DNP PROJECT APPROVAL

Candidate: Tonya Smith Bright

Major: Graduate Nursing

DNP Project Title: Implementing Stop the Bleed in Schools

Approval:

_______________________________________ _____________________
Jennifer Frank Date
Assistant Professor, Department of Nursing
DNP Chair

_______________________________________ _____________________
Lori S. McGrath Date
DNP Course Coordinator

_______________________________________ _____________________
Donna C. Dunn Date
DNP Program Coordinator

_______________________________________ _____________________
Kim Helms Date
Director of Online and Graduate Studies

_______________________________________ _____________________
Channing R. Ford Date
Senior Director, Graduate Studies
IMPLEMENTING STOP THE BLEED IN SCHOOLS

A DNP Project Submitted to the

Graduate Faculty
of Jacksonville State University
in Partial Fulfillment of the
Requirements for the Degree of
Doctor of Nursing Practice

By

TONYA SMITH BRIGHT

Jacksonville, Alabama

June 15, 2021

iii
 copyright 2021
All Rights Reserved

______________________________________________
Tonya Smith Bright June 15, 2021

iv
 ABSTRACT

Background: An emergency or disaster can strike at any time, even during the day, while

numerous students are in school. This paper will discuss how an educational program

initiating Stop the Bleed (StB) in public schools prepares and equips school nurses to

respond to a bleeding emergency in the school setting.

Design method: Initiate StB as a ‘train-the-trainer’ course for school nurses. School

nurses will have knowledge, training, and supplies to train employees at their schools.

Conduct pre- and post-surveys to assess learning objectives and attitudes toward training

and readiness.

Conclusion: The StB educational intervention effectively improved knowledge by 22%,

tourniquet application by 40%, and wound packing by 38%. Confidence in responding to

bleeding emergencies increased from 55% to 70%, and school preparedness increased

from 75.8% to 100%.

Implications for Nursing: The implementation of the StB educational intervention

provided emergency preparedness education and hands-on skills training to identify and

treat bleeding emergencies. The train-the-trainer aspect has the potential to train

numerous laypersons in the school setting. Research demonstrates improvements in

knowledge and confidence after attending the one-hour StB training course.

Keywords: Stop the Bleed, tourniquet, hemorrhage response, bleeding emergency

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 TABLE OF CONTENTS

Abstract........................................................................................................................ iv

Introduction ................................................................................................................. 1

Background............................................................................................................. 1

Problem Statement.................................................................................................. 3

Organizational Description of Project Site.............................................................. 4

Review of the Literature............................................................................................... 4

Theoretical Framework/Evidence-Based Practice Model............................................ 9

Goals, Objectives & Expected Outcomes.................................................................... 12

Project Design.............................................................................................................. 12

Project Site and Population.......................................................................................... 14

Setting Facilitators and Barriers................................................................................... 14

Implementation Plan/Procedures.................................................................................. 15

Measurement Instrument(s) .................................................................................... 17

Data Collection Procedure...................................................................................... 17

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 Data Analysis ......................................................................................................... 17

Results ......................................................................................................................... 18

Discussion ................................................................................................................... 20

Cost-Benefit Analysis/Budget ..................................................................................... 20

Timeline ...................................................................................................................... 21

Ethical Considerations/Protection of Human Subjects............................................... 21

Conclusion .................................................................................................................. 23

References................................................................................................................... 24

Appendix A.................................................................................................................. 36

Appendix B.................................................................................................................. 39

Appendix C.................................................................................................................. 42

Appendix D ................................................................................................................. 43

Appendix E .................................................................................................................. 44

Appendix F .................................................................................................................. 45

Appendix G ................................................................................................................. 46

Appendix H ................................................................................................................. 47

Appendix I ................................................................................................................... 48

Appendix J ................................................................................................................... 49

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Appendix K ................................................................................................................. 50

Appendix L .................................................................................................................. 51

Appendix M ................................................................................................................. 52

Appendix N.................................................................................................................. 53

Appendix O ................................................................................................................. 54

viii
 Implementing Stop the Bleed in Schools

Introduction

Natural disasters, traumatic events, and other emergencies can occur at

any time and disrupt the daily routine of families, schools, and communities

(National Center on Safe Supportive Learning Environments, 2019; Russell,

2019). Human-made emergencies include bombings or shootings, while natural

disasters encompass tornadoes, hurricanes, and tsunamis. The Center for Disease

Control and Prevention (CDC) emphasizes the importance of establishing

priorities to act quickly and efficiently in response to disasters (CDC, 2018). The

first five minutes before emergency personnel arrive are vital in improving patient

outcomes and emergency preparedness (Kress, Conlin, & Jackson, 2019).

Background

Recent global threats have heightened awareness due to the terrorist

bombings of September 11th, 2001, the Boston Marathon bombing, and the Flight

357 crash (Sonneborne et al., 2018; Usher et al., 2015b; Veenema et al., 2016;

Yan et al., 2015). The Columbine High School shooting in 1999 first introduced

active shooter events in the school setting (Clark, Bass, & Boiteaux, 2019). Since

2009, McIntosh, Brelage, Pokorny, Duckham, and Boucher (2020) reported 288

school shootings in the United States with Wolfe and Walker (2019) research

reported 45 school shootings occurring in the first 46 weeks of 2019.

Any catastrophic event could cause widespread casualties and devastation,

making emergency preparedness essential for all schools (U.S. Department of

Commerce & National Oceanic and Atmospheric Administration, n.d.). To

1
minimize the effects of dangerous situations, Russell (2019) writes that school

administrators, faculty, parents, and students can work together to maintain school

safety. With an increase in school violence, training educators to decrease

morbidity and mortality in the school setting is essential (Ciraulo et al., 2020;

Jones, Brown, Esslinger, Strickland, & Kerby, 2019; Nanassy et al., 2020). Over

the last decade, mass casualty events (MCE) have increased with more than 180

school shootings (Al Sabah et al., 2018; Goolsby et al., 2020; Lei et al., 2019;

Varanelli, Basilio, & Breda, 2019). In 2015, the American College of Surgeons

(ACS) reported uncontrolled hemorrhage was one of the leading causes of

preventable deaths due to trauma.

In the school setting, community members like teachers, school support

staff, and school resource officers may serve as first responders (Nanassy et al.,

2020). Nurses are on the front line to treat disaster victims (Varanelli et al., 2019),

and school nurses have the opportunity to establish and maintain a core group of

trained individuals in the school setting (Jones et al., 2019; Liu et al., 2019). StB

plays a pivotal role in preparing the public to respond in MCE to save lives (Al

Sabah, Al Haddad, & Al Saleh, 2018; Andrade, Hayes, & Punch, 2020; Ciraulo et

al., 2020; Dhillon et al., 2019; Goolsby et al., 2020; Jones et al., 2019; Lei et al.,

2019; Nanassy et al., 2020; Schroll et al., 2020; Zwislewski et al., 2019).

StB is a national campaign to train bystanders to assist with bleeding

emergencies until medical professionals arrive (U.S. Department of Homeland

Security, 2020). In 2019, the American College of Surgeons Committee on

Trauma (ACSCOT) developed a standardized curriculum which contains a

2
didactic lecture with three embedded videos, a hands-on demonstration, and a

skills-based practice session for manual compression, wound packing, and

tourniquet application (ACS, 2019). The closest person to the victim with life-

threatening bleeding is best positioned to provide immediate care. A victim with a

bleeding emergency can die within five minutes (Department of Homeland

Security, 2020).

Since the American College of Surgeons prefers instructors to have formal

healthcare training to serve as ‘train-the-trainers’, school nurses are the focus of

this DNP project and influence the possible impact in the school setting (Jones et

al., 2019). Nanassy et al. (2020) conducted a study of school nurses that showed

increased knowledge, self-confidence, school preparedness, and skill development

with wound packing and tourniquet application after an educational intervention.

Problem Statement

With the increase of disastrous events, schools lack adequate preparation

to handle the immediate response needed. Emergency preparedness and disaster

training, with StB implementation, are required to educate faculty and staff on

their roles and responsibilities during such an event at school. This project aims to

explore the following question: does implementing the StB educational

intervention, as compared to no training, increase the knowledge, confidence,

preparation, and skill to respond to an emergency? The DNP project's educational

intervention will teach school nurses to recognize a bleeding emergency and

respond appropriately until professional help arrives. The aim of the intervention

is increased knowledge, confidence, and skill to respond to bleeding emergencies.

3
School nurses will serve as trainers for faculty and staff at their schools, with new

guideline implementation beginning with the 2021-2022 school year.

Organizational Description of Project Site

The DNP candidate chose a southeastern, public, county school system to

implement StB in the school setting.

Literature Review

Expectations of Schools

One-fourth of the U.S. population is children, with approximately 49.8

million students attending public schools, with another five million attending

private schools on any given day in the U.S. (Rebmann, Elliott, Artman,

VanNatta, & Wakefield, 2016; Silverman et al., 2016). Parents and society expect

schools to provide safe learning environments with personnel having the training

and resources needed to react appropriately to emergencies (Burke et al., 2015).

With the increased prevalence of school shootings, school employees need the

education and skill to stop life-threatening bleeding (Moton et al., 2020).

Evidence-Based Practice

Tourniquets save lives as first evidenced in 2003 in Iraq (Ciraulo et al.,

2020); the death rate dropped 85% after initiating tourniquet use (Ali et al., 2021).

Research from the battlefields of Iraq and Afghanistan contributed to the Hartford

Consensus' effort to translate military successes to the civilian world to improve

the survivability from bleeding emergencies (Goolsby et al., 2020; Jones et al.,

2019; Lei et al., 2019; Lowndes et al., 2019; Lu & Spain; Muret-Wagstaff, Faber,
4
Gamboa, & Lovasik, 2020; Nanassy et al., 2020; Schroll et al., 2019; Schroll et

al., 2020; Varanelli et al., 2019; Villegas et al., 2020; Zwislewski et al., 2019).

Just as tourniquets saved lives on battlefields, StB training can save lives in the

school setting by teaching school employees to recognize and treat bleeding

emergencies. The StB initiative aims to educate and train non-medical laypersons

to recognize bleeding emergencies and to learn techniques to control bleeding (Al

Sabah et al., 2018; Dhillon et al., 2019; Goolsby et al., 2020; Goralnick et al.,

2018; Latuska et al., 2019; Lei et al., 2019; Liu et al., 2019; Schroll et al., 2019;

Varanelli et al., 2019; Villegas et al., 2020). Initiating StB training in all county

schools prepares every campus to respond to an emergency.

StB techniques decrease complications, mortality, and transfusion due to

hemorrhage (Villegas et al., 2020). Studies have found that 35% of prehospital

deaths (Jones et al., 2019) and 40% of trauma mortality (Lowndes et al., 2019) are

due to bleeding. Recognition and treatment of bleeding emergencies and

activation of the emergency medical services (EMS) are the StB course goals

(Schroll et al., 2020). Al Sabah et al. (2018) and Dhillon (2019) emphasize the

importance of small groups to practice skills-based simulation of wound packing

and tourniquet application. Andrade et al. (2020) recommend an instructor-to-

student ratio of 1:5.

Tourniquet application improves drastically with StB training. Ross et al.

(2018) found only 16.9% of laypersons apply a tourniquet accurately without

training. After training, Andrade et al. (2020) and Goralnick et al. (2018) record

88% accuracy in applying tourniquets. A six-fold reduction in mortality exists

5
when laypersons apply tourniquets in a prehospital setting (Teixeira et al., 2018).

Lei et al. (2019) and Pasley et al. (2018) explain that StB skills are applicable in

numerous scenarios like industrial and farming accidents, motor vehicle crashes,

and penetrating wound incidents occurring at home, work, school, or any public

venue.

An estimated 57% of hemorrhagic deaths could be prevented (Lei et al.,

2019). In 2012, Sandy Hook Elementary School in Connecticut was the site of a

mass shooting and served as an impetus for a national call to action to decrease

mortality from exsanguination (Ciraulo et al., 2020; Goolsby et al., 2020; Liu et

al., 2019; Lu & Spain, 2020; Nanassy et al., 2020; Zwislewski et al., 2019). The

Boston Marathon Bombing in 2013 highlighted the lack of training and resources

in civilian settings to control hemorrhage and prevent death (Al Sabah et al.,

2018; Schroll et al., 2019; Schroll et al., 2020). When 243 people were injured,

only 27 received tourniquet application before arriving at the hospital; all 27 lived

(Liu et al., 2019). The Las Vegas Harvest Festival shooting in 2017 reported a 30-

minute delay in medical professionals arriving at the scene to help victims (Al

Sabah et al., 2018). Average response times for EMS range from 7.7 minutes in

urban areas to 14.5 minutes in rural areas (Al Sabah et al., 2018; Andrade et al.,

2020; Goralnick et al., 2018; Jones et al., 2019). Since death occurs in minutes,

first responders' delays make immediate care of bystanders imperative to improve

outcomes (Al Sabah et al., 2018; Andrade et al., 2020; Jones et al., 2019; Moton

et al., 2020; Pasley et al.,2018).

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 StB training improves the confidence in responding to a bleeding

emergency (Andrade et al., 2020; Lei et al., 2019; Nanassy et al., 2020; Schroll et

al., 2019; Schroll et al., 2020; Villegas et al., 2020). Nanassy et al. (2020)

reported improved self-efficacy and school preparedness after course completion.

In studies conducted by Andrade et al. (2020) and Lei et al. (2019), participants

improved knowledge after course completion. Enhanced knowledge and skill

demonstration was found in studies by Schroll et al. (2019; 2020) after a one-hour

training class regardless of the level of medical training of participants.

School Vulnerabilities and Deficiencies

Schools are vulnerable due to the number of children who attend which

have many physical, emotional, psychological, and security needs (Burke et al.,

2015; Kruger et al., 2018; Rebmann, Elliott, Artman, Van Natta, & Wakefield,

2015; Silverman et al., 2016). In addition, nurses lack education and training to

respond to multi-casualty events (Burke et al., 2015; Georgino, Kress, Alexander,

& Beach, 2015; Nilsson et al., 2016; Rebmann, Elliott, Artman, Van Natta &

Wakefield, 2018; Seyedin, Polatabadi, & Rajabifard, 2015). An Australian study

of 194 emergency nurses revealed 85% failed the knowledge test regarding

disaster preparedness (Jiang et al., 2015). Georgia lawmakers invested hundreds

of thousands of dollars installing a dozen StB kits in each of the 2,300 schools in

Georgia (Khalili, 2019) and providing training for school employees (Henriquez,

2020). Since 2019, Texas, Arkansas, and Indiana have passed legislation to

provide StB kits in schools (Altizer, Fouche, Harris, & Shartar, 2019).

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Impact of School Nurses

Around 58,000 school nurses care for America's 55 million schoolchildren

and play a fundamental part in the preparation of any unforeseen event occurring

during the school day, making it imperative for the school nurse to possess

knowledge of emergency preparedness and disaster response (Burke et al., 2015;

Nickitas, Cogan, & Mazyck, 2019; Ugalde et al., 2018). Nurses comprise the

majority of frontline responders in disaster management (Usher et al., 2015a; Yan

et al., 2015). Therefore, nurses play an integral role in disaster response (Huh &

Kang, 2018; Nilsson et al., 2016; Sonneborn et al., 2018; Thobaity, Plummer, &

Williams, 2016). Nurses require education and training to improve the outcomes

of disasters (Ugalde et al., 2018; Veenema et al., 2016; Yan et al., 2015). By

promoting awareness and identifying gaps in school emergency plans, nurses take

the lead in school preparedness (Burke et al., 2015; Liu et al., 2019; McIntosh,

Brelage, Pokorny, Duckham, & Boucher, 2019). As a result of their knowledge

and skills, nurses prove to be indispensable medical professionals in the school

setting (Alim, Kawabata, & Nakazawa, 2015; Jiang et al., 2015). Emergency

preparedness training raises awareness of the nurse (Chilton & Alfred, 2017). To

increase the impact in the community, one StB kit should be available in each

school along with practice kits to conduct future training of employees (Moton et

al., 2015).

Evidence-Based Practice – Verification of Chosen Option

StB will be taught as an educational intervention/quality improvement

initiative, and a county protocol for annual training will be established.

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Educational Program Goals

The StB educational intervention aims to bridge the gap between

knowledge and preparation by explaining the history and benefits of planning,

informing the nurses of their roles and responsibilities during an emergency, and

shifting attitudes towards preparedness (Nilsson et al., 2016). The outcome of the

educational intervention is to prepare and increase the knowledge, confidence,

and skill of the nurse to respond to bleeding emergencies through education and

training (Alim et al., 2015; Huh & Kang, 2018; Jiang et al., 2015; Nilsson et al.,

2016; Sonneborn et al., 2018; Usher et al., 2015a; Usher et al., 2015b; Yan et al.,

2016).

Educational Program Outcomes

An effective educational training program improves knowledge and

readiness to respond to an emergency (Alim et al., 2015; Huh & Kang, 2018; Kim

& Lee, 2020). The StB content was found feasible and valuable for the school

setting, and educational gains were reported (Rebmann et al., 2016).

Theoretical Framework

The Protective Action Decision Model (PADM) utilizes the Reasoned

Action Theory as its foundation (Heath, Lee, Palenchar, & Lemon, 2018). The

Theory of Reasoned Action (TRA) is a conceptual framework stating attitudes,

beliefs, and behaviors towards societal norms and self-control affect intentions

and predict behavioral changes (Heath et al., 2018; Ajzen, 2012). People believe

in social norms concerning family, friends, colleagues, health professionals, and

9
governmental agencies, each exhibiting specific behavioral expectations. The

intention and initiation of a behavioral change are dependent on personal beliefs,

norm expectations, and motivation. Interventions must motivate and ensure an

actual change in behavior (Ajzen, 2012).

The PADM is a multi-step process involving how information about a

potential threat transcends into possible solutions. The decision-making process

employs environmental and social cues regarding information sources to impact

reception and comprehension before perceiving the threat and responding with

action. Preconceived expectations, competing demands, and degree of risk

determine how people discover, understand, interpret, and respond to possible

disasters (Lindell & Perry, 2012). Stop the Bleed campaigns aim to inform the

public of potential disaster scenarios and encourage planning and preparation to

reduce their impact (Heath & Abel, 1996).

Probability, consequences, and fear of the unknown establish

environmental perception. The public needs to possess the information required to

make informed decisions on disaster planning. Previous personal impacts from

disasters, like property damage, injury, or death, motivate behavior change.

Preventive measures are more likely to be taken if the certainty and severity of a

disaster are immediately imminent. The necessary effort, time, cost, and skill

outweigh the impact, according to the TRA (Lindell & Perry, 2012).

Stakeholders, including employers, media, medical professionals, and

authorities, have the power to enact action. The public must receive the same

information from all stakeholders. Environmental and public health agencies

10
possess the expertise and public trust to present the facts. The public expects the

government to protect them, health agencies to make appropriate

recommendations, and the media to report pertinent data on the type of disaster

and possible implications, according to the PADM. Preparation decreases the

impact of disasters, while the lack of preparation increases the risk of harm and

damage (Lindell & Perry, 2012).

The decision to change behavior comprises risk identification and

assessment and protective action assessment and implementation. In identifying

the risk, people assess if the threat is applicable and valid to them, with the higher

the risk, the greater the response. The assessment determines the probability and

severity of impact, which also increases the responsive action. Gaining personal

knowledge through reading and watching the news helps detail protective

measures and alternatives to implement. The threat justifies the response or

action. People must consider all aspects of a plan. For example, potential

evacuation necessitates considering medical needs, transportation, destination,

and evacuation routes. The series of processing stages enact protective actions

(Lindell & Perry, 2012).

PADM wields predictive validity in managing the public's response to

environmental hazards and explains why people take preventive action. (Lindell

& Perry, 2012; Heath et al., 2018). Having a disaster plan increases confidence in

emergencies (Heath & Abel, 1996). Proactive measures decrease the public's

concern, while knowledge increases their sense of control (Heath & Abel, 1996).

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Goals, Objectives, Expected Outcomes

The StB educational intervention's objective is to improve the confidence,

knowledge, and skill of school nurses by teaching them how to recognize and

treat bleeding emergencies. After completing the one-hour training, the goals and

outcomes are to increase the knowledge, confidence, and skill needed to respond

to bleeding emergencies by instructing and practicing manual compression,

wound packing, and tourniquet application.

Project Design

This DNP candidate sought and obtained certification as a StB instructor

and utilized an established curriculum. A quasi-experimental design measured and

compared school nurses' knowledge, confidence, and skills after implementing the

StB educational intervention. The project is a practice intervention to improve

performance and develop new practice guidelines in the school setting using a

mixed-method approach. The researcher gathered qualitative demographic

information and quantitative data from the participants using a Likert scale with

five points. Informed consent, with a written and verbal explanation of the Doctor

of Nursing Practice (DNP) project, was obtained. The instructor emphasized

personal safety regarding Universal Precautions and scene safety.

An anonymous, standardized survey instrument was utilized before the

educational intervention to establish a baseline of knowledge and skill (see

Appendices A, B, and C). The instrument consisted of:

 three true/false questions to assess knowledge,

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  two rank order questions to evaluate procedural steps in packing a wound

and applying a tourniquet,

 one question with check all applicable answers to identify bleeding

victims,

 two Likert scale questions to assess confidence and preparedness,

 one question with choices and an explanation of how to make schools

more prepared for bleeding emergencies, and

 one open-ended question for any additional comments about the course.

Scoring of assessments used a binary-scale for right and wrong responses. Before

the educational intervention, a skills-based assessment encompassed a three-item

checklist for wound packing and an eight-item checklist for tourniquet

application. StB instructors recorded a binary scoring of completion or omission

of steps. Two school resource officers and the county coroner, who are certified

StB instructors, volunteered to assist with skills evaluations.

Various strategies demonstrated successful results in improving

emergency preparedness knowledge and skills. A needs assessment directed the

DNP project educational intervention path for the desired audience. Participants

received written information regarding the material taught. A pilot project was

ideal in evaluating the feasibility and effectiveness of the educational training

program (Moran, Burson, & Conrad, 2020). Ramirez-Cortez and World Bank

(2017) reiterated the importance of evaluating the aim, objectives, content, ability

to respond, and the impact of the educational training program using local, state,

13
and federal resources and methods to update knowledge, attitudes, and skills

towards emergency management.

Project Site and Population

The site chosen was a southeastern, public, county school system. The

administration permitted the implementation of the StB educational program. The

nursing supervisor supported the plan, required all school nurses' attendance, and

allowed time during professional development.

The school system has 30 schools with 20,913 students and 2,471 faculty

and staff. The educational training program was split into two sessions to

maintain social distancing due to COVID-19. The researcher needed a classroom

and a computer with an internet connection and audiovisual capabilities to view

the PowerPoint presentation. Participants were all school nurses employed within

the county school system. All school nurses were female (see Appendices D, E,

and F for demographic data).

Setting Facilitators and Barriers

The lead nurse was a facilitator, and the school principal was a preceptor

in the school setting. The lead nurse required all school nurses to attend training

and allowed time and space on a professional development day for the practice to

occur. The lead nurse also provided the technology and resources to assist in

presenting information and implementing the educational training program. The

Shelby County Coroner allowed access to materials for the class, including

Combat Application Tourniquets and prosthetic limbs.

14
 Barriers included changing formats to comply with the Alabama

Department of Public Health (ADPH) COVID-19 guidelines. In response to those

recommendations, training was split into two sessions to maintain social

distancing guidelines. Each participant had a tourniquet, strip of cloth, and a pen

to use throughout the exercise. Everyone in attendance wore masks. Gloves and

hand sanitizer were also available. Three stations were used for skill evaluations

with a StB instructor at each station, maintaining a 1:5 ratio. Manikins did not

replicate active hemorrhage or feedback mechanisms to determine effectiveness.

All participants had prior medical training.

The questionnaire was a self-assessment opinion survey, which has a risk

of bias. Other barriers included the level of skill and desire of participants to learn

new information. Some participants had received prior training on StB. All

respondents were willing to learn to keep their school safe. Four school nurses did

not have access to a StB kit, so each nurse received a StB kit after training. In

addition, all school nurses received a practice kit.

Implementation Procedures/Plan

To assist school nurses in preparing for mass casualty events, the

researcher chose the StB educational intervention and obtained approval from

Jacksonville State University's Proposal Evaluation and Review Committee and

Institutional Review Board (IRB) before proceeding with the DNP project.

Administrative personnel with Shelby County Schools granted permission for

implementing the StB course in the school setting. The lead nurse for Shelby

15
County Schools assisted in reserving the room and audiovisual equipment needed.

She required all school nurses to attend the train-the-trainer course. Participation

in the research study was voluntary. The consent form stated that participation

was voluntary and withdrawal during the project was permissible without any

penalty. Participants were randomly assigned to one of two groups by the lead

nurse. This DNP candidate arranged a supportive environment for participants on

January 11, 2021.

The one-hour educational intervention included a pre-test/evaluation to

establish baseline data on knowledge and skill proficiency and a post-

test/evaluation for measuring and comparing data. First, all participants listened to

a didactic lecture that included a PowerPoint presentation with three embedded

videos standardized by the ACSCOT. An interactive discussion and

demonstration of bleeding control techniques followed. Next, instructors

evaluated participants at three skills stations that consisted of a prosthetic limb,

packing material, tourniquets, gloves, hand sanitizer, and an instructor certified in

StB. The three stations measured six feet apart to comply with the CDC and

ADPH COVID-19 guidelines. The instructor-to-student ration was 1:5 and the

StB instructor recorded skill performance on each participant.

Educational materials included the ACSCOT training program on StB.

Each participant received printed handouts of the PowerPoint presentation. All

participants received a folder containing instructor materials and a practice kit to

demonstrate competent skill completion. Manikins were sanitized as directed by

the CDC.

16
Measurement Instruments

To measure this DNP project's outcomes, a pre-assessment, post-

assessment, and skills checklist was borrowed with permission from Latuska et al.

(2019; see Appendix A, B, and C).

Data Collection Procedures

Recruitment. The project population consisted of school nurses working

within the county school system. Training attendance was mandatory, but

participation in the research study was voluntary without penalty or repercussions.

All surveys, questionnaires, and evaluations were anonymous and contained

number identifiers to match pre- and post-surveys/evaluations. The researcher

administered a survey/evaluation before and after the educational intervention. A

statistician generated data and the results of the study.

Intervention. The educational intervention consisted of the ACSCOT StB

course with a PowerPoint presentation with three embedded videos. Interactive

discussion with a demonstration of bleeding control techniques followed.

Participants practiced skills at stations with an instructor certified in StB after the

lecture. Lastly, participants completed a post-test/evaluation of skills.

Data Collection. Nurses did not reveal their names or identifiable

information to encourage honesty and ease of survey completion. However, to

match pre- and post-tests/evaluations for comparison, participants used number

identifiers.

Data Analysis. A study was conducted to determine if attending sessions

could show improvement in preparedness, confidence, knowledge, and

17
demonstration skills. A total of 30 school nurses were asked to complete surveys

before and after the training session. Turley (personal communication, May 14,

2021) concluded most participants had 11-20 years of experience (37.93%) and

listed the highest attained education level as BSN (44.83%; see Appendices D and

E). Eleven nurses had received prior training, two nurses left the question blank,

and 17 nurses had not received prior training (see Appendix F). Confidence in

responding to bleeding emergencies increased from 55% to 70%, and school

preparedness to respond increased from 75.8% to 100% (see Appendices G and

H).

At the end of the survey, the participants were asked: How can your

school be more prepared to respond to a life-threatening bleeding emergency?

They were given options to select whether equipment, training, or new procedures

would aid in preparation. Responses to equipment aiding preparedness increased

from 69.0% to 70.0%, establishing clear procedures increased from 86.2% to

90.0%, and more training decreased from 93.1% to 90.0% (F. Turley, personal

communication, May 14, 2021). Therefore, school nurses seem to think

equipment, procedures, and training are important in being prepared for

emergency scenarios on campus.

Results

StB training improved the knowledge, confidence, and skills of

participating school nurses. The perceived ability to respond and be prepared to

respond to bleeding emergencies also improved with training. Conducting a

paired t-test compared the knowledge, tourniquet demonstration skills, and

18
pressure packing demonstration skills before and after training. The scores were

converted to percentages ranging from 0.00 to 1.00. At the .05 level of

significance, there is sufficient evidence to show the scores for the knowledge

test, tourniquet demonstration skills, and pressure packing demonstration skills

are all significantly higher after participants attend training sessions. The

knowledge test score increased 22% (t = 8.12, df = 29, p < 0.001). The tourniquet

demonstration skills score increased by 40% (t = 7.75, df = 28, p <0.001). The

pressure packing demonstration skills score increased by 38% (t = 9.58, df = 28, p

<0.001; F. Turley, personal communication, May 14, 2021; see Appendices I, J,

and K). See Table 1 for a comparison of scores before and after training.

Table 1

Comparison of scores before and after training

Pre-Score Post-Score p-value

Knowledge 0.69 (0.17) 0.91 (0.11) <0.001
Tourniquet Demo 0.56 (0.28) 0.97 (0.05) <0.001

Skills
Pressure/Packing 0.54 (0.24) 0.93 (0.14) <0.001

Demo Skills

Discussion

19
 Due to the improvement in knowledge, confidence, preparation, and skills,

the StB training is beneficial for schools to implement. The StB PowerPoint

presentation and training require an hour to complete. Annual renewal keeps the

training fresh in the minds of employees. StB knowledge, confidence, and skills

improved after training. With the proper equipment, procedures, and training,

school nurses felt prepared to handle bleeding emergencies. School nurses act as

trainers for all other school employees. The techniques taught in StB may be used

in numerous situations at home, work, school, or any public venue involving

trauma or penetrating wounds.

Cost-Benefit Analysis/Budget

A cost/benefit analysis will justify this DNP project in the school setting.

The DNP candidate will not receive any compensation for the educational training

program. The participants will be at work when the study occurs. A nominal fee

exists for instructional supplies. The facility chosen by the DNP candidate was

her place of employment and did not require any cost to utilize. The DNP

candidate is certified and trained by the appropriate national agencies to teach the

materials. The DNP candidate will absorb the time needed to organize and present

the educational training program. The DNP project has the potential to save lives

in the school setting by teaching faculty and staff how to recognize and treat

bleeding emergencies until medical professionals arrive. Therefore, the benefits of

this project exceed the costs.

Timeline

20
 The educational training program occurred on a professional development

day, January 11, 2021. To accommodate social distancing requirements, 15 nurses

attended each hour-long class.

Ethical Considerations/Protection of Human Subjects

The researcher obtained approval from Jacksonville State University’s

IRB before initiating the DNP project (see Appendix L). Potential participants

received an explanation of the research study and consent forms, which explained

that participants could withdraw from the study at any time without repercussions.

The StB educational training program incorporates DNP Essentials I, III, VI, VII,

and VIII components. Essential I involves developing a new strategy to augment

and ease health care delivery in emergencies. The design and content of the

educational intervention utilize the components of Essential III, with critical

appraisal of literature and evidence, and employs information technology to

design interventions within the COVID-19 guidelines of the ADPH for reopening

schools. The educational intervention involved communication and collaboration

with different professionals within the school system. Policies, practices,

standards of care, and scholarly projects apply DNP Essential VI. Clinical

prevention and population health, DNP Essential VII, are directed toward the

population of school-aged children in the community and the faculty/staff

responsible for their care while attending school. The educational training

program investigated scientific data from various arenas to address psychosocial

and cultural aspects to facilitate intervention and evaluation of health promotion

21
and injury prevention goals after discovering a gap in preparedness. Educating

faculty, staff, and nurses in the school setting meets DNP Essential VIII.

The project goal is to train the school nurses with minimal risk to

participants. As an educational training program, the project did not implicate

vulnerable populations or patients. The questionnaire included self-reported

competencies and measured knowledge of specific concepts, which may induce

feelings of inadequacy with minimal risk. Since the activities of the project were

academic and demonstrative, minimal risk for harm exists. Participants signed

consent forms before commencing the intervention. The information provided to

participants will ensure preparedness to handle bleeding emergencies without

harming participants, faculty, staff, students, or the school.

Conclusion

The StB educational intervention was effective at improving knowledge,

tourniquet application, and wound packing. As a result, confidence in responding

to bleeding emergencies increased from 55% to 70%, and school preparedness to

respond increased from 75.8% to 100%. In turn, as trainers, school nurses will

continue to disseminate the StB program to faculty and staff at each school in the

county. Being prepared to respond to bleeding emergencies may be the difference

between life and death.

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34
 APPENDIX A

Stop the Bleed Pre-Assessment

Latuska et al. V.18June2018 5 digit number: _____________

Please indicate whether the following statements are true or false by placing a T or F
in the column next to the statement.

1. ______ The first thing you should do when you see an injured person is rush to
help them.

2. ______ When utilizing a tourniquet to stop bleeding, the tourniquet should be

placed below the site of bleeding.

3. ______ All methods used to stop bleeding have one thing in common-
compressing a bleeding blood vessel to stop bleeding.

The next two questions outline actions to be performed to control bleeding. Please
place the following statements in the correct order that you would perform them.
Place a 1 in the space of the first thing you would do, a 2 in the place of the second,
etc.

4. Please place the following actions in the correct order to control bleeding in an
extremity without access to a tourniquet.
______ Alert Emergency Medical Responders

______ Apply steady direct pressure

______ Find the source of bleeding

______ Pack the wound with gauze or a clean cloth

35
 5. Please place the following actions in the correct order to control bleeding in an
extremity with access to a tourniquet.
______Wrap the tourniquet around the bleeding extremity 2 to 3 inches above
the bleeding site

______Pull the free end of the tourniquet to make it as tight as possible and
secure the free end

______Twist or wind the windlass until bleeding stops

______Secure the windlass to keep the tourniquet tight

______Secure the tail of the tourniquet through the clips

______Put the time strap over the secured tail

______Note the time the tourniquet was applied

Please place an “X” next to all of the following that apply.

6. Which of the following are signs of life-threatening bleeding?

______ Blood that is spurting out of the wound

______ Blood that won’t stop coming out of the wound

______ Blood that is pooling on the ground

______ Clothing that is soaked with blood

______ Bandages that are soaked with blood

______ Loss of all or part of an arm or leg

______ Bleeding in a victim who is now confused or unconscious

36
Latuska et al. V.18June2018 5 digit number: _____________

Please rate extent to which you agree with the following statements by circling one of
the options below.

1. I think my school is prepared to handle a life-threatening bleeding emergency.

Strongly Disagree Neither agree Agree Strongly

Disagree nor disagree Agree

2. I am confident in my ability to respond to a life-threatening bleeding

emergency.

Strongly Disagree Neither agree Agree Strongly

Disagree nor disagree Agree

Please place an “X” next to all of the following that apply.

3. How can your school be more prepared to respond to a life-threatening

bleeding emergency? ______ Equipment
______ Training

______ Establishing clear procedures

______ Other (please specify below)

_________________________________________________________________

_________________________________________________________________

Demographics

1. Have you previously received training on Stop the Bleed? Yes No

2. What is your highest level of education?

Diploma/LPN/LVN ADN BSN MSN

3. How many years of experience as a nurse do you have?

1-5 years 6-10 years 11-15 years 16-20 years >20 years

37
 APPENDIX B

Stop the Bleed Post-Assessment

Latuska et al. V.18June2018 5 digit number: ______

Please indicate whether the following statements are true or false by placing a T or F
in the column next to the statement.

1. ______ The first thing you should do when you see an injured person is rush to
help them.

2. ______ When utilizing a tourniquet to stop bleeding, the tourniquet should be

placed below the site of bleeding.

3. ______ All methods used to stop bleeding have one thing in common-
compressing a bleeding blood vessel to stop bleeding.

The next two questions outline actions to be performed to control bleeding. Please
place the following statements in order that you would perform them. Place a 1 in the
space of the first thing you would do, a 2 in the place of the second, etc.

4. Please place the following actions in the correct order to control bleeding in an
extremity without access to a tourniquet.
______ Alert Emergency Medical Responders

______ Apply steady direct pressure

______ Find the source of bleeding

______ Pack the wound with gauze or a clean cloth

38
 5. Please place the following actions in the correct order to control bleeding in an
extremity with access to a tourniquet.
______Wrap the tourniquet around the bleeding extremity 2 to 3 inches above
the bleeding site

______Pull the free end of the tourniquet to make it as tight as possible and
secure the free end

______Twist or wind the windlass until bleeding stops

______Secure the windlass to keep the tourniquet tight

______Secure the tail of the tourniquet through the clips

______Put the time strap over the secured tail

______Note the time the tourniquet was applied

Please place an “X” next to all of the following that apply.

6. Which of the following are signs of life-threatening bleeding?

______ Blood that is spurting out of the wound

______ Blood that won’t stop coming out of the wound

______ Blood that is pooling on the ground

______ Clothing that is soaked with blood

______ Bandages that are soaked with blood

______ Loss of all or part of an arm or leg

______ Bleeding in a victim who is now confused or unconscious

39
Latuska et al. V.18June2018 5 digit number: ______

Please rate extent to which you agree with the following statements by circling one of
the options below.

1. After completing the Stop the Bleed training, I think my school is prepared to
handle a life-threatening bleeding emergency.

Strongly Disagree Neither agree Agree Strongly

Disagree nor disagree Agree

2. After completing the Stop the Bleed training, I am confident in my ability to

respond to a life-threatening bleeding emergency.

Strongly Disagree Neither agree Agree Strongly

Disagree nor disagree Agree

Please place an “X” next to all of the following that apply.

3. How can your school be more prepared to respond to a life-threatening

bleeding emergency? ______ Equipment
______ Training

______ Establishing clear procedures

______ Other (please specify below)

_________________________________________________________________

_________________________________________________________________

Please provide any additional comments below:

_________________________________________________________________

_________________________________________________________________

40
 APPENDIX C

Stop the Bleed Psychomotor Checklist

Latuska et al. V.18June2018

Demonstration of proper use of a bleeding control tourniquet

 Wrap the tourniquet around the bleeding arm or leg

 Ensure the tourniquet is about 2 to 3 inches above the bleeding

site

 Pull the free end of the tourniquet to make it as tight as possible and secure the free
end

 Twist or wind the windlass until bleeding stops

 Secure the windlass to keep the tourniquet tight

 Secure the tail of the tourniquet through the clips

 Put the time strap over the secured tail

 Note the time the tourniquet was applied

Total: /8

Demonstration of proper direct pressure and wound

packing technique

 Pack (stuff) the wound with bleeding control gauze (preferred), plain gauze, or clean
cloth

 Apply steady pressure while packing the bleeding wound with both hands directly

 Continue to hold pressure after packing complete

Total: ___________ /8

41
 APPENDIX D

Participants Educational Level/Licensure

Educational Level / Licensure

14

12

10
Number of Nurses

0
Blank LPN ADN BSN MSN

42
 APPENDIX E

Participants Nursing Experience

Nursing Experience
12

10

8
Number of Nurses

0
1-5 years 6-10 years 11-15 years 16-20 years >20 years Blank

43
 APPENDIX F

Participants Training

Previous Training
2

11

17

blank no yes

44
APPENDIX G

Confidence

45
 APPENDIX H

School Preparedness

46
 APPENDIX I

Tourniquet Application Skill

Tourniquet Applicati on
9 9
8 8
7 7
6 6
Correct Steps

5 5
4 4
3 3
2 2
1 1
0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Participants

after training before training

47
 APPENDIX J

Wound Packing Skill

Wound Packing Skill

3.5 3.5

3 3

2.5 2.5
Correct Steps

2 2

1.5 1.5

1 1

0.5 0.5

0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Participants

after training before training

48
 APPENDIX K

Knowledge of Participants

Knowledge
7 7

6 6

5 5
Correct Answers

4 4

3 3

2 2

1 1

0 0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Participants

after training before training

49
 APPENDIX L

Letter of IRB Approval

50
 APPENDIX M

Letter of Agency Approval

51
 APPENDIX N

Letter of Site Approval

52
 APPENDIX O

Informed Consent Document

Title of the study: Emergency Preparedness in the School Setting

Purpose of Research: To educate students, school faculty and staff, and school
nurses regarding pandemic and mass casualty events.

Evaluation of Procedures: Education will be provided either in person or via

internet depending on COVID guidelines from ADPH. An anonymous
questionnaire/evaluation will be given before and after the education to measure
objectives.

Location of Where the Research Will Take Place: Oak Mountain Intermediate
School for students, faculty, and staff. The library, cafeteria, or classrooms may
be used due to spacing restrictions and internet availability. A conference room at
the Shelby County Instructional Services Center in Alabaster for school nurses
depending on presentation format, spacing, and internet availability.

Length of Time: Student will receive an hour presentation from the American
Red Cross. Faculty and staff will receive training on pandemic, first aid, CPR, and
Stop the Bleed which will require 2-4 hours. School nurses will receive training
on pandemic, Stop the Bleed, and START triage method which will require 2
hours.

Risks and Discomforts: You will be asked to complete a survey/evaluation and

participate in education on emergency preparedness. There is minimal risk. After
education, you will be asked to complete another survey/evaluation.

Benefits: If you learn the latest information on pandemics and mass casualty
events, you can better respond to emergencies and improve outcomes of disasters.

Confidentiality: Informed consent for this research will be kept private to the
extent allowed by law. The information obtained from this study will be published
without names or personal identification. Surveys/evaluations will be anonymous.
All records will be maintained for a year from the study, locked inside a safe at
the researcher’s house.

Refusal or Withdrawal Without Penalty: If you agree, you will be taking part
in the study, which is voluntary. There will be no penalty if you decide you do not

53
want to participate. You may choose to withdraw from the study and notify the
researcher at any time. Withdrawal will not affect your employment.

Cost of Participation: There is no cost to participate, unless certified in CPR.

Informed Consent Document (continued)

Payment to Participate: There will be no payment exchanged.

Questions: If you have any questions, concerns, or complaints about the research,
please contact Tonya Bright, RN, MSN at 205-682-5223 or tbright@shelbyed.org.
She will be glad to answer any questions. If you have any questions about your
rights as a participant, concerns, or complaints about the research, you may
contact Dr. Allison Newton, Chair of the Institutional Review Board for
Jacksonville State University, at 256-782-5108, or anewton@jsu.edu.

Legal Rights: You are not waiving any of your legal rights by signing this
consent form.

Permission Form for Research on

Emergency Preparedness in the School

Setting

I have read and received a copy of the description of the study. I understand the
procedure described above. I, _____________________, agree to participate in
the study.

_________________________________________ _________________
Signature Date

54