The Journal of School Nursing2022, Vol. 38(2) 194–202© The Author(s) 2020Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520924455journals.sagepub.com/home/jsn
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.
asthma, self-management, emergency medications, education, management, school nurse
Asthma affects 8.3% of children in the United States (Centers for Disease Control and Prevention [CDC], 2018). Uncontrolled asthma contributes to 10.5 million health care provider visits, 13.8 million missed school days, 1.6 million emergency room visits, and over 3,600 deaths in children each year (Akinbami et al., 2016). There is an even larger disparity in Alabama with 11% of children reporting current asthma prevalence rate and with Black children (16.4%) having a higher prevalence rate than White children (9.0%; Alabama Department of Public Health [ADPH], 2013, 2018). Childhood asthma is the leading cause of school absenteeism due to a chronic disease, and almost one in two Alabama schoolchildren miss at least 1 day of school each year for uncontrolled asthma (ADPH, 2013). Like many states, Alabama has a large rural population with 44% of schools located in these areas (National Center for Education Statistics, 2014). In Alabama’s public schools, over half of the students are economically disadvantaged (52%; Alabama Department of Education, 2018). In addition, in Alabama, 62 of the 67 counties are designated as medically underserved, with at least a portion of the other 5 having a medically underserved area (ADPH, 2019). These factors combine to hamper optimum management of asthma for schoolchildren in Alabama.
The Alabama Asthma Coalition (AAC) was revived and reenvisioned in 2017. The AAC’s mission is to improve the quality of life for those living with asthma in Alabama through education, advocacy, surveillance, and partnerships. The AAC currently has 73 partners. In 2017, the AAC identified as an education priority to engage school nurses to determine their needs in school-based management of asthma. Although stakeholders in the coalition were working with the school nurses through annual trainings, collaboration with the Alabama Association of School Nurses (AASN), and interprofessional community-based asthma education programs, we had not surveyed the nurses themselves. The purpose of this study was to assess the perceptions of Alabama school nurses on managing asthma in the school including barriers they identified to providing optimal asthma management. We aimed to assess the perceptions of the Alabama school nurse on managing asthma in the school including significant barriers to optimum care. Objectives of this study were as follows:
Health care professionals frequently attribute high morbidity, mortality, burden, costs, and challenges in the care of children aged 7–12 years with asthma to insufficient or ineffective family care or self-care (Akinbami et al., 2016). Inadequate and less effective management of asthma results from poor adherence with health care provider recommendations and inaccuracy of symptom perception and symptom severity recognition by children and families. Children with asthma and their families can recognize symptoms or early exacerbations when educated on avoiding asthma triggers like tobacco smoke, mold, outdoor air pollution, and colds and flu (Gibson-Young et al., 2014). Using inhaled corticosteroids can also prevent asthma episodes and other prescribed daily long-term control medicines correctly (Ebell et al., 2019). Medication effectiveness is hampered by not using spacers and confusion about medication action or purpose. To address these issues, the National Asthma Education and Prevention Guidelines (U.S. Department of Health and Human Services, National Heart Lung and Blood Institute, 2007) were updated and disseminated to health care providers. The guidelines specify that a successful asthma management plan include educating students and caregivers about the condition of asthma including asthma management and triggers.
Managing children in the school setting with asthma often leads to challenges for school nurses. It is imperative to address asthma and how it can be controlled in a schoolbased setting. School nurses are on the front line of asthma management, and barriers to managing asthma in the school setting must be explored. School nurses are responsible for monitoring, evaluating, and managing children identified as having asthma, although some have reported that this information is not always known by the school nurse (Ebell et al., 2019; Svavarsdottir et al., 2013). Even when the school nurse identifies students, there are barriers to optimum asthma management. Studies, including reviews, surveys, interviews, and focus groups consistently report the following as significant barriers: lack of resources, including medication; insufficient, time due to heavy responsibilities; and lack of communication with families and providers.
Lack of supplies/resources (e.g., inhalers, spacers, peak flow meters) and medications is frequently reported as a top barrier to effective care (Ebell et al., 2019; Hanley & Toronto, 2016; Hillemeier et al., 2006; Papalardo et al., 2019; Quaranta & Spencer, 2016). For example, in a recent survey of 120 Chicago public school nurses, 73% reported lack of medication as the biggest barrier to asthma management (Papalardo et al., 2019). Another frequently reported barrier is limited time and heavy responsibilities with multiple schools, which prevent them for providing optimum education and management (Ebell et al., 2019; Hanley & Toronto, 2016; Papalardo et al., 2019; Quaranta & Spencer, 2016; Rivkina et al., 2014). School nurses have indicated that asthma care in the school is limited by difficult communication between those in the educational system, providers in the health care system, and the family (Cain & Resnick, 2018; Ebell et al., 2019; Hanley & Toronto., 2016; Quaranta & Spencer, 2016; Rivkina et al., 2014; Svavarsdottir et al., 2013). In a recent survey of the National Association of School Nurses (NASN), 54% reported lack of communication with health care providers as a barrier (Quaranta & Spencer, 2016).
Gaps in policies and procedures and missing forms or permissions (such as medication administration forms) can also adversely impact care (Cain & Resnick, 2018). Use of unlicensed school personnel to manage asthma can also be a barrier (Bruzzese, et al., 2006; Cain & Resnick, 2018). The school nurse often needs to rely on unlicensed personnel including teachers and administrative staff, some of whom have limited understanding of asthma and asthma management for medication administration (Bruzzese, et al., 2006). In a future study by Bruzzese and colleagues (2011), an intervention was designed to shift focus to the adolescentaged individual living in urban areas. It is imperative to address what is best in mostly rural states when in the school-aged years.
There are measures that support quality asthma management in schools. McCabe et al. (2019) found there was value in continuing education, educational interventions, and use of resources such as an asthma action plan in promoting school nurse self-efficacy in asthma management. Having a school nurse in every school supports all students with chronic disease management including asthma (American Academy of Nursing [AAN], 2018; NASN, 2018b).
Having legislation and policies that support the school nurse and student self-management of asthma is also important. Policies on student self-administration of asthma medication (American Lung Association [ALA], 2014; CDC, 2011; NASN, 2018) as well as those that allow for rescue medication to be available at the school in case of a child’s worsening symptoms or an emergency also support best practices and outcomes (ALA, 2019; CDC, 2014b). In Arizona where legislation was passed in 2017 to allow for stock inhalers in schools, an evaluation study demonstrated that 84% of students who used the stock inhalers then returned to the classroom (Lowe et al., 2019).
The framework for this study is the Roy Adaptation Model (RAM), applying the Middle Range Theory of Adapting to Chronic Illness (Roy, 2014). In the RAM, adaptation is the process and outcome whereby persons use “conscious awareness and choice to create human and environmental integration†(Roy, 2019). For children with asthma, that environment includes the school. Children with asthma adapt to the chronic illness through self-management activities and supportive care of the school nurse and other personnel. The components of the middle-range theory—stimuli, coping processes, and adaptive modes—applied to the school-aged child with asthma are listed in Figure 1.
The school-aged child with asthma often has focal stimuli that come to the attention of the nurse. Triggers such as smoke in the car on the way to school, outdoor pollen, and poor indoor air quality such as mold in an older school contribute to immediate episodes on arrival to school. Upon further assessment, the nurse may identify additional focal stimuli such as poor medication adherence, ineffective selfmanagement, lack of symptom recognition, and inaccurate dosing of controller medications. These focal stimuli are often the result of contextual stimuli of lack of effective family support and residual stimuli of economically disadvantaged or medically underserved population.
The nurse brings skills to support coping strategies in regulator mechanism (physiological management) and cognator mechanism (education). The nurse and other providers are extrinsic support persons contributing to adaptation. The school nurse brings knowledge of the asthma condition and awareness of the importance of integration of knowledge, physical well-being, and collaborative actions. In the current study, the school nurses were asked to identify barriers to optimal care.
Outcomes of adaptation in the schoolchild are possible in all four adaptive modes. Fewer/milder asthma episodes are positive outcomes in the physiologic adaptive mode, enhanced self-management is a positive outcome in the self-concept mode, improved school performance (including fewer absences) is a positive outcome in the role function mode, and enhanced effectiveness of collaboration with teachers, parents, school nurse, and providers are evidence of adaptation in the interdependence mode.
In this survey of school nurses, findings regarding their strengths, needs, resources, education, barriers, and policies will be described based on the framework. Implications for practice are related to the nurses’ roles in promoting adaptation.
This study was a cross-sectional design with public and private school nurses as the target population. The Auburn University institutional review board (IRB) approved the protocol through expedited review and a waiver of written consent.
Four team members of the AAC represented school nurses, academic nurse educators, primary care provider nurse practitioner, and researchers. One was a former state director to the NASN and former president of the AASN. The Alabama State Department of Education Health Administrator (ALSDE) also approved the survey for distribution.
Building a survey that would capture the perceptions of Alabama nurses was a priority. School nurses in Alabama are supported by the (ALSDE) support services. It was paramount to have the State School Nurse Administrator’s support and input into survey development. If additional education was indicated, we wanted to be able to provide this through their annual trainings. In addition, the AAC wanted to be appraised if there were issues beyond education that could be addressed through advocacy or health care.
Questions were drawn from recognized barriers that had presented in continuing education offerings, primary care, and the literature. The survey was kept brief to assure completion by participating nurses. The initial draft of questions went through more than 10 revisions based on review by authors, administrators, experts, and school nurses, providing content and face validity. It should be noted that questions included description of nursing care assessments, not usually reported in the literature. These are considered essential to understanding the role of the nurse in managing asthma in schools in Alabama. Survey included specific school nurse demographics including full or part time; role of nurse: lead nurse, licensed practical nurse (LPN)/registered nurse (RN)/advanced practice registered nurse (APRN), or specific certifications; and years as a nurse and years as a school nurse. The 12-item survey included 9 questions (more than 1 answer could apply or participants ranked answers in importance). Three questions were open-ended (see Table 1). Data were collected by pen-and-paper survey. Surveys were anonymous with no identifying data collected. A letter of information was provided, and return of the survey was considered implied consent. The survey included both closed quantitative and qualitative (open-ended) questions. Surveys were designed to take approximately 10–15 min to complete and school nurses had the opportunity to opt out of data collection, and school nurses were approached at the midpoint of a large, state, school nurse conference held over the summer of 2018. Participants did not share any data outside of this one survey. All data were managed by the project investigator (PI) noted on the IRB and analyzed with descriptive statistics (SPSS Version 26). Participant comments provided depth to support the quantitative results.
School nurses in Alabama who attended a School Nurse Workshop (in Mobile, AL) sponsored by the Alabama State Department of Education in Summer 2018 were invited to participate. Nurses represented Alabama’s 67 counties and included both county and city school districts. Of 408 registered attendees, 173 participated in the survey for a 43% response rate.
The majority of participants were registered nurses (67%). Most were also employed full-time (85%) and years of experience as nurses ranged from 4 to 58 years with experience as a school nurse ranging from just hired for the upcoming school year to 33 years. Nurses had many specialty certifications such as basic (basic life support [BLS]), pediatric (pediatric advanced life support [PALS]), and advanced (advanced cardiac life support [ACLS]) certifications for cardiopulmonary resuscitation, yet none were certified asthma educators.
After review of the survey data, three themes were identified including school nurses role in facilitating asthma management, barriers to school nurses managing asthma, and the school nurse needs to facilitate asthma management. This section will describe with reported results highlighted.
School nurses daily assess students who are scheduled daily use of an Inhaler as well as when an illness or asthma complications occur. In support of facilitating control of asthma, nurses reported that they routinely assess the following on a daily basis: current asthma symptoms (95%), response to treatment (87%), student’s knowledge (85%), patterns of asthma symptoms (84%), environmental factors (83%), and parent/guardian knowledge (76%). About 81% of nurses’ report using asthma action plans. Additional assessment mentioned was primarily related to evaluating medication use and administration techniques.
An excellent tool to assess asthma severity are peak flow meters, yet only 15% of school nurses report having these available at their schools. Most nurses have good quality stethoscopes (94%) and pulse oximeters available to assess student’s asthma symptoms (93%). Parent/guardian completed asthma history questionnaires are also available to school nurses only 31% of the time. When asked about other tools available for or needed for assessment, nurses primarily listed tools for treatment such as nebulizers, inhalers, and spacers. For emergencies, only 5% of school nurses reported a rescue inhaler was available.
School nurses reported facing many barriers to performing asthma education with students and or families. The biggest barriers were not enough time to schedule in a school day (64%) and the inability to get out of the nurse’s office and into the classroom (56%). Nurses generally felt that they had enough resource material (79%) and technology (94%) and that their knowledge was sufficient to provide education (96%) although occasionally a student’s lack of equipment (spacers, peak flow meters, etc.) was problematic (37%). Most of the additional barriers commented on by 5% of the participants pertained to difficulties engaging parents “lack of parent interest,†“lack of parent concern,†and “parents do not always understand the implications of ... {Management decisions}.â€
Spacer or valve-holding chambers are recommended for use with all inhaled medications in children. Most reported that students do indeed use spacers (81%) and nurses perceived reasons for not using fell into three main categories, the most common was related to the cost of the spacer and that in many cases insurance would only pay for one when it would be most advantageous to have an additional one to leave at school. One nurse stated, “too expensive (only one at home).†Nurses also perceived that spacers were not available for two primary reasons, physicians were not writing prescriptions for them, and/or parents were not sending them with students to school, explained another nurse “MD did not order, or parents do not provide.†Lastly, there was the belief that students who are in middle or high school do not usually require spacers.
Asthma exacerbations are challenging in the school setting and nurses perceive that the most common reasons for exacerbations were exposure to triggers/irritants (56%), failure to take controller medications (42%), upper respiratory infections (40%), and anxiety/stress (17%). Lesser reported reasons were exercise (7.2%) and weather changes (1%).
In Alabama schools, a component of student health is the Wellness Plan Guideline. Wellness Plan Guidelines are recommended for each school district to create supportive nutritional and physical activities throughout the school system in the school year. Additionally, these guidelines should be designed independently by school districts (CDC, 2014a). These wellness initiatives affect child asthma outcomes through identification of chronic child conditions and creating a healthy environment before, during, and after school. Less than half of the participating school nurses (41%) reported using the Wellness Plan with only 5% reporting using the resources available in the plan to educate students and families. Around 27% do not use a current Wellness Plan, and 28% do not know if their school has a Wellness Plan.
The Wellness Policy is required in every school system in the state of Alabama, and every 3 years the policy is evaluated. This policy must be placed on school website and open to the public. The Nutrition Director is most often the Chairman for the Wellness School District Committee, and not every school district includes a nurse as a member on this committee. This policy deals with wellness regarding nutrition, exercise and wellness, along with health promotion education.
Nurses overwhelmingly were interested in learning more about how they could help students with asthma stay healthy and in school (94%) even though only 8% stated they needed more information to feel competent. Their preferred educational methods were in person education and training (74%) with self-tutorials (46%) and mixed methods such as live in person, online, and support groups (37%). Synchronous webinars were rated lowest at 31%.
Nurses were also interested in finding out more about what is available for providing asthma education for students and/or families (68%). About 14% report using videos; however, the most commonly used other methods (reported by 10%) were written information such as pamphlets, handouts, and worksheets along with verbal education and occasionally presentations, posters, and photos. No “Apps,†games, or other digital technology was reported.
When asked about specific resources or education needed to help care for the student with asthma (topics, skills, updates, etc.) nurses desired “updates†on many aspects of asthma assessment and management, including skills using equipment, techniques for inhaler use, asthma triggers, and exposure to triggers and allergens. School nurses also hoped that the rest of the school staff could be provided with education about asthma and how it impacts students. This was highlighted along with a desire to find a way to engage and educate families of children with asthma.
Ways that nurses felt the AAC could support the care of schoolchildren with asthma was primarily through education for students and parents and even providers and some felt that community outreach might be a good way to accomplish this. They also felt that more interactive tools for teaching students would be of benefit.
School nurses report high levels of appropriate assessment of asthma symptoms in children and adolescents in school, which are consistent with the NASN’s policy statement on, care for children with chronic illness in the school (2017). In addition, Alabama has a school nurse available for every school; however, many states have not yet achieved this goal despite the AAN’s (2017) recommendation. Although the vast majority of school nurses in Alabama report they have the tools they need for assessing severity of symptoms (stethoscope and pulse oximeter), they overwhelmingly lack peak flow meters. Similar issues with lack of resources are consistent with prior reports (Ebell et al., 2019; Hanley & Toronto, 2016; McCabe et al., 2019).
The nurses reported that they have enough knowledge and skill to manage asthma in children and adolescents in school, but based on their comments there is opportunity for clarification on some issues related to insurance coverage for inhalers and processes to assist children and families in securing additional spacers and medication for use at school. These issues are often complicated and require regular updates on insurance program changes.
Similar to prior studies (McClure et al., 2020; Rivkina et al., 2014), the nurses report a hindrance with their ability to provide education based on time and difficulty engaging parents and families. McClure and colleagues (2020) implemented community partnerships to improve asthma care in schools. This study demonstrated a mutually beneficial collaboration in managing asthma through health promotion and patient teaching interventions. Nurses expressed a strong desire to help students with management and selfmanagement of their asthma and help them stay in school. A recommended strategy that was supported by the survey results would be to open up asthma education to more school staff, parents, and students. One place to start would be the state-mandated wellness policy, which currently addresses nutrition, exercise, and health prevention education. A large concern is school nurses are not part of the committee.
Barriers to providing treatment based on symptoms are many, including lack of medication delivery systems and emergency medications along with policies and procedures to support their use. All 50 states have legislation to allow students to self-carry medication for asthma with varying degrees of consistency (Toups et al., 2018). Despite recommendations from ALA, and the NASN, only 13 states have enacted legislation to allow for emergency use of rescue inhalers in schools and Alabama is not included (ALA, 2014, 2019; NASN, 2018).
Survey results demonstrate school nurses’ contributions to adaptive processes and suggest opportunities for improvements of these (see Figure 2). School nurses are critical personnel to integrate adaptation across the environment of school, the most significant environment next to home for adaptation.
Convenience sampling and a small sample size limit this study. However, the opportunity to participate was available to nurses from all 67 counties, and therefore its generalizability to the state of Alabama is strengthened. The results may not be supported in other states. As a cross-sectional design, the data are also limited to that of a snapshot of one point in time.
The results of this study provide guidance for the AAC in prioritizing its work to achieve its goal of improving the quality of life for those living with asthma in Alabama through education, advocacy, surveillance, and partnerships. It is important to evaluate the current perceptions of school nurses. In this case, school nurses’ feel competent to manage asthma in the schools but desire assistance with educating other stakeholders to expand asthma education beyond school nurses to reach a broader group of stakeholders in the management of asthma in the school setting. The priority for action is to engage our partners and advocate for legislation and policies to provide access to medication when needed, including emergencies for students in school. While results are specific to Alabama school nurses but are potentially similar in other states and therefore may be applicable at least in part to other states, school districts, and schools. These same collaborative recommendations could be applied to all states and schools. Similar research may be beneficial to other advocacy groups in other states. In addition, research to determine the impact of gathering this type of data to inform and support policy change to improve asthma care for children in schools is needed.
We are grateful for the work of school nurses across Alabama. We would like to acknowledge the Members of the Alabama Asthma Coalition from 2018 to 2019, Nurse Administrator Jennifer Ventress, and The Alabama State Department of Education.
All authors contributed to conception of manuscript, draft, and revisions. All authors gave final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Linda Gibson-Young, PhD, AE-C, FAANP https://orcid.org/0000-0003-0676-8507
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Linda Gibson-Young, PhD, AE-C, FAANP, is an associate professor in School of Nursing at the Auburn University.
Julee Waldrop, DNP, PNP, FAANP, FAAN, is at the College of Nursing, University of South Alabama.
Brenda Lindahl, RN, is a nurse administrator at the Auburn City Schools.
Ellen Buckner, PhD, RN, CNE, AE-C, FNAP, is a professor in Ida Moffett School of Nursing at the Samford University.
1 School of Nursing, Auburn University, AL, USA
2 College of Nursing, University of South Alabama, Mobile, AL, USA
3 Auburn City Schools, Auburn, AL, USA
4 Ida Moffett School of Nursing, Samford University, Birmingham, AL, USA
Corresponding Author:Linda Gibson-Young, PhD, AE-C, FAANP, School of Nursing, Auburn University, 710 South Donahue Drive, Suite 2241, Auburn, AL 36849, USA.Email: gibsolm@auburn.edu
