Barriers to Asthma Management as Identified by School Nurses

School Nurse Perspectives on Addressing Chronic Absenteeism

Chronic absenteeism is associated with poor health and educational outcomes. School nurses have great potential to address the health and educational needs that contribute to absenteeism. Through qualitative analysis of interviews with school nurses, we characterize their current role in reducing absenteeism and identify barriers 3 that limit their capacity to meet this goal, organized by the Framework for 21st Century School Nursing Practice. Interviewees (n = 23) identified actions perceived to reduce absenteeism aligned with domains of care coordination, leadership, quality improvement, and community and public health. Barriers perceived to limit the capacity of school nurses to address absenteeism were identified within these domains and ranged from student- and family-level to federal-level barriers. Specific healthcare system-level barriers included insufficient communication with community-based healthcare teams and the need for coordinated approaches across health and education sectors to address absenteeism. Strategic opportunities exist to address barriers to comprehensive school nursing practice and reduce absenteeism.

School Nurse Perspectives on Collaboration With Primary Care Providers

BACKGROUND

School nurses are rarely integrated into primary care teams to their full potential. We aimed to characterize school nurses' perceptions related to current and optimal collaboration with primary care providers (PCPs) and identify actionable solutions to improve efficiency, quality, and coordination of pediatric care.

METHODS

We conducted and qualitatively analyzed interviews with school nurses to characterize structures, processes, and perceived benefits of optimized school nurse-PCP collaboration.

RESULTS

School nurse interviewees (n = 23) identified factors important to school nurse-PCP collaboration within 2 domains: information sharing and relationship building. Information sharing themes included health information sharing laws, data sharing systems, and technology-based communication systems. Relationship building themes included health care sector understanding of the school nurse role, PCP knowledge of school health requirements, shared professional development opportunities, and time and personnel. Perceived benefits of optimized PCP-school nurse collaboration were identified for children, PCPs, school nurses, and parents.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Needs assessments and action plans guided by the domains of information sharing and relationship building can inform local improvements to optimize school nurse-PCP collaboration.

CONCLUSIONS

School nurses highlighted cross-sector solutions to enhance school nurse-PCP collaboration including integrated information sharing systems and intentional relationship building.

Child and caregiver experiences and perceptions of asthma self-management

Asthma is the most common chronic condition of childhood. Self-management is integral to good asthma control. This qualitative paper explores how children with asthma and their parents perceive asthma, their experience with asthma, and how they manage symptoms, preventions and medications within and outside the home. We undertook 15 focus groups with 41 school-aged (6-11 years) children with asthma and 38 parents. Parents and their children attended the same focus groups. We used thematic analysis to analyse the transcripts. Our findings show the impact asthma can have on children's social and emotional wellbeing and highlight how reliant school-aged children are on their parents to effectively manage their asthma. Parents reported being unsure when their child's symptoms warranted visiting their doctor or hospital. Schools were identified as a source of difficulty regarding asthma management; families reported that children may be self-conscious about their asthma and using their inhaler at school. School policies and teachers' lack of asthma knowledge were reported to exacerbate children's reluctance to use their inhaler at school. Our results have implications for the design and implementation of children's self-management interventions for their asthma, particularly when they are at school and away from their parents.

School Nurses' Available Education to Manage Children with Asthma at Schools: A Scoping Review

PROBLEM

Despite reports that asthma is the leading cause of school absenteeism and the third leading cause of hospitalization in children under 15 years, little is known about how school nurses are educated and trained to manage asthma in schools. The current scoping review sought to describe the published literature on available asthma education programs for school nurses to manage asthma in schoolchildren.

ELIGIBILITY CRITERIA

This paper used Arksey and O'Malley's (2005) scoping review framework to identify the existing literature on the education and training received by school nurses to provide evidence-based practice care to school students with asthma, aged 5 to 18 years.

SAMPLE

A search strategy was developed and implemented in 6 electronic databases including PubMed, CINAHL, EMBASE, ERIC, MEDLINE, and PsycINFO, from 1980 to 2020. A total of 1012 citations were identified, 27 full-text articles were retrieved and assessed for eligibility, and eight studies were finally reviewed and synthesized.

RESULTS

The educational programs throughout four interventional studies consisted of a one-time training session, followed by a practical demonstration. Four out of 8 included studies assessed school nurses' previous exposure to an asthma educational programs through needs assessment surveys. The education delivery methods need to be synchronized with global technological advances and the availability of smartphones.

CONCLUSION

There is a need to highlight school nurses' asthma educational needs and the preferred ways of delivering asthma programs to school nurses. The review also called for ongoing skill and knowledge assessment strategies to ensure the delivery of evidence-based practice care.

IMPLICATIONS

There is a need to standardize asthma education programs delivered to school nurses. Future empirical research is recommended to investigate and evaluate such programs.

Facilitators and Barriers to Implementation of School-Based Telehealth Asthma Care: Program Champion Perspectives

OBJECTIVE

Asthma is one of the most common chronic conditions of childhood, conferring an immense burden on children and their caregivers. School-based telehealth approaches for asthma care provide the opportunity to deliver convenient, cost-effective care to more children in the school setting. Our study objective was to characterize school-based telehealth asthma program delivery experiences and examine barriers and facilitators to telehealth program implementation.

METHODS

Interviews were conducted with telehealth program staff and school stakeholders in nine schools engaged in a school-based telehealth asthma program. A structured interview guide was designed using the Exploration, Adoption/Preparation, Implementation, Sustainment (EPIS) framework. A template analysis qualitative approach was used to identify themes related to implementation processes.

RESULTS

Interviews identified key telehealth implementation strategies including building relationships, marketing and provision of technical assistance, education and support to aid program delivery. Key facilitators to successful program implementation included strong partnerships between the telehealth and school teams, a shared commitment to enhancing access to asthma care for children, and strong nurse leadership. Primary barriers to implementation included lack of family/caregiver involvement and competing demands for nurses.

CONCLUSIONS

This study identified barriers and facilitators to implementing a school-based telehealth asthma program that can be used to guide education, training and support strategies to enhance program delivery. Recommended implementation strategies include building strong program-school partnerships, creating a shared vision to improve access to care, and building engagement in families and communities while supporting nurse leaders and family involvement with training and resources. These results can help guide future telehealth interventions.

Health insurance, pediatric asthma, and emergency department usage

This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10 years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.

School nurses' perceptions regarding barriers and facilitators in caring for children with chronic diseases in school settings: A mixed studies review

This study aimed to understand school nurses' perceptions regarding barriers to and facilitators for health care services for children with chronic diseases in school settings. Using the PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and Web of Science databases, a mixed studies review was conducted for literature published between January 2011 and June 2020. We performed a mixed-methods systematic review using a convergent integrated approach. A quality appraisal of the included studies was conducted using a mixed-methods appraisal tool. Twenty-seven articles (10 qualitative, 10 quantitative, and seven mixed-methods) that met the inclusion criteria were analyzed. Integrated findings that emerged from data synthesis were categorized into four levels (intrapersonal level, interpersonal level, institutional level, and community and public policy level) based on a socio-ecological model framework. This mixed systematic review provides a comprehensive understanding of school nurses' perceived barriers and facilitators when providing school health care for students with chronic diseases and how these barriers and facilitators interact across multiple systems. Further policies and strategies should be developed to provide effective school health services considering this study's findings.

School Nurses' Perspectives on Components of Asthma Programs to Address Pediatric Disparities

OBJECTIVE

To use a community engaged, collaborative approach with school nurses working within an urban community, to develop recommendations for future school-based interventions targeting pediatric asthma disparities.

METHODS

Open-ended survey data were collected from 33 nurses (77% of nurses in the school district) during a face-to-face monthly health services meeting. Questions asked nurses to estimate the proportion of students with asthma with the necessary forms and medications at school and to describe perceived barriers to having such forms and medications, and potential initiatives that could be implemented. A 30-min asthma education class was also piloted with school nurses, who then rated its acceptability and feasibility. Open-ended survey data were analyzed using thematic analysis.

RESULTS

Nurses estimated that 12% of students with asthma had an asthma action plan, 19% had a medication release form, and 15% had medications at school (i.e. inhalers). Four themes emerged regarding barriers to asthma management in schools and strategies for promoting asthma management in schools: coordination of care, asthma education, access to care, and medication adherence. Nurses noted the need for education focused specifically on teaching inhaler technique, and better communication between schools, providers, and families.

CONCLUSIONS

School nurses provided valuable information regarding specific barriers, as well as approaches to addressing these barriers in a future intervention. Findings suggest that a school-based intervention needs to address coordination among schools, parents, and medical providers, and will be optimally effective if it also addresses structural barriers.

School Nurses Perceptions on Managing Asthma in Alabama Schools

Asthma is the most common chronic condition in children under 18. In Alabama, 11% of children report a diagnosis of asthma compared to the United States with 9.5%. Childhood asthma is the leading cause of school absenteeism due to a chronic disease, and Alabama children with asthma miss approximately 10 days of school each year for uncontrolled asthma. Managing children in the school system with asthma can often be challenging for school nurses. In this cross-sectional study, perceptions of Alabama school nurses on managing asthma in the school were explored. School nurses feel prepared to manage asthma but identify lack of certain resources and supportive policies, especially access to medications as barriers to optimum care. Implications for statewide advocacy at the policy level and broadening educational activities are supported by the survey results.

Evaluating outcomes of children's asthma self-management education through sustainable community-university partnerships

OBJECTIVE

To evaluate the outcomes of a children's asthma management education program delivered through a community-university partnership.

DESIGN

Quasi-experimental pretest/posttest.

SAMPLE

Convenience sample of 50 children with asthma, grades 2-5, and their parent/caregiver from nine elementary schools in New York State.

MEASUREMENTS

Child Asthma Management Self-Efficacy Survey, Child Asthma Control Test^© , Parent Asthma Knowledge Test.

INTERVENTION

Nursing students certified as Open Airways for Schools facilitators administered the program once weekly for 5 weeks. Parent handouts were sent home after each session. Pre/posttests for all measures were completed prior to Open Airways and at completion.

RESULTS

Improved asthma management self-efficacy (p < .001) and improved asthma control (p = .013) for children with asthma were noted. Parent asthma knowledge was high pre- and posttest with no significant change. Parental knowledge regarding inhaled corticosteroids was consistently low.

CONCLUSIONS

Collaboration between universities and local school systems allows for mutually beneficial exchange of knowledge and resources to address the need for asthma self-management for children with asthma. Nursing students trained in asthma management develop expertise and provide sustainable resources for this education.

Factors Associated With School Nurses' Self-Efficacy in Provision of Asthma Care and Performance of Asthma Management Behaviors

Asthma is a chronic disease affecting nearly 6 million children in the United States and accounts for nearly 14 million missed school days. School nurses' performance of asthma management behaviors (AMBs) may reduce exacerbations, thereby decreasing emergency visits and hospitalizations and increasing attendance at school. Self-efficacy can have a positive effect on AMBs. More research is needed on the interplay between environmental factors in school nurses' work setting, self-efficacy in providing asthma care (hereafter "self-efficacy in asthma care"), and performance of AMBs. This study used a descriptive cross-sectional online survey design with practicing registered school nurses in Pennsylvania (N = 231). Data analysis included descriptive statistics, correlation tests, and multiple regression. In separate models, self-efficacy in asthma care and student-nurse ratio were significantly associated with performance of AMBs. Schools and school nurses need stronger efforts to strengthen self-efficacy in asthma care, with the goal of increasing nurses' performance of AMBs.

Asthma and the Public School Teacher: A Two State Study

Background: Asthma is one of the most common chronic health problems experienced by school-age children. As a result, school professionals need to be well informed about this chronic illness so that they can adequately support the needs of students with asthma. Methods: This study examines data collected from a sample of teachers (n = 593) in 2 large southeastern states regarding their familiarity with asthma self-carry and self-administration laws and policies and training received related to general chronic health conditions including asthma. Results: Teachers, on average, reported little training received at either undergraduate or graduate levels. Although teachers noted knowledge about asthma, acquired through in-service training or to a lesser degree formal education, a high percentage of teachers reported receiving no asthma-related training through such approaches. Conclusions: Data in this study are consistent with data collected in a similar study in 2001 suggesting that while asthma prevalence has increased, education about the condition has not. Implications for school teachers, school administrators, school nurses, teacher educators, and asthma education personnel are provided.

A Review of School Nurses' Self-Efficacy in Asthma Care

Asthma is the most common pediatric chronic respiratory illness and has a significant influence on children's health, school attendance, and overall school success. Despite the effect of education and training, gaps remain in understanding school nurses' self-efficacy (SE) in asthma care. The purpose of this integrative literature review is to gain a greater understanding of school nurses' SE in asthma care. Themes and topics in the current school nursing literature regarding SE in asthma care include the value of continuing education, educational interventions, and the use of resources in clinical practice such as the asthma action plan. This review indicates the importance of developing a greater understanding of the unique features of school nursing, the necessary resources, and the external factors that influence practice. Further research to establish a framework to evaluate how a change in practice may support school nurses' SE and promote positive student health outcomes is needed.

Young Muslim Women Living with Asthma in Denmark: A Link between Religion and Self-Efficacy

Asthma is a chronic respiratory disease that can be controlled with appropriate medicinal treatment. Adherence to pharmacological treatment is therefore critical. Self-efficacy plays a key role in adherence to medicine in chronic diseases, including asthma. Additionally, ethnic minorities have poor adherence to medicines. However, the impact of religion on self-efficacy and adherence is understudied. Therefore, the aim of this study was to explore the role of self-efficacy in adherence to asthma medicine treatment and the influence of religion on self-efficacy among young, Muslim minority women. A focus group and individual interviews with 10 Muslim minority women (14–24 years of age) living in Denmark were conducted. Data analysis was deductive using Bandura’s theory of self-efficacy and modes of agency. Overall, religion was shown to affect self-efficacy. The women reported changes in self-perceived self-efficacy during the holy month of Ramadan. In addition, praying was used as an alternative to medicine for controlling asthma symptoms. However, the women did not perceive religion and treating asthma with medicine as mutually exclusive, but rather as coexisting for the shared goal of controlling asthma symptoms. It is important for healthcare professionals (HCPs) to be aware of the link between self-efficacy, religion and adherence to asthma medicine treatment. This awareness can aid HCPs in giving advice regarding adherence to asthma treatment, and when monitoring treatment to improve the quality of asthma care for young Muslim minority women.

Caregiver Asthma in Urban Families: Implications for School Absenteeism

Asthma is a significant contributor to missed school days, especially for children living in urban settings. This preliminary study examined the impact of caregiver asthma on school absenteeism in a sample of 102 urban children with asthma from African American, Latino, and non-Latino White backgrounds. Caregivers and children participated in a single research session; 32 caregivers had asthma. Children of caregivers with asthma missed more days of school than children whose caregivers did not have asthma (3.97 vs. 2.43 days, p < .05, Cohen's d = .40). Other indicators of child asthma morbidity (e.g., hospitalizations) did not differ across caregiver asthma status. Findings highlight that caregiver asthma may be an added risk factor for school absenteeism among children with asthma. For children with a high frequency of asthma-related school absenteeism, school nurses may find it useful to provide educational resources and referrals for caregivers with asthma.

Exploring School Nurse Interventions and Health and Education Outcomes: An Integrative Review

School nurses intervene with students, parents, and school staff to advance the health and academic success of students. We conducted an integrative literature review of published research to describe the types of school nurse interventions and health and education outcome measures and to examine how school nurse interventions were linked to student outcomes. Sixty-five studies met the inclusion criteria. We used the National Association of School Nurses' Framework for 21st Century School Nursing Practice to categorize school nurse interventions and health and education outcome measures. The majority of interventions were categorized under the care coordination principle, most commonly, motivational interviewing and counseling. In 17 studies, school nurse interventions were linked to improved student outcomes. Most studies (80%) were descriptive. To advance school nursing science, researchers can build on this foundation with more rigorous research methods to evaluate the impact of school nurse interventions and activities on student health and education outcomes.