}, 2018a). School nurses were specifically concerned about parental mistrust of the American health-care system and the need for greater dialogue pertaining to school health with immigrant and refugee families. ICSs shared family concerns regarding access to health care, differing views of health and wellness, and fear of deportation, which may create a barrier to seeking services from the County Health Department or school nurse. These health-related barriers to learning cannot fully be addressed without exploring CC development as a first step and an important component of school nursing practice as stated in the National Association of School Nurses’ (NASN) Framework for 21st Century School Nursing Practice under Community and Public Health (NASN, 2018)
A review of the associated literature began in Ovid, CINAHL, and PubMed, using the search terms school nurses, cultural competency, culturally diverse students, and school health. Limits to the search were English language and dates published after 2000. To search for measures of CC, the key words of cultural competency assessment and nurses were combined. A continued search for information on the CLAS Standards was completed by combining the terms National CLAS Standards and school health.
Culturally diverse students have unique health-care needs that impact attendance and academic achievement. Along with adapting to a new culture, language, and school system, students and families must interface with the American health-care system, where cultural beliefs may differ from their own (McNaughton, Hindin, & Guerrero, 2010). Different cultural groups may have varying definitions of health, illness, and what constitutes acceptable treatment, while also using folk medicine that may be unfamiliar to Western health-care providers (Whitman et al., 2010). The important consideration of how these cultural beliefs impact health and wellness has been emphasized by multiple sources (Gambol & Gambol, 2002; Mendonca et al., 2009). A 2016 report on child migrants and refugees (Murphey, 2016) noted that additional factors such as migration experience, family stability, and economic insecurity can impact the health status of immigrant and refugee students who may present to the school nurse with vague physical symptoms and psychological distress (Roche, Vaquera, White, & Rivera, 2018). Authors also highlight the importance of how income and health literacy impact the ability to access and understand the health-care system, which in turn affects the health of students and ability to perform in school (Gambol & Gambol, 2002; Mendonca et al., 2009; Whitman et al., 2010).
The School Nursing: Scope and Standards of Practice states that school nurses are to “practice in a manner that is congruent with cultural diversity and inclusion principles” (American Nurses Association and NASN, 2017, p. 63). Authors repeatedly highlight the need for culturally competent school nurse practice (Carr & Knutson, 2015; Lowe & Archibald, 2009; Mendonca et al., 2009), yet there is acknowledgement that many school nurses feel consistent levels of uncertainty when caring for culturally diverse students regardless of their educational background (Matza et al., 2015; Markey, Tilki, & Taylor, 2018). Although helpful documents such as the Guidelines for Implementing Culturally Competent Nursing Care (Douglas et al., 2014) exist, there is little in the literature to suggest what defines appropriate CC education designed specifically for school nurses, which may be related in part to the complex and qualitative nature of cultural competence in various settings.
The National Standards for Culturally and Linguistically Appropriate Services (CLAS) were created in 2000 and rereleased in an enhanced version in 2013 by the Office of Minority Health (OMH) through the U.S. Department of Health and Human Services (2017a) as a guideline of principles to reduce health-care disparities across health-care institutions (https://thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedCLASStandardsBlueprint.pdf). NASN collaborated with OMH in 2015 (Matza et al., 2015) to develop a webinar addressing how the standards relate to school health. Carr and Knutson (2015) suggest the development of CC education for school nurses could benefit from the incorporation of CLAS Standards, though no subsequent studies or projects were found demonstrating its specific use in this search. Despite the length of time since the inception of CLAS, there is relative unawareness of the standards and how to effectively implement them in many health-care settings (Barksdale et al., 2017).
The primary aim of this project was to increase school nurse CC by developing a more formalized CC program that introduced the National CLAS Standards and followed with the development of education and resources customized to meet the needs of this specific group. Jongen, McCalman, and Bainbridge (2018), along with Douglas et al. (2014), stress the importance of beginning with a cross-cultural approach to CC education that teaches general skills helpful to navigate cross-cultural situations and avoid stereotyping. However, to provide an accurate cultural assessment, the school nurse must also have knowledge of common cultural health beliefs of the major culturally diverse groups served (Douglas et al., 2014).
A secondary project aim was to increase the interprofessional collaboration between district school nurses and ICSs. The ICS group possesses the knowledge and expertise critical to understanding the needs of the specific cultural groups served, while the school nurses are the resident health experts familiar with local health resources and are comfortable navigating the community health system. A more intentional collaboration between the two groups might better address health-related issues for culturally diverse students.
The Theory of Reasoned Action, also known as the Reasoned Action Approach to Explaining and Changing Behavior, created by Fishbein and Ajzen in 2010 (Yzer, 2012), served as a psychological behavior change theory useful in this project. The general premise of the theory is that a belief held regarding a behavior will serve as a guide to determine whether the behavior is performed (Yzer, 2012). The theory also attempts to examine how certain influences or persuasions can impact attitudes, which when combined with subjective norms and perceived control can ultimately impact behavioral intent and behavior (Persuasion, 2017). In the case of developing CC, self-reflection on cultural beliefs and bias is part of the education used with the CLAS Standards and precedes the action of providing CC care. The goal was to provide insight on the importance of CC and education to equip and inspire the school nurses to deliver more culturally competent care to students that in turn will positively impact the student’s academic experience.
The program theory reflects both the desired effect of the project intervention and the process required to achieve it. Although appropriate CC educational content for nurses may vary among school districts, most public schools will have similar scheduling issues and may benefit from an understanding of the process considerations as shown in Figure 1, under “process theory.” This depicts the organizational and service elements necessary to deliver the program intervention. Limited professional days for school nurses to gather as a group, coordination of educational content with available speakers, room space, and follow-up all created the need for detailed planning to ensure project completion within the school year.
We used a one-group pretest–posttest design with convenience sampling to determine a baseline level of CC and assess whether change occurred after implementing CC education and programming utilizing the National CLAS Standards. Cost, feasibility, and ethical considerations associated with the public school setting were necessary in determining the most appropriate method for this quality improvement project.
Project approval was obtained from the district assistant superintendent and reviewed for human subject protection by the University of Minnesota using the online Institutional Review Board (IRB) determination tool to indicate quality improvement work that is exempt from IRB review. Information gathered from the ICSs and nurse participation in the survey were voluntary and not tied to job performance or evaluation. Students and families were not directly contacted or accessed for any portion of the project.
The project was completed in a suburban school district located in the Upper Midwest, consisting of 15 public schools with a total population of approximately 10,000 students. Participating school nurses included 17 registered nurses and 1 licensed practical nurse. The educational backgrounds of the school nurses ranged from associate degree to graduate level, with the majority holding a baccalaureate-level education. Age of the nurses ranged from 32 to 60. The district is also home to nine ICSs who provide services in each school, working directly with students, staff, and families in effort to close the achievement gap for culturally diverse students. The ICSs carry the common bond of immigrant or refugee status, or being related to an immigrant or refugee, giving them firsthand knowledge of the experience and relatability to the various cultural groups in the service area. The project team included the health services supervisor, the lead ICS, and program interventionalist.
Initial planning began early in the school year between the program interventionalist and health services supervisor to discuss how the program might look and to create a timeline. The preparatory components required to develop the program were to identify the needs of the district immigrant and refugee students and families and to identify the educational needs of the nurses. The program interventionalist received permission from the ICS supervisor to conduct separate interviews with each ICS, who were asked a series of questions designed to elicit knowledge and perceived needs of the culturally diverse students and families they serve. Each school building in the district has a unique blend of students, based on geographical area, therefore needs vary somewhat based on age and location of students. An anonymous summary of responses was created for the project team to discuss and for the nurses to review prior to the planned educational sessions. The educational needs of the nurses were identified by an open-ended question added to the preprogram questionnaire, which asked them to describe culturally related topics and resources they felt would help them in practice. The NASN webinar discussion guide also served as a helpful aid to further identify concerns for the nurses that could be summarized and reviewed by the project team for later use.
The program officially began by having participants view the webinar, The National CLAS Standards: CLAS is in Session, designed specifically for school nurses created by OMH and NASN (U.S. Department of Health and Human Services, 2017b). The free webinar and discussion guide are available on both the NASN and Think Cultural Health websites. The webinar offers an introduction to the National CLAS Standards and how they apply to school nursing practice with the principal goal of “Providing effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs” (U.S. Department of Health and Human Services, 2017a, p. 13). The accompanying discussion guide reviews the standards and allows for appropriate pause points to review case study examples and reflect upon real-life practice experiences and concerns. This session took place on a fall workshop day for approximately 2 hr, with the health service supervisor exiting during discussion so the first group of nurses could speak openly about their experiences and concerns without fear of job critique. The second group of nurses were to view the webinar on the next scheduled workshop day in January. The nurses were divided into two groups, elementary and secondary, to allow for required participation in building related programming as well. It was also anticipated the smaller group size might facilitate more dialogue during the webinar stop points.
The project team met several weeks later to discuss the ICS and nurse responses and begin to determine programming that would take place during the second half of the school year. Two educational and participative sessions were planned in follow-up to the webinar, for continued CC development on subsequent workshop days. The content of these sessions was designed to meet the specific needs of this nurse group and was determined by prioritizing predominant concerns noted on the questionnaire and webinar guide that could be addressed within the current school year. The nurse responses from the January group were also to be included after obtained. The sessions would be led by the ICSs and include understanding the role of the ICS, utilizing the language line, the culture of poverty, and a panel discussion of various health and cultural beliefs of the most prominent cultural groups represented in the school district. These topics are in accordance with CLAS Standard 4, to “educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis” (U.S. Department of Health and Human Services, 2017a, p. 13).
The project team planned to meet between sessions to review or make adjustments in the process or content as needed. The program interventionist was to administer the postprogram questionnaire on a final wrap-up day at the end of the school year to complete the yearlong programming and evaluate outcomes.
The intervention process was guided by the development of a project timeline, which included preplanned dates for the educational sessions, e-mail reminders to participating nurses, and other related actions and served as a “to-do” list throughout the school year. An attendance log was created to track nurse participation and served as an indicator for necessary follow-up. Nurses were to receive continuing education credits for attendance. An activity log was created to record project details as they occurred and proved helpful to evaluate the program process by comparing it to the timeline after each phase of implementation. Nurses were also encouraged to share feedback or suggestions throughout the process with the program interventionalist and/or health services supervisor.
Evaluation of effect was measured by utilizing the CC Assessment (CCA) survey, created by Myer-Schim, Doorenbos, Miller, and Benkert (2003) and modified in 2005 after expert review (Doorenbos, Myer-Schim, Benkert, & Borse, 2005). The CCA was developed based on the premise that CC consists of four components: cultural diversity, culture awareness, cultural sensitivity, and culturally competent behaviors (CCB). The authors note, “It is not expected that healthcare providers achieve complete cultural competence, but rather that they continue to strive to match their competencies to the specific populations and subgroups with whom they work” (Doorenboos et al., 2005, p. 326).
The CCA consists of two subscales that examine cultural awareness and sensitivity (CAS), and performance of CCB. The CAS subscale contains 11 items including a Likert-type response of “strongly agree, agree, disagree, strongly disagree, and no opinion.” The CCB subscale consists of 14 behavior-based items with response options of “always, very often, somewhat often, sometimes, few times, never, and not sure.” Scoring instructions for each subscale obtained by the corresponding author indicate that a larger total number suggests greater awareness and sensitivity as well as a greater number of CCB demonstrated. The CCA also assesses the nurse’s cultural diversity experience through several nonscaled questions relating to exposure to racial/ethnic groups. Although not created specifically for school nurses, it has been utilized in multiple practice settings and demonstrated acceptable reliability with a Cronbach’s α of 0.89 (n = 405 health-care workers) and adequate construct validity supported by factor analysis (Doorenbos et al., 2005). The most recent version of the CCA accessed (March 2016) also contained a Marlow–Crowne Social Desirability Scale, which is separate from the CAS and CCB and was determined not to be appropriate for use in this project.
The CCA was administered to the participating school nurses prior to viewing the CLAS webinar and again at the end of the school year when all educational sessions were completed. An open-ended question was added to the postprogram questionnaire to allow an opportunity for the nurses to comment on how they would like to see the health services department move forward with continued CC programming.
Evaluating the secondary aim of increasing interprofessional collaboration between the school nurses and ICSs was to be accomplished by completion of the programming as planned. This departmental-level partnership was new, so project completion alone would provide attainment of the goal. Determining plans for ongoing collaboration between departments would be discussed after the program was complete, and posttest results were analyzed.
Summary statistics using the SAS Version 9.4 software program were used to quantify survey responses, highlight trends, and note differences between pretest and posttest data. The CCA coding/scoring instructions, provided by the instrument’s authors, offered insight into the two CCA subscales. A summary of responses to the open-ended question on the posttest questionnaire was provided for the health services supervisor to aid in future educational planning.
The program intervention began in the fall, according to the proposed timeline. Careful consideration was required to create time for all participating nurses to view the CLAS webinar and allow for make-up opportunities if needed due to limited professional development days.
The elementary school nurses were to view the CLAS webinar in January; however, the workshop session was canceled due to a snowstorm, which created the need for modification of both the timeline and implementation strategy. The remaining late start or professional development days were to be reserved for the subsequent CC educational sessions; therefore, the elementary school nurses were asked to view the webinar and complete the discussion guide individually, with coverage for their respective health offices provided by program staff over a 2-week period. This process was time-consuming and less than ideal as the benefit of group discussion in response to the webinar was lost. However, the nurse responses were summarized as consistent with the secondary nurse group and used as planned to help define the subsequent educational sessions with the project team.
The first educational session that occurred on a February late start day was focused on the role of the ICS, how to use interpreter services, and the language line (the school district contracts with an outside service to provide interpreters via telephone for staff to communicate with non-Englishspeaking parents). The session was well received and had an attendance rate of 94.4%. The next session was scheduled for March and was to center on the culture of poverty, along with a panel discussion of ICSs to discuss common health beliefs of the predominant cultural groups within the district. Attendance was at 88.9% that morning; however, the afternoon panel discussion was canceled due to another snowstorm. Concerns regarding the inclement weather may have impacted nurse focus and retention of information learned. The last available late start day in May was added to the project timeline to make up for the panel discussion omitted in March. The final wrap-up day in June, which included administration of the postprogram questionnaire, had an attendance rate of 16/18 or 88.9%.
The timing of the educational sessions was restricted by the school year calendar and then further hampered by inclement weather. The intended schedule was to moderately space the sessions to facilitate continuation of discussion and keep the topics fresh in the minds of the participating nurses. Unfortunately, the larger gaps between sessions required greater review of previous sessions and decreased the time available for planned activities and Q & A.
The program outcomes are primarily highlighted by results of the CCA instrument’s two subscales: The Cultural Awareness and Sensitivity subscale (CAS) and the CC Behavior subscale (CCB). The preprogram CAS results were generally high for the group, with a median and modal score of 6 (range 1–7 with larger number signifying greater CAS per scoring instructions, Doorenbos et al., 2005). Postprogram results were similar, with a slight increase in scores ranging from 6 to 7 (see Figure 2). The scores on the CCB subscale also ranged from 1 to 7, with the higher score depicting a greater demonstration of CC behaviors. The preprogram scores ranged from 2 to 5.5, with a modal score of 4. Postprogram scores showed little change, with a slight increase of scores in the 3–4 range (see Figure 3). Question 5 on the CCA was a nonscaled self-report of CC, and asked, “Overall, how competent do you feel working with people who are from cultures different than your own?” The response options included “very competent, somewhat competent, neither competent nor incompetent, somewhat incompetent, and very incompetent.” Prior to the program’s educational sessions, 50% of participating nurses responded with “somewhat competent.” After program completion, 94% of participating nurses responded with “somewhat competent” (see Figure 4).
Additional information to note includes the number of racial/ethnic groups encountered in workplace over the last 12 months, which according to the CCA measures the nurse’s diversity experience. A greater number reflects greater exposure to diversity (Doorenbos et al., 2005). The reported responses ranged from 2 to 7.5, with a modal score of 6. This reflects the earlier acknowledgement of differences based on geographical location of the various schools in the district. The nurses were also asked whether they had any prior CC education. Sixty-six percent responded “yes,” with the majority noting it was employer-sponsored.
The findings of this quality improvement project support the development of a more formal CC education program for the district’s school nurses, using the National CLAS Standards NASN webinar as a launch point. However, it is not clear that CC was increased by the time of project completion based on scoring results obtained from the CCA. The nonscaled measure of self-reported CC did show favorable results with almost all nurses reporting to feel at least “somewhat competent” in caring for students of other cultures at the end of the program year.
The secondary aim of increasing collaboration between school health services and the ICSs was achieved as the ICS group readily agreed to provide the CC education and expressed a desire to continue future work in partnership with the nurses. The ICS group also expressed gratitude for recognition of their expertise and the opportunity to share their knowledge with the nurses in this capacity. Informal feedback from the nurses confirmed they also appreciated the concentrated time with the ICS group and the opportunity to benefit collectively from their expertise. Oftentimes, the information exchanged and conversations between each building nurse and assigned ICS are brief due to the nature of busy school days. The group setting for the educational sessions and opportunity to ask questions allowed for a more relaxed atmosphere and platform to address important cultural health issues.
Regardless of findings, all participants agreed this effort is important work and coincides with the mission of the school district to provide personalized learning (ECCS, 2018b). Although many nurses had exposure to prior district-wide CC education over the years, this was the first program specifically aimed at addressing how CC impacts the health of students, which was a strength of the project. Based on the literature search conducted at the initiation of the project, it may also be one of the first quality improvement projects to utilize the National CLAS Standards as a framework for developing CC education in school nursing.
While the outcomes cannot be directly associated with the program intervention, the progression of the project alone highlighted an important topic of concern to the district school nurses. The yearlong focus on the topic of CC provided a “persuasion,” as noted in the Theory of Reasoned Action (Yzer, 2012), that may influence future behavior by the nurses.
Although it was anticipated that CAS subscale scores might improve after program completion, the scores were high prior to programming, which albeit a positive problem to have, limited further improvement. The school nurse’s educational background may have contributed to the high level of CAS, considering many are baccalaureate prepared and have had some exposure to CC education as part of Baccalaureate Nursing curriculum. However, it is important to note that of the 66% of the nurses who reported having prior CC education, the primary source was listed as “employer-sponsored.” This could suggest a greater recollection of more recent CC education provided in the workplace as opposed to what was provided in college. Another interpretation is that scores reflected a higher “perceived” versus actual level of CAS.
Postprogram CCB subscale scores were not anticipated to significantly increase, with the recognition that two educational sessions would likely not be enough to produce a change in behavior. Another issue to note is the lack of district infrastructure currently available to support some of the nursing actions the CCB surveys in the questionnaire, which may have impacted results. One example is a question that asks whether the nurse documents a cultural assessment. The district’s current electronic health record does not have an area to document such an action. Purnell (2016) notes a widespread lack of tools available for evaluating the delivery of culturally competent care, based on current documentation systems.
The subscale scores also raise several issues to ponder. Does having a relatively high level of CAS necessarily correlate with a high level of CCB? We cannot assume that having an intellectual understanding of the concept is enough to automatically lead to a greater level of comfort in cross-cultural situations or a change in behavior. Awareness and sensitivity alone do not provide the tools for action. In this situation, the issue of time (or lack of) may be the intervening factor that when combined with knowledge and additional practice may yield more positive results.
The project costs were mainly time and resource allocation, along with minor costs for printing discussion guides and surveys. The project focus on CC utilized the entire allotment of nurse paid professional development days for the school year, which was necessary to create an initial impact, but at the cost of eliminating other professional development opportunities for the nurses and contributing ICSs. Continued education credits were given to the nurses for attending the educational sessions. The ICS group was given approval by the achievement and integration supervisor to spend the time required to collaborate and provide the presentations as part of their district role.
The project had multiple limitations. Although the CCA instrument has been utilized in public health nurse settings (Starr & Wallace, 2009), it was not specifically designed for school nurses, who have unique practice environments that require special consideration. The sample of the nurses was small, with imperfect attendance that likely impacted results. The total amount of time allotted for the educational sessions was likely not enough to fairly ascertain or expect a change in CC behavior. The attendance on the final day was further impacted by the discovery that two participants present did not complete the postprogram questionnaire. The project timeline was in accordance with available paid professional days for the nurses, but the spacing of educational sessions was less than ideal due to snow days. Modification of the timeline was difficult for the project team, having little or no control over the academic calendar or weather of the Upper Midwest.
This district is unique in having a group of ICSs, who provided the bulk of CC education for the nurses. The ability to have such a built-in resource without extra cost to the district was clearly an advantage that other districts may not have. The ICSs were also impacted by the weather-related timeline changes and required approval to share their time for the additional educational sessions added. Lastly, the National CLAS Standards do not provide a specific guide for school nurse practice. While this broad framework allows for customization of programs to each school district, the measurement of outcome achievement is difficult to define.
School nurses play a pivotal role in community health and deserve to have the necessary tools to provide individualized and culturally competent care to all students. This quality improvement project demonstrates that school nurses reflect high levels of CAS but desire and deserve ongoing CC education supported by the schools in which they serve. The project also highlights challenges that may arise when working with school nurses due to limited time away from the health office and academic calendar restrictions. School health programs are called to develop the capacity for nurses to deliver and document culturally competent care so that evaluation is possible and contributions to evidence-based practice can be made. Further studies on how the National CLAS Standards can prompt development of CC programs are encouraged, along with creative strategies to allow school nurses to lead this effort (see Table 1 for links to resources). Additional suggestions include partnership with local public health departments or academic institutions, who often have many available untapped resources. The formation of a culturally diverse community or parent advisory board could also be valuable in providing CC education as well as promoting a more trusting relationship between school staff and the community at large for those school districts that do not have a comparable ICS position.
The project exemplifies one approach to a yearlong CC education program for school nurses, using the National CLAS Standards as a framework to develop a greater understanding of CC and the specific needs of students served in the district. Two educational sessions alone were not enough to increase overall CC based on the CCA results; however, they did contribute to increasing the nurse’s perceived competency in caring for students from other cultures. Participants expressed a favorable response to the program and efforts made toward addressing the important topic of CC and diversity within the district.
The CC program cannot be sustained utilizing each school year’s full allotment of workshop days, but discussion is in progress to plan an annual CC programming day for the nurses. Discussion was also initiated regarding increased efforts to document CC assessment and create further infrastructure to support CC awareness and behaviors. One such development was the creation of an online CC resource library, placed on the district’s staff website in the health services area. The CC resource library provides access to vetted information that includes continuing education opportunities, language aids, health information resources, links to helpful websites, fact sheets, and so on. These tools allow nurses immediate access to information, which can support individualized care for culturally diverse students and the notion that CC cannot be a “one-size-fits-all” approach (Lowe & Archibald, 2009). The online access also exemplifies the need to reach school nurses through multiple avenues, based on their unique time frames and availability.
The National CLAS Standards provide an excellent starting point for discussion and the creation of CC programming for school nurses. The use of the CLAS webinar and general framework allows for the creative formation of programming suited for the unique needs of school health programs across the country. The Think Cultural Health website, along with the NASN website, offers no-cost resources to school nurses and others involved in the health of culturally diverse students.
Permission to utilize the CCA for this project was obtained from corresponding author Ardith Doorenbos in October 2017.
I would like to acknowledge the dedicated nurses of Eastern Carver County Schools and thank them for their participation in this project. I would also like to acknowledge project team member Virma Behnke for her time and contributions, along with the district intercultural specialists for their time and expertise.
All authors contributed to the design of the manuscript as well as to the analysis and interpretation of the data. They were equally involved in the revision process, gave final approval on the text, and as agreed to be accountable for all aspects of work ensuring integrity and accuracy. Manuscript was drafted by S. Hurrell.
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.
Stacey R. Hurrell, DNP, RN, LSN https://orcid.org/0000-0001-6452-7360
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Stacey R. Hurrell, DNP, RN, LSN, is a substitute school nurse at Eastern Carver County Schools, USA.
Tara L. Cliff, MPH, RN, LSN, is the Supervisor of Health Services at Eastern Carver County Schools, USA.
Cheryl L. Robertson, PhD, MPH, RN, FAAN, is a professor of Nursing at the University of Minnesota, USA.
1 Eastern Carver County Schools, Chaska, MN, USA
2 University of Minnesota, Minneapolis, MN, USA
Corresponding Author:Stacey R. Hurrell, DNP, RN, LSN, Eastern Carver County Schools, Chaska, MN 55318, USA.Email: srhurrell@yahoo.com
