⭐⭐⭐⭐⭐ Explain Why Partnership Working May Be Difficult In A Multidisciplinary Team

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Explain Why Partnership Working May Be Difficult In A Multidisciplinary Team

Roles, responsibilities, and liability terms also are typically outlined within joint explain why partnership working may be difficult in a multidisciplinary team agreements States, districts, and schools should use a systematic explain why partnership working may be difficult in a multidisciplinary team when developing, implementing, and monitoring healthy eating and uniform layer cut activity policies. Students can explain why partnership working may be difficult in a multidisciplinary team and poll their peers, provide valuable Berkeley And Immaterialism to shape explain why partnership working may be difficult in a multidisciplinary team, help plan and market changes, and promote the explain why partnership working may be difficult in a multidisciplinary team of healthy eating initiatives. Baroque Period Essay Economists Publications journals. In older adults, fractures lead to physical disabilities, depression, reduced quality of life, and potentially death 56, Dangerous behaviors e. At present [ when? The Devil In Great Island Chapter Summary book will remind you that sometimes, less is more. School nutrition services staff members may modify menus to include healthier foods, such as serving more fruits, vegetables, and whole grains, and offering a greater variety of low-fat foods, including fat-free and low-fat milk.

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From my own practice I remember the back rounds in particular as a rather ritualistic, pressured area of care. They were discarded because they lacked scientific basis, but they had some merit. Some rituals have been replaced by more scientific or theoretical ones. Whether the nursing process and nursing models have actually improved care for patients is debatable. It also remains to be seen whether clinical supervision, reflection, deciding interventions and perhaps nursing diagnosis will improve patient care in the future or if these are just further contributions to the theory-practice gap. Tradition is evident in much of practice. There are some other aspects of care that perhaps originate in religion or superstition, for example leaving a window open to let the spirit out when a patient dies.

Traditional beliefs are learnt in practice but there is a lack evidence to support their use and there is a conflict with logic or common sense. However, bodies deteriorate more slowly at cooler temperatures and opening a window may provide some comfort to relatives who believe in an afterlife, so perhaps there is some evidence to support this practice after all.

Rather than continuing rituals without question or discarding them without investigation, it is more appropriate to research all these traditional aspects of care and discard those that are ineffective or harmful. Practices from all knowledge sources should be subject to questioning, including information practice and evidence from research, as knowledge from any source may be false or need revision. Numerous authors write about nursing knowledge from a range of viewpoints. Carper tried to capture all types of knowing in nursing, referring to aesthetic, emotional, personal and ethical elements to knowing. This has been used as a model for reflection Johns, and the existence of intuition, for example, is debated Turnbull, ; Marks-Moran, There is little written about the use of senses such as sight, hearing, touch and smell to generate nursing knowledge and about the practical need for dexterity, for example.

All these types of knowledge are needed to do a dressing well, for instance, and are important aspects of knowledge. These are all elements we subconsciously use in practice and that are hidden to some extent. Nurses in practice often have their own humour and own terms for things. This knowledge can be linked to the particular department and is rather like the knowledge of a cult, hidden from the uninitiated, and difficult to identify and teach. This may be a way of coping with stress but can be part of socialisation or means to identify who belongs to that team or department. Nursing knowledge in academia is often not understood. This nursing knowledge created away from practice may need interpretation if it is to be used in practice and if it is not to contribute to the theory-practice gap Haines and Donald, It is important that the ideas expressed are not lost in the interpretation.

Knowledge needs to be translated into good practice Joyce, Nurses need to be taught how to evaluate all sources of knowledge and must learn how to become critical thinkers, as this will increase the amount and quality of nursing knowledge. Nurses also need, perhaps, to think about practice elements and to learn from experience. Reflective practice seems to be in vogue Rashotte and Charnevale, It is the application of knowledge that is unique to nursing McKenna, The need for nursing knowledge is of course influenced by patients.

Patients are becoming more informed and ask nurses increasingly about aspects of health and care that affect them. As pointed out, nursing knowledge originates around the form of enquiry but is often rooted in other professions. As professions tend to be formed around a clear classification of knowledge, establishing professional status is more difficult for nursing. Some nursing knowledge is acquired via socialisation into an organisation - boundaries of behaviour become part of our nursing knowledge, for example.

Expert nurses and those who are motivated, innovative and perhaps take the profession forward help to push the barriers in terms of knowledge. Those who question practice, understand the rationale for what they do, explain it to patients as well as apply it appropriately prove to be the best nurses. Knowledge breeds knowledge and the clinical skills and knowledge needed to care for patients continue to change dramatically. Nursing knowledge has become more complex and specialised and is constantly evolving. New types of knowledge will continue to be evident - the complexities of practice create more debate than the old, ritualistic care-giving.

What could be called nursing knowledge comes from a variety of sources including both theoretical and practice perspectives - clinical decisions should be based on what is evidence rather than just opinion or belief. The aim for the profession should be to improve practice by questioning findings from all sources. Gaining knowledge raises an awareness of personal and professional accountability and the dilemmas of practice. The care and support plan could include:. After the birth of the baby, the midwifery services should update the health visiting services on the health of both mother and baby.

The midwife can explain the purpose of the parent-held personal child health record and how it will be used by the midwife, health visitor and GP. At discharge from community midwifery care, the midwife could complete appropriate sections of the parent-held personal child health record to facilitate transfer of care to the health visitor. The New Baby Review is done by the health visitor and should ideally occur within 14 days after birth. However, in some circumstances, this is not possible. Ahead of this review, health visitors should have received information from midwifery services about the woman and the baby they are visiting.

An action plan could be a particular consideration for women and partners or fathers with complex social factors. Where a woman or father or partner is identified as vulnerable for example, maternal mental health, learning disability, obstetric issues, domestic abuse and so on they can be asked to co-create an individualised action plan with the midwife and health visitor. As this is associated with additional resource, it should be planned with care and provided only when appropriate. If women require midwifery input after day 14, the midwife and health visitor should aim to have a verbal handover in addition to a written handover. This could be via an online meeting or phone call. From 28 weeks of pregnancy a face-to-face contact is to be made with every pregnant woman by the health visiting service.

Many women welcome the opportunity to have contact with their health visitor antenatally 9. To facilitate this contact, midwifery services need to provide information about women to the health visiting service. Many midwifery services share information after the week scan when the pregnancy is seen as viable. This reduces the risk of health visitors contacting women who have suffered a miscarriage. After the contact, health visitors can share any relevant information about the woman and her pregnancy with the midwifery services.

As of to , there is a new requirement for GPs to offer a 6 to 8 week postnatal check for new mothers, as an additional appointment to that for the baby. This makes communication between health visitors and GPs of greater significance than ever before. It is also important to communicate with the GP if women have declined health visiting services In this section, evidence and practice examples are presented to provide suggestions of how care continuity and collaboration between midwifery and health visiting services can be provided. These consist of:. Information can be shared in a number of ways; face-to-face or online meetings, telephone or email contacts, forms and through sharing of health records.

Face-to-face meetings are particularly valued by healthcare professionals when supporting families with complex needs 5. Whatever form the communication takes, it needs to be timely and accurate to facilitate good support for women and their family. A midwife discharging a postnatal woman called to inform the allocated health visitor that there was little food in the home and the access to Healthy Start support that had been in place had now ended.

There were no other concerns and the family was under a universal care pathway. The health visitor was able to access a food parcel that same day and arrange delivery to the family. She then provided telephone support to the family to re-apply for Healthy Start vouchers to supplement their food budget. Although the midwife and health visitor had not needed to complete joint contacts for this family under Universal care, prompt communication of an identified need meant that health visiting services were able to respond quickly and put support in place for this family. Women report that fragmented communication between midwifery and health visiting services sometimes results in receiving inconsistent information from healthcare professionals 7.

Women also find themselves having to repeat their clinical information and needs to each healthcare professional , which can be irritating and distressing, especially for women with pregnancy- or birth-related trauma. To avoid women having to repeat themselves and to enable consistent information, a tool was developed in Sheffield to share infant feeding plans between parents, midwives and health visitors see practice example 7. The infant feeding leads for both midwifery and health visiting met regularly to explore how practitioners could be supported to engage in timely and effective communication.

Extensive consultation took place with main stakeholders including community and postnatal midwifery matrons, postnatal ward and health visiting team leaders, advanced neonatal nurse practitioners, midwives, nursery nurses and mothers and it was agreed that a parent-centred approach would be most appropriate in line with the current personalisation agenda. A booklet was developed where parents document feeding and expressing, read when and how the plan will be reviewed, how they will be supported back to breast feeding and access further information.

It also assists health professionals to review feeding progress and to update the plan, in collaboration with the parents. In addition, a new feeding plan sticker is completed by the midwife and placed in the Child Health Record to alert the health visitor to consult the plan. This tool is part of a process to promote seamless care between the midwifery and health visiting services in Sheffield, to support mothers whose baby is on a feeding plan. Previously, communication between the midwife, health visitor and mother lacked consistency regarding ongoing support when a feeding plan was in place. There can be inconsistencies about how much information is shared 5. To overcome this, clear liaison forms can help information sharing. For example, Buckinghamshire, Oxfordshire and Berkshire West Local Maternity System has communication guidelines and a liaison form to help information sharing.

The form outlines any additional support a woman may need at any time during her care, including physical, emotional, social or educational needs. In some areas, information is shared via forms sent on email. In other areas, IT systems has been developed for rapid and regular information sharing. This has been identified as a communication barrier between midwifery and health visiting services, but can also include Family Nurse Partnerships and GP services as well Practice example 8 outlines the information sharing in Bedfordshire, Luton and Milton Keynes Local Maternity System between midwifery and health visiting services. An information sharing agreement was designed to provide the health visiting service in Bedfordshire with the demographic details of every pregnant woman booked for delivery in the Bedfordshire hospitals.

This data is used to facilitate antenatal visits by health visitors. Accurate contact and personal details, and date of expected birth are required by the health visiting service after 24 and prior to 32 weeks of pregnancy. Previously, community midwives provided information direct to health visitors, however this was patchy, often inaccurate, provided on paper and has proven difficult to achieve. As a result, a low number of antenatal women received a visit prior to the birth by health visitors. A joint working group was identified to include commissioners, the maternity service and the health visiting service.

The maternity service investigated ways in which their electronic patient records system could be interrogated to obtain the data required and used a software package that could perform this function. A process was drawn up to include the following:. To date, very few women have refused an antenatal contact with the health visitor. Feedback from women is regularly positive, and shows that the service is appreciated. Before the new process started, midwives were trained in the role of the health visitor, the current offer by health visitors for all pregnant women, how to gain consent from women, how to ensure the maternity system can read that consent has been given, what to do if a woman refuses to share information with the health visiting service, the importance of sharing complex information with the health visiting service and the importance of sharing late or out of area women with the health visiting team locally.

This in turn may cause women to receive conflicting advice, reduced support or incorrect advice about the support available to them from each profession. To increase uptake of the health visiting antenatal contact, Bedfordshire, Luton and Milton Keynes Local Maternity System held training for midwives regarding the health visiting role and service. This, together with an improved electronic information sharing system, increased antenatal contacts see practice example 8. When a midwife-health visitor team approach is adopted with women, it becomes easier for women to seek support and connect with services, and discuss their concerns.

Practice example 9 provides an example of how a collaborative partnership can be developed. Initially, meetings were arranged with the midwifery leads or matrons from both acute trusts and the Clinical Lead from HCP. The purpose of these initial meetings was to review current practice and identify where improvements could be made, using a PDSA Planning, Doing, Studying, Acting approach. These meetings were held face-to-face. Other key individuals who could support progression of this project were identified.

The digital midwives were involved very early in the discussions. Proactive commissioners have been pivotal in supporting the building of relationships and facilitating opportunities for change management. There has also been collaboration with service users. Face-to-face workshops can help build rapport and getting to know each other. Co-location of services can improve formal and informal communication, making it faster and more efficient to collaborate.

To ensure greater collaborative working within a co-located setting, clear pathways and joint policies are needed. Alongside these, facilitative organisational structures and strong managerial support needs to be provided For example, regular meetings between midwifery and health visiting managers allows for practice to be discussed and audited and any changes disseminated quickly. A number of resources are needed to implement effective care continuity. Resources include appropriate staffing levels and workloads, adequate time, organisational and managerial support and shared IT systems 5. For example, managerial support is needed to develop standard operating procedures.

Barriers to sharing information that can facilitate care continuity includes different service commissioners and therefore funding structures, IT systems, service boundaries and places of work. An example of how enhanced resourcing through managerial support and protected staff time led to improved multi-disciplinary working and care planning can be seen in practice example 10 derived from the Lambeth Early Action Partnership LEAP Health Team. An interprofessional health care team was formed to examine how the primary care professionals who provide care for pregnant women and their families could work better together. The team comprised 4 front-line clinicians a local GP, a health visitor, and 2 midwives from different local trusts , operating in a flat hierarchy.

Team members were given protected time for this work, which they carried out on the basis of a one day a week secondment from their front-line work. They were given the autonomy to explore any issues that they identified, with a light-touch management steering approach, and were supported to disseminate and implement the solutions they identified. Together they developed a forensic map of what did and did not work, gathering information through shadowing, meeting stakeholders and service mapping. This led to the development of a wide-range of projects including regular interprofessional meetings to discuss vulnerable families, shared access to local care records held electronically, shared practitioner contact lists, interprofessional training, and improved resources for assessment and referral.

Outcomes include improved care planning and multidisciplinary working affecting areas such as safeguarding, medical concerns and family issues. High-quality data analysis tools and resources are available for all public health professionals to identify the health and health needs of the local population. This contributes to the decision-making process and plans to improve services and reduce inequalities. Commissioners and local services need to demonstrate the impact of their services and this can be achieved by using local measures.

Below are examples of outcomes and how they can be measured. A range of background factors for each local area and other indicators relating to women, children and young people can be found in the Child and maternal health section on PHE Fingertips and in the annually updated local authority child health profiles, which can be extracted in PDF format from the Fingertips platform. Better Births , Although evaluations should not be used to audit or rank schools or penalize school staff members , , evaluations can be used to motivate schools to make changes and monitor school-level implementation of school district, state, and federal policies.

Two fundamental types of evaluation are process and outcome. In process evaluation, educators collect and analyze data to determine who, what, when, where, and how much of program activities have been conducted. Process evaluation is the foundation of evaluation because it specifies the activities involved in policies, programs, and practices, and whether they were implemented as intended. In addition, process evaluation allows education agency staff members to assess how well a policy, program, or practice has been implemented and what strengths and improvements are necessary. Outcome evaluation explores whether intended outcomes or specific changes occur as a direct result of policies, programs, or practices.

Outcomes might include changes at the school level e. Outcome evaluation can require a great deal of time, money, and expertise, and individual schools are unlikely to be able to conduct outcome evaluations on their own. A full-fledged outcome evaluation might be beyond the reach of most schools and is more likely the purview of state and local education agencies. However, some outcome-related questions can be answered using simple methods available to most schools.

Outcome evaluation can focus on short- or long-term outcomes of policies, programs, or practices, including changes in practices at the school level or changes in student knowledge, attitudes, skills, behaviors, or health outcomes. Conduct process evaluation of nutrition and physical activity policies and practices. Schools should conduct a process evaluation of their healthy eating and physical activity policies and practices. Process evaluation topics for schools might include the following:.

Conduct outcome evaluation of healthy eating and physical activity policies, programs, and practices. In addition to the process evaluation topics, schools might evaluate changes that occurred after a policy, program, or practice was implemented. Outcome evaluation topics include the following:. The Physical Activity Evaluation Handbook illustrates the six steps of program evaluation in the framework with physical activity program examples Understanding Evaluation: The Way to Better Prevention Programs describes evaluation activities that school districts and community agencies can use to assess various programs State and local education agencies and schools can consult with evaluators at universities, school districts, or state departments of education and health to identify methods and materials for evaluating their efforts.

The physical surroundings and psychosocial climate of a school should encourage all students to make healthy eating choices and be physically active. The physical environment includes the entire school building and the area surrounding it; facilities for physical activity, physical education, and food preparation and consumption; availability of food and physical activity options; and conditions such as temperature, air quality, noise, lighting, and safety The psychosocial environment includes the social norms established by policies and practices that influence the physical activity and eating behaviors of students and staff members Developing and maintaining a supportive school environment can improve the sustainability of healthy eating and physical activity policies and practices that support healthy lifestyles ,, Box 2.

Provide adequate and safe spaces and facilities for healthy eating. School nutrition services should serve healthy food in an environment that allows students to pay attention to what they are eating and enjoy social aspects of dining , Students can enjoy meal time more when they feel relaxed and are able to socialize without feeling rushed. Actions to support safe and healthy eating include. Other food environment activities, such as school gardens, school salad bars, and farm-to-school programs, can enrich the eating and educational experience by providing quality produce and opportunities for hands-on multidisciplinary learning In , the National School Lunch Act was amended with a provision encouraging institutions participating in the school lunch and breakfast programs "to purchase unprocessed agricultural products, both locally grown and locally raised, to the maximum extent practicable and appropriate" In addition to integrating local agriculture products, such as fruits, vegetables, and eggs, into the school cafeteria, farm-to-school activities include hands-on education through school garden programs and field trips to local farms, classroom nutrition education, and alternative fundraising using local produce School garden programs have the potential to strengthen the healthy development of students through improved knowledge about fruits and vegetables ,, , increased preference for fruits and vegetables ,, , and increased consumption of fruits and vegetables ,,, Schools also should ensure that students have access to safe, free, and well-maintained drinking water fountains or dispensers during school meals, as required by the Healthy, Hunger-Free Kids Act , as well as throughout the school day This provides a healthy alternative to sugar-sweetened beverages and can help increase students' overall water consumption , Ensure that spaces and facilities for physical activity meet or exceed recommended safety standards.

All spaces and facilities for physical activity, including playing fields, playgrounds, gymnasiums, swimming pools, multipurpose rooms, cafeterias, and fitness centers, should be regularly inspected and maintained, hazardous conditions should be corrected immediately, and a comprehensive safety assessment should be done at least annually , Regular inspection and maintenance of indoor and outdoor play surfaces should ensure that environmental safety devices are provided and maintained, including , Develop, teach, implement, and enforce safety rules. Safe physical activity requires proper conditioning and use of appropriate equipment where needed.

Dangerous behaviors e. Explicit safety rules should be taught to and followed by students in physical education, extracurricular physical activity programs, and community sports and recreation programs ,, Adult supervisors should consistently reinforce safety rules, which should be posted in key locations. One person, such as the school health coordinator or lead physical education teacher, should be responsible for ensuring that safety measures are in place and updated as needed , ; however, minimizing physical activity--related injuries and illnesses among children and adolescents is the joint responsibility of teachers, administrators, coaches, athletic trainers, school nurses, other school and community personnel, parents, and students , Maintain high levels of supervision during structured and unstructured physical activity programs.

Trained staff members or volunteers, including coaches, teachers, parents, paraprofessionals, and community members, should supervise all physical activity programs. Staff members should be aware of the potential for physical activity--related injuries and illnesses among students so that the risks for and consequences of these injuries and illnesses can be minimized.

To prevent injuries during structured physical activity schools can. Children and adolescents also could be provided with, and required to use, protective clothing and equipment appropriate for the type of physical activity and the environment Protective clothing and equipment includes footwear appropriate for the specific activity; helmets for bicycling; helmets, face masks, mouth guards, and protective pads for football and ice hockey; shin guards for soccer; knee pads for in-line skating; and reflective clothing for walking and running. As a general recommendation, all protective equipment should 1 be in good condition; 2 be inspected and maintained frequently; 3 be replaced if worn, damaged, or outdated; 4 provide a good fit for the athlete; and 5 be appropriate for the sport and position.

In addition, children and adolescents need to be trained to use equipment correctly; this is particularly true of helmets To prevent injuries during unstructured play time, schools should consider implementing training sessions for staff members focusing on observation techniques, behavior management, appropriate supervision, and emergency response procedures Additional information that schools might want to integrate into training sessions can be found in the Consumer Product Safety Commission Handbook for Public Playground Safety In general, playground supervisors should 1 repetitively teach children playground rules; 2 prevent, recognize, and stop children's dangerous and risky behavior; 3 help children to identify, acknowledge, and prevent their risky behavior; and 4 model appropriate safety behavior , When possible, schools can support those supervising unstructured physical activity by following the National Program for Playground Safety NPPS recommendations that the playground supervision ratio of teachers to students be equal to the indoor classroom ratio Increase community access to school physical activity facilities.

Schools should provide community access to physical activity facilities, such as gymnasiums, tracks, baseball and softball fields, basketball courts, outdoor play areas, and indoor fitness centers during the school day and out-of-school time ,, Establishing a formal policy or agreement, such as a joint use agreement, between schools and community organizations can help increase student, family, and community access to physical activity facilities and programs.

A joint use agreement is a policy that allows two or more entities e. Joint use agreements provide details about the facilities to be shared, as well as scheduling, management, maintenance, and costs of the shared facilities. Roles, responsibilities, and liability terms also are typically outlined within joint use agreements Access to these facilities can help to increase visibility of schools, provide community members a safe place for physical activity, and might increase partnerships with community-based physical activity programs , Frequently, schools have the facilities but lack the personnel to deliver extracurricular physical activity programs.

Community resources can expand existing school programs by providing program staff members as well as intramural and club activities on school grounds. For example, community agencies and organizations can use school facilities for after-school physical fitness programs for students, weight management programs for overweight or obese students, and sports and recreation programs for students with disabilities or chronic health conditions. Adopt marketing techniques to promote healthy dietary choices.

Marketing techniques can be used to promote healthy foods and beverages among students. The following techniques have been used in schools to increase the likelihood of students choosing healthier foods and beverages:. Use student rewards that support health. Student achievement or positive classroom behavior should only be rewarded with nonfood items or activities.

The use of food as rewards, especially foods with little nutritional value, might increase the risk that children associate such foods with emotions, such as feelings of accomplishment , Providing food based on performance or behavior connects the experience of eating food to the student's perceptions and mood. Rewarding students with food during class also reinforces eating outside of meal or snack times.

This practice can encourage students to eat treats even when they are not hungry and instill lifetime habits of rewarding or comforting themselves with unhealthy eating, resulting in overconsumption of foods high in added sugar and fat Although few studies have examined the effect of using food rewards on students' long-term eating habits, the IOM Nutrition Standards for Foods in Schools report determined that such use of foods in schools is inappropriate because this practice establishes an emotional connection between foods and accomplishments.

When an extrinsic reward system is used, rewards should be nonfood items or activities e. Do not use physical activity as punishment. Teachers, coaches, and other school and community personnel should not use physical activity as punishment or withhold opportunities for physical activity as a form of punishment. Using physical activity as a punishment e. Exclusion from physical education or recess for bad behavior in a classroom deprives students of physical activity experiences that benefit health and can contribute toward improved behavior in the classroom , Disciplining students for unacceptable behavior or academic performance by not allowing them to participate in recess or physical education prevents students from 1 accumulating valuable free-time physical activity and 2 learning essential physical activity knowledge and skills.

Schools can take numerous steps to help shape a health-promoting psychological environment. For example, they can adopt and enforce a universal bullying prevention program that addresses weight discrimination and teasing ,, , ensure that students of all sizes are encouraged to participate in a wide variety of physical activities , display posters or other visual materials that feature a diverse combination of students being active and eating healthy, and avoid practices that single out students on the basis of body size or shape Schools should avoid elimination games such as dodge ball, bombardment, and elimination tag that limit opportunities for all students to be active School health, mental health, and social services staff members can play a key role in helping to communicate and promote these practices.

The school nutrition policy should ensure a safe environment for students with chronic health conditions. The policy should cover all venues where foods and beverages are available, during the regular and extended school day, and all families and staff members should be informed of the policy Nutrition service staff members should be provided with information and support to assist students who are on nutrition programs or diets prescribed by their health-care provider.

USDA provides guidance on accommodating children with special dietary needs, supported by the USDA nondiscrimination regulation , allowing for substitutions or modifications in the National School Meals Program for children whose disabilities restrict their diet as certified by a licensed physician The school nutrition service staff members also should consider making food substitutions for students with food allergies, for students with food intolerances, or on a case-by-case basis for students who are medically certified as having a special medical dietary need The school environment should support students with disabilities and chronic health conditions in being physically active and making healthy eating choices. A chronic health condition is defined as any illness, disease, disorder, or disability of long duration or frequent recurrence, including asthma, diabetes, serious allergies, epilepsy, and obesity Schools should establish policies that allow full participation by all students in physical activity, including extracurricular activities, and ensure access to preventive and quick-relief medications as indicated by a student's Individualized Health Care Plan, plan, Individualized Education Plan IEP , or all of these as appropriate , Coordination between health services staff members, special education, nutrition services staff members, and health and physical education staff members can help ensure that these policies are established.

Schools are in a unique position to promote healthy dietary behaviors and help ensure appropriate food and nutrient intake among their students. Many schools provide students with access to foods and beverages in various venues across the school campus, including meals served in the cafeteria as part of the federally reimbursable school meal program and competitive foods i. Schools should model and reinforce healthy dietary behaviors by ensuring that only nutritious and appealing foods and beverages are provided in all venues accessible to students Box 3. Schools should provide students with access to breakfast, lunch, and other important programs e. A school meal program offers students the opportunity to apply knowledge and skills learned through nutrition education, can affect students' food choices by providing nutrient information of the foods available, and can encourage students to make healthy choices 98,, School districts and independent schools that choose to take part in the federal school meal programs receive cash reimbursements and entitlement funds for USDA Foods commodities , provided that the meals they serve meet federal requirements and that they offer free or reduced price lunches to eligible students.

Students who participate in school meal programs have been found to consume more milk, fruits, and vegetables and have better nutrient intake than those who do not participate , However, participants in the School Breakfast Program and National School Lunch Program also have higher sodium intake from school meals than those who do not participate Student participation in school meal programs, particularly breakfast, has been shown to be associated in the short term with improved student functioning on a broad range of psychosocial and academic measures 65, Studies of students who participated more often in school breakfast programs showed increases in test scores and significant decreases in the rates of school absence and tardiness compared with students whose participation remained the same or decreased 65, Encourage participation in school meal programs among all students.

In the school year, boys participated in the National School Lunch Program at a higher rate than girls, elementary school students participated at a higher rate than middle and high school students, students who were eligible for free and reduced-price meals participated at a higher rate than students who were not income eligible, rural students participated at a higher rate than urban students, and students whose parents did not attend college participated at a higher rate than those parents who did. In the school year, boys participated in the School Breakfast Program at a higher rate than girls, non-Hispanic black students participated at a higher rate than Hispanic students and non-Hispanic white students, elementary school students participated at a higher rate than middle and high school students, students who were eligible for free and reduced-price meals participated at a higher rate than students who were not income eligible, students who spoke Spanish in the home participated at a higher rate than students who spoke English, and rural students participated at a higher rate than urban students All students are eligible to participate in the school meal program; however, schools receive a smaller reimbursement for students who exceed income limits than for students from low-income families.

Increased effort is needed to ensure that participation in a school meal program that complies with the Dietary Guidelines for Americans is promoted and supported. To encourage increased participation in school meal programs by all students, schools can use the following strategies:. The school meal program should provide various healthy, appetizing, and culturally appropriate choices to help students meet their nutritional needs.

Meals served in the National School Lunch Program and School Breakfast Program must meet federally defined nutrition standards based on the Dietary Guidelines for Americans for schools to be eligible for federal subsidies. Decisions about the specific foods to offer and how to prepare them are made by local school food authorities. The IOM report School Meals: Building Blocks for Healthy Children recommendations reflect current dietary guidance including increasing the requirements for fruits, vegetables and whole grains, requiring only fat-free and low-fat milk, and decreasing the amount of sodium and trans fat in school meals.

Schools also should take necessary action to prevent or minimize the risk for foodborne illness among participants in the National School Lunch Program and School Breakfast Program. School food authorities are required to develop and implement a food safety program based on a hazard analysis critical control point system This law allows school food authorities to identify potential food hazards, identify critical points where hazards can be eliminated or minimized through control measures, and establish monitoring procedures and corrective action.

Ensure that meals meet federally defined nutrition standards. Schools have made considerable progress in meeting federal nutrition requirements for school meals. However, although three fourths of schools met the fat standards in school breakfasts, less than one third of schools met the standards for calories from fat or saturated fat in the average lunch For both breakfast and lunch, average levels of sodium were higher and fiber was lower than the Dietary Guidelines for Americans recommendations School Challenge to create healthier food and beverage choices. Schools that engage in the Healthier U. School Challenge commit to meeting specified criteria including stricter nutrition standards such as increasing the number of servings of whole-grain foods, dark green and orange vegetables, and dry beans and peas.

School nutrition services staff members may modify menus to include healthier foods, such as serving more fruits, vegetables, and whole grains, and offering a greater variety of low-fat foods, including fat-free and low-fat milk. Other ideas include serving foods such as salsas for fresh flavor and less fat; making reductions and substitutions, such as reducing salt and using low-fat mayonnaise and salad dressings; and preparing foods in different ways, such as baking rather than frying French fries or serving baked potatoes instead , Ensure that schools have kitchen facilities and equipment needed to cook quality, appealing meals. Support should be provided to schools to upgrade kitchen facilities with state-of-the-art equipment, which can help ensure that school meals are appealing to children and that they are prepared using the most healthy cooking techniques and food products available.

Serving baked instead of fried foods can make a substantial difference in the amount of calories, fat, and saturated fat that children consume. Ovens, instead of deep-fat fryers, are needed to bake fries, but not all schools have such equipment and need financial support to purchase these types of items ,, Outdated kitchen equipment, limited and inadequate kitchen facilities, and food budgets are substantial barriers for school nutrition staff members to provide healthy and appealing school meals , Recent trends associated with the need to update kitchen equipment in school nutrition programs include an increased emphasis on health and wellness, food security and emergency preparedness, smaller and more mobile equipment e.

Use healthy food preparation methods and purchasing techniques. Healthy food preparation methods play an important role in providing nutritious and appealing meals and include practices such as substitution techniques i. When making substitutions or reductions in ingredients, schools should standardize the recipe to account for the changes in yield and meal pattern requirements. Standardized recipes help to ensure that the products are prepared consistently, provide a defined yield, and list the meal pattern contribution. Schools should seek out and taste test standardized recipes that are low in fat, oil, salt, and sugar to ensure that they are acceptable to students. Schools may consider USDA Foods commodities , which have been modified to reduce sodium and fat, including saturated fat, as substitutions for less healthy ingredients.

Nationwide, in , among schools in which school staff members had responsibility for cooking foods for students, the most commonly practiced healthy food preparation methods were using nonstick spray or pan liners instead of grease or oil; draining fat from browned meat; roasting, baking, or broiling meat rather than frying; and steaming or baking other vegetables excluding potatoes. The least commonly practiced healthy food preparation methods were reducing sugar in recipes or using low-sugar recipes, using low-sodium canned vegetables instead of regular canned vegetables, and using cooked dry beans, canned beans, soy products, or other meat extenders instead of meat Schools also can use various purchasing techniques to procure healthier options while maintaining food costs.

For example, local school districts can form a cooperative co-op to improve purchasing power with food distributors. This can increase the availability and reduce cost of healthier foods. Schools also can use USDA Foods commodities or ask the school district to consider creating or assigning space for a central warehouse, which allows for storage of large quantities of foods from bulk purchases and USDA Foods shipments. Serve foods and beverages that are appealing and presented attractively. Taste tests can be used to determine which healthy options students prefer When planning menus and purchasing food items that appeal to students, appearance, texture or consistency how the food feels in the mouth and how it cuts , flavor, and service temperature the ideal temperature for serving the food are important Offering various colorful fruits and vegetables with meals and snacks enhances their nutritional value and appeal.

Students drink more milk when it is offered cold and in attractive packaging such as single-serving or portable plastic milk bottles Competitive foods, which are any foods or beverages sold or served outside of the school meal program, are the principal source of the low-nutrient, energy-dense foods that students consume at school. Unlike school meals, which must meet specified nutrition standards, foods and beverages sold or provided outside of the meal program are largely exempt from federal requirements or standards. The existing federal requirement, last updated in , prohibits the sale of foods of minimal nutritional value FMNV during meal periods in areas where reimbursable school meals are served , The federal regulations for competitive foods prohibit the sale of FMNV.

However, schools can sell these foods and beverages at other locations on the school campus during the entire school day, and other foods and beverages of low nutritional value such as chips, most candy bars, and noncarbonated, high-sugar drinks can be sold anywhere on campus, including the food service area. These standards will apply to foods and beverages sold on school campus during the school day. In the last decade, a total of 39 states passed a law or policy addressing competitive foods and beverages in schools that was stronger than the current federal requirements. The most commonly available competitive foods are high in sugar, fat, and calories, including high-fat salty snacks, high-fat baked goods, and high-calorie sugar-sweetened beverages, such as soft drinks, sports drinks, and fruit drinks ,, Some progress has been made in limiting the availability of unhealthy foods in schools.

Consequently, offering competitive foods in vending machines at schools is associated with significantly higher BMI among middle school students Access to sugar-sweetened beverages and low-nutrient, energy-dense foods at school significantly increases student calorie intake from sugar-sweetened beverages per school day. The third School Nutrition Dietary Assessment Study found that sugar-sweetened beverages not including flavored milk obtained at school contributed to an additional 29 kcal per school day for middle school students and 46 kcal per school day for high school students.

Low-nutrient, energy-dense foods obtained and consumed at school contributed 86 kcal per school day for middle schools students and kcal per school day for high school students. Attending schools without stores or snack bars that sell foods or beverages is estimated to significantly reduce sugar-sweetened beverage consumption by 22 kcal per school day for middle school students and 28 kcal per school day for high school students In addition, restricting access to snack foods is associated with more frequent fruit and vegetable consumption Nutrition standards list criteria to help schools determine which foods and beverages should be offered on a school campus.

Implementing nutrition standards can involve increasing food and beverage options, such as requiring that schools offer fruits or vegetables at all locations where other foods are available, and limiting options, such as stipulating that schools cannot sell foods with more than a specified number of calories and grams of fat per serving. State and local education agencies can pass nutrition standards that are stronger than the federal requirements limiting the sale of competitive foods. Implementing nutrition standards can be an effective strategy to improve the nutritional quality of foods offered and purchased in the school setting , which might affect dietary intake The Healthy, Hunger-Free Kids Act of requires each school district's local wellness policy to include nutritional guidelines for all foods available on each school campus that promote student health and reduce childhood obesity Schools should implement nutrition standards that provide students with only healthy choices throughout the regular and extended school day and throughout the campus that are consistent with and reinforce positive nutrition education messages received in the classroom.

Fruits, vegetables, whole grain products, and fat-free or low-fat dairy products should be offered, whereas foods that do not contain important nutrients; foods that are high in fat, added sugar, or sodium; and sugar-sweetened beverages should be eliminated or limited. Portion sizes should be reasonable for the age of the student IOM used a rigorous scientific review process to develop the Nutrition Standards for Foods in Schools, which provides guidance on which foods and beverages schools should offer on school campuses The IOM standards recommend that all competitive food offerings be consistent with the Dietary Guidelines for Americans and, in particular, help children and adolescents meet the guidelines for consumption of fruits, vegetables, whole grains, and fat-fat or low-fat milk or milk products The IOM standards include 13 standards for foods and beverages sold and available on campus during the school day, after-school activities, evening and community events, and on-campus fundraising.

The standards address the nutritive e. CDC created four audience-specific fact sheets about the IOM standards that can serve as a resource to support the development of strong nutrition standards for foods outside of school meal programs. Schools should systematically track the financial implications of implementing strong nutrition standards.

Limited data are available on the impact of changes in nutrition standards in schools on total revenue generated by sales of food and beverages However, mounting evidence suggests that schools can maintain financial stability while offering only foods and beverages that meet strong nutrition standards , Implementing strong nutrition standards can increase school lunch participation, which financially benefits schools ,, Strategic promotion of healthier food and beverage choices and lowering the price of healthier foods e.

Use the contracting process to improve the nutritional quality of competitive foods and beverages. Schools that adopt strong nutrition standards for competitive foods should revise existing food and beverage contracts so that healthier options are available for students Vending machine contracts that schools establish with food and beverage companies give the companies selling rights in return for cash and noncash benefits or incentive items such as scoreboards, cups, T-shirts, posters, and drink bottles Schools and school districts can cancel, not sign, not renew, or negotiate contracts so that only foods and beverages that meet strong nutrition standards are available to students.

For example, some schools have new districtwide vending contracts to centralize purchasing and approval of foods and beverages sold and have placed the management of new contracts under school nutrition departments to ensure better nutritional content of vending machine items State departments of education can support schools by providing online nutrition calculators or an updated list of products that meet nutrition standards.

Schools can use these tools to ensure that products meet nutrition standards and help select products to include in a vending contract. Market healthier foods and beverages. Schools can take advantage of marketing strategies to promote the appeal of healthier foods and beverages in various ways. Marketing healthy options might persuade students to purchase healthy foods and beverages. For example, cafeteria taste tests offer students an opportunity to taste the healthier options offered in the cafeteria , Taste testing provides students an opportunity to inform staff members which healthy food and beverage products they like and dislike Strategies to promote the appeal of fruits and vegetables in schools and influence student purchases of healthy foods and beverages include , Schools also can build partnerships to market healthy food choices to students Strategies to present a consistent message for offering healthier foods and beverages throughout the school community include linking the cafeteria with the classroom e.

Schools can involve students in leading changes toward healthier competitive foods and beverages. Involving students in the decision-making process can decrease resistance to change. Students can survey and poll their peers, provide valuable input to shape policy, help plan and market changes, and promote the sustainability of healthy eating initiatives. Use fundraising activities and student rewards that support health. Schools should incorporate fundraising activities that use only healthy foods, involve physical activity, or sell nonfood items.

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