The Centers for Disease Control and Prevention (CDC) encourages the use of the Whole School, Whole Community, Whole Child (WSCC) model for integrating health practices in the school setting (Lewallen et al, 2015). The WSCC model emphasizes a collaborative approach to improve student health and academic outcomes. The Whole Child element of the model maintains the child as the focal point through five tenets: (1) being healthy, (2) being safe, (3) being engaged, (4) being supported, and (5) being challenged. There are 10 school health services or programs for which the Whole School model focuses. These include health education, physical education, school health services, healthy and safe school environment, counseling, psychological, social services, family and community involvement, health promotion for staff, and nutrition services. 

The WSCC model calls for collaborating with a variety of professionals and programs across the school setting to improve student physical, cognitive, social, and emotional development (Hunt et al, 2015). The call of the WSCC to work in collaborative teams for improved student outcomes supports the increasing demand for health professionals to work in interprofessional teams to improve patient outcomes (WHO, 2010).

Audiologists working in the school-based environment are called to participate in interprofessional collaborative practice by way of academic foundation and memberships to professional organizations. The Educational Audiology Association (EAA) Recommended Professional Practice for Educational Audiology (2009) outlines the minimum professional practice competencies for audiologists working in the school setting. In addition, the EAA also states that professional management, such as training and supervision of support personnel, and leadership include activities around raising public awareness and fostering collaboration between community-based audiologists and the school system. 

The American Speech–Language–Hearing Association (ASHA) 2016 Schools Survey Summary Report: Numbers and Types of Responses, Educational Audiologists indicates specific challenges for providing educational audiology services. These challenges include budget constraints, large caseloads, paperwork, and limited understanding regarding the role of an educational audiologist. The current trends in educational audiology, specifically the barrier of the lack of understanding of the role of an educational audiologist, may be addressed by increasing collaborative practice in school health services programs. 

Interprofessional Collaboration Practice: What Is It? 

The World Health Organization (WHO) published a Framework for Action on Interprofessional Education and Collaborative Practice (2010). In this framework, WHO issued a call to action for health and education systems to infuse interprofessional education and collaboration in all aspects of health service in an effort to strengthen health systems, improve health outcomes, and increase workforce satisfaction and well-being. Interprofessional education occurs when two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.

Interprofessional practice occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with parents, families, care givers, and communities to deliver the highest quality of care across settings. 

In 2009, the Interprofessional Education Collaborative (IPEC) was formed by six national associations of health professions in an effort to promote interprofessional learning experiences in the academic environment among professions providing patient-centered care. These member organizations developed the Core Competencies for Interprofessional Collaborative Practice (2011) that outline the foundation for developing, implementing, and assessing interprofessional curriculum. IPEC is composed of 20 different national organizations that represent a broad base of health professions such as nursing, physician assistants, audiology, speech–language pathology, social work, and public health. The four core competencies were updated in 2016 (see IPEC reference) and are defined as the following:

  1. Values and Ethics of Interprofessional Practice: Work with individuals of other professions to maintain a climate of mutual respect and shared values.
  2. Roles and Responsibilities: Use the knowledge of one’s own role and those of other professions to assess and address appropriately the health-care needs of patients and promote and advance the health of populations.
  3. Interprofessional Communication: Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.
  4. Teams and Teamwork: Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.

These core competencies can be directly applied to interprofessional team building in the school setting to increase efficiencies in health services programs to ensure improved student outcomes.

Interprofessional Collaborative Teams in School Health Programs

School health services, one of the 10 programs included in the WSCC model, are defined by the School Health Policies and Program Study (SHPPS) as a “coordinated system that ensures a continuum of care from school to home to community health-care provider and back” (Nicholson et al, 1997). 

The seven goals of school health programs are to

  1. Ensure access to primary health care.
  2. Deal with crisis medical situations.
  3. Provide mandated screening and immunization monitoring.
  4. Provide systems for the identification and solution of
  5. students’ health and educational issues.
  6. Provide comprehensive and appropriate health education.
  7. Provide a healthful and safe school environment that facilitates learning.
  8. Provide a system of evaluation of the effectiveness of the school health program. 

These seven goals are key to defining the roles and responsibilities of individual members of a school-based interprofessional team. Interprofessional teams practicing in the school settings will be made up of individual members with different knowledge and skill sets. These differences can be both a strength and a challenge for the effectiveness of a team. 

Effective teams must foster a culture of equality among the members. The ability for each member of a team to share knowledge and skills as a way to facilitate creative solutions for school health programs is the foundation of success. Essential skills are required to be an effective team member (Hall, 2005). 

These skills include the following:

  • Cooperation: Acknowledging and respecting others’ viewpoints and reflecting on personal perspective
  • Assertiveness: Supporting one’s viewpoint with confidence
  • Responsibility: Accepting and sharing responsibility and participating in group decision-making
  • Communication: Effective sharing of information and ideas
  • Autonomy: Ability to work independently
  • Coordination: Efficient organization of group tasks

Individual team member ability to apply these essential skills creates the foundation for an effective team dynamic. 

Interprofessional Team Members in School-Based Setting

Defining the roles and responsibilities of individual team members is dependent on the goals of the team and the individual professions represented. Audiologists often work on teams with speech–language pathologists and nurses in school health programs (Richburg, 2011, Hendershot et al, 2011). Each of these professions have their own values, skills, professional culture, and language. Successful interprofessional practice requires well-developed team processes that include a team facilitator, shared goals, defined roles and responsibilities, continuous communication, mutual trust and respect, team decision-making, and reflective practice (Hall, 2005).

Educational Audiology

Child School Hearing Screening ImageEducational audiology services provide the foundation for determining if students have access to effective communication in the classroom (Anderson, 2015). Access to communication in the classroom is required to ensure academic success for students that supports social and emotional development as outlined in the WSCC model (Crandell and Smaldino, 2000).

The EAA (2009) outlines the minimum professional practice competencies for audiologists working in the school setting using the Individuals with Disabilities Education Act (IDEA, 2011) as a framework. These practice competencies are identification and prevention programs, audiological assessments, referrals, educational management, and direct educational services. Responsibilities can include activities such as hearing-screening programs; audiological assessments and referrals; provision of in-service training; hearing-conservation curriculum; and assessment, evaluation, and monitoring assistive listening devices.

These roles and responsibilities support the seven goals of school health programs in many facets including providing hearing screenings, identifying solutions for students with hearing loss, providing education in prevention and conservation, and creating a healthy and safe environment for students, families, and teachers managing hearing loss.

School Nursing

The National Association of School Nurses Framework for 21st Century School Nursing Practice (Maughan, 2016) is based on student-centered care principles. Student-centered care includes working in collaboration with families and caregivers to ensure students’ needs are addressed. The role of nurses is focused on five key principles: (1) standards of practice (knowledge and skills), (2) care coordination, (3) leadership, (4) quality improvement, and (5) community and public health. 

Responsibilities for school nurses include nurse-led care coordination, chronic disease management, collaborative communication, direct patient care, counseling, policy development and implementation, program data collection, health education, prevention programs, screenings, and increasing access to care. The American Academy of Pediatrics identifies the school nurse as the on-site, health-care representative for students and should be considered the leader in coordinating health services teams (AAP, 2008). 

Speech-Language Pathology in Schools

ASHA’s Roles and Responsibilities of Speech-Language Pathologists in Schools: Professional Issues Statement (2010) provides an overview of the roles and responsibilities of speech–language pathology in schools. Speech–language pathologists provide speech–language services from pre-K through high school ages. They serve individuals with communication disorders (language, articulation, fluency, and swallowing), determine educational impact of disorders served, contribute to curriculum for students with disabilities, highlight language and literacy, and provide these all in a culturally competent manner. 

Responsibilities within this role include prevention of academic failure, assessment in collaboration with others to identify students with communication disorders, intervention appropriate to learning needs, data collection and analysis of student outcomes, and maintenance of compliance with federal and state mandates while performing their duties. Speech–language pathologists are partners in integrating intervention for hearing loss into the classroom setting (Richburg and Knickelbein, 2011). 

Each of these professions has specific expertise outlined in their scope of practice and also demonstrate overlapping roles and responsibilities in the school setting. These redundancies may lead to inefficient practices in the development, implementation, and monitoring of health-service programs. 

TABLE 1. Interprofessional Team.

Team Facilitator

  •  School Nurse

Team Members

  •  Audiologist
  •  Speech–Language Pathologist

GOALS/VALUES

*defined by team members

 

IMPLEMENT THE FOLLOWING:

  • Effective two-tier hearing-screening program
  • Individualized student referral and intervention plans
  • Streamlined communication from school to home to health-care provider
  • Effective monitoring of outcomes of individual students
  • Effective monitoring of hearing-screening program outcomes

ROLES AND RESPONSIBILITIES

 

School Nurse Icon

School Nurse

ACT AS FACILITATOR FOR TEAM AND PROGRAM.

  • Coordinate schedule for team meetings.
  • Schedule screening day in coordination with school administrators and teachers.
  • Document student screening outcomes in school data-management system.

DRIVE COMMUNICATION BETWEEN SCHOOL AND PARENTS/CAREGIVERS.

  • Obtain parental/caregiver consent.
  • Relay student hearing-screening outcomes to parents/caregivers.
  • Provide resources for referral needs.

MONITOR INDIVIDUAL STUDENT OUTCOMES.

  • Document outcome of referral.
  • Initiate further recommendations based on outcomes of follow-up.

AUDIOLOGIST ICON

Audiologist

TRAIN HEARING-SCREENING PERSONNEL.

  • Develop training materials based on best practice protocol.

DRIVE APPROPRIATE REFERRALS.

  • Direct service delivery for rescreens.
  • Provide recommendations for follow-up plan based on rescreen outcomes.
  • Document recommendations.

MONITOR SCREENING-PROGRAM OUTCOMES.

  • Monitor overall effectiveness of program by recording:
  • Noise levels in test environment 
  • Refer rates of initial screening
  • Overall referral rate of screening program
  • Percentage of students who received appropriate follow-up

MANAGE EQUIPMENT.

  • Determine appropriate equipment for hearing-screening program.
  • Review annual calibration of equipment.
  • Troubleshoot equipment.
  • Ensure adequate and appropriate supplies.
  • Manage and monitor infection-control procedures.

SPEECH PATHOLOGIST ICON

Speech–Language Pathologist

COMPLETE POST-INTERVENTION HEARING SCREENINGS.

  • Provide rescreens of students’ post-intervention to ensure adequate hearing for effective communication in the classroom.

PROVIDE IN-SERVICE TRAINING FOR STAFF/TEACHERS ON EFFECT ON COMMUNICATION IN THE CLASSROOM.

  • Provide resources and training for classroom teachers on the effect of hearing loss on listening in the classroom.

INTERPROFESSIONAL COMMUNICATION

INITIAL PLANNING MEETING TO DISCUSS SCHEDULING AND TRAINING NEEDS.

  • Schedule training of screening personnel.
  • Schedule date of hearing screening.
  • Schedule date of rescreen.

DAY OF HEARING SCREENING.

  • Work with school staff/administration to determine appropriate testing environment.
  • Coordinate with teachers on student flow throughout the day.

DOCUMENTATION AND FOLLOW-UP.

  • Audiologist documents referral recommendations and notifies nurse on day obtained.
  • Nurse provides referral recommendations to parents/caregivers within 48 hours of receiving outcomes.
  • Nurse ensures follow-up of referral recommendation within two weeks of communicating to parents/caregivers.
  • May require secondary follow-up driven by nurse
  • Referral to speech–language pathologist for rescreen implemented once follow-up has been completed or referral to  audiologist for full audiologic assessment as needed.

IMMEDIATE TEAM COMMUNICATIONS AS NEEDED.

WRAP-UP MEETINGS TO DISCUSS FINAL OUTCOMES AND SUGGESTED IMPROVEMENT OF HEARING SCREENING PROGRAM.

 

School-Based Hearing-Screening Programs

The Institute of Medicine’s Committee on Comprehensive School Health Programs in Grades K-12 indicates that screening programs are considered a key provision of school health services, with 86.8 percent of schools providing vision and hearing screenings (Nicholson et al, 1997). The prevalence of hearing loss for ages 6–19 years increases to 14.9 percent from 1.4 out of 1,000 (or 0.14 percent) at birth (Niskar et al, 1998). The increased prevalence of hearing loss in the school-aged population indicates that effective hearing screening and hearing conservation programs in this population play a critical role in ensuring that children have adequate access to the auditory signal in the school setting. 

School-based hearing-screening programs vary significantly and are guided largely by local policy and statewide regulations and mandates (Sekhar et al, 2013). Variability exists among the states and within local education agencies (LEA) at the state level. This variability exists in terms of mandating hearing screening, screening personnel, training of personnel, and protocol. These inconsistencies present many challenges for local districts to implement these programs effectively. These challenges may be addressed using interprofessional teams as a way to create consistencies in protocol, streamline coordination and follow-up, and increase overall satisfaction with the hearing-screening program.

School-Based Hearing-Screening Program: An Example

The roles and responsibilities described for the professions of audiology, nursing, and speech–language pathology in the schools have multiple areas for collaboration. Table 1 is an example of how an interprofessional team in the schools may be structured to implement an effective hearing-screening program. 

In this model, the school-based nurse is the primary facilitator of the hearing-screening program. Current practices reveal that school nurses nationally average working in three buildings with an average of 924 to 1,072 students (Mangena, 2015). ASHA recommends a 1:10,000 ratio of educational audiologist per student. This indicates that the school nurse will have a significantly deeper understanding and knowledge of the school community including students, their families, faculty, and administrators. 

The article “School Nurses’ Role in Identifying Children at Risk of Noise-Induced Hearing Loss” (Hendershot et al, 2011) states that 81 percent of nurses say they had mandates for screening student hearing. Speech–language pathologists indicate that hearing screenings are the most common service they provide in the schools (95.7 percent) and they receive the most benefit from working with audiologists for those screenings (Richburg and Knickelbein, 2011). 

Audiologists can provide significant support to these professionals in hearing screenings including training screening personnel, educating professionals regarding the impact of hearing loss on effective communication in the classroom, and ensuring appropriate referrals for follow-up. The American Academy of Audiology Childhood Hearing Screening Guidelines (2011) recommends tympanometry and otoacoustic emission testing for those students whose pure-tone screenings are not developmentally appropriate for the rescreen process. This screening protocol supports the need for audiologists to provide direct service provision in these programs to correctly identify results and make recommendations based on outcomes of these tests. 

Teams for school-based hearing-screening programs that include individual members who use the essential skills of effective teamwork and follow the interprofessional practice competencies will improve outcomes for students and highlight the roles and responsibilities of each team member.

Conclusion

The increased call for interprofessional collaborative practice across educational and health-profession models provides opportunity for audiologists to increase public awareness of the role of educational audiology services, how those services support the WSCC model, and improve existing health-service programs. 

Understanding the unique and shared roles and responsibilities of other health professions in the school setting will support the development of effective interprofessional teams. 

Using the core competencies of interprofessional collaborative practice as a foundation for creating teams can lead to improved health-services programs in schools, increase workforce satisfaction, and improve overall health outcomes for students.