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Medication Management in Primary and Secondary Schools: Evaluation of Mental Health Related In-Service Education in Local SchoolsThomas J. Reutzel, PhD, is a professor in the Department of Pharmacy Practice at Midwestern University Chicago College of Pharmacy, Downers Grove, IL
Archana Desai, PhD, is an associate professor in the Department of Pharmaceutical Sciences at Midwestern University Chicago College of Pharmacy, Downers Grove, IL
Gloria Workman, PhD, is an associate professor in the Department of Behavioral Medicine at Midwestern University College of Health Sciences, Downers Grove, IL
John A. Atkin, AM, LCSW, is an adjunct assistant professor in the Department of Behavioral Medicine at Midwestern University College of Health Sciences, Downers Grove, IL
Sarah Grady, PharmD, is a clinical associate professor at Drake University College of Pharmacy and Health Sciences, Des Moines, IA
Timothy Todd, PharmD, is an associate professor in the Department of Pharmacy Practice at Midwestern University Chicago College of Pharmacy, Downers Grove, IL
Nhu Nguyen, PharmD, RPh, is a clinical pharmacist at Rush-Copley Medical Center, Aurora, IL
Melissa Watkins, PharmD, RPh, is a staff pharmacist at Osco Pharmacy, Chicago, IL
Kim Tran, PharmD, RPh, is a staff pharmacist at Walgreens, Nashville, TN
Nian Liu, PharmD, RPh, is a staff pharmacist at CVS Pharmacy, Chicago, IL
Michelle Rafinski is a PharmD candidate at Midwestern University Chicago College of Pharmacy, Downers Grove, IL
Thanh Dang, PharmD, RPh, is a consultant in Southern California
An increasing number of students are taking medications while they are in school or are under the influence of medication during school hours. In a novel effort, clinical pharmacists and mental health therapists worked together to provide "mini-in-service" educational programs on psychological disorders and medications used to treat these disorders. The purpose of this study was to implement and evaluate the effectiveness of these educational programs presented to school nurses, teachers, school administrators, and other personnel. The study compared participant responses before and after attending a medication in-service session on a psychological disorder and its related medications. Results indicated that in-service education on attention deficit/hyperactivity disorder (ADHD) and depression improved the knowledge and confidence levels of school personnel regarding medications and symptoms. Feedback indicated school personnel wanted longer educational sessions and more information on these disorders and treatments. School nurses working with health professionals can improve education for staff, families, and students about mental health disorders and their treatment.
Key Words: in-service • medications • depression • ADHD • school nurse • pharmacist • therapist A substantial number of students take medication before or during school hours. It is well known that school nurses do not administer all of these doses. Indeed, unlicensed assistive personnel (UAP), including teachers, secretaries, administrators, and others, play a large role in medication administration, storage, and related matters in many schools. Although it is fair to say these unlicensed individuals lack strong backgrounds in drug therapy, it is also true that even school nurses would benefit from further instruction and information regarding the safe and effective use of medications and their related disease states. For example, one study found that a significant minority of school nurse participants scored very poorly on questions about attention deficit/hyperactivity disorder (ADHD). This study also noted that three true/false questions about ADHD were missed by more than half of all participants. Only 49% of these nurses were confident of the safety of stimulant medications used to treat ADHD, and large numbers expressed the desire to acquire more knowledge (81%) or skill (90%) in managing this disorder (Frisch, Moser, Hawley, Johnston, & Romereim, 2003). In the present study, a small group of local nurses attending a conference was administered a needs assessment. The assessment consisted of both direct and indirect questions related to educational needs for school nurses and health aides. Short-acting bronchodilators were identified as the drug taken most often in school; methylphenidate was second. These nurses were also interested in learning more about antidepressants, ADHD, inhalers, and diabetes. Taken together, these factors indicated a need for educational programming for school nurses and health aids or UAP that address specific disease states, especially psychological disorders, and the medications used to treat them. The purpose of this study was to implement and evaluate the effectiveness of "mini-in-service" educational programs presented to school nurses, teachers, administrators, and other school personnel.
Although it is difficult to estimate the actual number of children taking medication in primary and secondary schools, it is evident that an increasing number of students are taking medications while in school, or are under the influence of medication during school hours. In 1989, the National Council on Patient Information and Education (NCPIE) estimated that approximately 13 million people in the United States under the age of 18 were taking medications in any 2-week period. They also noted that an increased number of children were presenting in school with ADHD and other conditions requiring medication administration during school hours (NCPIE, 1989). In a 1998 study, 10 years after the NCPIE figures were published, an editorial in the British Medical Journal reviewed several empirical studies and concluded that an increasing number of children were entering British schools with more "new" diagnoses, behavioral and otherwise (Bannon & Ross, 1998). These authors reported that increased numbers of children with psychiatric and physical illnesses were coming under their care because of the newer medications available that make it possible to manage them in a mainstream school setting. The editorial reported that parents were relying more on teachers to take at least partial responsibility for their children’s health and medications. However, the authors noted that school nurses were better equipped to handle these issues but were not available on a regular basis (Bannon & Ross, 1998). "Although the amount of ADHD medication taken at schools has gone down in recent years, due in large part to the advent of extended release methylphenidate, the variety of medications taken at school has increased. This means that medication management in schools has become more, not less, complicated for school nurses." A more recent example of how medical and pharmaceutical advances increase the complexity of drug therapy generally and medication management in schools specifically is that in 2004 alone, 36 new chemical entities were approved by the Food and Drug Administration (FDA, 2004). An analysis of antidepressant medication use by children in the United States between 1997 and 2002, based on the publicly funded Medical Expenditure Panel Survey, indicated that pediatric use of antidepressant medications increased significantly from 1.3% in 1997 to 1.8% in 2002. Furthermore, there was a 4% increase in antidepressant use from 1999 to 2000 among adolescents (Vitiello, Zuvekas, & Norquist, 2006). It also has been estimated that between 3% and 4% of children in the United States have been diagnosed with ADHD (Mather, 2005). Although the amount of ADHD medication taken at schools has gone down in recent years, due in large part to the advent of extended release methylphenidate, the variety of medications taken at school has increased. This means that medication management in schools has become more, not less, complicated for school nurses (McCarthy, Kelly, Johnson, Roman, & Zimmerman, 2006). Even if a medication is taken (or forgotten) at home in the morning, it can have an effect on a child’s attention span and/or other important behaviors while in school. Section 504 of the Rehabilitation Act of 1973 requires that services be provided by the school district to meet the needs of handicapped children so they may be incorporated into mainstream schools (Illinois Department of Human Services & Illinois State Board of Education, 2000). This act was amended by The Individuals with Disabilities Education Act in 1997. Such policies of inclusion have set requirements that demand more of health care personnel in schools. There are not sufficient licensed staff members to meet these demands. Although school nurses have been the only health care professional in the school setting, school budgets cuts and increased numbers of students taking medications in school have created an ever increasing gap between the number of school nurses and the number of students requiring their care (Johnson & Hayes, 2006). Not all schools have full-time or even part-time nurses. A national study of medication administration practices among school nurses found that 75.6% of nurses delegated medication administration to other school personnel (McCarthy, Kelly, & Reed, 2000). In fact, a 2006 study reported that, on average, one school nurse was responsible for 2.6 schools in Florida and spent 15.4 hr per week at each school (Johnson & Hayes, 2006). Another study, published that same year, found that school nurses in Pennsylvania were forced to delegate medication-administration related functions to unlicensed personnel even though their Nurse Practice Act did not allow such delegation (Ficca & Welk, 2006). The bottom line is that school nurses often delegate medication administration tasks to unlicensed personnel. Lack of licensed personnel, up-to-date drug information resources, and medication management skills means that students might not be receiving optimum or rational drug therapy. Rational drug therapy is defined as medication use that maximizes patient health status, minimizes unwanted side effects, and controls the social cost of achieving these ends (Rucker, 1988). For example, one study reported that unlicensed personnel delegated the task of medication administration and documentation often identified drug names by manufacturer or distributor alone rather than by generic or brand name. This suggests that personnel, in some cases, do not even know the name of the medication they are administering (Francis, Hemmat, Treloar, & Yarandi, 1996). Clearly, education is needed for unlicensed personnel when nurses are unavailable to take on the task of medication administration. Unlicensed personnel would benefit by knowing more about the medications they are distributing. School nurses could also benefit from continuing education on medications, particularly the many new medications indicated for children and adolescents. In addition, they can help to advance rational drug therapy in school by arranging, when possible, educational programs for both licensed and unlicensed personnel.
The Need for Collaboration
Mental Health
Pharmacists The present study is the first formal study of pharmacists and mental health therapists collaborating with school nurses to provide health-related educational programs to school nurses and other school personnel. It combines aspects of the Kury and Kury study (collaboration) and the DeSocio, Stember, & Schrinsky study (education). The purpose of this research study was to implement and evaluate the effectiveness of "mini-in-service" mental health educational programs presented to school nurses, teachers, administrators, and other personnel involved in student medication use.
Before implementing and evaluating the educational programs described here, it was necessary to have an established relationship with local school nurses. Because of several years of interaction and the development of mutual trust between the primary investigator and local school nurse leaders, permission was given to the researchers to administer a needs assessment at a meeting of local school nurses. Based on the results of this needs assessment, the principals of all schools in one affluent county that includes most of the Western Suburbs of Chicago were sent a cover letter and brochure (n = 297). These materials asked principals if their school would like to take advantage of free in-service presentations on the topics of depression, ADHD, asthma, or other topics of their choice. Fifteen schools accepted the offer; all but one requested in-services on ADHD and/or depression. The other school was interested in asthma, and a program was provided to middle school students there. Because mental-health-related issues were of greatest interest to the schools, it was decided to focus on this topic for the in-service programs. Therefore, the asthma program is not discussed in this article. In all 15 schools, the principal forwarded the brochure to the school nurse who then contacted the researchers. Schools requesting a program on depression and/or ADHD included 1 Catholic and 7 public grade schools, 3 public middle schools, 1 public high school, 1 community unit school district (Grades K-12), and one childhood development center (preschool and special kindergarten). In addition, the depression in-service program was given to a group of attendees at the annual meeting of the Illinois Association of School Nurses. The total number of venues discussed here is 15. Institutional Review Board approval was granted by the researchers’ university prior to the conduct of the research. Clinical pharmacists and mental health therapists from a local biomedical university developed and presented a 1-hour mini-in-service program on ADHD and/or depression. Both pharmacists have the professional doctoral degree and have completed residencies. One of the therapists is a licensed PhD psychologist, and the other is a licensed clinical social worker with a master’s degree. Each program made use of audiovisual media, typically PowerPoint, and consisted of the therapist first providing background on the disease state of interest, including epidemiological data, diagnostic criteria, symptoms, nondrug treatment options, and potential interventions by school personnel. This was followed by the clinical pharmacist describing drug therapy options in detail, including drug type, duration, side effects, potential food and drug interactions, and other therapeutic-related topics. Audience questions were taken during and after the presentations. All presenters made alterations to their material as necessary to account for the type of audience and the grade levels of the school where the program was presented. In-service attendees were all school personnel. At 12 schools (321 participants), only ADHD was addressed by the speakers. At the school nurse conference (12 participants), only the topic of depression was covered. At 2 schools (25 participants), both ADHD and depression were presented. Pre- and posttests were administered before and after the presentations to evaluate the participants’ understanding of ADHD or depression and the medications used to treat them. These cognitive pre–post tests were composed of 14 (ADHD) or 16 (depression) true/false/don’t know questions that evaluated understanding. These tests were constructed by reviewing the presenters’ PowerPoint programs. In addition, pre-and posttests included other questions asking respondents to rate their confidence levels, using 5-point Likert-type scales (strongly agree/agree/neutral/disagree/strongly disagree), regarding their knowledge of ADHD or depression and how medications are used to treat these conditions. Finally, the posttest evaluated participant satisfaction levels with the presentations, using similar 5-point Likert-type scales as well as open-ended questions asking the respondents to comment on how the presentations could be improved.
Missing data were plentiful, mainly because most participants did not have time to fill out posttests. Although a total of 358 participants attended in-service programs, completion and collection of posttests were problematic at several of the sites. For example, even though 37 participants completed depression cognitive pretests and 328 ADHD cognitive pretests, only 24 and 54 participants, respectively, completed both the pre- and posttests. The lead investigator was present at all 15 in-service programs, and it was clear that the posttest problem was because of lack of time. By the time a presentation ended and questions were answered, the participants had to move on to other scheduled obligations. Therefore, it is unlikely that the posttests completed reflect a selection bias (i.e., that only the most interested and knowledgeable participants completed them). As a result of the dearth of posttests collected, the data subjected to the statistical methods presented here varied from analysis to analysis. The distribution of subjects across venues was fairly even, although three schools had more than 40 attendees (Table 1). Table 2 shows that both licensed and unlicensed personnel were present at the sessions. School nurses and teachers were the two largest groups that attended the educational presentations, 25% and 46.7%, respectively. The large number of missing data in Table 2 is because of the fact that the question asking about position appeared only on the post-test.
As shown in Table 3, in-service attendees showed significant increases (p  .05) in their mean cognitive scores for both the ADHD and depression test. When considering baseline knowledge only (i.e., the scores of participants that completed depression pretests and/or ADHD pretests, regardless of whether or not they completed posttests), the pretests means are virtually identical to those shown in Table 3 (12.46 versus 12.46 and 9.37 versus 9.57, respectively). This is additional evidence that there was no selection bias (i.e., that those completing the posttests were not starting out from a position of greater knowledge than those that did not complete posttests).
Individual cognitive test item scores are not shown, but participants showed the largest gains in comprehending that depression is not a short-term, acute disease; that not all persons with depression should be on medications to enhance their quality of life; that ADHD is largely a childhood psychiatric disorder; that ADHD symptoms usually develop before the age of seven; that ADHD has a genetic component; that short-acting stimulants are preferred for the initial management of ADHD; and that Strattera, a nonstimulant, can be a good alternative medication for the treatment of ADHD.
Table 4 shows that attendees at the depression presentation had significant gains on three of six confidence items, symptoms, risk factors, and types of antidepressants, whereas attendees of the ADHD program had significant gains on all six items (p
Table 5 illustrates that participants at both the depression and the ADHD programs were highly satisfied with the presentations. When provided the opportunity to write in comments, 55% of the participants suggested the presentation should be longer than 1 hour, possibly a full-day in service; 10% suggested the presentation should give more tips on how to work with students who have ADHD or depression; and 10% thought that the presentation was "good as is." Fifteen percent of participants suggested that future presentations cover alternatives to medication, provide even more information on ADHD and/or depression, or cover other childhood diseases. Other topics that participants would like to have covered were bipolar disorder, EpiPen use, albuterol use, new medications for infection and obesity, over-the-counter drugs, and methods to teach children with ADHD and other psychological disorders. Additional comments provided by participants were all positive and appreciative.
Further analyses (Table 6) found that unlicensed personnel (i.e., teachers, health aides, paraprofessionals, and administrators) had significantly lower mean scores on the depression and ADHD pretests than the licensed professionals (nurses, psychologists, vision technician, speech pathologist, and social worker). Posttest results showed that unlicensed individuals were able to catch up to the licensed individuals’ baseline (i.e., their pretest). However, the unlicensed individuals still scored lower than the licensed individuals on the posttests, although the differences were not significant at p = .05.
This was the first formal study of clinical pharmacists and mental health therapists working together to provide educational programs to school personnel, both licensed and unlicensed. Based on in-service requests from school nurses offered this service, it is apparent that nurses were more interested in learning about ADHD and depression than other disease states. Also, grade schools and middle schools were more interested in receiving the teaching intervention than high schools. School nurses contacted the researchers to arrange for the in-services in all 15 cases. It is not clear what happened to the cover letter and brochure at the other schools (i.e., whether or not the principal passed the materials on to any other personnel). The multidisciplinary mini-in-service educational program described here had its origin in a needs assessment of school nurses and was only possible because of their support. This support was gained only after years of interaction and the development of mutual respect. The in-service program was effective in increasing knowledge about specific psychological disorders and medication treatment for these conditions. Participants were given the opportunity to provide feedback regarding how to improve these health in-services. School personnel requested that the presentations be longer, showing that the intervention was beneficial and needed. School personnel are aware of medication problems and are willing to help their students. Respondents also expressed a need for more training on how to deal with these problems. "Overall, the ADHD/depression in-services increased the knowledge of school nurses and other school personnel about medications and these psychological disorders, enabling them to be more aware of important issues and to better manage medications."
Limitations
Implications for School Nursing Practice Because the decision to initiate this study was based on an earlier needs assessment of school nurses, the study demonstrates that school nurses and other health care professionals can collaborate effectively to address the need for information on medication management in school environments. Increased knowledge and confidence levels in both licensed and unlicensed personnel should lead to a decrease in medication errors during medication administration, and to an improvement in the safety and effectiveness of drug therapy. "Because the decision to initiate this study was based on an earlier needs assessment of school nurses, the study demonstrates that school nurses and other health care professionals can collaborate effectively to address the need for information on medication management in school environments."
Authors’ Note: This research was funded in part by the Chicago College of Pharmacy Intramural Research Grant Program. In March 2006, an earlier version of this article was presented as a poster at the Annual Meeting of the American Pharmacists Association in San Francisco, CA.
Bannon, MJ, & Ross, EM. (1998). Administration of medicines in school: Who is responsible? British Medical Journal, 316(23), 1591-1593
The Journal of School Nursing, Vol. 24, No. 4,
239-248 (2008)
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Abstract
REVIEW OF THE LITERATURE