The Journal of School Nursing2021, Vol. 37(5) 353–362© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519878866journals.sagepub.com/home/jsn
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 careâ€), and performance of AMBs. This study used a descriptive crosssectional 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, school nurse knowledge/perceptions/self-efficacy, school nurse ratios, quantitative research
School nurses have a critical responsibility in providing care for emergent, chronic, and episodic health issues including asthma. Asthma is the most common chronic respiratory illness in children (Zahran, Bailey, Damon, Garbe, & Breysse, 2018). It is strongly correlated with absenteeism (Cicutto, Gleason, & Szefler, 2014; Hollenbach & Cloutier, 2014) with nearly 36,000 children missing school on a daily basis due to asthma symptoms. School nurses require confidence in their capacity to deliver care to manage the needs of the child with a chronic illness (Lewallen, Hunt, Potts-Datema, Zaza, & Giles, 2015).
School nurses are well suited to provide comprehensive asthma management behaviors (AMBs). “AMBs†encompass the suggested clinical behaviors of assessment, advice, support, and referral regarding treatment of asthma. In their work, school nurses interact with students, parents, and faculty around health-related issues including asthma. The nurse may offer asthma teaching to students, faculty, and parents; join forces with community health providers to produce medication orders and asthma action plans (AAPs; Lemanske et al., 2016); and help to reduce environmental irritants in the school setting (Hollenbach & Cloutier, 2014). Research suggests that school nurses have the ability to expand asthma care through AMBs including education, standardization of and communication of school policies, use of an AAP, a well-defined set of rules concerning self-carried asthma inhalers, and appraisal of environmental irritants for asthma exacerbations (Hollenbach & Cloutier, 2014; Kakumanu, Antos, Szefler, & Lemanske, 2017).
School nurses with high self-efficacy are crucial for the optimization of care and the potential to influence health behavior and outcomes for all children including those without chronic illness (Fisher, 2006; Quaranta & Spencer, 2015; Quelly, 2014). Bandura’s (1977) social cognitive theory (SCT) defined self-efficacy as “belief in one’s capabilities to organize and execute the courses of actions required to produce given attainmentsâ€(p. 3). Gist and Mitchell (1992) emphasized that a person’s assessment of his or her self-efficacy varied by work setting. When routines are inhibited by a shortage of resources or external constraints, self-efficacy is negatively affected, which may hinder the implementation of goals and skill performance (Bandura, 1986).
Environmental factors can influence school nurses’ clinical care. A robust picture of the environmental factors that affect self-efficacy in asthma care and performance of AMBs may offer insight into school nurses’ support needs, regarding professional asthma management practices. Environmental factors such as student–nurse ratio (Combe et al., 2015; Endsley, 2017), variation in staffing mix (Combe et al., 2015; Daughtry & Engelke, 2018; Dolatowski et al., 2015; Endsley, 2017; Fauteux, 2010; Jameson, Engelke, Anderson, Endsley, & Maughan, 2017), and number of schools a nurse is assigned per week (Fauteux, 2010; Mangena & Maughan, 2015) require further study. Additional exploration may help determine whether these environmental factors play a role in school nurses’ self-efficacy, or belief, in their capability to offer quality asthma management. There is limited examination unique to personal and environmental factors that may affect school nurses’ self-efficacy in asthma care (McCabe, McDonald, Connolly, & Lipman, 2019). The interplay between environmental factors and self-efficacy may explain variation in the performance of AMBs (see Figure 1). Similarly, better insight into environmental factors’ impact on self-efficacy may shed light on useful interventions that promote self-efficacy in school nurses.
An appreciation of the influence of school nurses’ self-efficacy on their provision of asthma care may serve to enhance the support that they require to realize preferred health-care behaviors in an ideal environment. The purpose of this study was to examine the relationship between environmental factors, school nurses’ self-efficacy in asthma care, and performance of AMBs. Additionally, it aimed to identify whether self-efficacy in asthma care served as a mediator between the environmental factors and the outcome performance of AMBs. The knowledge gained from this inquiry offers information about the relationship between the environmental factors, self-efficacy in asthma care, and performance of AMBs and informs stakeholders of school nurses’ role in asthma management. This investigation may strengthen school nurses’ influences in school health policy advancement and performance of AMBs.
This study utilized a descriptive cross-sectional online survey design. An application submitted to the University of Pennsylvania’s Institutional Review Board (IRB) was approved with exempt status. SCT served as a guide for the proposed relationships and study variables under investigation. Theorists debate whether human behavior resides in the individual or the environment (Bandura, 2018). The proposed relationships (Figure 1), adapted from Bandura’s (1986) causal model of SCT, support the association between personal and environmental factors and school nurses’ performance of AMBs. An imposed work environment (the school setting) affects workers (school nurses). The interpretation of and reaction to the environment may be determined personally (Bandura, 2012). As a result, personal factors affect the efficacy of school nurses.
Recruitment efforts targeted school nurses working in the state of Pennsylvania. Practicing registered school nurses in Pennsylvania were eligible for inclusion. Exclusion criteria included registered nurses (RN) who were retired or not currently employed in a school. There were approximately 980 nurses who were members of the Pennsylvania Association of School Nurses and Practitioners (PASNAP), the organization that assisted with deployment of recruitment materials, at the time of the survey. PASNAP members received a notification via e-mail with a link to the online survey (hosted on the PASNAP website).
Demographic information about the school nurses included age, gender, ethnicity, and race. Characteristics of the nurses incorporated education, certification, and years of practice as a school nurse. Data on years of practice as a nurse, number of hours assigned to a school per week, and information about the representative school in which the nurse was employed (the school where he/she spent the most hours per week) were also collected.
Ratio of student to nurse was defined as the total number of students in a school per number of RN. This continuous variable was calculated based on the number of RN in a given school and the number of students in that school.
School nurse staffing mix was defined as the presence or lack of presence of support staff in the school health office in addition to the RN. The RN completing the survey was asked whether he or she worked alone, with another RN, with a licensed practical nurse (LPN), and/or with an unlicensed assistive personnel (UAP).
Number of schools to which the nurse was assigned per week: Participants were given the option of reporting one–eight schools, which was then treated as a continuous variable.
Self-efficacy in providing asthma care, the proposed mediator variable, was measured with the Asthma Self-Efficacy Survey for School Nurses (Quaranta, 2013). This 19-item survey developed by Quaranta and Spencer(2016) included Likert scale options (1 = false, 2 = mostly false, 3 = mostly true, and 4 = true; possible range 19–76), with a Cronbach’s α of .77 in this sample. Items were summed as a continuous measure for analysis, and higher scores indicated higher asthma self-efficacy.
Performance of AMBs, the dependent variable, was measured by the Asthma Management Behavior Survey for School Nurses (Quaranta, 2013). The 11-item survey developed by Quaranta & Spencer (2016) consisted of two sections, one that included performance of AMBs (Cronbach’s α of .88 in this sample) and another that included the rating of importance of the behaviors. This study only analyzed data on the performance of behaviors. Scores on the performance section of the questionnaire ranged from 11 to 22 (Quaranta, 2013). Items for the performance of behaviors were binary responses answered with 1 = does not perform the behavior at least 90% of the time when encountering the behavior in practice or 2 = does perform the behavior at least 90% of the time. Items were summed as a continuous measure for analysis, and higher scores indicated higher performance of AMBs.
Data were exported from REDCap, a protected web application for designing and managing online surveys and databases, and stored on a secure server for analysis, utilizing a statistical package (Stata Version 15). Descriptive statistics were calculated (frequencies and percentages for binary/categorical variables, means, and standard deviations for continuous variables). The Pearson correlation coefficient (r) was used to measure the bivariate relationships between continuous variables. t Tests for independent samples for self-efficacy in asthma care and performance of AMB by staffing mix (another RN, LPN, and UAP) were implemented to conduct a preliminary assessment of group differences. Two separate multiple linear regression models were applied to predict the outcomes of (1) self-efficacy in asthma care and (2) performance of AMBs using environmental factor variables as independent variables. Additionally, multiple linear regression was used to predict the outcome performance of AMBs using self-efficacy in asthma care as the independent variable. For regression analysis, education level was dichotomized into two groups: Group 1 (diploma, associate’s, or bachelor’s degree) and Group 2 (master’s degree, Doctor of Nursing Practice, or PhD). If a mediation analysis is warranted, the Baron and Kenny model and Sobel test are the suggested analysis methods used to explain the association of environmental factors with school nurses’ performance of AMBs as mediated by self-efficacy (Baron & Kenny, 1986). A sample size of 167 would attain 80% power to detect an effect size of 0.05 (Cohen, 2013) with sufficient power for all analyses. All analyses were done in Stata Version 15 (StataCorp, 2017).
Figure 2 illustrates the derivation of the analytic sample (N = 231). Table 1 displays the participant characteristics. Most of the nurses included in the study were over 50 years of age (>53%), female (>98%), White (>98%), non-Hispanic (>99%), certified as a school nurse in the state of Pennsylvania (>83%), and held a master’s degree or higher (>57%). Table 1 also outlines the key environmental variables of student–nurse ratio, school nurse staffing, and typical number of schools the nurse was assigned per week. The mean number of students reported in a school was 730.19 (428.34). The average student–nurse ratio was 515.27 (327.58) students to one registered school nurse. Although staffing mix is detailed in Table 1, of the 231 school nurses, 15 reported working with a RN and LPN, 1 with an RN and UAP, and 2 with an RN, LPN, and UAP. The majority of nurses were assigned to one school (>65%). Table 1 reflects that the school nurses reported a high overall SE score (M = 66.6, SD = 6.6, Mdn = 68, IQR = 10). Similarly, they reported an overall high performance of AMB score (M = 18.9, SD = 2.4, Mdn = 19, IQR = 4).
Table 2 outlines the correlations. School nurses with a lower student–nurse ratio reported a higher mean performance of AMB scores (r = −.29). Higher self-efficacy in asthma care was moderately associated with increased performance of AMBs (r = .32). There were no significant differences in self-efficacy in asthma care based on staffing mix with RN alone as the referent group vs. plus another RN (t = −0.38, p = .70), vs. plus an LPN (t = 0.93, p = .35), or vs. plus a UAP (t = −1.3, p = .20). There were no significant differences in performance of AMBs scores with the presence of another RN (t = −1.37, p = .17) or UAP (t = −0.95, p = .34). However, in bivariate analyses, school nurses who worked with an LPN reported an average lower performance of AMBs (t = 2.94, p = .004). Number of schools the nurse was assigned did not have a statistically significant association with self-efficacy in asthma care (r = −.04) or performance of AMBs (r = −.05).
As outlined in Table 3, multiple regression analysis indicated that school nurses working with more desirable environmental influences (lower student–nurse ratio, presence of support staff, and lower number of schools assigned per week) did not report a statistically significant higher self-efficacy in asthma care.
As outlined in Table 4, multiple regression analysis indicated that when controlling for staffing mix and number of schools assigned per week, school nurses with a lower student–nurse ratio reported overall higher mean performance of AMB scores. The overall model explained 8% of the variance (adjusted) in performance of AMBs. In the multiple regression analysis, the relationship between school nurses’ performance of AMBs with LPN staffing was no longer significant. The multiple regression model indicated that for each unit increase in student–nurse ratio, the mean performance score of AMBs differed by 0.002 (95% CI −0.003, −0.0009]). This translates to a 1-point decrease in performance of AMB score with an additional increase of 500 students per nurse. Therefore, a nurse who had 500 students would have a predicted performance of AMB score of 19.23 [20.23 + (−0.002) (500)] while a nurse who had 1,000 students would have a performance of AMB score of 18.23 [20.23 + (−0.002) (1000)].
As outlined in Table 5, multiple regression analysis indicated that when controlling for education, certification and, years of school nursing experience, self-efficacy in asthma care predicted performance of AMBs. The overall model explained 9% of the variance (adjusted) in performance of AMBs. The multiple regression model indicated that for each unit increase in self-efficacy in asthma care, the mean performance of AMB score differed by 0.12 (95% CI [0.07, 0.16]). Therefore, a school nurse who had a self-efficacy in asthma care score of 60 would have a predicted mean performance of AMB score of 18.47 [11.5 + 0.12 (60)], while a school nurse who had a self-efficacy in asthma care score of 70 would have a predicted mean performance of AMB score of 19.9 [11.5 + 0.12 (70)]. A mediation analysis was not pursued as the environmental factors were not associated with self-efficacy in asthma care.
This study indicated that school nurses’ increased self-efficacy in asthma care and lower student–nurse ratio were significantly associated with increased performance of AMBs. However, self-efficacy in asthma care was not a mediator for the environmental factors and performance of AMBs. Nevertheless, the significant association between self-efficacy in asthma care and school nurses’ performance of AMBs is important because it provides information about the determinants of nurses’ behaviors and the sources of those determinants.
The findings of this survey support previous research that demonstrated a positive relationship between school nurses’ self-efficacy in asthma care and performance of AMBs (Borgmeyer, Jamerson, Gyr, Westhus, & Glynn, 2005; Quaranta & Spencer, 2015). Therefore, self-efficacy may be considered a helpful contributor to school nurse behaviors promoting health. Schools and school nurses need more extensive efforts to increase self-efficacy in asthma care as a way of supporting nurses’ performance of AMBs.
The phenomenon of student–nurse ratio is often discussed in school health literature, but very little quantitative data exist to support a specific ratio (Dolatowski et al., 2015; Fauteux, 2010; Guttu, Engelke, & Swanson, 2004; Jameson et al., 2017). In this study, school nurses with a lower student–nurse ratio reported overall higher mean AMB performance scores, although the overall performance score did not change dramatically with an increase in student–nurse ratio. Additionally, even though significance was found in some of the models, the adjusted R2 of 8% and 9% is low and therefore does not explain much of the variance in the models. While this study did not find a significant relationship between student–nurse ratio and self-efficacy in asthma care, further investigation is needed. It is possible that if school nurses perceive themselves as more self-efficacious in their roles, they may be better able to work with varying staffing ratios. It is also possible that there are other factors at play alongside staffing ratio such as the demands of direct care (assessment, medication administration) and indirect care (paperwork, writing care plans; Alghamdi, 2016; Endsley, 2017). Although these constructs were not measured in this study, it is important to comprehend the extent to which they add to nursing workload, as students and school settings become more complex.
The nurse practice act, which defines safe, competent nursing care as outlined by state law, differs by state, as do the requirements for school nurse employment. In Pennsylvania, school nurses practice in an educational setting and are licensed through the Pennsylvania State Board of Nursing. This study did not find a significant relationship between education or certification with self-efficacy in asthma care and performance of AMBs. This supports existing literature (Fisher, 2006; Quaranta & Spencer, 2015). The majority of school nurses in this study were state-certified (>83%) and held a master’s degree or higher (>57%). Few were nationally certified (<8%). After adjusting for education and certification when evaluating the association between self-efficacy in asthma care and performance of AMBs of school nurses, the relationship remains significant. One possible explanation is that a high number of Pennsylvania school nurses are both certified and have master’s degrees.
Self-efficacy is a dynamic concept and may shift over time (Zulkosky, 2009). When school nurses care for children with asthma, they encounter new treatments and recommendations regarding care that may necessitate that they learn new skills (Blackmon-Jones, 2017). Additionally, school systems experience organizational changes and workforce turnover that may affect staff rapport (Griffith, 2004). The current study did not support a significant relationship between staffing mix and number of schools the nurse was assigned per week with either self-efficacy in asthma care or performance of AMBs. The lack of direct association may be due to the fact that the investigated relationships are more complex than currently understood. For example, the inclusion of items such as variability of full-time equivalent staff, nursing coverage, and licensure may need to be incorporated into school nurse practice models (Willgerodt, Brock, & Maughan, 2018).
A few limitations of this study should be noted. First, the use of cross-sectional data prevented the examination of causal relationships between the predictors and performance of AMBs. Since this is a developing area of research, the cross-sectional online survey design helped gain a preliminary understanding of the link between variables. The results form a foundation for future study that would examine relationships longitudinally, which would allow for a review of cause and effect. This study was also limited to school nurses in one state. While this was beneficial in that it allowed for the acquisition of a preliminary understanding of the variables’ relationship, future work should include more than one state, to increase generalizability to the larger school nursing community. A final limitation of the study was that the data collected were self-report. While nurses were encouraged to answer with full candor, some may have felt that there was a “correct†answer to give and therefore may not have responded truthfully.
The self-efficacy piece of SCT is critical in the study of motivation and learning (Artino, 2012). School nurses need more than education alone because knowledge itself does not make a person act or perform (Bandura, 1977, 1986, 1997). School nurses must have the belief that they can successfully perform AMBs under typical and atypical situations. Success in the school health setting requires skills and efficacy beliefs that boost the performance of those skills. Bandura refers to this relationship as “reciprocal causation,†in which the operating of one element relies on the operating of the other (Artino, 2012). The study of self-efficacy has shown that a person who is given the flexibility and support to learn and demonstrate a skill in diverse environments builds knowledge and experience that support the innate ability to perform a task and belief in the ability to do it (Bandura, 1977). Therefore, school nurses require information and experience in an environment supportive of both learning and practice.
Effective interventions to promote school nurses’ self-efficacy in asthma care and performance of AMBs should incorporate behaviors such as examination, simulation, reflection, and debriefing (Abelsson & Bisholt, 2017; Lalleman, Bouma, Smid, Rasiah, & Schuurmans, 2017; Monahan, Sparbel, Heinschel, Rugen, & Rosenberger, 2018). A vicarious, or observational, experience can include shadowing a colleague in a clinical setting. Findings from a group of ambulatory nurses demonstrated that an observational experience with other RNs in orientation was helpful when nurses transitioned from an inpatient setting to ambulatory care (Allen, 2016). A mastery experience, or performance of a skill, can include demonstration and redemonstration activities such as the proper use of a metered-dose inhaler or a peak flow meter. An additional approach to increase school nurses’ self-efficacy in asthma care can include participation in a collaborative network (Bunger et al., 2016; Nadeem, Weiss, Olin, Hoagwood, & Horwitz, 2016). Findings from a group of mental health clinicians interested in behavioral therapy found that collaborative learning contributed to the development of their self-efficacy in their chosen area of care (Bunger et al., 2016). In this cooperative learning experience, participants discovered that active experience and education gained from experts (mastery experience), collaboration between peers with similar levels of expertise (vicarious experience), and communication among colleagues who offered professional support (verbal persuasion) were all helpful to the development of self-efficacy.
Changes in student–nurse ratio may be difficult to achieve, and additional research is needed to identify what is best for student health outcomes. Schools should support the position statements of the National Association of School Nurses (NASN) and the American Academy of Pediatrics (AAP) to have a nurse in every school (Council on School Health, 2016; Dolatowski et al., 2015). More research is also needed into models of care that incorporate a broader workload lens, supporting evidence-based practice. In conjunction with ratio, research that includes other variables when considering school health staffing models is warranted. Ideal school nurse staffing recognizes that using a caseload or student–nurse ratio as a distinct indicator is not the best tactic for developing staffing models (Jameson et al., 2017). Model development should include a workload lens that includes such details as calculation of full-time equivalent staff, transparency on assignment of ancillary staff, influence of social determinants of health on the delivery of care, and health and safety needs of students, families, and the school community (Cicutto et al., 2017; Combe et al., 2015; Willgerodt et al., 2018).
It is crucial that future researchers investigate and offer recommendations on the most successful methods to increase school nurses’ self-efficacy in asthma care and performance of AMBs. Future research should investigate opportunities to offer school nurses protected time and resources for asthma management instruction and training. The development of an intervention study involving the use of simulation should be considered. A school-focused simulation activity geared toward caring for the child with a diagnosis of asthma should incorporate assessment, decision-making regarding treatment, interpretation of peak flow and an AAP, an understanding of when to call the provider and/or 911, and a plan for the proper time to return the child to the classroom safely.
Additional research is needed into school nurses’ work environment and its influence on self-efficacy in asthma care, performance of AMBs, nursing, and student outcomes. A multicenter study could be highly effective in the expansion of practice models that champion school-centered asthma care and workload. This would support a research priority of the NASN—to consider models of school health services—and also reinforce infrastructure and system modifications needed to provide optimal, evidence-based care to students. Investigation into models of school-based asthma care is necessary, especially for schools with limited resources. School nurse workforce researchers should consider collaborations with researchers who have knowledge of hospital-based staffing issues and performance (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Lake et al., 2017; Needleman, 2016). While the settings are different, researchers can impart details concerning workforce development in school health. Finally, future research design should consider the gathering of longitudinal data to investigate the influence of nursing care on student health outcomes.
The landscape of school health is changing. There are more children attending school who have chronic disorders. This study found that school nurses’ self-efficacy in asthma care was significantly associated with performance of AMBs. These findings affirm previous work that linked school nurses’ asthma self-efficacy and asthma care (Borgmeyer et al., 2005; Quaranta & Spencer, 2015). This study also found a link between student–nurse ratio and performance of AMBs. Further investigation must continue so that schools can build positive environments for school nurses and students and activities that promote self-efficacy in asthma care. School nurses should implement the suggested recommendations to increase self-efficacy in asthma care and work with stakeholders to address safe staffing environments. The results of this preliminary work indicate the need for other researchers to understand, record, and quantify school nursing practice and its influence on student health outcomes. School nurses can actualize their potential in asthma management when they improve performance of AMBs and gain skills that increase their self-efficacy in asthma care.
All authors contributed to the design, data analysis, and interpretation and were involved in critical revisions of the manuscript, thereby giving final approval on the text. E. McCabe drafted the manuscript. All authors agree 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 the following financial support for the research, authorship, and/or publication of this article: National Institute of Nursing Research (T32NR007100), National Association of School Nurses, Office of Nursing Research, University of Pennsylvania, and The Pennsylvania Association of School Nurses.
Ellen M. McCabe, PhD, PNP-BC, RN https://orcid.org/0000-0003-2901-1670
Catherine McDonald, PhD, RN, FAAN https://orcid.org/0000-0003-3856-8542
Abelsson, A., & Bisholt, B. (2017). Nurse students learning acute care by simulation—Focus on observation and debriefing. Nurse Education in Practice, 24, 6–13. doi:10.1016/j.nepr.2017.03.001
Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. The Journal of Nursing Administration, 38, 223–229. doi:10.1097/NNA.0b013e3181aeb4cf
Alghamdi, M. G. (2016). Nursing workload: A concept analysis. Journal of Nursing Management. doi:10.1111/jonm.12354
Allen, J. W. (2016). Transitioning the RN to ambulatory care. Nursing Administration Quarterly, 40, 115–121. doi:10.1097/NAQ.0000000000000151
Artino, A. R. (2012). Academic self-efficacy: From educational theory to instructional practice. Perspectives on Medical Education, 1, 76–85. doi:10.1007/s40037-012-0012-5
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215. doi:10.1037/0033-295X.84.2.191
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.
Bandura, A. (1997). Self-efficacy: The exercise of control. Dallas, TX: Freeman. doi:10.5860/CHOICE.35-1826
Bandura, A. (2012). On the functional properties of perceived self-efficacy revisited. Journal of Management, 9–44. doi:10.1177/0149206311410606
Bandura, A. (2018). Toward a psychology of human agency: Pathways and reflections. Perspectives on Psychological Science, 13, 130–136. doi:10.1177/1745691617699280
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182. doi:10.1037/0022-3514.51.6.1173
Blackmon-Jones, L. (2017). A strategy to promote successful transition to school nursing. NASN School Nurse (Print). doi:10.1177/1942602X16656383
Borgmeyer, A., Jamerson, P., Gyr, P., Westhus, N., & Glynn, E. (2005). The school nurse role in asthma management: Can the action plan help? The Journal of School Nursing, 21, 23–30. doi:10.1177/10598405050210010601
Bunger, A. C., Hanson, R. F., Doogan, N. J., Powell, B. J., Cao, Y., & Dunn, J. (2016). Can learning collaboratives support implementation by rewiring professional networks? Administration and Policy in Mental Health and Mental Health Services Research, 43, 79–92. doi:10.1007/s10488-014-0621-x
Cicutto, L., Gleason, M., Haas-Howard, C., Jenkins-Nygren, L., Labonde, S., & Patrick, K. (2017). Competency-based framework and continuing education for preparing a skilled school health workforce for asthma care: The Colorado experience. Journal of School Nursing, 33, 277–284. doi:10.1177/1059840516675931
Cicutto, L., Gleason, M., & Szefler, S. J. (2014). Establishing school-centered asthma programs. Journal of Allergy and Clinical Immunology, 134, 1223–1230. doi:10.1016/j.jaci.2014.10.004
Cohen, J. (2013). Statistical power analysis for the behavioral sciences. Abingdon, England: Routledge.
Combe, L. G., Bachman, M. B., Dolatowski, R., Endsley, P. E., Hassey, K., Maughan, E., … Zeno, E. (2015). School nurse workload: Students are more than just numbers. NASN School Nurse, 30, 283–288. doi:10.1177/1942602X15596582
Council on School Health. (2016). Role of the school nurse in providing school health services. Pediatrics, 137. doi:10.1542/peds.2016-0852
Daughtry, D., & Engelke, M. K. (2018). Demonstrating the relationship between school nurse workload and student outcomes. Journal of School Nursing, 34, 174–181. doi:10.1177/1059840517725790
Dolatowski, R., Endsley, P., Hiltz, C., Johansen, A., Maughan, E., Minchella, L., & Trefry, S. (2015). School nurse workload: Staffing for safe care. Position Statement. NASN School Nurse, 30, 290–293. doi:10.1177/1942602X15594143
Endsley, P. (2017). School nurse workload: A scoping review of acute care, community health, and mental health nursing workload literature. Journal of School Nursing, 33, 43–52. doi:10.1177/1059840516681423
Fauteux, N. (2010). Unlocking the potential of school nursing: Keeping children healthy in school and ready to learn. Charting Nursing’s Future, 14, 1–8.
Fisher, K. L. (2006). School nurses’ perceptions of self-efficacy in providing diabetes care. The Journal of School Nursing, 22, 223–228. doi:10.1177/10598405050220040701
Gist, M. E., & Mitchell, T. R. (1992). Self-efficacy: A theoretical analysis of its determinants and malleability. Academic of Management Review, 17, 183–211. doi:10.5465/AMR.1992.4279530
Griffith, J. (2004). Relation of principal transformational leadership to school staff job satisfaction, staff turnover, and school performance. Journal of Educational Administration. doi:10.1108/09578230410534667
Guttu, M., Engelke, M. K., & Swanson, M. (2004). Does the school nurse-to-student ratio make a difference? Journal of School Health, 74, 6–9. doi:10.1111/j.1746-1561.2004.tb06593.x
Hollenbach, J. P., & Cloutier, M. M. (2014). Implementing school asthma programs: Lessons learned and recommendations. Journal of Allergy and Clinical Immunology, 134, 1245–1249. doi:10.1016/j.jaci.2014.10.014
Jameson, B. E., Engelke, M. K., Anderson, L. S., Endsley, P., & Maughan, E. D. (2017). Factors related to school nurse workload. The Journal of School Nursing, 34, 211–221. doi:10.1177/1059840517718063
Kakumanu, S., Antos, N., Szefler, S. J., & Lemanske, R. F. (2017). Building school health partnerships to improve pediatric asthma care: The school-based asthma management program. Current Opinion in Allergy and Clinical Immunology, 17. doi:10.1097/ACI.0000000000000347
Lake, E. T., de Cordova, P. B., Barton, S., Singh, S., Agosto, P. D., Ely, B.,… Aiken, L. H. (2017). Missed nursing care in pediatrics. Hospital Pediatrics, 7, 378–384. doi:10.1542/hpeds.2016-0141
Lalleman, P., Bouma, J., Smid, G., Rasiah, J., & Schuurmans, M. (2017). Peer-to-peer shadowing as a technique for the development of nurse middle managers clinical leadership: An explorative study. Leadership in Health Services, 30, 475–490. doi:10.1108/LHS-12-2016-0065
Lemanske, R. F., Kakumanu, S., Shanovich, K., Antos, N., Cloutier, M. M., Mazyck, D.,… Williams, P. (2016). Creation and implementation of SAMPRO™: A school-based asthma management program. Journal of Allergy and Clinical Immunology, 138, 711–723. doi:10.1016/j.jaci.2016.06.015
Lewallen, T. C., Hunt, H., Potts-Datema, W., Zaza, S., & Giles, W. (2015). The whole school, whole community, whole child model: A new approach for improving educational attainment and healthy development for students. Journal of School Health, 85, 729–739. doi:10.1111/josh.12310
Mangena, A. S., & Maughan, E. (2015). The 2015 NASN school nurse survey. NASN School Nurse, 30, 328–335. doi:10.1177/1942602X15608183
McCabe, E. M., McDonald, C., Connolly, C., & Lipman, T. H. (2019). A review of school nurses’ self-efficacy in asthma care. Journal of School Nursing, 35. doi:10.1177/1059840518808886
Monahan, L., Sparbel, K., Heinschel, J., Rugen, K. W., & Rosenberger, K. (2018). Medical and pharmacy students shadowing advanced practice nurses to develop interprofessional competencies. Applied Nursing Research, 39, 103–108. doi:10.1016/j.apnr.2017.11.012
Nadeem, E., Weiss, D., Olin, S. S., Hoagwood, K. E., & Horwitz, S. M. (2016). Using a theory-guided learning collaborative model to improve implementation of EBPs in a state children’s mental health system: A pilot study. Administration and Policy in Mental Health and Mental Health Services Research, 43, 978–990. doi:10.1007/s10488-016-0735-4
Needleman, J. (2016). The economic case for fundamental nursing care. Canadian Journal of Nursing Leadership, 29, 26–36. doi:10.12927/cjnl.2016.24643
Quaranta, J. E. (2013). The performance of the school nurses’ asthma management behaviors in relationship to their asthma knowledge, asthma attitude and asthma self-efficacy. State University of New York at Binghamton. Retrieved from http://search.proquest.com/docview/1432195344?accountid=13042%5Cnhttp://oxfordsfx.hosted.exlibrisgroup.com/oxford?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&genre=dissertations+%26+theses&sid=ProQ:ProQuest+Dissertations+%26+Theses+G
Quaranta, J. E., & Spencer, G. A. (2015). Using the health belief model to understand school nurse asthma management. The Journal of School Nursing, 31, 430–440. doi:10.1177/1059840515601885
Quaranta, J. E., & Spencer, G. A. (2016). Barriers to asthma management as identified by school nurses. Journal of School Nursing, 32, 365–373. doi:10.1177/1059840516641189
Quelly, S. B. (2014). Influence of perceptions on school nurse practices to prevent childhood obesity. The Journal of School Nursing, 30, 292–302. doi:10.1177/1059840513508434
StataCorp. (2017). Stata Stastistical Software: Release 15. College Station, TX: StataCorp LLC.
Willgerodt, M. A., Brock, D. M., & Maughan, E. D. (2018). Public school nursing practice in the United States. Journal of School Nursing, 34. doi:10.1177/1059840517752456
Zahran, H. S., Bailey, C. M., Damon, S. A., Garbe, P. L., & Breysse, P. N. (2018). Vital signs: Asthma in children—United States, 2001–2016. Morbidity and Mortality Weekly Report, 67, 149–155.
Zulkosky, K. (2009). Self-efficacy: A concept analysis. Nursing Forum, 44, 93–102. doi:10.1111/j.1744-6198.2009.00132.x
Ellen M. McCabe, PhD, PNP-BC, RN, is an assistant professor of nursing at Hunter-Bellevue School of Nursing, Hunter College, The City University of New York, NY, USA.
Catherine McDonald, PhD, RN, FAAN, is an assistant professor of nursing at University of Pennsylvania School of Nursing and assistant professor in nursing in pediatrics at School of Medicine, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
Cynthia Connolly, PhD, RN, FAAN, is a Rosemarie B. Greco term endowed professorship in advocacy and professor of nursing at University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
Terri H. Lipman, PhD, CRNP, FAAN, is an assistant dean for community engagement, Miriam Stirl endowed term professor of nutrition, and professor of nursing of children at University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
1 Hunter-Bellevue School of Nursing, Hunter College, The City University of New York, NY, USA
2 University of Pennsylvania School of Nursing, Philadelphia, PA, USA
Corresponding Author:Ellen M. McCabe, PhD, PNP-BC, RN, Hunter-Bellevue School of Nursing, Hunter College, The City University of New York, 425 East 25th Street, New York, NY 10010, USA.Email: em3766@hunter.cuny.edu