The Journal of School Nursing2025, Vol. 41(3) 390–397© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231181351journals.sagepub.com/home/jsn
AbstractRates of diabetes in youth are rising and more than 1 million children have diabetes. School nurses are central to a school-aged child’s diabetes care and they must make important moment-to-moment decisions requiring understanding of and comfort with diabetes care and technology. The rapid changes in diabetes care and technology make ongoing education essential, yet access to up-to-date and practical education is limited for many school nurses. Integrating needs data and stakeholders’ input, this group developed Diabetes in School Health (DiSH) to address this gap. We adapted a well-established, innovative, and easily-accessible telementoring educational model, Project ECHO, to create a collaborative learning community. In the first year, 9 diabetes experts and >150 school nurses joined live DiSH sessions. DiSH has been well-received by the school community and next steps include expansion of DiSH to other states and study of impact of DiSH on health disparities.
Keywordscommunity of practice, telehealth, peer education, Project ECHO, health disparities, diabetes mellitus
Worldwide, the incidence and prevalence of diabetes (type 1 and type 2) in youth are rising and over one million children live with diabetes (Hamman et al., 2014; International Diabetes Federation, 2021). Diabetes management typically requires frequent testing of glucose levels and administration of insulin. Along with diabetes educators and clinicians, school nurses are critical in providing care and supporting families in successful diabetes management in childhood. The rapid changes in diabetes care and technology make ongoing education essential, yet access to up-to-date and practical education is limited for many school nurses. With this context in mind, this team aimed to identify the needs of school nurses to better provide excellent diabetes care to students who need it most. Consequently, the team created a process to develop and disseminate Diabetes in School Health (DiSH), a telementoring educational program to address the identified needs.
The purpose of this study was to identify the needs of school nurses to help address gaps in knowledge and education in order to support high-quality diabetes care for students and to establish a process to develop and disseminate a telementoring educational program to address the identified needs. The research question was: Is the proposed DiSH school nurse telementoring program needed, and if so, what form should it take and how should it be disseminated?
School nurses are expected to perform and appropriately delegate much of the practical management of diabetes care during the school day (Centers for Disease Control and Prevention, 2022). Keeping up with the advances in diabetes technology is challenging due to continually evolving modalities including insulin pumps, closed-loop hybrid systems, continuous glucose monitoring systems, and newer forms of insulin and glucagon. The National Association of School Nurses (NASN) has robust resources to support the school nurse’s role in chronic disease care, including diabetes care (Wilt & Jameson, 2021). The American Diabetes Association (ADA) directs school nurses to these resources as well, while providing additional resources about diabetes care for non-medical school personnel. However, few diabetes resources for school nurses and school health personnel are interactive, dynamic and keep up with the pace of the rapidly changing standards of diabetes care and technology.
Project ECHO (Extension for Community Healthcare Outcomes) is a virtual healthcare initiative that launched in 2003 (University of New Mexico, 2021). Project ECHO programs use a “hub and spoke model,” connecting specialists (hubs) with community providers (spokes). Originally used for primary care spokes, this model has since been adapted to educating other spokes, such as nursing home clinicians during peak COVID years (Dowling et al., 2020; Lingum et al., 2021). Project ECHO combines the concept of community of practice with the use of telementoring. A community of practice is defined as “a group of people who share a concern or a passion for something they do, and learn how to do it better as they interact regularly” (Wenger-Trayner, 2015, para 1). “During telementoring sessions healthcare providers use telecommunication technology to deliver and receive training, education, and support that builds healthcare capacity” (Health Resources & Services Administration, 2022, para 1). This format brings essential information to community members in a readily accessible medium. The Project ECHO model has been used successfully to educate school staff on a number of specific health conditions, including seizure management, traumatic brain injuries (TBIs), mental health, and diabetes (Lyons et al., 2022; McAvoy et al., 2022; McPhillips et al., 2021; Shimasaki et al., 2021).
McPhillips et al. (2021) used the Project ECHO model to educate school nurses on seizure management and increase access to seizure resources. Their study reported increased confidence and level of collaboration following participation in the program. Another ECHO adaptation was developed to support school personnel with management of TBI injuries (e.g., concussion), and guide when students should return to learning. This group found improvements in school personnel knowledge and self-efficacy (McAvoy et al., 2022). A 2022 study reported on an ECHO program to support mental health care in schools. This group reflected that an ECHO-based model may be a promising tool but the data was not robust enough to provide any causal conclusions (Lyons et al., 2022).
The most relevant application of Project ECHO was completed by Shimasaki et al. (2021). The group reported on a 4-week, 1-hour cohort Project ECHO program aimed at diabetes care training for school nurses in Colorado (Shimasaki et al., 2021). Shimasaki et al. (2021) reported effectiveness in “increasing school nurses’ self-efficacy, workplace support, professional satisfaction, and intentions to create practice change” (p. 315).
Our ambulatory pediatric diabetes practice at an academic diabetes center in the Midwest routinely interacts with school nurses through consultation on individual patients and when providing orders for medical management. One of our providers recognized the challenges and gaps in communication and education surrounding diabetes care in schools. There was also a need for increased partnership between school nurses and pediatric diabetes experts to work together to improve diabetes care in schools. With an understanding of the great impact of Project ECHO, she translated this idea into a grant-funded collaborative and interactive telementoring pediatric diabetes education program for school nurses, DiSH. The goal of the DiSH program is to have pediatric diabetes experts join with school nurses to build a community for ongoing collaborative learning and idea exchange related to diabetes care in schools. The potential value of this program resonated statewide with stakeholders in the school nurse community as well as locally in our pediatric diabetes clinic.
We proposed developing an adapted Project ECHO model with pediatric diabetes experts as the “hub” and school health offices (e.g., school nurses) as the “spokes”. This adaptation serves to build a community of learning where pediatric diabetes clinical team members and school nurses and health staff can engage, share ideas, and problem solve to improve knowledge of and comfort in providing diabetes care within the school setting.
We developed and administered an online program development needs assessment questionnaire (see supplemental material online). Questions were designed to:
(1) Gauge school nurse interest in the overall concept of an online collaborative telementoring program with pediatric diabetes experts to improve diabetes care in schools.
(2) Gather information about which topics would be of highest demand and most useful to the school nurses.
(3) Collect baseline information about their knowledge and comfort related to diabetes management in the school setting.
We accepted the possibility that program participants and survey recipients may be non-school nurses who work in schools to provide diabetes care for students (e.g., teachers, administrative staff, and health aides). This program development study was deemed exempt by the University of Wisconsin Institutional Review Board. In collaboration with the Wisconsin Department of Public Instruction, the questionnaire was distributed to school nurses throughout the state. We aimed to disseminate the DiSH program to all school nurses in Wisconsin, as most schools have students with diabetes, and care of each individual requires updated diabetes skills and education.
Our team collaborated with the American Academy of Pediatrics (AAP) to receive Project ECHO training and assistance with DiSH program development. We created a planning committee of experts, including a pediatric endocrinologist, clinical nurse specialist, school nurse liaison from the Wisconsin Department of Public Instruction, and support staff. We consulted the already active Project ECHO programs at our institution for program development guidance. Using the results from the initial needs assessment questionnaire of school nurses, feedback from our planning committee, and consultation with other Project ECHO programs, we created a program operations structure, marketing plan, and educational curriculum for the DiSH program. A visual reference is included in Figure 1. This plan included a list of session topics and content experts (diabetes providers, nurses, dietitians, mental health professionals, and experts in school policy). While we developed an initial curriculum, the plan was designed to be dynamic and adaptable over time based on continued needs assessments and feedback from local school nurse participants.
We offered monthly DiSH sessions late in the school day on the third Wednesday of each month during the school year. The hour-long sessions are hosted via an online video conferencing platform (Project ECHO Zoom). The program started with a short 10–15 minutes didactic presentation by pediatric diabetes experts followed by questions, shared experiences and case scenario discussions between the diabetes experts (hub) and school nurses (spokes). The didactic portion was archived and available for viewing between live sessions. A visual representation is presented in Figure 1. The program is intentionally designed to encourage engaging dialogue, collaborative learning, and community connections. Attendees earn 1 hour of continuing education credit for participating in each session. There is no fee to participate in the session or to claim continuing education credits.
The total distribution of the pre-program questionnaire (see supplemental material) was difficult to estimate as the link was distributed using a listserv and forwarding via email was encouraged. In total, 60 nurses responded to the online pre-questionnaire. See results in Table 1.
In 2020, the inaugural year of DiSH, we hosted eight DiSH sessions and one special COVID session for school nurses as the COVID-19 pandemic began. We also designed, produced, and disseminated three DiSH “a la carte” sessions. The “a la carte” sessions were pre-recorded didactic sessions related to diabetes care topics designed to be accessed on a more flexible schedule for school nurses and staff during school breaks. This inaugural curriculum is outlined in Table 2.
Over the first year, monthly session attendance varied (36–150 participants, mean: 92, median: 81), with geographic distribution in 412 schools throughout Wisconsin. As participants, the school nurses determined their level of engagement in the discussion portion of the session. DiSH committee members encouraged engagement by facilitating conversations between experts and school nurses and encouraging use of cameras and microphones (when available to participants).
To guide continual improvement adaptations, a questionnaire was distributed to participants intermittently throughout the inaugural season and feedback was continually incorporated.
Session structure was updated as needed, based on participant feedback and community of practice literature. A case study format was used to facilitate the discussion portion for the first five sessions. We then transitioned to using a dynamic scenario presentation with prompted questions, as this format seemed to foster more discussion and individual participant engagement. This also allowed the discussion to focus on more than one scenario with more anecdotes and practical sharing of experiences from school nurses and diabetes experts.
After the first two DiSH sessions, our implementation proved timely in early 2020 when the COVID-19 virus was declared a pandemic on March 11, 2020. We quickly redesigned the March 18, 2020 session to provide information relevant to school nurses about the emerging COVID-19 crisis by featuring a pediatric infectious disease and global health expert to discuss COVID-19 in the context of school. While not specific to diabetes, this session provided school nurses with timely and relevant information, and allowed for direct dialogue with an expert in the field. This demonstrated the benefit of adapting Project ECHO for DiSH as a vehicle for connection and communication between school nurses and pediatric specialists as well as planting the seed for expanding the scope of our work in the future. For the remaining sessions in spring 2020, we dedicated a portion of time in each session to again host an infectious disease expert to provide current school health guidance during the COVID-19 pandemic. In Augusts 2020 we also offered a special session for all school staff on returning to school during the COVID-19 pandemic. This session had 138 participants. While the pandemic has impacted human connectedness dramatically during lock-downs, the foundational use of teleconferencing has allowed for continued growth and connection within the DiSH community despite restrictions on in-person gatherings.
Building a community of practice is implicit in the Project ECHO model and also emphasizes the importance of open-mindedness, working closely within the particular practice community to better understand and meet needs. The DiSH program was designed to harness the strength and scope of Project ECHO to improve diabetes care in schools, while adding a dimension of dynamic and practical curriculum and continual improvement process. The only other Project ECHO program targeting school diabetes care to date was based in Colorado. Their project’s aim and inspiration were similar to our DiSH team, to improve care of students with diabetes. However, the Colorado ECHO program design, content, and dissemination of the program differed from DiSH in several ways.
First, Colorado’s program had a static curriculum based on evidence-based strategies for diabetes care. In contrast, the DiSH program used the school nursing assessment to create a dynamic curriculum to address the changing local educational needs.
Second, the Colorado ECHO followed a cohort rather than continuous format, and participation was limited to 20–30 maximum participants. This strengthened study data and its ability to make stronger conclusions, and may have fostered an intimate learning environment, but may have limited participant access to and networking as a result of the program. DiSH is a continuous format, where participants can attend as many or few of the sessions each school year as they choose and are available.
Finally, the Colorado ECHO was offered as a one-time 4-week program for the two study cohorts, whereas DiSH offers on-going monthly sessions throughout each school year, each with archived didactic videos accessible between sessions. The one-time format studied in Colorado may be ideal for foundational or refresher courses for school nurses but lacks the recurring support and relationship-building connectedness of a monthly continuous ECHO. The 4-week one-time static curriculum and cohort format of Colorado ECHO may be an excellent complement to the ongoing monthly dynamic curriculum and continuous format of DiSH ECHO. We hypothesize a new or seasoned school nurse wanting more focused training may prefer the Colorado ECHO, while other practicing school nurses that are interested in keeping up on changing diabetes care may prefer the format of DiSH ECHO. Future collaborative studies are needed to evaluated optimal application of these related but distinct Project ECHO models which both seem to have great potential to improve diabetes care in schools.
As we planned and offered DiSH sessions, we realized a need to expand our planning committee and expert speakers. The addition of a social worker to our planning committee provided a key perspective on the challenges of navigating the complexities of chronic illness for pediatric patients and families within our community. This addition informed our planning and enriched our discussion with school staff.
From the initial DiSH session, we have placed significant emphasis on pre-session planning and taking an organized approach to session management as outlined in Figure 1. We developed a process to outline our session and individual roles in a “DiSH Stage Notes” document that is circulated among our planning committee several days prior to the session (see supplemental material). Stage notes provide simple reminders and cues for the DiSH session team and serve to ensure that necessary work is carried out and key ideas are shared. Stage notes were updated with each session.
Participation by school nurses can vary by session. Some users may not have access to a camera or may not wish to join with video. Other users may have difficulty navigating the Zoom teleconferencing platform to share ideas or may be nervous to speak up during the session. We have tried to engage participants and make the online platform less intimidating by (1) asking participants to wave at the beginning of each session, (2) encouraging video-on when sharing stories and questions, (3) fostering a respectful and safe environment, and (4) refraining from archiving discussion portions of the session to protect open sharing, with the goal of more participants with video-on discussion time, even if not for the entirety of the session. Although only a subset of participants actively engage in the session discussion (active discussion using audio/video or chat function), feedback from participants suggests that this still results in meaningful discussions and allows those with less experience or comfort with technology to experience the community of learning and further their diabetes knowledge. We have also found that moving away from a structured case presentation to using questions that stimulate discussion lends a more relaxed, personable feel to the session and supports our goal of sharing and building a community of learning. We were able to create this community of learning while protecting student confidentiality. We continue to develop strategies and ongoing improvements to the DiSH Project ECHO program as we grow a dynamic, dedicated and engaged community of practice to improve diabetes care in schools.
DiSH was founded in 2019 with an aim to support school nurses to provide person-centered, high-quality diabetes care to children in the school setting. DiSH uses Project ECHO’s unique “spokes” and “hub” model to provide specialist expertise (hub) to school nurses and others in the school setting (spokes), a central location for the child’s diabetes care. Additionally, its unique telementoring format embraces a readily accessible, flexible, and conversational structure, using a dynamic and locally-tailored curriculum. This approach distinguishes DiSH from other available education resources in its ability to quickly adapt to the specific needs of the learners and provide an informal setting to have frank discussions and supportive conversation within a community of school nurse and diabetes experts. The setting also raises awareness of the ever-evolving changes to diabetes care and technology and highlights the health disparities seen in diabetes management.
We recommend other healthcare teams outside of Wisconsin consider replication of the DiSH program, tailoring content and design to local needs. We would be thrilled to directly support and engage with any groups interested and have included our contact information in this paper. Future aims of this group include analysis of DiSH’s impact on needs identified in pre-DiSH questionnaires, DiSH expansion to early childhood education (e.g., HeadStart), other states/regions, other chronic conditions (e.g., seizures, asthma, allergies), evaluation of DiSH’s impact on diabetes care and health disparities, and collaboration with other groups committed to improving diabetes care in schools.
The authors would like to thank the University of Wisconsin Department of Pediatrics as well as school nurses and health staff throughout Wisconsin for making this project possible. They would also like to thank David Allen, Ellen Wald, Jonathan Kohler, Bob Gordon, Ellie Chybowski, Reva Finkelman, Tori Benson and Daniel Moore for their support for Diabetes in School Health (DiSH).
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Cars Curing Kids [grant number 133-AAH7442, MSN238842].
Allison J. Pollock https://orcid.org/0000-0003-2361-4390
Santhi N. Logel https://orcid.org/0000-0003-2028-8518
Supplemental material for this article is available online.
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Allison J. Pollock, MD is an assistant professor and pediatric endocrinologist in the Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; an affiliate assistant professor in the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA and a honorary fellow in the Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Whitney N. Beaton, MSN is a clinical nurse specialist of Pediatric Diabetes in the University of Wisconsin Health, American Family Children’s Hospital, Madison, WI.
Bobbi A. Burgess, BS is a medical student in the University of Wisconsin School of Medicine and Public Health, Madison, WI.
Santhi N. Logel, MD is an assistant professor of Pediatric Endocrinology in the University of Virginia, Charlottesville, VA.
Louise Wilson, MS, BSN, RN, NCSN is a State School Nursing/Health Services Consultant in the Wisconsin Department of Public Instruction, Madison, WI.
Jolene Eggert Ciha, CCLS, APSW, a Social Worker in the Pediatric Specialty Clinics of the University of Wisconsin Health, American Family Children’s Hospital, Madison, WI.
Jaclyn Allen, DNP, RN is a clinical nurse specialist of Pediatric Diabetes in the Children’s Wisconsin, Milwaukee, WI.
1 Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
2 University of Washington School of Medicine, Seattle, WA, USA
3 Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
4 Pediatric Diabetes, University of Wisconsin Health, American Family Children’s Hospital, Madison, WI, USA
5 Pediatric Endocrinology, University of Virginia, Charlottesville, VA, USA
6 Wisconsin Department of Public Instruction, State School Nursing/Health Services Consultant, Madison, WI, USA
7 Pediatric Specialty Clinics, University of Wisconsin Health, American Family Children’s Hospital, Madison, WI, USA
8 Pediatric Diabetes, Children’s Wisconsin, Milwaukee, WI, USA
Corresponding Author:Allison J. Pollock, 4800 Sand Point Way NE, Seattle, WA 98105, USA.Email: Pollock8@uw.edu
