Digital Repository Doctoral Projects Spring 2021 Improving Pre-Kindergarten Child Health Outcomes by Integrating the Role of a Nurse Practitioner as a Health Consultant in a School-Based Setting Angela Curtis Page, MSN, APRN, PPCNP-BC Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Page, A. C. (2021). Improving Pre-Kindergarten Child Health Outcomes by Integrating the Role of a Nurse Practitioner as a Health Consultant in a School-Based Setting Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Improving Pre-Kindergarten Child Health Outcomes by Integrating the Role of a Nurse Practitioner as a Health Consultant in a School-Based Setting by Angela Curtis Page A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 25, 2021 Mary Anne Hales Reynolds PhD, RN, ACNS-BC Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director 1 Improving Pre-Kindergarten Child Health Outcomes by Integrating the Role of a Nurse Practitioner as a Health Consultant in a School-Based Setting Angela C. Page, MSN, APRN, PPCNP-BC Annie Taylor Dee School of Nursing, Weber State University April 24, 2021 2 Acknowledgements One of my greatest joys in life is being with healthy, happy children who are exploring their world, filled with imagination, energy, and love. They never cease to amaze me with their perspectives, expressions, curiosities, and ability to be mindfully present in each moment. Learning how to help young children be healthy and ready to learn has become my passion day and night for these past many months. Just ask my husband, Mike, who would listen to me as I eagerly shared morning musings that baked as I slept about how to increase children’s access to health services in educational settings here in Utah. Thank you, Mike, for not only listening to my many morning musings, but also patiently tolerating my late night marathons when you went to sleep alone. You are my best friend, editor, and cheerleader. Thank you for believing in me and supporting my many hours away from you to bring this project to fruition and give my dream a firm springboard into the future. My heartfelt gratitude goes to my children Sophie (and Steve), Daniel (and McKenzie), Annie (and Brandon), Mary, Gregory, Jonathan, and first grandchild, Olivia, for their constant support and encouragement to fulfill my educational goals and professional dreams. It was you all who brought me such joy as I watched you grow from sweet infants to capable, healthy, and happy adults. Mom, I still remember the nights you tucked me into bed and told me I would go to college one day, a privilege you never had and always wanted. You are still one of the best-educated women I know. Dad, thank you for supporting my college dreams for many, many years. Without you, I would not have been here today, continuing to learn and grow. To my sister, Natalie, we share a common vision of serving the emotional and physical needs of 3 students so they can be healthy and ready to learn. I can’t think of a better person to walk this road with and look forward to many more adventures together in this cause. My very special thanks goes to Camie Bearden, Director of the MSL Children’s School and principal of the WSU Charter Academy. I respect and admire your openness and eagerness to do whatever is best for the children and educators. Your vision of interdisciplinary teams serving Pre-K children is innovative and motivating. My thanks also goes to all the educators, staff, parents and children at the school. You are resilient, dedicated, bright and willing. Watching you live through the pandemic and continue with your lives and learning was inspiring to me. Not an easy task. Many, many thanks to my DNP project lead, mentor, and colleague, Dr. Mary Anne Reynolds. It is not easy to lasso a tornado, bring it into the barn, and then let the rain create a beautiful rainbow. Somehow you did what was not easy, and I thank you. And finally, my deep gratitude goes to Dr. Deborah Judd who took a chance on hiring me to play a part in the fledgling FNP program and the DNP program she envisioned and worked so hard with many others to get off the ground and into the air. I am one of many who are grateful for your passion, dedicated leadership and vision to produce capable FNP/DNP health care providers who will be serving the needs of Utahns across the lifespan for years to come. 4 Abstract Children between the ages of three and six are in a period of critical growth and development. A school-based preschool is an ideal location for critical early vision, hearing, speech/language, and immunization screenings to identify problems that could adversely affect a child’s learning ability. The purpose of this Doctor of Nursing Practice project was to improve pre-kindergarten health outcomes by integrating a Pediatric Nurse Practitioner (PNP) as a health consultant in a school setting. Pre-school and kindergarten health screenings were coordinated between the PNP, school educators, speech/language pathologists, and community partners. A tracking system was established, and data were gathered on students who were screened and referred to and received interventions. Parents and educators completed a post-survey that evaluated satisfaction with the PNP health consultant’s role. Immunization monitoring and intervention revealed that 99.5% of children were completely immunized compared with 94% of children the previous year. 30% of children were identified as needing referrals for health services compared to 8% from the previous year. The majority of parents and educators were extremely satisfied with the PNP’s role and expressed a desire for continuation. In a preschool setting, a PNP can positively impact population health management outside of the traditional medical setting. A school-based PNP improves healthcare access, thereby enhancing the common goal of improving young children’s health outcomes. Keywords well-child care, healthcare access, school-based health, preschool health screening, and immunizations 5 Improving Pre-Kindergarten Child Health Outcomes by Integrating the Role of a Nurse Practitioner as a Health Consultant in a School-Based Setting Health during preschool years influences health outcomes in adulthood. Quality education and health support in these early years can have a positive impact on well-being into adulthood (U.S. Department of Health and Human Services and U.S. Department of Education, n.d.). Timely and targeted health interventions support an optimal path for a preschooler’s overall growth and development (Leininger & Levy, 2015). A preschool environment is an ideal place for health care providers to access and assess young children (Gance-Cleveland & Yousey, 2005). For preschoolers and kindergartners (hereafter referred to as Pre-K) at The Melba S. Lehner (MSL) Children’s School and Weber State University (WSU) Charter Academy, timely and targeted on-site healthcare services and consultation are not readily available. Lacking on-site health services may adversely affect the Pre-K child’s overall health and thereby influencing the child’s educational achievement. The purpose of this Doctor of Nursing Practice (DNP) project, is to introduce a pediatric nurse practitioner (PNP) as a health consultant to the Pre-K educational team. The PNP can monitor, safeguard, and improve healthcare access in the form of immunization and health screenings and referrals in coordination with parents and Pre-K educators. Adding a nurse practitioner to the MSL Children’s School and WSU Charter Academy will significantly improve healthcare access and health outcomes for Pre-K children (Gance-Cleveland & Yousey, 2005). 6 Review of the Literature This literature review includes key elements of health care for Pre-K children, including well-child care, healthcare access, school-based health, and coordinated early intervention. These key elements address local, state, national, and international perspectives on defining and improving health outcomes for the Pre-K child. Historical perspectives, as well as up-to-date evidence, are included in this literature review. The databases used for this literature review were Cinahl, Medline, and ERIC. Google Scholar was also used to identify key articles. Well-Child Care Pre-K children are defined as children between the ages of three to five years (Center for Disease Control and Prevention (CDC), n.d.). Pre-K children typically are healthy and mainly require access to medical care for preventive services such as immunizations, education about nutrition, sleep, elimination, and accident prevention for long-standing health maintenance and good health outcomes (Leininger & Levy, 2015). These preventive services are considered well-child care. According to Kuo et al. (2006), well-child care is the surveillance of child growth and development provided by qualified individuals and focuses on the detection of and early intervention for health problems. Pre-K well-child care includes health supervision, developmental surveillance, school performance, psychosocial assessment, care coordination, and immunizations (American Academy of Pediatrics, 2020). The American Academy of Pediatrics (AAP) states that the assessment of immunization status is an essential aspect of Pre-K well-care (American Academy of Pediatrics, n.d.). Immunizations offer the benefits of a decrease in disease for the individual and for the community (Doherty et al., 2016). The United States has no federal policy about vaccine administration whereas vaccine policy is relegated to individual states and is usually required for 7 school entrance (Zier & Bradford, 2020). The Center for Disease Control (CDC) Vaccines at Four and Six Years of Age (n.d.) states that a Pre-K child needs the fifth dose of diphtheria, tetanus, and pertussis (DTaP), the fourth dose of polio (IPV), the second dose of measles, mumps, and rubella (MMR), the second dose of varicella, and an influenza vaccine each year. Another critical aspect of Pre-K well-child care is health screenings. Health screenings during well-child visits are an effective way to detect health concerns that can adversely impact the normal and healthy growth and development (Weber & Jenni, 2012). The AAP recommends Pre-K screening for vision, hearing, and speech/language deficits (American Academy of Pediatrics, 2020). An important aspect of performing these screenings is identifying the particular vision, hearing, or speech/language concern and referring the child for follow-up services to help rectify the problem thus facilitating normal development and education. (Weber & Jenni, 2012). Advanced practice nurses in Utah are uniquely licensed to diagnose, treat, correct, consult and refer for common health problems in preschool children, such as failed health screenings (Nurse Practice Act, 2013). According to the Utah Administrative Code R384-201, vision screening, referral, and intervention is required for all preschoolers and kindergartners in the state educational system (Utah Administrative Code, 2020). Hearing screening and referral is only recommended by the Utah Department of Health (UDOH) for kindergartners or those with suspected hearing loss (Utah Department of Health, Children with Special Healthcare Needs Bureau, Early Hearing Detection and Intervention, n.d.). Speech/language screening for kindergartners and preschoolers is only required in Utah by the Utah State Board of Education (USBE) if a child has an individualized education plan (IEP) (Utah State Board of Education, 2016). 8 Healthcare Access Pre-K children cannot care for their health alone. A child is dependent upon parents for access to healthcare, including well-child care. Levesque et al. (2013) state that healthcare access means not only that the child has health insurance, but health care is accessible for both the parent and the child. Parental access to well-child care for their Pre-K child is determined by economic, educational, and workforce status (Healthcare Workgroup First Things First, 2007). Healthcare is the provision of health services by licensed individuals trained and educated to prevent disease and restore health for individuals and groups (Merriam-Webster Medical Dictionary, n.d.). Access to healthcare is further explained by Goddard and Smith (2001) as “the ability to secure a specified set of healthcare services, at a specified level of quality, subject to a specified maximum level of personal inconvenience and cost, while in possession of a specified amount of information” (p. 1151). Access to quality healthcare services for individuals and populations is vital for promoting and maintaining health, and preventing and managing disease. Factors limiting access to healthcare can lead to unmet health needs, delays in receiving appropriate services, financial burdens, and preventable hospitalizations (Healthy People 2020, 2020). Leininger and Levy (2015) describe child health and access to medical care as having a supply side (i.e. health workers supplying the medical interventions) and the demand side (i.e. the parents seeking medical care for their children). They defend the notion that healthcare access alone does not improve child health, but healthcare access at critical times, places, and contexts does improve child health. They further state that the effective timing of healthcare access includes uninterrupted preventive health services such as well-child care and immunizations. Successful healthcare locations include placing healthcare providers in schools 9 to provide increased healthcare access to children regardless of socioeconomic status, chronic health condition, or low health literacy (Leininger & Levy, 2015). Healthcare access through well-child screenings may take place in a primary health care provider’s office, public health clinics, or in a community setting, such as a preschool or kindergarten. Well-child health screenings provided in a group Pre-K setting have positive overall health and educational outcomes (D’Onise et al., 2010; Donoghue, 2017; Gance- Cleveland & Yousey, 2005; Kuo et al., 2006; Leininger & Levy, 2015; U.S. Department of Health and Human Services and U.S. Department of Education, n.d.; Weber & Jenni, 2012). Vision screening performed by appropriately trained nurses can achieve a high level of specificity and sensitivity for detecting vision problems in preschoolers (Mathers et al., 2010). Hall (2016) suggests that nurses are adequate screeners for hearing loss. A systematic review conducted by The American Academy of Pediatrics (AAP) (2015) regarding speech/language screening lists nurses as trained screeners for speech/language problems in preschool children. Pre-K programs are also an excellent place to survey and document the immunization status of preschoolers and kindergarteners and assist in decreasing disease both for individuals and for the school community (Gance-Cleveland & Yousey, 2005; U.S. Department of Health and Human Services and U.S. Department of Education, n.d.; Zier & Bradford, 2020). According to Cupp & Curley (2020) it is the role of an advanced practice nurse concerned about population health to assure that smaller-scale documentation of immunization status as well as health screenings are connected to larger-scale data information bases, such as the USIIS system, to contribute to smaller and larger-scale population-based health outcomes. 10 School-Based Health According to Gustafson (2005), school-based healthcare is the delivery of basic health services to children on-site at a school. The blend of childhood education and childhood health began in the early 1900s with the first school nurse, Lillian Wald, visiting children who were absent from school and educating parents and children about treatment and preventive measures that would help them return to school. Over the years, this coordination of education and health services has led to the development of school-based health centers throughout the country (Gustafson, 2005). School-Based Health Centers (SBHC) seek to adapt the delivery of primary child healthcare services to children and families by focusing on the coordination of these services with educators, mental, social, and physical healthcare professionals (Gustafson, 2005). The AAP recognizes school-based healthcare access as an evidence-based approach to coordinated health services (Council on School Health, 2012). Presently, there are more than 2,500 school-based health centers across 48 states and U.S. territories that serve mainly elementary, middle school, and high school students with licensed physical and mental health care providers (School-Based Health Alliance, n.d.). Very few SBHC serve the preschool population (T. Alexander, personal communication, October 28, 2019). The 2018 State of Preschool Report of the National Institute for Early Education Research (NIEER) states that only 42 of 61 programs met the benchmark for the vision, hearing, and health screenings and referrals for the state-funded Pre-K initiatives (Friedman-Krauss et al., 2018). Coordinated Early Intervention Children whose health needs are not met consistently will have difficulty learning (U.S. Department of Health and Human Services, 2020). Pre-K children need timely access to medical services during infectious disease outbreaks, for chronic health or developmental conditions, or 11 when chronic stress or adverse childhood experiences create mental health impairments (Leininger & Levy, 2015). For example, a cross-sectional study by Kulp et al. (2016) demonstrates that uncorrected vision deficits in Pre-K children results in significantly worse performance on literacy tests. The AAP notes that high-quality Pre-K education includes immunizations, infection control, adequate nutrition, environmental safety, oral health, physical activity, injury prevention, emergency preparedness, and policies for children with special health care needs, and adequate staffing ratios and qualifications (Donoghue, 2017). A joint policy statement by the U.S. Department of Health and Human Services and the U.S. Department of Education regarding the alignment of health and early learning systems asserts that healthcare and early learning systems “operate in silos, missing key opportunities to maximize both the health and early learning outcomes of children” (n.d., p.3 para3). It is vital that health and early education systems coordinate services to help children and families thrive (U.S. Department of Health and Human Services, 2020). Evidence of that silo-type operation is seen in a systematic review by D’Onise et al. (2010) where they noted there were no great health benefits from only attending preschool. Not all preschools offer the same quality of care. High-quality early intervention programs provide the greatest short and long-term health and education benefits (Shaw & Goode, 2008). Health screenings, including immunization screening, offered in a school-based setting provide timely, targeted, and accessible health services that are important for the well-being of Pre-K children. The screening, treatment, and referral for those services are an important aspect of overall child health and wellness. Nurse practitioners provide “safe, high-quality, cost-effective, coordinated and comprehensive clinical care grounded in evidence–based practice…” (NONPF Board of Directors, 2015, para.4). The PNP is uniquely qualified by professional 12 education, national certification, and licensing to screen, document, and refer Pre-K children for identified health issues (Nurse Practice Act, 2019; Pediatric Nursing Certification Board, n.d.). This DNP project aims to provide those screening, documentation, and referral services at the MSL Children’s School and WSU Charter Academy in an accessible and coordinated way to improve child health outcomes. Theory Kotter’s Theory of Change was used to guide the change process that will take place within the WSU Children’s School and MSL Charter Academy (Finkleman, 2018). This theory described steps that a leader used to guide the process of change within an organization. These steps were: 1) create a sense of urgency, 2) build a guiding coalition, 3) form a strategic vision and initiatives, 4) enlist a volunteer army, 5) enable action by removing barriers, 6) create short-term wins, 7) sustain acceleration, and 8) institute change (Madsen, 2016). Kotter’s theory helped guide the leader to help others see a need for change and the importance of acting immediately. The leader then formed a coalition of people from within the organization that helped create the strategic vision that showed how the future would be different from the past and how the initiatives were directly linked to that vision. The concept behind Kotter’s theory of change was that large-scale change only occurred when the whole organization rallied around the vision and saw it as a needed opportunity for improvement. The guiding coalition recognized and removed barriers that blocked the change and then communicated and celebrated the steps toward improvement. Success continued to drive success as the whole community embraced the change and overcame barriers. Finally, the change was instituted when it became an integrated and routine part of the organizational vision, structure, and overall functioning (Madsen, 2016). 13 Kotter’s Theory of Change relates to this DNP project by explaining that adding health services and consultation to the existing early childhood educational team constituted a change in usual operating systems. The theory explained a method to effectively implement the changes. Before the intervention, the educational team was performing health screening, consultation, and referrals to the best of their ability. They saw a need for a streamlined, integrated, and thorough approach to conducting these health services within their organization led by a health care expert. There were gaps in follow-up, timeliness, and complete implementation of current health guidelines that affected the health and wellbeing of both the children and staff. The DNP leadership skill required to implement these changes was creating an urgent guiding vision as to how school-based health could improve the dual health and educational goals of early childhood development. Communicating this vision and creating streamlined workflows required educator and parental participation. As the administrative and educational staff saw success in improved workflows and child health and educational outcomes with implementation of school-based health, this sustained continued integration of the two services, instituting better coordination of the goals of early childhood health and early childhood education. Summary Pre-K well-child care in the form of health screenings and immunizations administered in a school-based setting can improve healthcare access and generate positive health and education outcomes for Pre-K children. The goal of this DNP project is to increase well-care access at the WSU Pre-K school program by introducing a PNP to consult with parents and educators to improve immunization, screening, and referral rates for vision, hearing, and speech/language difficulties. This collaboration of licensed and qualified health and education services will unify 14 health care providers, educators, families to support the wellbeing of MSL Children’s School and WSU Charter Academy Pre-K children individually and as a group. Project Implementation Plan Overall Goal and Outcomes The goal of this DNP leadership project was to increase preschool children’s access to basic health services in order to improve health outcomes. This was accomplished in three ways: 1) adding a nurse practitioner (NP) health consultant to the MSL Children’s School and WSU Charter Academy, 2) developing two aspects of school-based well-care: immunizations and health screening, and 3) implementing a referral tracking system for children who need further follow-up. Setting A university-based, accredited, public preschool/kindergarten with children ages 1 to 6 years old was the ideal setting for the DNP project to improve health outcomes by increasing access to healthcare and implementing a modified model of school-based health services. WSU Moyes College of Education, Department of Family Studies is located in Ogden, Utah. The Department of Family Studies houses The MSL Children’s School and the WSU Charter Academy is housed in the McKay building located northwest section of campus. The schools provide quality education and child-care for Pre-K from the surrounding community, as well as students and employees of Weber State University (Weber State University, n.d.). The school is also a learning lab for WSU students who are obtaining degrees in Early Childhood Education, Family Studies, and Social Work. The learning lab provides a setting where students can “learn about and practice teaching, curriculum development, program 15 management, or gain experience observing children so that they are better prepared for their future professions” (Weber State University, n.d.). In 2003, The WSU Children’s School earned the accreditation from the Association for the Education of Young Children (NAEYC) which is a prestigious recognition achieved by less than seven percent of early childhood education programs nation-wide This accreditation is voluntary and demonstrates that the MSL Children’s School desires to institute nationally-standardized health improvement activities such as health screenings, immunizations, safety guidelines, and sanitation procedures (Weber State University, 2003). The MSL Children’s School and WSU Charter Academy educators and board were supportive of adding a NP health consultant not only to maintain their accreditation status, but also to improve the stated DNP projected child health outcomes. Population The Children’s School cared for approximately 99 children between the ages of 0-6 years old and employed eight full-time teachers, 14 assistant teachers, and two paraprofessionals. In 2019, the children’s racial make-up at the school consisted of 71% Caucasian, 17% Hispanic, 5% Asian, 3% African American, and 2% Arabic. In 2019, the school also had approximately 35 children who qualified as economically disadvantaged (C. Bearden, personal communication, March 26, 2020). The children under 3 years old were in the after school/daycare program which is also a part of the MSL Children’s School and was not included in the qualifying numbers of Pre-K children’s health screenings and referral system. The parents were primarily students or employees of WSU and members of the community living in close proximity to the center. Resources 16 A resource available for immunization surveillance at the Children’s School was the Utah Statewide Immunization Information System (USIIS) (Utah Department of Health, n.d.-b). This state-wide immunization tracking system helped the school identify which children were fully immunized or exempt and which children needed to receive additional vaccines to meet the Utah guidelines for entrance into a preschool (Utah Department of Health, n.d.-a). This system was a no-cost system available to all registered preschools in the state of Utah. Another immunization resource was the Weber County Health Department and the child’s primary care provider.. There were two excellent resources available to assist with Pre-K vision, hearing, speech /language screenings. The Friends for Sight organization (Friends for Sight, n.d.) is a volunteer organization that services preschools and kindergarten to screen for visual impairment. This organization was scheduled by the educators to vision screen the children at both the MSL Children’s School and WSU Charter Academy fall of 2020. The MSL Children’s School and Charter Academy also had access to two speech/language pathologists who were contracted to performing hearing screenings and speech/language screenings. Barriers An anticipated barrier to the DNP project was the disruption of hearing, speech/language and vision screening due to the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV- 2) or COVID-19 pandemic. Due to the pandemic, the children were not in school to have their vision, hearing, and speech/language screenings for two weeks due to mandatory quarantine for positive COVID cases at the school. This required effective coordination and flexibility with the speech/language pathologist and tec to ensure each child had opportunity for screening. One speech/language pathologist gave birth during the fall and was not able to finish hearing and speech/language screenings on a few students. 17 Friends for Sight, a volunteer community service organization, came to the preschool to perform vision screening for each child. Due to quarantine during the pandemic, vision screenings were scheduled and rescheduled, but finally were completed. Ethical Considerations Ethical considerations were privacy of health and educational information. Requirements included obtaining informed parental consent to collect, manage, and support the health of the individual child and the population of children at the school. Health Information Portability and Accountability Act (HIPAA) and The Family Educational Rights and Privacy Act (FERPA) regulations were closely monitored and upheld. The rights of the parents to manage the health and education of their children in a culturally and family-centric manner were honored by parental consent for, participation in, and return of information from the health screenings. Project Implementation and Timeline The timeline began with the preparation phase in April 2020 with the finalization of the WSU Annie Taylor Dee School of Nursing (ATDSON) collaborative agreement. It continued with the development of a prototype hiring plan titled Pre-K School Health Consultant Hiring Plan (Appendix A) and prototype contract agreement titled Memorandum of Agreement (MOA) (Appendix B). The hiring plan included the minimum requirement of a bachelor’s of science in nursing (BSN) with experience in community/public or school health and current Basic Life Support (BLS) certification. The maximum requirement was an FNP (Family Nurse Practitioner (FNP) or PNP) with experience in community/public or school health and current BLS certification. For this DNP project, the nurse to be “hired” for the DNP project is a PNP with a master’s degree in nursing (MSN) with current BLS certification. 18 The implementation phase began after DNP project approval and review by the Institutional Review Board (IRB). The PNP evaluated health-related school policies and was introduced to educators during a board meeting and parents through an email announcement. PNP virtual visits to the school, due to pandemic precautions, created the opportunity to connect with teachers and administrators to establish trust and a positive working relationship. The DNP organized a data management and referral tracking system to measure the effectiveness of health and immunization screenings and referrals. A Likert scale survey was created to measure the educators’ and parents’ satisfaction with the addition of a PNP health consultant. The PNP assisted educators in obtaining preschool access to the USIIS (Utah Statewide Immunization Information System). It was during this implementation phase that data collection regarding immunization rates, vision, hearing, and speech/language screenings for the 2019-2020 school year were gathered for a comparison to the upcoming 2020-2021 school year. Pre-K health screenings were completed in March due to the interruptions in school schedules with four school and classroom quarantine closures. During this implementation phase, current data specific to passing or not passing vision, hearing, speech/language screening was gathered and evaluated by the PNP health consultant. PNP referrals for treatment were made to parents and coordinated with educators. The evaluation phase took place the later part of March 2021. During this time, final immunization status and data from screening and referrals were compiled and data analyzed. A three question Likert scale survey and one open-ended question (4 questions total) was emailed to parents and educators to ascertain their level of satisfaction with a PNP nurse consultant at the school. 19 Evaluation and Data Analysis Evaluation of the impact of the PNP role included records review of the number of immunizations, screenings and referrals. The record review also provided an opportunity to evaluate the effectiveness of the new tracking system. Data obtained from 108 records reviewed from 2019-2020 was compared with data obtained from 99 records reviewed in 2020-2021. A survey was emailed to parents and staff combined. The survey contained three Likert scale questions and one open-ended question evaluating the role of a PNP as health consultant during the fall of 2020. Immunization data for the 2020-2021 school year for 29 kindergartners and 70 preschoolers were tracked on a shared Google Sheets. The data showed an overall 5.5% increase in the number of completely immunized children in 2021. For preschoolers, data showed a percentage improvement in every immunization category measured from 2020-2021 as compared with data from 2019-2020. For kindergartners, the 2021-2020 data showed a 9% improvement as compared with last school year, in the percent of children of completely immunized, children with exemptions to all immunizations, and in the percent of children who were up-to-date with the MMR vaccine. The categories of percent of kindergartners with no immunization documentation and incomplete immunization at the time of enrollment were unchanged from 2020-2021 and 2019-2020, respectively. Vision screening for kindergartners showed no improvement in percentages of the total number of children screened (100% both years) and the percentage of children referred for services (100% both years). The percent of kindergartners receiving glasses after a failed screening in 2020-2021 decreased (75%) from 100% in 2019-2020. This decrease in percentage was due to the fact that one kindergartener failed vision screening last year and received glasses. 20 Four kindergarteners failed vision screening this year and only three r4eceived glasses. The one child not receiving glasses was due to parent preference. Preschooler vision screening did not take place in 2019-2020. In 2020-2021 the 68 preschooler vision screenings, referrals, and percentage of children receiving glasses after a failed exam improved from the previous year. Hearing screening for kindergartners showed improvement from 2019-2020 (88%) to 2020-2021 (100%). The percent of kindergartners failing the hearing screening and referred in 2019-2020 (10%) was not comparable to the percent of kindergartners failing the hearing screen and referred because no kindergartners failed the hearing screening in 2020-2021. No preschoolers received hearing screening in 2019-2020. In 2020-2021, 69% of preschoolers were screened for hearing loss, 7% were referred for services and 100% received intervention for the failed hearing screening as a scheduled visit to a medical provider to remove earwax before a repeat screening can be performed. Speech/language screening, referral, and intervention for kindergartners were 100% in 2019-2020 and 2020-2021 respectively. Speech/language screening was not performed for preschoolers in 2019-2020. In 2020-2021, 39% of preschoolers were screened for speech and or language concerns, 25% were referred for services, and 100% preschoolers received speech and/or language services. To determine the level of parent and educator satisfaction with the addition of a PNP as a health consultant to the MSL Children’s School and WSU Charter Academy, a three question Likert scale with one open-ended question survey were emailed to 135 persons with 44 responses (33% response rate). Ninety percent were somewhat or extremely satisfied, and there was one person (10%) who was neither satisfied nor dissatisfied with the role of the PNP.When asked about their level of satisfaction with a PNP as a health consultant for COVID consultations 21 during the fall of 2020, 90% were somewhat or extremely satisfied and only one respondent (10%) were neither satisfied nor dissatisfied with the role of the PNP. Comments of the satisfaction survey showed a 33% response rate. One-hundred percent were supportive of a PNP as a health consultant on a day-to-day basis for the 2021-2022 school year. A representative comment of support is “I believe a health care partnership is essential to any school setting and is even more essential for the early development years. I applaud MSL and WSU charter for building this partnership and I would highly recommend this partnership to continue and grow in as many ways as possible.” Twenty-three percent of respondents were not aware that a PNP was consulting with the Children’s School and Charter Academy for health screenings, immunizations, and COVID consultations; two of these three respondents indicated they were in support of the role. Thirty-one percent of respondents indicated support of a PNP for COVID consultations. One statement highlighting this sample of COVID-related consultative responses stated, “I do appreciate all the protocol that was put into place and do feel like the school was safe, but I would have had more trust in the COVID recommendations knowing they were coming from a medical professional and not from the school or government.” Discussion, Recommendations, and Conclusions Discussion The PNP acted in a leadership role for this project by analyzing resources needed for health screenings and immunizations, assessing gaps in those resources and implementing interdisciplinary solutions for those gaps. The many facets of this project included immunization monitoring, vision screening with referral and follow up as well as hearing and speech/language screening with referral and follow up. The following discussion includes resources and barriers 22 encountered by the PNP leader and educators and how those resources were used to fill in gaps noted and solutions implemented to keep the focus on helping the preschool or kindergarten child be healthy and ready to learn. Before implementing the quality improvement project, staff and administration collected the state-required paper student immunization records from parents and recommended needed immunizations. Difficulty for administrators arose when a parent did not have a child’s immunization record, there were questions about exemption status, or immunization acquisition, and in returning immunization documentation to administrators. Also noted was the difficulty for parents providing complete immunization records because of a family move, change of health care provider, or change in insurance. A multidisciplinary team decided that implementing the computer-based Utah State-wide Immunization Information System (USIIS) for the preschool and kindergarten would be helpful. Barriers were overcome through locating lost immunization records, completing incomplete records, and understanding what student immunizations were still needed. A shared Google Document was created between the administrators and the PNP. The results of the combined effort of the administrators and PNP resulted in improved immunization rates from the previous school year. Anecdotally, the administrators reported decreased frustration and time in finalizing the immunization report required by the state when a PNP was assisting. Before the quality improvement project was implemented, the kindergarten and preschool vision screenings were scheduled by administrators with a community non-profit organization who would come once to offer vision screening for the students who were present that day. The educators and the non-profit group would then attempt to contact the parents of children who failed the vision screening and ask that the child be seen by a vision specialist to determine if 23 vision correction was indicated. The community non-profit group would help the parents who did not have health insurance secure the child’s vision examination and glasses if needed. The preschool children did not receive vision screening services 2019-2020 because of the restrictions placed on gatherings to reduce the spread of the virus at the beginning of the COVID-19 pandemic. Any preschoolers or kindergartners who were absent the day of the vision screening were not screened. The PNP attempted to screen all the kindergartners and preschoolers who were absent on the day of the vision screening or who were new to the school since the vision screening date by borrowing a vision spot screener from the local Head Start Preschool. Two preschoolers were absent again on the day of the PNP rescreen attempt. The added screening effort by the PNP resulted in approximately 18 more preschooler’s vision screened and four more preschoolers referred for vision services. The preschool and charter academy administrators hired a speech/language pathologist and speech/language technician to screen all the kindergarten children and provide speech/language services to those needing intervention, as per USBE Special Education Rule (Utah State Board of Education, 2016). Preschoolers were not routinely screened for speech and language difficulties. The speech/language professionals would perform hearing screening for the kindergarteners. The PNP attempted to perform a hearing screening for all the kindergartners and preschoolers who were absent on the day of the original hearing screening or who were new to the school since the hearing screening date by borrowing a hearing Oto-Acoustic Emissions (OAE) screener from the local Head Start Preschool. All the kindergartners were screened for hearing difficulties and 48 of the 70 preschoolers, who were present on the day of the screening, were screened for hearing loss by the PNP. The added screening effort by the PNP resulted in 24 five preschoolers identified and treated for hearing loss and seven preschoolers identified and referred for speech/language impairment. The results of the PNP as a health consultant satisfaction survey clearly revealed the desire for parents and educators to have ready and trusted access to a health care provider who has a unique interest in the growth, development, health, and education of their child while at school. Parents leave their valued and vulnerable preschool or kindergarten child in the care of licensed adult educators for 3.5 to 8 hours during the day while many are at work and inaccessible for immediate physical intervention if a health concern arises. Health care consultation with a medical home primary care provider is not quickly and simultaneously accessible for educators and parents in a school-based setting. Immediate and simultaneous access to a PNP consultant for a health concern during school relieves concern and stress for parents and educators alike when student health-related issues arise. COVID-19 Pandemic The pandemic was an unexpected challenge to health screenings and immunizations. Pandemic control efforts decreased children’s access to immunizations, vision, hearing, and speech/language screenings, and interventions throughout the 2019-2020 and the 2020-2021 school year. The administrators, families, and students experienced major disruptions in learning activities, hygiene, and check-in/check-out routines. There were three sets of multiple day quarantine classroom closures, during the fall of 2020 and the spring of 2021 when COVID-19 cases were confirmed at the school. Everyone expressed anxiety over teacher and student mask-wearing, intensive cleaning procedures, and fear of becoming infected with the virus. Constantly changing protocols and the unknown nature of the virus spread and whether masks were mandatory and evidence-based for preschoolers and kindergartners, contributed to the anxiety 25 and stress experienced by educators, administrators, families, and children. Therefore, the project was adapted through persistence with scheduling vision and speech/language screeners, longer data collection time and more parental contact through phone calls and emails instead of face-to face interactions. An unexpected role for the PNP was in delivering COVID health consultations. Widespread and effective communication about PNP as a health consultant during the pandemic was complicated by the role not being formally addressed in the project’s scope, yet finding it desired by the education team and within the legal and ethical scope of the PNP practice, the PNP took part in COVID protocol formation, board meetings, and formal and informal educator in-service precaution training. Recommendations Based on the key lessons learned from this DNP project, recommendations for continuing the integration of a PNP as a health consultant and improving child health outcomes are: 1) generate and secure increased trust between educators, parents, and the PNP through continual interactions and role development, 2) further cultivate the legal and financial contracts between the educators and PNP, and obtain the needed screening equipment, 3) develop a seamless documentation system, such as a software application, for managing and integrating health and education data, and 4) expand the role of the nurse practitioner outside the traditional clinic setting to include health promotion, health education and illness treatment through use of a Hiring Plan (Appendix A) and Memorandum of Agreement (MOA) (see Appendix B). 26 Conclusion The project data demonstrate that when a PNP is involved in health screenings and consultation in a school-based setting, health outcomes improve. Unimpaired vision, hearing, speech/language capabilities as well as communicable disease immunity are essential for a child to be healthy and ready to learn. Educators are not licensed to prescribe health promotion and disease prevention practices for their students, yet they are charged by rule, law, or expectation to address health issues that affect student learning. Interdisciplinary teams, including medical, mental, and educational professionals, are essential to a whole-child learning approach, with each discipline complementing the discipline of the other in creating a more effective health and learning outcome for the student. 27 Reference List American Academy of Pediatrics. (n.d.). Immunizations. https://www.aap.org/en-us/advocacy-and- policy/aap-health-initiatives/immunizations/Pages/Immunizations-home.aspx American Academy of Pediatrics. (2020). Bright futures guidelines and pocket guide. https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/ Pages/default.aspx American Academy of Pediatrics (AAP). (2015). Screening for speech and language delay in children 5 years old and younger: A systematic review. Pediatrics, 136(2), e448–e362. https://doi.org/10.1542/peds.2014-3889 Center for Disease Control and Prevention (CDC). (n.d.). Child development: Preschooler (3-5 years old). https://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/ preschoolers.html Center for Disease Control (CDC). (n.d.). Vaccines at four to six years. https://www.cdc.gov/vaccines/parents/by-age/years-4-6.html Council on School Health. (2012). School-based health centers and pediatric practice. Pediatrics, 129(2), 387–393. https://doi.org/10.1542/peds.2011-3443 Cupp Curley, A. L. (Ed.). (2020). Population-based nursing: Concepts and competencies for advanced practice (3rd ed.). Springer Publishing Company. https://doi.org/10.1891 /9780826136749 Doherty, M., Buchy, P., Standaert, B., Giaquinto, C., & Prado-Cohrs, D. (2016). Vaccine impact: Benefits for human health. Vaccine, 34, 6707–6714. https://www.sciencedirect.com /science/article/pii/S0264410X16309434 28 D’Onise, K., Lynch, J. W., Sawyer, M. G., & McDermott, R. A. (2010). Can preschool improve child health outcomes? A systematic review. Social Science & Medicine, (70), 1423– 1440. https://doi.org/10.1016/j.socscimed.2009.12.037 Donoghue, E. A. (2017). Quality early education and child care from birth to kindergarten. Pediatrics, 140(2), 1–6. https://doi.org/10.1542/peds.2017-1488 Finkleman, A. (2018). Quality improvement: A guide for integration in nursing. Jones and Bartlett Learning. Friends for Sight. (n.d.). Friends for Sight. https://www.friendsforsight.org/ Gance-Cleveland, B., & Yousey, Y. (2005). Benefits of a school-based health center in a preschool. Clinical Nursing Research, 14(4), 327–342. https://doi.org/10.1177/1054773805278188 Goddard, M., & Smith, P. (2001). Equity of access to health care services: Theory and evidence from the UK. Social Science, 53(9), 1149–1162. https://doi.org/10.1016/S0277- 9536(00)00415-9 Gustafson, E. M. (2005). History and Overview of School-Based Health Centers in the US. Nursing Clinics of North America, 40(4), 595–606. https://doi.org/10.1016/j.cnur.2005.08.001 Hall, J. W., III. (2016). Effective and efficient pre-school hearing screening: Essential for successful early hearing detection and intervention (EHDI). The Journal of Early Hearing Detection and Intervention, 1(1), 2–12. https://digitalcommons.usu.edu/cgi/ viewcontent.cgi?article=1016&context=jehdi 29 Health Workgroup First things First. (2007). Child health-definition [Fact sheet]. http://www.azftf.gov/WhoWeAre/Board/Documents/Program%20Committee/Health/Jan uary%2013,%202011%20Meeting%20- %20Health/07%20Child%20Health%20Definition%20Recommendation.pdf Kuo, A. A., Inkelas, M., Lorstein, D. S., Samson, K. M., Schor, E. L., & Hafton, N. (2006). Rethinking well-child care in the United States: An international comparison. Pediatrics, 118(4), 1692-1702. http://link.gale.com/apps/doc/A153304550/AONE?u=ogde72764& id=zotero&xid=d94f8ab6 Kulp, M. T., Ciner, E., Maguire, M., Moore, B., Pentimonti, J., Pistilli, M., Cylert, L., Candy, T. R., Quinn, G., & Ying, G. (2016). Uncorrected hyperopia and preschool early literacy: Results of the vision in preschoolers - hyperopia in preschoolers (VIP-hip) study. Opthalmology, 123(4), 681–689. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4808323/pdf/nihms741639.pdf Leininger, L., & Levy, H. (2015). Child health and access to medical care. The Future of children / Center for the Future of Children, the David and Lucile Packard Foundation, 25(1), 65–90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978135/ Levesque, J. F., Harris, M. F., & Grant, R. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12(18), 1-9. https://doi.org/10.1186/1475-9276-12-18 Madsen, S. (Director). (2016). Kotter’s 8 Step Change Management Model [Film; Video file]. Project Manager.com. https://www.youtube.com/watch?v=7qlJ_Y8w5Yk 30 Mathers, M., Keyes, M., & Wright, M. (2010). A review of the evidence on the effectiveness of children’s vision screening. Child: Care, Health and Development, 36(6), 756–780. https://doi.org/10.1111/j.1365-2214.2010.01109.x Merriam-Webster Medical Dictionary. (2020). Definition of HEALTH CARE. https://www.merriam-webster.com/dictionary/health+care Nurse Practice Act, Utah. Stat. 58-31b-101 (2013). https://dopl.utah.gov/laws/58-31b.pdf NONPF Board of Directors. (2015). The doctorate of nursing practice NP preparation: NONPF perspective. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/DNP/NONPFDNP StatementSept2015.pdf Office of Disease Prevention and Health Promotion. (n.d.). Healthy People 2020. Healthy People 2020. https://www.healthypeople.gov/ Pediatric Nursing Certification Board. (n.d.). Certified pediatric nurse practitioner-primary care. https://www.pncb.org/cpnp-pc School-Based Health Alliance. (n.d.). Census. https://www.sbh4all.org/ Shaw, E., & Goode, S. (2008). Fact sheet: Vulnerable young children. The University of North Carolina Chapel-Hill. https://ectacenter.org/~pdfs/pubs/factsheet_vulnerable.pdf U.S. Department of Health and Human Services. (2020). Aligning Health and Early Learning Systems. U.S Department of Education. https://www.acf.hhs.gov/ecd/health U.S. Department of Health and Human Services and U.S. Department of Education. (n.d.). Policy statement to support the alignment of health and early learning systems. [Policy brief]. https://www2.ed.gov/about/inits/ed/earlylearning/files/health-early-learning-statement. pdf 31 Utah Administrative Code. (2020, January 1). Rule R384-201 School-based vision screening for students in public schools. https://rules.utah.gov/publicat/code/r384/r384-201.htm#/T1 Utah Department of Health. (n.d.-a). Immunization Program: School and early childhood program requirements. https://immunize.utah.gov/school-early-childhood-program-requirements/ Utah Department of Health. (n.d.-b). Utah State-wide Immunization Information System (USIIS). https://immunize.utah.gov/usiis/ Utah Department of Health, Children with Special Healthcare Needs Bureau, Early Hearing Detection and Intervention. (n.d.). Utah school-age hearing screening protocol. Utah Department of Health. https://health.utah.gov/cshcn/pdf/EHDI/Utah%20K- 12%20Hearing%20Screening%20Protocol.pdf Utah State Board of Education. (2016, October). Special education rules. https://www.schools.utah.gov/file/bff61848-ae42-4265-a654-6dae5f398507 Weber, P., & Jenni, O. (2012). Screening in child health: Studies of the efficacy and relevance of preventive care practices. Deutsches Ärzteblatt International, 109(24), 431–435. Weber State University. (n.d.). The Melba S. Lehner’s children’s school. https://www.weber.edu/childrensschool Weber State University. (2003, January 30). Melba S. Lehner Children’s School earns NAEYC accreditation. Weber State University. https://www.weber.edu/WSUToday/013003NAEYCO.html Zier, E., & Bradford, D. (2020). To attend or not to attend? The effect of school-immunization exemption policies on enrollment rates for prekindergarten, kindergarten and elementary-aged youth. Vaccine, 38(11), 2578–2584. https://doi.org/10.1016/j.vaccine.2020.01.079 32 Appendix A Pre-K School Health Nurse Consultant Hiring Outline Position Title Pre-K School Health Nurse Consultant Requisition Number (Human Resources) Position Number (Human Resources) Responsible Hiring Manager /Supervisor Camie Bearden EEO Category (Human Resources) FLSA (Human Resources) Campus Location Weber State University Campus-Ogden UT Weber State University Community Center Campus-Ogden UT Position Category Hourly Contracted Hours per Week 4-6 Weeks per Year 9 months Hourly Pay Rate 25-70 dollars per hour, depending on qualifications Job Summary/Basic Function Health Consultant will provide evidence-based, early childhood health and wellness consultation and services for The Melba S. Lehner Children's School and the Weber State University Charter Academy with the intent to improve the physical and mental health and wellness of the children, parents, and staff at the school. Required Qualifications BSN Nursing, with current licensure in the State of Utah. Current Basic Life Support (BLS) certification by the American Red Cross. Preferred Qualifications DNP or MSN Nursing, Family Nurse Practitioner (FNP) or Pediatric Nurse Practitioner (PNP), FNP or PNP national certification and current licensure by the State of Utah as an Advanced Practice Registered Nurse (APRN). Current basic life support (BLS) certification by the American Red Cross. Additional Information Experience with primary care, acute and chronic care of children and community/public/school health experience preferred. Background Check? Yes Funding Information Please provide the index code (6 digits) and organization code (5 digits) for the funding source for the position. If the position will be funded from multiple sources. Please add a listing for each source and include the percent funded from each source. Index (6 digits) (Human Resources) Org (5 digits) (Human Resources) Percent (must equal 100) (Human Resources) 33 Proposed Job Duties Job Duties: List in order of importance, and in detail, the job function and duties assigned. 1. Children’s health screening supervision and referral for vision, dental, nutrition, speech and language, hearing, and mental/emotional health. 2. Immunization status evaluation and closed referral loop for each child and staff member 3. Chronic disease school management for children with diabetes, asthma, anaphylaxis, heart disease, epilepsy, etc. 4. Consultation and coordination with parents, staff and primary care providers for the children’s health needs that affect learning. Posting Detail Information Number of Vacancies 1 Job Open Date tba Review Date tba Job Close Date tba Open Until Filled tba Search Committee Chair Access Camie Bearden Notes to Applicant To apply, complete the online application, attach a resume, and a cover letter. If you are hired, please keep in mind that you will need to complete a Memorandum of Agreement prior to beginning work. The screening of applicants will begin immediately. Criminal Background check is required as a condition of employment. **This is a pooled position. Applicants are selected from the pool as positions become available. After a period of time, the pool will expire and applicants will be notified Notes to HR This position is a contracted in-department position hired by Camie Bearden and paid through a purchase order arranged by Camie. Advertising Sources WSU Website, Indeed, Glassdoor, Utah department of workforce services Index (Human Resources) Pass Message Thank you for your interest in this position. The screening and selection process is currently underway and will continue until a successful candidate is chosen. Should review of your qualifications result in a decision to pursue your candidacy, you will be contacted. Fail Message Thank you for your interest in this position. Based on your responses to the questions on the employment application, you do not meet the minimum qualifications for this 34 position. Please do not let this discourage you from applying for other positions that interest you. Quick Link for Direct Access to Posting http://jobs.weber.edu/postings/8964 (example only) ADA Essential job Function Physical Activity of this position (Please check all that apply) Stooping. Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full motion of the lower extremities and back muscles. , Kneeling. Bending legs at knee to come to a rest on knee or knees. Crouching. Bending the body downward and forward by bending leg and spine. , Reaching. Extending hand(s) and arm(s) in any direction. Standing. Particularly for sustained periods of time. , Walking. Moving about on foot to accomplish tasks, particularly for long distances or moving from one work site to another. Talking. Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. , Hearing. Perceiving the nature of sounds at normal speaking levels with or without correction. Ability to receive detailed information through oral communication, and to make the discriminations in sound Physical Requirements of this Position (Please check only one block) Light work. Exerting up to 20 lbs of force occasionally and/or up to 10 lbs of force frequently and/or a negligible amount of force constantly to move objects. Use of arm and/or leg controls exerting forces greater than that for sedentary work. Visual Acuity Requirements Including: color, depth perception, and field of vision. Corrected visual acuity to 20/40 with adequate depth perception and field of vision for adequate physical examination of students. Color vision is not required. The conditions the worker will be subject to in this position. (Please check all blocks that apply) The worker is not substantially exposed to adverse environmental conditions (such as in typical office or administrative work). 35 Appendix B Memorandum of Agreement This Memorandum of Agreement (MOA) is made on (date) by and between the Melba S. Lehner (MSL) Children's School and Weber State University (WSU) Charter Academy, Weber State University, Moyes College of Education, 1351 Edvalson St, Dept. 1301, Ogden, Utah, 84408- 1301, hereinafter "The MSL Children's School and WSU Charter Academy" and (RN/FNP/PNP), hereinafter "Health Consultant". The parties hereby bind themselves to undertake a Memorandum of Agreement ("Agreement") under the following terms and conditions: TERM. The term of this Agreement shall be 9 months unless terminated sooner in accordance with the terms of this Agreement (the "Term"). GOALS AND OBJECTIVES. Health Consultant will provide evidence-based, early childhood health and wellness consultation and services for the MSL Children's School and WSU Charter Academy with the intent to improve the physical and mental health and wellness of the children, parents, and staff at the school. The Parties to this agreement shall abide by the terms of this agreement to achieve the following goals and objectives: The following goals will bring about these improvements: 1) Improve the children’s physical health through immunization services, vision, hearing and speech and language services/screening and providing acute and chronic illness management during school hours. 2) Improve interprofessional collaboration through consulting on children with individualized developmental, physical or mental health or educational needs. 3) Strengthening parental involvement regarding mental and physical health issues encountered in early childhood that may include, but not be limited to parent surveys, permission to coordinate services with their Medical Home, provide educational offerings and collaboration with specific mental and physical health concerns while at school. 4) Improving staff consultation support through staff surveys, educational offerings and student/child health consultation. 5) Health Consultant will work collaboratively with the MSL Children’s School and WSU Charter Academy Staff and Administrators and/or Board Members to jointly institute quality early childhood health and wellness improvements. OBLIGATIONS OF THE PARTIES. The MSL Children's School and WSU Charter Academy shall perform the following obligations: 1. The MSL Children's school and WSU Charter Academy shall provide access to the computer and paper files of the children and such administrative files as deemed necessary to make and complete the stated goals. 2. The MSL Children’s school and WSU Charter Academy shall provide Health Consultant access to communicate with children, staff, and administrators/board members regarding the goals of this memorandum. 36 Health Consultant shall perform the following obligations: 1. Health Consultant shall provide the health and wellness services to the MSL Children’s School and WSU Charter Academy as stated in the previous five objectives. CONFIDENTIALITY. Subject to sub-clause (2) below, each party shall treat as strictly confidential all information received or obtained as a result of entering into or performing this Agreement. Each party may disclose information which would otherwise be confidential if and to the extent: (i) required by the law of any relevant jurisdiction; (ii) the information has come into the public domain through no fault of that party; or (iii) the other party has given prior written approval to the disclosure, provided that any such information disclosed shall be disclosed only after consultation with and notice to the other party. RELATION OF THE PARTIES. The nature of the relationship between MSL The Children's School and WSU Charter Academy and Health Consultant is that of two independent contractors working together to achieve a common goal. CONSIDERATION. This Agreement is being made in consideration of the following: 1. The MSL Children’s School and Charter Academy shall provide a payment to Health Consultant of $70 per hour for 4 hours a week starting (Date), and until the end of this contract. Payment will be made based on the number of hours worked for each entity. REPRESENTATIONS AND WARRANTIES. Each party to this Agreement represents and warrants to the other party that he/she/it:- (a) has full power, authority and legal right to execute and perform this Agreement; (b) has taken all necessary legal and corporate action to authorize the execution and performance of this Agreement; (c) this Agreement constitutes the legal, valid and binding obligations of such party in accordance with its terms; and (d) shall act in good faith to give effect to the intent of this Agreement and to take such other action as may be necessary or convenient to consummate the purpose and subject matter of this Agreement. TERMINATION. Either party may terminate its performance of related obligations under this Agreement if the other party fails to rectify a material breach under a portion of this Agreement within thirty (30) days of receipt by the breaching party of written notice of such breach from the non-breaching party. In such case, the non-breaching party shall be entitled, without further notice, to cancel that Party's involvement pursuant to the agreement, without prejudice to any claim for damages, breach of contract or otherwise. The parties agree that the failure or termination of any portion or relevant provision of this Agreement will not be a basis for terminating other severable obligations or provisions of this Agreement, unless the failure or breach is such that the entire Agreement loses substantially all of its value to the non-breaching party. 37 Any termination of this Agreement shall not absolve the Parties from the obligation to observe the confidentiality measures and other restraints as set out herein. REMEDIES ON DEFAULT. In addition to any and all other rights a party may have available according to law, if a party defaults by failing to substantially perform any provision, term or condition of this Contract (including without limitation the failure to make a monetary payment when due), the other party may terminate the Agreement by providing written notice to the defaulting party. This notice shall describe with sufficient detail the nature of the default. The party receiving such notice shall have 14 days days from the effective date of such notice to cure the default(s). Unless waived by a party providing notice, the failure to cure the default(s) within such time period shall result in the automatic termination of this Agreement. WORK PRODUCT OWNERSHIP. Any copyrightable works, ideas, discoveries, inventions, patents, products, or other information (collectively the "Work Product") developed during the course of work under this Contract will remain the exclusive property of the party who created the work or idea. Upon request, the other party to this contract will execute all documents necessary to confirm or perfect the exclusive ownership of the party who created the work or idea to the Work Product. FORCE MAJEURE. If performance of this Agreement or any obligation under this Agreement is prevented, restricted, or interfered with by causes beyond either party's reasonable control ("Force Majeure"), and if the party unable to carry out its obligations gives the other party prompt written notice of such event, then the obligations of the party invoking this provision shall be suspended to the extent necessary by such event. The term Force Majeure shall include, without limitation, acts of God, fire, explosion, vandalism, storm or other similar occurrence, orders or acts of military, or civil authority, or by national emergencies, insurrections, riots, or wars, or strikes, lock-outs, work stoppages. The excused party shall use reasonable efforts under the circumstances to avoid or remove such causes of non-performance and shall proceed to perform with reasonable dispatch whenever such causes are removed or ceased. An act or omission shall be deemed within the reasonable control of a party if committed, omitted, or caused by such party, or its employees, officers, agents, or affiliates. ARBITRATION. Any controversies or disputes arising out of or relating to this Agreement shall be resolved by binding arbitration in accordance with the then-current Commercial Arbitration Rules of the American Arbitration Association. The parties shall select a mutually acceptable arbitrator knowledgeable about issues relating to the subject matter of this Agreement. In the event the parties are unable to agree to such a selection, each party will select an arbitrator and the two arbitrators in turn shall select a third arbitrator, all three of whom shall preside jointly over the matter. The arbitration shall take place at a location that is reasonably centrally located between the parties, or otherwise mutually agreed upon by the parties. All documents, materials, and information in the possession of each party that are in any way relevant to the dispute shall be made available to the other party for review and copying no later than 30 days after the notice of arbitration is served. The arbitrator(s) shall not have the authority to modify any provision of this Agreement or to award punitive damages. The arbitrator(s) shall have the power to issue mandatory orders and restraint orders in connection with the arbitration. The decision rendered 38 by the arbitrator(s) shall be final and binding on the parties, and judgment may be entered in conformity with the decision in any court having jurisdiction. The agreement to arbitration shall be specifically enforceable under the prevailing arbitration law. During the continuance of any arbitration proceeding, the parties shall continue to perform their respective obligations under this Agreement. CONFIDENTIALITY. Both parties acknowledge that during the course of this Agreement, each may obtain confidential information regarding the other party's business. Both parties agree to treat all such information and the terms of this Agreement as confidential and to take all reasonable precautions against disclosure of such information to unauthorized third parties during and after the term of this Agreement. Upon request by an owner, all documents relating to the confidential information will be returned to such owner. NOTICE. Any notice or communication required or permitted under this Agreement shall be sufficiently given if delivered in person or by certified mail, return receipt requested, to the addresses listed above or to such other address as one party may have furnished to the other in writing. The notice shall be deemed received when delivered or signed for, or on the third day after mailing if not signed for. ASSIGNMENT. Neither party may assign or transfer this Agreement without prior written consent of the other party, which consent shall not be unreasonably withheld. ENTIRE AGREEMENT. This Agreement contains the entire agreement of the parties regarding the subject matter of this Agreement, and there are no other promises or conditions in any other agreement whether oral or written. This Agreement supersedes any prior written or oral agreements between the parties. AMENDMENT. This Agreement may be modified or amended if the amendment is made in writing and signed by both parties. SEVERABILITY. If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If a court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited. WAIVER OF CONTRACTUAL RIGHTS. The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party's right to subsequently enforce and compel strict compliance with every provision of this Agreement. GOVERNING LAW. This Agreement shall be governed by and construed in accordance with the laws of Utah. 39 SIGNATORIES. This Agreement shall be signed on behalf of the Melba S. Lehner Children's School and Weber State University Charter Academy by Camie Bearden, MEd and on behalf of Health Consultant by (name of health consultant and credentials) and effective as of the date first written above. Melba S. Lehner Children's School and Weber State University Charter Academy: ___________________________________ By: Camie Bearden, MEd (Health Consultant‘s Name): ___________________________________ By: Health Consultant’s Name and Credentials 40 Appendix C Preschool Pre-Consultant 2019-2020 N=108 Post-Consultant 2020-2021 N= 70 Improved Not Improved No change % of total immunized 97% 99 % Improved Kindergarten Pre-Consultant 2019-2020 N=34 Post-Consultant 2020-2021 N=33 Improved Not Improved No change % of total immunized 91% 100% Improvement % children with exemptions to all immunizations 9% 0% Improvement % children with no immunization or exemption documentation 0% 0% No change % children with incomplete immunization at the time of enrollment 3% 3% No change % children up-to-date MMR 91% 100% Improvement 41 % children with exemptions to all immunizations 5% 0% Improved % children with no immunization or exemption documentation 97% 0% Improved % children with incomplete immunization at the time of enrollment 2% 1% Improved % children up-to-date MMR 99% 100% Improved 42 Appendix D Kindergarten Vision Screening Pre-Consultant 2019-2020 N=33 Post- Consultant 2020-2021 N=29 Improved Not Improved No change % of total screened 100% 100% No change % children failing screen referred 100% 100% No change % children failing exam received glasses 100% 75% Not improved Preschool Vision Screening Pre-Consultant 2019-2020 N=108 Post-Consultant 2020-2021 N=68 Improved Not Improved No change % of total screened 0 % 97% Improved % children failing screen referred 0% 100% Improved % children received intervention 0% 20% Improved Kindergarten Hearing Screening Pre-Consultant 2019-2020 N=33 Post-Consultant 2020-2021 N=29 Improved Not Improved No change % of total screened 88% 100% Improvement % children failing screen/referred 10% 0% Not applicable % children received intervention 0% 0% No change Preschool Hearing Screening Pre- Consultant 2019-2020 N=108 Post- Consultant 2020-2021 N=70 Improved Not Improved No change % of total screened 0 % (108) 69% Improvement % children failing screen/referred 0% 7% Improvement % children received intervention 0% 100% Improvement Kindergarten Speech/Language Screening Pre-Consultant 2019-2020 N=34 Post-Consultant 2020-2021 N=29 Improved Not Improved No change % of total screened 100% 100% No change % children referred for services 18% 31% No change % children received intervention 100% 100% No change 43 Preschool Speech/Language Screening Pre-Consultant 2019-2020 N=108 Post-Consultant 2020-2021 N=70 Improved Not Improved No change % of total screened 0% 39% Improved % children referred for services 0% 25% Improved % children received intervention 0% 100% Improved 44 Appendix E Health Consultant Satisfaction Survey (Qualtrics) Extremely Dissatisfied Somewhat dissatisfied Neither Satisfied nor Dissatisfied Somewhat Satisfied Extremely Satisfied 1.Overall, how satisfied are you with having a pediatric nurse practitioner as a health consultant in the fall of 2020 for immunizations, vision, hearing, and speech/language screening for the MSL Children’s School and WSU Charter Academy? 0% 0% 10% 20% 70% 2. Overall, how satisfied are you with having a pediatric nurse practitioner as a health consultant in the fall of 2020 for COVID consultations for the MSL Children’s School and WSU Charter Academy? 0% 0% 10% 15% 75% Definitely would not Probably would not Not Sure Probably would Definitely would 3. Would you want to have a pediatric nurse practitioner as a health consultant on a day to day basis for student and staff health issues in the coming school year? 0% 0% 9% 27% 62% 45 4. If you would like to share any additional comments about your thoughts on a pediatric nurse practitioner as a health consultant for the MSL Children’s School and WSU Charter Academy, please enter them below. 1. I was actually not aware of the pediatric NP at the WSU school. I think that is fantastic and would have loved to have known about it. I very much appreciate the flu vaccine clinic. I am curious if my daughter, in the 1-year old classroom, was screened for hearing, speech, etc. If so, I would love to know what the results were. I understand certain services may be reserved for certain children tagged as needing each service. 2. I didn’t personally get to interact with the PNP. Perhaps it was more for the older Kindergarten aged children? 3. I think it would be helpful for staff to have access to the pediatric NP for questions and concerns about the students/children 4. I appreciate all she did to help the school with Covid19. Early screening is important for all children. 5. For us, we are well covered and cared for through our normal pediatrician. However, I am a principal at a school without any healthcare support and would LOVE to be able to have a health care professional available for the many many students who do not have access or stability like we do. I believe a health care partnership is essential to any school setting and is even more essential for the early development years. I applaud MSL and Wsu charter for building this partnership and I would highly recommend this partnership to continue and grow in as many ways as possible. 6. The flu clinic this year was great! So well run, and so convenient. 7. This is a value add for many of us! Thank you for your service! 8. It would be nice to have an NP that could help with child anxiety treatment, as that was something we've needed this year for our student. 9. I'm an economist, so I want to know the costs and benefits before I say I do or do not want something. The only part we participated in (I think) was the flu shot clinic, which was nice, but had it not happened, we would have gone to our pediatrician's flu clinic. But glad we were able to help someone on their way to their Dr. of nursing practice. 10. Thank you for helping us prepare for this crazy year during Covid. Answering our questions before school started helped us to have a clearer idea and some fear gone surrounding all things Covid. 11. I feel that having a pediatric nurse practitioner this past year has been a huge asset. The Age of Covid has, certainly, added extra challenges, but even in a "normal" year, having someone who we can contact about concerns that we as teachers have identified, or that families have communicated to us is so helpful. In addition, having someone with the 46 contacts needed to schedule sight, hearing, and immunization clinics every year helps us serve the whole child. 12. I’m very glad to have had access to the flu vaccination clinic and to vision and hearing screenings for my child. I wish I had known that there was pediatric nurse practitioner making COVID recommendations for the school. I do appreciate all the protocol that was put into place and do feel like the school was safe, but I would have had more trust in the COVID recommendations knowing they were coming from a medical professional and not from the school or government. 13. I honestly didn't know we had a pediatric nurse practitioner working with the Children's School, but I think it's a great idea. 14. I really enjoyed having the opportunity to particpate/choose exam/vaccines clinics. 15. I think it is extremely helpful to have this available not just with covid but in general 16. BEst