- Email: [email protected]
Improving Asthma Management in the Elementary School Setting: An Education and Self-management Pilot Project
Journal of Pediatric Nursing 42 (2018) 16–20
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Improving Asthma Management in the Elementary School Setting: An Education and Self-management Pilot Project Natasha McClure, DNP, RN, CPNP a,⁎, Mackenzie Seibert, MSN, RN b, Taylor Johnson, MSN, RN, CPNP b, Leslie Kannenberg, MSN, RN b, Trey Brown, MSN, RN, FNP-C b, Melanie Lutenbacher, PhD, MSN, RN, FAAN c a b c
Vanderbilt University School of Nursing, 315 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, United States Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, United States Vanderbilt University School of Nursing, 524 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, United States
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Article history: Received 8 September 2017 Revised 1 June 2018 Accepted 2 June 2018 Available online xxxx Keywords: Asthma Self-assessment School of nursing School nurse Asthma education
a b s t r a c t Purpose: To increase daily asthma symptom self-assessments of elementary school students using Green Means Go, an asthma education and self-assessment program, via a partnership between an elementary school and a school of nursing. Methods: Over four months, accelerated MSN nursing students provided small group education sessions to teach students and teachers to identify asthma symptoms by Asthma Action Plan (AAP) zones and actions for each zone. To promote continuity of care between school and home, a teacher-parent communication log during yellow zone days was encouraged. Results: Students with asthma (n = 90), teachers (n = 12) and parents (n = 1) participated. Previously no students performed daily self-assessments and at program end, all students accurately identified symptoms, AAP zones, and action steps. A total of 789 symptom self-assessments were recorded. Teachers reported increased asthma knowledge. One parent attended an education session and one home visit was completed. No communication logs were returned. Conclusions: Partnerships between elementary and nursing schools may be an effective strategy for delivery of health programs to high-risk children with chronic diseases. Self-assessment of symptoms and taking appropriate actions at school are critical components of early asthma intervention, particularly when a school nurse is not always available. Training teachers to follow a child's AAP within school policies is a critical second step. Home visits showed potential as a strategy for engaging parents. Practice implications: In the current climate of school nurse shortages, management of asthma-related episodes in school can be improved with similar partnerships and programs that promote health education and selfmanagement. © 2018 Published by Elsevier Inc.
Background Over 8% of children in the United States (US) under the age of 15 have a diagnosis of asthma (Centers for Disease Control and Prevention [CDC], 2016). Childhood asthma prevalence in Tennessee (TN) is 9.5% (Brantley, 2018). National asthma management guidelines recommend that every patient with asthma have an asthma action plan (AAP) provided by a clinician (National Heart, Lung, & Blood Institute [NHLBI], 2007a, 2007b). Asthma management guidelines specifically developed for schools outline the minimum standard for every child with asthma. To meet this standard, each child must have a written AAP, update it regularly, share it with all teachers and school staff that provide educational support to the child with asthma, and ensure access ⁎ Corresponding author. E-mail address: [email protected] (N. McClure).
https://doi.org/10.1016/j.pedn.2018.06.001 0882-5963/© 2018 Published by Elsevier Inc.
to assistance from trained personnel is provided (NHLBI, 2014). However, many schools do not comply with this recommendation. State and school district policies determine a school's mandate for having such a plan in place, as well as allocating resources to schools to care for children with asthma. Written AAPs serve as a guide to patients and families for symptom self-management. They include a description for when and how to adjust medications and when to seek emergency medical care (Edwards, 2013). A commonly used AAP model is the “traffic light” with green, yellow, and red zones. Each color zone corresponds to a symptom level (i.e., green = symptom free; yellow = asthma symptoms present; red = severe symptoms present) (NHLBI, 2007a, 2007b). The yellow zone indicates loss of asthma control and is a trigger for the use of quick relief medications to manage immediate symptoms in a setting outside of a medical care facility (Dinakar et al., 2014). If symptoms are unrelieved after a period of time in the yellow zone, parents are
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instructed to consult their healthcare provider to reduce the risk of further exacerbation requiring emergency (ED) care or hospitalization. If severe symptoms are present and unrelieved by quick relief medications, such as in the red zone, caretakers are instructed to seek ED/urgent care immediately (NHLBI, 2007a). School nurses have a key role in asthma management in this setting. They are responsible for coordinating all essential components of asthma management, such as ensuring each student has an AAP and a quick-relief inhaler, recognizing asthma symptoms, and implementing the AAP (American Lung Association [ALA], 2009). Most importantly, nurses are equipped with the assessment skills required to monitor a child's condition over time and provide asthma management education to school staff and teachers (ALA, 2009). School-based asthma education programs, particularly those that include teachers and parents, can improve health and asthma knowledge, self-efficacy and self-management (Coffman, Cabana, & Yelin, 2009; Findley et al., 2011). Significant challenges associated with such efforts include the part-time nature of many school nurses and multi-school responsibilities. At least 30% of public schools have a nurse who works part-time in one or more schools. Only 45% of schools have a nurse present throughout the entire school day every day (Robert Wood Johnson Foundation [RWJF], 2013). These time constraints are a significant barrier to a school nurse's ability to provide asthma education or perform routine asthma symptom assessments and challenge the school to provide effective support to the children with asthma. Health promotion and patient education interventions delivered through academic partnerships with schools of nursing and a partner organization may be a mutually beneficial solution to address this problem (Smith, Lutenbacher, & McClure, 2015). When the partner organization is a high need, low resource school with a gap in nursing coverage, nursing students are able to provide a needed service and potentially alleviate the healthcare delivery burden for the school (McClure, Lutenbacher, O'Kelley, & Dietrich, 2017). Such partnerships also provide a means for bridging the practice preparation gap in regard to nurses caring for vulnerable populations in the primary care setting (Kreulen, Bednarz, Wehrwein, & Davis, 2008). School aged children spend most of their wakeful time at school, however, schools may not have processes in place to notify healthcare providers or parents when a child has a yellow zone day or uses quick relief medication. If symptoms are unreported during this key time, opportunities to continue the AAP at home or arrange primary care appointments to manage asthma symptoms before they worsen are lost. This may result in a potentially avoidable school absence, ED visit or hospital admission. Measuring the frequency of asthma symptoms, such as wheezing or use of a quick relief medication, is recommended. Clinicians are able to use this data to evaluate how well asthma is controlled, determine the frequency for follow up care required to achieve good asthma control, or establish the need for referral to specialists (NHLBI, 2007a). Stepping up or down on recommended medications may be indicated based on symptom frequency (NHLBI, 2007b). Local Problem In the state of Tennessee, the current full-time school nurse to student ratio is 1:3000 (Tennessee Department of Education, 2017). In one large metropolitan school district in Tennessee, the staffing ratio and procedure-driven model of care require that the nurse's time be primarily used to perform skilled nursing procedures that may not be delegated, such as administration of tube feeding, according to the Tennessee Board of Nursing (TN BON) standards (TN BON, 2016). Tasks such as medication administration and supervision of medication self-administration may be delegated to trained school personnel (TN Dept. of Education and TN Dept. of Health, 2014). In this staffing model, nurses are often assigned to multiple schools in order to maintain compliance with state laws and school policies. The school in the
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pilot site for this project is responsible for multiple schools and is on site monthly and routinely available by phone to school staff and teachers. The local public school district uses parental report to identify diagnoses for chronic diseases, such as asthma, through routine collection of health history forms each academic year. Through this process, it was determined that approximately 5000 students districtwide reported a diagnosis of asthma. An audit of the pilot elementary school was conducted to determine the scope of the problem at the school level. This revealed that 60 students (18%) reported having a diagnosis of asthma. Of those, only 23 diagnoses had been confirmed by a healthcare provider and had an AAP in place that reflected the provider's orders for medications the child should use when experiencing asthma symptoms. Of all students identified, only 9 (15%) had access to a quick relief inhaler (albuterol) at school. No existing asthma resources were identified within the school. These findings supported the need for asthma resources at this particular school and underscored the significance of undertaking this project. School office staff are trained by the school nurse to identify asthma symptoms and to oversee medication administration, including asthma inhalers. School administrators indicated that staff could potentially implement three asthma interventions. These included administering asthma medication (albuterol) if available, contacting a parent if medication was unavailable, or if medication did not alleviate symptoms, contacting emergency medical personnel if the child was in distress. Children in no apparent distress, whose parents could not be reached, returned to class. Aim The primary aim of this project was to pilot test the implementation of Green Means Go (GMG), an asthma education, self-assessment, and self-reporting program developed by nursing students and faculty. The goals of the project were to: 1) increase the number of children who perform daily asthma symptom self-assessments and increase knowledge of appropriate symptom identification and initiation of a child's asthma action plan (AAP) among children, parents and teachers, 2) increase communication between parents and the school when a child was in the yellow zone and the AAP should be initiated and, 3) provide nursing students with a relevant community health clinical experience to learn about chronic disease management in the school setting. Methods This project was implemented in one elementary school within a large, urban public school district in Middle Tennessee with approximately 84,000 students enrolled. The pilot school reported enrollment of 349 pre-K through fourth grade students with an average daily enrollment of 318. The student body was comprised of 89.7% African American, 5% Hispanic and 2% white students. Almost all students (96.9%) were economically disadvantaged (Tennessee Department of Education, n.d.). Developing the Partnership and Planning the Intervention. The academic community partnership (ACP) emerged through an outreach effort by the school of nursing faculty member, who approached the school principal with a proposal to provide a schoolbased asthma management program. Key school system stakeholders were identified and included school staff in a supervisory capacity at the district level, principals, teachers, and support staff. High interest in a possible program emerged and a subsequent meeting at the proposed site school was organized. During the meeting, elementary school staff and the principal expressed multiple concerns related to students with asthma at their school. These included the large number of students with asthma, lack of resources for these children within the school, knowledge deficits of teachers and school staff about asthma symptom identification and management, limited school nurse
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availability, and a lack of a formalized, school-wide training for staff and teachers. Available training at the time was limited to one-on-one training sessions provided by the school nurse to individuals who volunteered to supervise medication administration when the nurse was not on site. Privacy concerns were identified at the initial meeting. It was determined that school health records could not be released to outside agencies or partners based on the district's interpretation of the Family Educational Rights and Privacy Act (FERPA) (U.S. Department of Education, 2014). Student self-identification directly to the project team through classroom visits was selected as a potential referral mechanism to the proposed program to avoid potential violations of FERPA, as well as to avoid the challenge of low parental response rates to school initiated communications cited by school administrators and staff. Health history forms were reviewed by the liaison and teachers, who made additional referrals to the program. The GMG program was proposed, and upon principal approval, points of contact for the ACP were identified to move the project forward. This included the school office staff, school-level support services liaison and the nursing faculty member. The school of nursing team included a group of 10 community health students in an accelerated MSN program supervised by one Pediatric Nurse Practitioner (PNP) faculty member. The GMG team consisted of the PNP faculty member and ten students, the support services liaison, school secretary, and the 12 teachers with children with asthma in their classrooms who participated.
Implementation A three-pronged approach with specific asthma education curricula developed for students, teachers, and parents was used. All program activities and education sessions were held at the school and conducted by the nursing students. At the request of the principal, education sessions for students were scheduled by the school support services liaison outside of core subject instructional time, such as during art, music, or physical education. Teachers expressed preference for their sessions to be held during planning time. Green Means Go program: student component. Pre-K through fourth grade children were given the opportunity to self-identify as having a diagnosis of asthma to the GMG project team. The team conducted a visit with each classroom in the school to provide a brief description of GMG prior to the first scheduled education session. At the end of the program overview, children who self-selected to join the program left with the project team for their first lesson. A total of 30 students were identified through this method who were not previously reported to the school via routine health history forms. Ultimately, 90 children in 19 different classrooms were identified to have asthma through the combined efforts of health history forms and selfidentification. Ninety students and 12 out of 19 classroom teachers chose to participate. Students were divided into 6 groups by grade level (i.e., pre-kindergarten through fourth grade). Participants in kindergarten through fourth grades attended an initial 30-minute group education session and three additional 20 min sessions over a four month period. Pre-K participants had two education sessions over the course of the program that focused on asthma symptoms. They did not participate in daily symptom recording because they are unable to read and respond to the daily symptom questions and record selfassessment results independently. Education sessions for kindergarten through fourth grade occurred in this order 1) asthma symptoms and color zones according to the AAP traffic light model, 2) process for performing and recording daily self-assessments, 3) action steps to take on symptom days, and 4) assessment of knowledge of the AAP zones and associated symptoms. During the second session children were provided with a color coded asthma action plan zone card. Each zone contained symptom questions intended to help the child select their appropriate zone.
Children in the red or yellow zones were taught to report symptoms to school staff or teachers and to report to the office to receive medication if prescribed and available. All students recorded their daily zone assessment data on a personalized chart, which was collected and reviewed weekly by the GMG team. School staff followed their usual policies and procedures for determining when to contact parents for school pickup or contact emergency response personnel when symptoms were present. Green Means Go program: teacher component. Sessions were provided in small teacher groups by grade level during their designated planning time. Teacher sessions included 1) overviews of the AAP and color zones, 2) symptoms associated with each of the three zones, 3) the importance of early symptom identification and, 4) the use of a symptom log (provided to each teacher) for communication with parents to ensure continuity of use of the AAP across the school and home settings. Teachers were asked to assist in reminding children to perform daily self-assessments. They were instructed to follow existing school procedures for referring children to the office for follow up care when children were not in the green zone. They were encouraged to notify families through the communication log of the presence of yellow zone symptoms on day one in the yellow zone and each consecutive day in the yellow zone when observed. The GMG team conducted weekly check-ins with teachers during their planning time to ensure ample opportunities to ask questions, express concerns or identify areas for improvement in the implementation process. Teachers and other school staff and administrators were offered the American Lung Association's Asthma 1-2-3 training to supplement the GMG information session. Asthma 1-2-3 (ALA, 2016) is a standardized program that teaches basic asthma knowledge to school, daycare and other community facility personnel to help prepare them to care for children with asthma. This curriculum was selected because the content is aligned with national guidelines for asthma management and provides a comprehensive overview for laypersons without healthcare training or experience. Green Means Go Program: parent component. Parents were offered an asthma education session that provided 1) an overview of the AAP symptoms, zones, and action steps for establishing and maintaining asthma control, 2) a communication plan for checking in and responding to the communication log from their child's teacher and 3) education about the importance of managing asthma triggers in the home. Parents were offered home visits conducted by the GMG team to assess for the presence of environmental triggers and for individualized education on trigger management strategies. Measures Improvement in child knowledge of symptoms, asthma triggers, AAP zones and actions steps in the children who participated were measures selected to evaluate the GMG student component of the project. Children were asked to teach back symptoms, asthma triggers and AAP zones and action steps to individual members of the GMG team following each session to assess comprehension. Children read selfassessment questions and responded with the GMG team member at each session in order to assess their ability to accurately self-assess and self-report symptoms in order to evaluate the effectiveness of the self-assessment process. Daily participation during school days was used to measure the frequency self-assessments were performed. School attendance data and number of albuterol administrations by school staff were selected to evaluate the effectiveness of the self-reporting component of the program leading to asthma interventions. The school administration, however, was unable to provide this data to the project team. Post-assessment of teacher knowledge was assessed using the Asthma 1-2-3 curriculum post-test to evaluate teacher knowledge of asthma symptoms. At the end of the project, teacher feedback on their experience with the program was elicited through a seven question
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electronic survey to measure their satisfaction with the program. Teachers were asked about barriers to implementation and for general program feedback, as well as what types of information they may need in order to feel prepared to care for children with asthma in their classrooms. Responses were collected as narrative comments. The project was reviewed by the university Institutional Review Board and determined to be a quality improvement, non-research project. No ethical issues emerged in the planning or implementation of the project. Results Elementary School Students Ninety elementary school students participated in all education sessions of the GMG program. Of those, 60 (66.6%) were identified by a parent through health history forms as having a diagnosis of asthma to the school, 23 (25.5%) of those had the diagnosis confirmed by a healthcare provider and an AAP in place and 9 (10%) had access to a quick relief inhaler (albuterol) at school. Of the children who participated in the sessions, 100% were able to correctly verbalize their asthma zone at the end of each education session. Overall, twelve classrooms (63%) with a child with asthma participated in daily asthma zone recording for a total of 48 students. Daily participation of the 12 classrooms ranged from 9% to 85%, with average daily participation at 31.87%. Teachers Of the 19 classrooms with a child with asthma, 12 teachers (80%) with children diagnosed with asthma in their classrooms participated in the small group education sessions led by nursing students. Seven of the 19 classrooms (36.84%) did not complete any daily selfassessments throughout the program. All 19 teachers with a child with asthma in their classroom were invited to participate in a survey at the conclusion of the program regardless of whether or not they participated in teacher education sessions. All teachers were surveyed because children in all classrooms were offered the opportunity to participate in the program and education sessions regardless of their teacher's participation in teacher education sessions. Fourteen teachers (74%) responded to the survey. Of the respondents, 10 (71%) felt well prepared to help children perform asthma self-assessments. Several teachers offered ideas to strengthen the program. They suggested starting the program earlier in the school year to help integrate the program into the daily classroom routine. A commonly identified barrier to effective classroom implementation was time constraints. Five (38%) of respondents indicated they would like more information on asthma emergencies and strategies to make their classrooms asthma-friendly. Parents Only one parent attended the education session. Communication logs were sent home each week by the GMG team for children who reported yellow zones in the classroom chart. No communication logs were returned to teachers. School staff contacted several parents of children with high frequency of yellow zone symptoms by phone to offer additional resources, including school meetings and/or home visits through an existing home visit program within the nursing school that seeks to reduce asthma triggers through evidence-based home environmental interventions (McClure, Lutenbacher, O'Kelley, & Dietrich, 2017). Two parents were reached by phone. One parent declined additional resources and one parent accepted and completed a home visit. The mother reported concerns for mold and was provided with education for remediation strategies and resource linkage to a local non-profit that assists with mold testing and removal.
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Discussion The ACP and school-based support for GMG were integral to the successful pilot implementation of this program. All children who participated in the project were able to self-assess and choose the correct corresponding asthma zone by the end of the program. However, daily assessments were not consistently recorded by all children who participated. Lack of teacher engagement may have potentially contributed to lower student participation than anticipated. Whether or not the program was successfully implemented in a classroom (i.e., corresponding high student participation) may depend on the level of teacher involvement, which indicates teacher engagement is a critical component to focus on in future efforts. This program provided a method of recording the frequency of a child's asthma symptoms during the school day, which was thought to be a potential method of improving access to school based asthma resources. Nurses may perform this function in other settings where they are routinely available. They may also share this information with parents and healthcare providers. Communication logs sent home to parents were not returned to the school, so it is unclear if parents received them and if they did, whether they shared this information with their child's healthcare provider. This highlights the gaps in communication between schools, parents, and healthcare providers in this school district and at the pilot site identified by this program. Only one parent accepted the offer of a home visit. Although home visits may be an effective approach for teaching parents about asthma, increased participation is needed to fully evaluate their impact on the GMG program outcomes. In addition to providing the GMG curriculum content, home visits can provide the opportunity to assess the home for the presence of potential asthma triggers and discuss evidence based prevention strategies for reducing allergen exposure with the family, such as the use of pillow encasements, HEPA filters, frequent vacuuming, cockroach treatment and smoking cessation (NHLBI, 2007b).
Limitations The most significant limitation of the pilot program was that participants were asked to self-identify. Without confirmation of a child's diagnosis, students without asthma may have participated in the program and others with a diagnosis may have elected not to participate in the program. Because of the large number of students identified, a much higher number of children participated than anticipated for program development purposes, which yielded larger group sizes. We recommend that programs may want to consider school-based asthma screenings as a means to identify participants. With regard to evaluation, a more robust evaluation plan to assess the impact of the program on school attendance, truancy, and ED visits and hospitalizations related to asthma would provide valuable information about program outcomes. This data will be included in the next phase of the project. A cost analysis is also important to consider the financial impact of asthma-related school absences to the schools and the level of cost savings of partnerships and programs such as ours to the school district related to school absenteeism. The use of a standardized approach to evaluating pre and post program knowledge is preferable for both children and teachers. The Asthma 1-2-3 curriculum does not include a pre-test. Therefore, only post-participation knowledge assessment was evaluated. Although most teachers participated in the program, the average daily classroom participation in recording a child's self-assessed asthma zone was less than 40%. Even with this low rate, nearly 800 daily selfassessments were recorded. Beginning the program at the start of the academic year increases the likelihood of it being a part of the daily classroom routine from the outset. This may improve participation rates. Given the nature of this project, it is not possible to conclude
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with certainty that the observed outcomes are the result of this intervention but our results are very promising for future similar efforts. Pilot school staff reported that parent engagement is an ongoing challenge for the school. Multiple communication logs sent to parents went unreturned. School staff who were familiar with the neighborhood reported the best method of contacting parents was via phone or an in-person visit. This was a challenge because outside partners do not have access to parent information and could not easily establish contact with parents. The school liaison was able to assist; however, many attempts were unsuccessful due to non-working or inaccurate phone numbers. Practice Implications There are a number of considerations for practicing school or clinic nurses looking to replicate this program or initiate a similar partnership. First, it is imperative to conduct a thorough exploration of their organization's policies and procedures related to any requirements to establish an academic-community partnership, particularly in a school, including the development of a formal legal contract. School system requirements, such as fingerprinting or background checks, must also be considered and included when developing a timeline. Identifying and recruiting both faculty and school partner champions are key to successful program development and implementation. Faculty are increasingly more interested in creating clinical learning environments that offer real world experiences, however, poor alignment of goals and scheduling barriers can impede collaborations. Once a fit is established for nursing student learning objectives and health program outcomes, providing potential collaborators with a time frame for engagement that is as flexible as possible is critical. Another important planning component is sharing available baseline data to all partners. This can aid partners in understanding the current needs and assist with identifying evaluation metrics. Lastly, it is crucial to identify, very early in the process, times during the school schedule when the children and teachers are available to participate. This can alleviate frustrating schedule misalignments. Conclusion Management of asthma in schools continues to be a significant issue nationwide. There were many successful aspects of our project that support the feasibility of implementing GMG through an academic community partnership such as ours. Outcomes of the pilot highlight the possibility and importance of school-aged children learning to selfassess their asthma symptoms and taking appropriate steps to report symptoms to teachers or other staff. This is particularly significant in schools like the pilot school, where a nurse is not routinely available and where there are no existing asthma management programs in place. Programs that help students, teachers and parents to better understand asthma may increase safety and provide important opportunities for nursing students to gain insights into barriers in school health that impact health seeking and health care utilization behaviors, as well as develop meaningful projects that build their community health
nursing skill sets. Additionally, although there were challenges, the overall success of this project is an encouraging first step in demonstrating potential for evolving partnership models to provide schools with much-needed health resources to fill gaps in nurse services. References American Lung Association (2009). A national asthma public policy agenda. Retrieved from http://www.lung.org/assets/documents/asthma/National-Asthma-PublicPolicy-Agenda-January-2009.pdf. American Lung Association (2016). Education and training: Asthma 1-2-3. Retrieved from http://www.lung.org/local-content/_content-items/our-initiatives/educationand-training/asthma-1-2-3.html. Brantley, A. (2018). BlueCross, BlueShield of Tennessee health brief: Asthma & allergies; a state of the state. Retrieved from https://bettertennessee.com/health-brief-asthmaallergies/. Centers for Disease Control and Prevention (2016). National health interview survey: Early release of selected estimates based on data from the 2016 national health interview survey. Retrieved from https://www.cdc.gov/nchs/data/nhis/earlyrelease/ Earlyrelease201705_15.pdf. Coffman, J., Cabana, M., & Yelin, E. (2009). Do school-based asthma education programs improve self-management and health outcomes? Pediatrics, 124(2). https://doi.org/ 10.1542/peds.2008-2085. Dinakar, C., Oppenheimer, J., Portnoy, J., Bacharier, L. B., Li, J., Kercsmar, C. M., ... Nicklas, R. (2014). Management of acute loss of asthma control in the yellow zone: A practice parameter. Annals of Allergy, Asthma & Immunology, 113(2), 143–159. Edwards, A. L. (2013). Asthma action plans and self-management: Beyond the traffic light. Nursing Clinics of North America, 48(1), 47–51. Findley, S. E., Thomas, G., Madera-Reese, R., McLeod, N., Kintala, S., Martinez, A., & Herman, E. (2011). A community-based strategy for improving asthma and outcomes for preschoolers. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 88(1), 85–99. https://doi.org/10.1007/s11524-010-9479-8. Kreulen, G., Bednarz, P., Wehrwein, T., & Davis, J. (2008). Clinical education partnership: A model for school district and college of nursing collaboration. The Journal of School Nursing, 24(6), 360–369. McClure, N., Lutenbacher, M., O'Kelley, E., & Dietrich, M. (2017). Enhancing pediatric asthma care and chronic disease education through an academic practice partnership. Journal of Pediatric Nursing, 36, 64–69. National Heart, Lung, and Blood Institute (2007a). Asthma action plan. Retrieved from https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf. National Heart, Lung, and Blood Institute (2007b). National asthma education and prevention program expert panel report 3: Guidelines for the diagnosis and management of asthma. Retrieved from http://www.nhlbi.nih.gov/health-pro/guidelines/ current/asthma-guidelines/full-report. National Heart, Lung, and Blood Institute (2014). Managing asthma: A guide for schools. Retrieved from https://www.nhlbi.nih.gov/files/docs/resources/lung/NACI_ ManagingAsthma-508%20FINAL.pdf. Robert Wood Johnson Foundation (2013). School nurse shortage may imperil some children, RWJF scholars warn. Retrieved from http://www.rwjf.org/en/library/articlesand-news/2013/12/School-Nurse-Shortage-May-Imperil-Some-Children.html. Smith, K. M., Lutenbacher, M., & McClure, N. (2015). Leveraging resources to improve clinical outcomes and teach transitional care through development of academic-clinical partnerships. Nurse Educator, 40(6), 303–307. Tennessee Board of Nursing (2016). Tennessee board of nursing position statements. Retrieved from https://tn.gov/assets/entities/health/attachments/Position_Statement_ Booklet.pdf. Tennessee Department of Education (2017). School Health Laws. Retreived from https:// www.tn.gov/content/dam/tn/education/csh/csh_school_health_laws_2017.pdf. Tennessee Department of Education. (n.d.). State report card. Retrieved from https:// www.tn.gov/education/topic/report-card Tennessee Department of Education and Tennessee Department of Health (2014). Guidelines for use of health care professionals and health care procedures in a school setting. Retrieved from https://www.tn.gov/assets/entities/health/attachments/csh_ guidelines_healthcare_prof_proc.pdf. U.S. Department of Education (2014). Family Educational Rights and Privacy Act (FERPA). Retrieved from http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html.
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Improving Asthma Management in the Elementary School Setting: An Education and Self-management Pilot Project Natasha McClure, DNP, RN, CPNP a,⁎, Mackenzie Seibert, MSN, RN b, Taylor Johnson, MSN, RN, CPNP b, Leslie Kannenberg, MSN, RN b, Trey Brown, MSN, RN, FNP-C b, Melanie Lutenbacher, PhD, MSN, RN, FAAN c a b c
Vanderbilt University School of Nursing, 315 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, United States Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, United States Vanderbilt University School of Nursing, 524 Godchaux Hall, 461 21st Avenue South, Nashville, TN 37240, United States
a r t i c l e
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Article history: Received 8 September 2017 Revised 1 June 2018 Accepted 2 June 2018 Available online xxxx Keywords: Asthma Self-assessment School of nursing School nurse Asthma education
a b s t r a c t Purpose: To increase daily asthma symptom self-assessments of elementary school students using Green Means Go, an asthma education and self-assessment program, via a partnership between an elementary school and a school of nursing. Methods: Over four months, accelerated MSN nursing students provided small group education sessions to teach students and teachers to identify asthma symptoms by Asthma Action Plan (AAP) zones and actions for each zone. To promote continuity of care between school and home, a teacher-parent communication log during yellow zone days was encouraged. Results: Students with asthma (n = 90), teachers (n = 12) and parents (n = 1) participated. Previously no students performed daily self-assessments and at program end, all students accurately identified symptoms, AAP zones, and action steps. A total of 789 symptom self-assessments were recorded. Teachers reported increased asthma knowledge. One parent attended an education session and one home visit was completed. No communication logs were returned. Conclusions: Partnerships between elementary and nursing schools may be an effective strategy for delivery of health programs to high-risk children with chronic diseases. Self-assessment of symptoms and taking appropriate actions at school are critical components of early asthma intervention, particularly when a school nurse is not always available. Training teachers to follow a child's AAP within school policies is a critical second step. Home visits showed potential as a strategy for engaging parents. Practice implications: In the current climate of school nurse shortages, management of asthma-related episodes in school can be improved with similar partnerships and programs that promote health education and selfmanagement. © 2018 Published by Elsevier Inc.
Background Over 8% of children in the United States (US) under the age of 15 have a diagnosis of asthma (Centers for Disease Control and Prevention [CDC], 2016). Childhood asthma prevalence in Tennessee (TN) is 9.5% (Brantley, 2018). National asthma management guidelines recommend that every patient with asthma have an asthma action plan (AAP) provided by a clinician (National Heart, Lung, & Blood Institute [NHLBI], 2007a, 2007b). Asthma management guidelines specifically developed for schools outline the minimum standard for every child with asthma. To meet this standard, each child must have a written AAP, update it regularly, share it with all teachers and school staff that provide educational support to the child with asthma, and ensure access ⁎ Corresponding author. E-mail address: [email protected] (N. McClure).
https://doi.org/10.1016/j.pedn.2018.06.001 0882-5963/© 2018 Published by Elsevier Inc.
to assistance from trained personnel is provided (NHLBI, 2014). However, many schools do not comply with this recommendation. State and school district policies determine a school's mandate for having such a plan in place, as well as allocating resources to schools to care for children with asthma. Written AAPs serve as a guide to patients and families for symptom self-management. They include a description for when and how to adjust medications and when to seek emergency medical care (Edwards, 2013). A commonly used AAP model is the “traffic light” with green, yellow, and red zones. Each color zone corresponds to a symptom level (i.e., green = symptom free; yellow = asthma symptoms present; red = severe symptoms present) (NHLBI, 2007a, 2007b). The yellow zone indicates loss of asthma control and is a trigger for the use of quick relief medications to manage immediate symptoms in a setting outside of a medical care facility (Dinakar et al., 2014). If symptoms are unrelieved after a period of time in the yellow zone, parents are
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instructed to consult their healthcare provider to reduce the risk of further exacerbation requiring emergency (ED) care or hospitalization. If severe symptoms are present and unrelieved by quick relief medications, such as in the red zone, caretakers are instructed to seek ED/urgent care immediately (NHLBI, 2007a). School nurses have a key role in asthma management in this setting. They are responsible for coordinating all essential components of asthma management, such as ensuring each student has an AAP and a quick-relief inhaler, recognizing asthma symptoms, and implementing the AAP (American Lung Association [ALA], 2009). Most importantly, nurses are equipped with the assessment skills required to monitor a child's condition over time and provide asthma management education to school staff and teachers (ALA, 2009). School-based asthma education programs, particularly those that include teachers and parents, can improve health and asthma knowledge, self-efficacy and self-management (Coffman, Cabana, & Yelin, 2009; Findley et al., 2011). Significant challenges associated with such efforts include the part-time nature of many school nurses and multi-school responsibilities. At least 30% of public schools have a nurse who works part-time in one or more schools. Only 45% of schools have a nurse present throughout the entire school day every day (Robert Wood Johnson Foundation [RWJF], 2013). These time constraints are a significant barrier to a school nurse's ability to provide asthma education or perform routine asthma symptom assessments and challenge the school to provide effective support to the children with asthma. Health promotion and patient education interventions delivered through academic partnerships with schools of nursing and a partner organization may be a mutually beneficial solution to address this problem (Smith, Lutenbacher, & McClure, 2015). When the partner organization is a high need, low resource school with a gap in nursing coverage, nursing students are able to provide a needed service and potentially alleviate the healthcare delivery burden for the school (McClure, Lutenbacher, O'Kelley, & Dietrich, 2017). Such partnerships also provide a means for bridging the practice preparation gap in regard to nurses caring for vulnerable populations in the primary care setting (Kreulen, Bednarz, Wehrwein, & Davis, 2008). School aged children spend most of their wakeful time at school, however, schools may not have processes in place to notify healthcare providers or parents when a child has a yellow zone day or uses quick relief medication. If symptoms are unreported during this key time, opportunities to continue the AAP at home or arrange primary care appointments to manage asthma symptoms before they worsen are lost. This may result in a potentially avoidable school absence, ED visit or hospital admission. Measuring the frequency of asthma symptoms, such as wheezing or use of a quick relief medication, is recommended. Clinicians are able to use this data to evaluate how well asthma is controlled, determine the frequency for follow up care required to achieve good asthma control, or establish the need for referral to specialists (NHLBI, 2007a). Stepping up or down on recommended medications may be indicated based on symptom frequency (NHLBI, 2007b). Local Problem In the state of Tennessee, the current full-time school nurse to student ratio is 1:3000 (Tennessee Department of Education, 2017). In one large metropolitan school district in Tennessee, the staffing ratio and procedure-driven model of care require that the nurse's time be primarily used to perform skilled nursing procedures that may not be delegated, such as administration of tube feeding, according to the Tennessee Board of Nursing (TN BON) standards (TN BON, 2016). Tasks such as medication administration and supervision of medication self-administration may be delegated to trained school personnel (TN Dept. of Education and TN Dept. of Health, 2014). In this staffing model, nurses are often assigned to multiple schools in order to maintain compliance with state laws and school policies. The school in the
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pilot site for this project is responsible for multiple schools and is on site monthly and routinely available by phone to school staff and teachers. The local public school district uses parental report to identify diagnoses for chronic diseases, such as asthma, through routine collection of health history forms each academic year. Through this process, it was determined that approximately 5000 students districtwide reported a diagnosis of asthma. An audit of the pilot elementary school was conducted to determine the scope of the problem at the school level. This revealed that 60 students (18%) reported having a diagnosis of asthma. Of those, only 23 diagnoses had been confirmed by a healthcare provider and had an AAP in place that reflected the provider's orders for medications the child should use when experiencing asthma symptoms. Of all students identified, only 9 (15%) had access to a quick relief inhaler (albuterol) at school. No existing asthma resources were identified within the school. These findings supported the need for asthma resources at this particular school and underscored the significance of undertaking this project. School office staff are trained by the school nurse to identify asthma symptoms and to oversee medication administration, including asthma inhalers. School administrators indicated that staff could potentially implement three asthma interventions. These included administering asthma medication (albuterol) if available, contacting a parent if medication was unavailable, or if medication did not alleviate symptoms, contacting emergency medical personnel if the child was in distress. Children in no apparent distress, whose parents could not be reached, returned to class. Aim The primary aim of this project was to pilot test the implementation of Green Means Go (GMG), an asthma education, self-assessment, and self-reporting program developed by nursing students and faculty. The goals of the project were to: 1) increase the number of children who perform daily asthma symptom self-assessments and increase knowledge of appropriate symptom identification and initiation of a child's asthma action plan (AAP) among children, parents and teachers, 2) increase communication between parents and the school when a child was in the yellow zone and the AAP should be initiated and, 3) provide nursing students with a relevant community health clinical experience to learn about chronic disease management in the school setting. Methods This project was implemented in one elementary school within a large, urban public school district in Middle Tennessee with approximately 84,000 students enrolled. The pilot school reported enrollment of 349 pre-K through fourth grade students with an average daily enrollment of 318. The student body was comprised of 89.7% African American, 5% Hispanic and 2% white students. Almost all students (96.9%) were economically disadvantaged (Tennessee Department of Education, n.d.). Developing the Partnership and Planning the Intervention. The academic community partnership (ACP) emerged through an outreach effort by the school of nursing faculty member, who approached the school principal with a proposal to provide a schoolbased asthma management program. Key school system stakeholders were identified and included school staff in a supervisory capacity at the district level, principals, teachers, and support staff. High interest in a possible program emerged and a subsequent meeting at the proposed site school was organized. During the meeting, elementary school staff and the principal expressed multiple concerns related to students with asthma at their school. These included the large number of students with asthma, lack of resources for these children within the school, knowledge deficits of teachers and school staff about asthma symptom identification and management, limited school nurse
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availability, and a lack of a formalized, school-wide training for staff and teachers. Available training at the time was limited to one-on-one training sessions provided by the school nurse to individuals who volunteered to supervise medication administration when the nurse was not on site. Privacy concerns were identified at the initial meeting. It was determined that school health records could not be released to outside agencies or partners based on the district's interpretation of the Family Educational Rights and Privacy Act (FERPA) (U.S. Department of Education, 2014). Student self-identification directly to the project team through classroom visits was selected as a potential referral mechanism to the proposed program to avoid potential violations of FERPA, as well as to avoid the challenge of low parental response rates to school initiated communications cited by school administrators and staff. Health history forms were reviewed by the liaison and teachers, who made additional referrals to the program. The GMG program was proposed, and upon principal approval, points of contact for the ACP were identified to move the project forward. This included the school office staff, school-level support services liaison and the nursing faculty member. The school of nursing team included a group of 10 community health students in an accelerated MSN program supervised by one Pediatric Nurse Practitioner (PNP) faculty member. The GMG team consisted of the PNP faculty member and ten students, the support services liaison, school secretary, and the 12 teachers with children with asthma in their classrooms who participated.
Implementation A three-pronged approach with specific asthma education curricula developed for students, teachers, and parents was used. All program activities and education sessions were held at the school and conducted by the nursing students. At the request of the principal, education sessions for students were scheduled by the school support services liaison outside of core subject instructional time, such as during art, music, or physical education. Teachers expressed preference for their sessions to be held during planning time. Green Means Go program: student component. Pre-K through fourth grade children were given the opportunity to self-identify as having a diagnosis of asthma to the GMG project team. The team conducted a visit with each classroom in the school to provide a brief description of GMG prior to the first scheduled education session. At the end of the program overview, children who self-selected to join the program left with the project team for their first lesson. A total of 30 students were identified through this method who were not previously reported to the school via routine health history forms. Ultimately, 90 children in 19 different classrooms were identified to have asthma through the combined efforts of health history forms and selfidentification. Ninety students and 12 out of 19 classroom teachers chose to participate. Students were divided into 6 groups by grade level (i.e., pre-kindergarten through fourth grade). Participants in kindergarten through fourth grades attended an initial 30-minute group education session and three additional 20 min sessions over a four month period. Pre-K participants had two education sessions over the course of the program that focused on asthma symptoms. They did not participate in daily symptom recording because they are unable to read and respond to the daily symptom questions and record selfassessment results independently. Education sessions for kindergarten through fourth grade occurred in this order 1) asthma symptoms and color zones according to the AAP traffic light model, 2) process for performing and recording daily self-assessments, 3) action steps to take on symptom days, and 4) assessment of knowledge of the AAP zones and associated symptoms. During the second session children were provided with a color coded asthma action plan zone card. Each zone contained symptom questions intended to help the child select their appropriate zone.
Children in the red or yellow zones were taught to report symptoms to school staff or teachers and to report to the office to receive medication if prescribed and available. All students recorded their daily zone assessment data on a personalized chart, which was collected and reviewed weekly by the GMG team. School staff followed their usual policies and procedures for determining when to contact parents for school pickup or contact emergency response personnel when symptoms were present. Green Means Go program: teacher component. Sessions were provided in small teacher groups by grade level during their designated planning time. Teacher sessions included 1) overviews of the AAP and color zones, 2) symptoms associated with each of the three zones, 3) the importance of early symptom identification and, 4) the use of a symptom log (provided to each teacher) for communication with parents to ensure continuity of use of the AAP across the school and home settings. Teachers were asked to assist in reminding children to perform daily self-assessments. They were instructed to follow existing school procedures for referring children to the office for follow up care when children were not in the green zone. They were encouraged to notify families through the communication log of the presence of yellow zone symptoms on day one in the yellow zone and each consecutive day in the yellow zone when observed. The GMG team conducted weekly check-ins with teachers during their planning time to ensure ample opportunities to ask questions, express concerns or identify areas for improvement in the implementation process. Teachers and other school staff and administrators were offered the American Lung Association's Asthma 1-2-3 training to supplement the GMG information session. Asthma 1-2-3 (ALA, 2016) is a standardized program that teaches basic asthma knowledge to school, daycare and other community facility personnel to help prepare them to care for children with asthma. This curriculum was selected because the content is aligned with national guidelines for asthma management and provides a comprehensive overview for laypersons without healthcare training or experience. Green Means Go Program: parent component. Parents were offered an asthma education session that provided 1) an overview of the AAP symptoms, zones, and action steps for establishing and maintaining asthma control, 2) a communication plan for checking in and responding to the communication log from their child's teacher and 3) education about the importance of managing asthma triggers in the home. Parents were offered home visits conducted by the GMG team to assess for the presence of environmental triggers and for individualized education on trigger management strategies. Measures Improvement in child knowledge of symptoms, asthma triggers, AAP zones and actions steps in the children who participated were measures selected to evaluate the GMG student component of the project. Children were asked to teach back symptoms, asthma triggers and AAP zones and action steps to individual members of the GMG team following each session to assess comprehension. Children read selfassessment questions and responded with the GMG team member at each session in order to assess their ability to accurately self-assess and self-report symptoms in order to evaluate the effectiveness of the self-assessment process. Daily participation during school days was used to measure the frequency self-assessments were performed. School attendance data and number of albuterol administrations by school staff were selected to evaluate the effectiveness of the self-reporting component of the program leading to asthma interventions. The school administration, however, was unable to provide this data to the project team. Post-assessment of teacher knowledge was assessed using the Asthma 1-2-3 curriculum post-test to evaluate teacher knowledge of asthma symptoms. At the end of the project, teacher feedback on their experience with the program was elicited through a seven question
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electronic survey to measure their satisfaction with the program. Teachers were asked about barriers to implementation and for general program feedback, as well as what types of information they may need in order to feel prepared to care for children with asthma in their classrooms. Responses were collected as narrative comments. The project was reviewed by the university Institutional Review Board and determined to be a quality improvement, non-research project. No ethical issues emerged in the planning or implementation of the project. Results Elementary School Students Ninety elementary school students participated in all education sessions of the GMG program. Of those, 60 (66.6%) were identified by a parent through health history forms as having a diagnosis of asthma to the school, 23 (25.5%) of those had the diagnosis confirmed by a healthcare provider and an AAP in place and 9 (10%) had access to a quick relief inhaler (albuterol) at school. Of the children who participated in the sessions, 100% were able to correctly verbalize their asthma zone at the end of each education session. Overall, twelve classrooms (63%) with a child with asthma participated in daily asthma zone recording for a total of 48 students. Daily participation of the 12 classrooms ranged from 9% to 85%, with average daily participation at 31.87%. Teachers Of the 19 classrooms with a child with asthma, 12 teachers (80%) with children diagnosed with asthma in their classrooms participated in the small group education sessions led by nursing students. Seven of the 19 classrooms (36.84%) did not complete any daily selfassessments throughout the program. All 19 teachers with a child with asthma in their classroom were invited to participate in a survey at the conclusion of the program regardless of whether or not they participated in teacher education sessions. All teachers were surveyed because children in all classrooms were offered the opportunity to participate in the program and education sessions regardless of their teacher's participation in teacher education sessions. Fourteen teachers (74%) responded to the survey. Of the respondents, 10 (71%) felt well prepared to help children perform asthma self-assessments. Several teachers offered ideas to strengthen the program. They suggested starting the program earlier in the school year to help integrate the program into the daily classroom routine. A commonly identified barrier to effective classroom implementation was time constraints. Five (38%) of respondents indicated they would like more information on asthma emergencies and strategies to make their classrooms asthma-friendly. Parents Only one parent attended the education session. Communication logs were sent home each week by the GMG team for children who reported yellow zones in the classroom chart. No communication logs were returned to teachers. School staff contacted several parents of children with high frequency of yellow zone symptoms by phone to offer additional resources, including school meetings and/or home visits through an existing home visit program within the nursing school that seeks to reduce asthma triggers through evidence-based home environmental interventions (McClure, Lutenbacher, O'Kelley, & Dietrich, 2017). Two parents were reached by phone. One parent declined additional resources and one parent accepted and completed a home visit. The mother reported concerns for mold and was provided with education for remediation strategies and resource linkage to a local non-profit that assists with mold testing and removal.
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Discussion The ACP and school-based support for GMG were integral to the successful pilot implementation of this program. All children who participated in the project were able to self-assess and choose the correct corresponding asthma zone by the end of the program. However, daily assessments were not consistently recorded by all children who participated. Lack of teacher engagement may have potentially contributed to lower student participation than anticipated. Whether or not the program was successfully implemented in a classroom (i.e., corresponding high student participation) may depend on the level of teacher involvement, which indicates teacher engagement is a critical component to focus on in future efforts. This program provided a method of recording the frequency of a child's asthma symptoms during the school day, which was thought to be a potential method of improving access to school based asthma resources. Nurses may perform this function in other settings where they are routinely available. They may also share this information with parents and healthcare providers. Communication logs sent home to parents were not returned to the school, so it is unclear if parents received them and if they did, whether they shared this information with their child's healthcare provider. This highlights the gaps in communication between schools, parents, and healthcare providers in this school district and at the pilot site identified by this program. Only one parent accepted the offer of a home visit. Although home visits may be an effective approach for teaching parents about asthma, increased participation is needed to fully evaluate their impact on the GMG program outcomes. In addition to providing the GMG curriculum content, home visits can provide the opportunity to assess the home for the presence of potential asthma triggers and discuss evidence based prevention strategies for reducing allergen exposure with the family, such as the use of pillow encasements, HEPA filters, frequent vacuuming, cockroach treatment and smoking cessation (NHLBI, 2007b).
Limitations The most significant limitation of the pilot program was that participants were asked to self-identify. Without confirmation of a child's diagnosis, students without asthma may have participated in the program and others with a diagnosis may have elected not to participate in the program. Because of the large number of students identified, a much higher number of children participated than anticipated for program development purposes, which yielded larger group sizes. We recommend that programs may want to consider school-based asthma screenings as a means to identify participants. With regard to evaluation, a more robust evaluation plan to assess the impact of the program on school attendance, truancy, and ED visits and hospitalizations related to asthma would provide valuable information about program outcomes. This data will be included in the next phase of the project. A cost analysis is also important to consider the financial impact of asthma-related school absences to the schools and the level of cost savings of partnerships and programs such as ours to the school district related to school absenteeism. The use of a standardized approach to evaluating pre and post program knowledge is preferable for both children and teachers. The Asthma 1-2-3 curriculum does not include a pre-test. Therefore, only post-participation knowledge assessment was evaluated. Although most teachers participated in the program, the average daily classroom participation in recording a child's self-assessed asthma zone was less than 40%. Even with this low rate, nearly 800 daily selfassessments were recorded. Beginning the program at the start of the academic year increases the likelihood of it being a part of the daily classroom routine from the outset. This may improve participation rates. Given the nature of this project, it is not possible to conclude
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with certainty that the observed outcomes are the result of this intervention but our results are very promising for future similar efforts. Pilot school staff reported that parent engagement is an ongoing challenge for the school. Multiple communication logs sent to parents went unreturned. School staff who were familiar with the neighborhood reported the best method of contacting parents was via phone or an in-person visit. This was a challenge because outside partners do not have access to parent information and could not easily establish contact with parents. The school liaison was able to assist; however, many attempts were unsuccessful due to non-working or inaccurate phone numbers. Practice Implications There are a number of considerations for practicing school or clinic nurses looking to replicate this program or initiate a similar partnership. First, it is imperative to conduct a thorough exploration of their organization's policies and procedures related to any requirements to establish an academic-community partnership, particularly in a school, including the development of a formal legal contract. School system requirements, such as fingerprinting or background checks, must also be considered and included when developing a timeline. Identifying and recruiting both faculty and school partner champions are key to successful program development and implementation. Faculty are increasingly more interested in creating clinical learning environments that offer real world experiences, however, poor alignment of goals and scheduling barriers can impede collaborations. Once a fit is established for nursing student learning objectives and health program outcomes, providing potential collaborators with a time frame for engagement that is as flexible as possible is critical. Another important planning component is sharing available baseline data to all partners. This can aid partners in understanding the current needs and assist with identifying evaluation metrics. Lastly, it is crucial to identify, very early in the process, times during the school schedule when the children and teachers are available to participate. This can alleviate frustrating schedule misalignments. Conclusion Management of asthma in schools continues to be a significant issue nationwide. There were many successful aspects of our project that support the feasibility of implementing GMG through an academic community partnership such as ours. Outcomes of the pilot highlight the possibility and importance of school-aged children learning to selfassess their asthma symptoms and taking appropriate steps to report symptoms to teachers or other staff. This is particularly significant in schools like the pilot school, where a nurse is not routinely available and where there are no existing asthma management programs in place. Programs that help students, teachers and parents to better understand asthma may increase safety and provide important opportunities for nursing students to gain insights into barriers in school health that impact health seeking and health care utilization behaviors, as well as develop meaningful projects that build their community health
nursing skill sets. Additionally, although there were challenges, the overall success of this project is an encouraging first step in demonstrating potential for evolving partnership models to provide schools with much-needed health resources to fill gaps in nurse services. References American Lung Association (2009). A national asthma public policy agenda. Retrieved from http://www.lung.org/assets/documents/asthma/National-Asthma-PublicPolicy-Agenda-January-2009.pdf. American Lung Association (2016). Education and training: Asthma 1-2-3. Retrieved from http://www.lung.org/local-content/_content-items/our-initiatives/educationand-training/asthma-1-2-3.html. Brantley, A. (2018). BlueCross, BlueShield of Tennessee health brief: Asthma & allergies; a state of the state. Retrieved from https://bettertennessee.com/health-brief-asthmaallergies/. Centers for Disease Control and Prevention (2016). National health interview survey: Early release of selected estimates based on data from the 2016 national health interview survey. Retrieved from https://www.cdc.gov/nchs/data/nhis/earlyrelease/ Earlyrelease201705_15.pdf. Coffman, J., Cabana, M., & Yelin, E. (2009). Do school-based asthma education programs improve self-management and health outcomes? Pediatrics, 124(2). https://doi.org/ 10.1542/peds.2008-2085. Dinakar, C., Oppenheimer, J., Portnoy, J., Bacharier, L. B., Li, J., Kercsmar, C. M., ... Nicklas, R. (2014). Management of acute loss of asthma control in the yellow zone: A practice parameter. Annals of Allergy, Asthma & Immunology, 113(2), 143–159. Edwards, A. L. (2013). Asthma action plans and self-management: Beyond the traffic light. Nursing Clinics of North America, 48(1), 47–51. Findley, S. E., Thomas, G., Madera-Reese, R., McLeod, N., Kintala, S., Martinez, A., & Herman, E. (2011). A community-based strategy for improving asthma and outcomes for preschoolers. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 88(1), 85–99. https://doi.org/10.1007/s11524-010-9479-8. Kreulen, G., Bednarz, P., Wehrwein, T., & Davis, J. (2008). Clinical education partnership: A model for school district and college of nursing collaboration. The Journal of School Nursing, 24(6), 360–369. McClure, N., Lutenbacher, M., O'Kelley, E., & Dietrich, M. (2017). Enhancing pediatric asthma care and chronic disease education through an academic practice partnership. Journal of Pediatric Nursing, 36, 64–69. National Heart, Lung, and Blood Institute (2007a). Asthma action plan. Retrieved from https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf. National Heart, Lung, and Blood Institute (2007b). National asthma education and prevention program expert panel report 3: Guidelines for the diagnosis and management of asthma. Retrieved from http://www.nhlbi.nih.gov/health-pro/guidelines/ current/asthma-guidelines/full-report. National Heart, Lung, and Blood Institute (2014). Managing asthma: A guide for schools. Retrieved from https://www.nhlbi.nih.gov/files/docs/resources/lung/NACI_ ManagingAsthma-508%20FINAL.pdf. Robert Wood Johnson Foundation (2013). School nurse shortage may imperil some children, RWJF scholars warn. Retrieved from http://www.rwjf.org/en/library/articlesand-news/2013/12/School-Nurse-Shortage-May-Imperil-Some-Children.html. Smith, K. M., Lutenbacher, M., & McClure, N. (2015). Leveraging resources to improve clinical outcomes and teach transitional care through development of academic-clinical partnerships. Nurse Educator, 40(6), 303–307. Tennessee Board of Nursing (2016). Tennessee board of nursing position statements. Retrieved from https://tn.gov/assets/entities/health/attachments/Position_Statement_ Booklet.pdf. Tennessee Department of Education (2017). School Health Laws. Retreived from https:// www.tn.gov/content/dam/tn/education/csh/csh_school_health_laws_2017.pdf. Tennessee Department of Education. (n.d.). State report card. Retrieved from https:// www.tn.gov/education/topic/report-card Tennessee Department of Education and Tennessee Department of Health (2014). Guidelines for use of health care professionals and health care procedures in a school setting. Retrieved from https://www.tn.gov/assets/entities/health/attachments/csh_ guidelines_healthcare_prof_proc.pdf. U.S. Department of Education (2014). Family Educational Rights and Privacy Act (FERPA). Retrieved from http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html.