Original Research Report
Barriers to Asthma Management as
Identified by School Nurses
The Journal of School Nursing
2016, Vol. 32(5) 365-373
ª The Author(s) 2016
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DOI: 10.1177/1059840516641189
jsn.sagepub.com
Judith E. Quaranta, PhD, RN, CPN, AE-C1,
and Gale A. Spencer, PhD, RN1
Abstract
Asthma rates are increasing in children. School nurses have opportunities to care for children with asthma but need to
overcome barriers impacting their ability to manage asthma in the school setting. This study (a) assessed barriers present in
the school setting, (b) determined the impact of barriers on performance of asthma management behaviors, and (c) determined the impact of barriers on importance ratings of asthma management behaviors, asthma self-efficacy, and asthma attitudes (N ¼ 537). Results revealed 72% of the nurses reported at least one barrier. As numbers of barriers increased,
performance of asthma management behaviors decreased. Significant relationships were found between specific asthma
management behaviors and specific barriers. No significant relationships were found between barriers and asthma self-efficacy,
asthma attitude, or importance ratings of asthma management behaviors. Removing barriers may allow the nurse to perform
at greatest effectiveness, enhancing the positive outcomes that result from appropriate asthma management.
Keywords
asthma, quantitative research, barriers, school nurse, asthma management
Asthma disproportionately impacts the school age children.
In 2013, over 8% of children in the 5- to 14-year age-group
experienced asthma; this is the highest percentage of any
age-group. During this same year, among children less than
18 years, 57.9% experienced one or more asthma attacks
(Centers for Disease Control and Prevention, 2015). Hospitalization rates for this age-group were 18.3 per 10,000 in
2012 as compared to the adult rate of 13 per 10,000 (Bloom,
Jones, & Freeman, 2013). An especially troubling aspect is
that asthma rates are increasing over time. In 2010, 8.4% of
the population had asthma compared to 7% in 2001 (Akinbami et al., 2012; American Academy of Allergy, Asthma &
Immunology [AAAAI], 2015b).
It is unclear why asthma rates are increasing. Some
research supports the hygiene theory, suggesting that living
conditions might be too clean, reducing exposure to germs,
impacting the body’s immune systems to react appropriately. Other research suggests that the rising prevalence may
be due to a variety of other factors. Increased antibiotic use
parallels the upsurge of asthma. Early antibiotic use may
change bacterial flora, impacting the development of allergic diseases. Other studies associate the increased use of
acetaminophen with the development of asthma. Increased
obesity has also been implicated as a contributing factor for
the increase in asthma prevalence. Vitamin D deficiency,
resulting from increased time spent indoors, is also being
investigated as a contributing factor (AAAAI, 2015a).
Regardless of the cause, it is imperative to manage this
disease to prevent poor outcomes.
The need for asthma interventions is reinforced through
several national initiatives. Healthy People 2020 provided
the national health objectives for improving health of
Americans; it also provides goals for preventing disease and
disability and improving health (U.S. Department of Health
and Human Services, 2015). Many of the objectives are
focused on asthma and underscore attainable outcomes for
school nurses. School nurses are in optimal positions to
provide asthma education, including instruction on inhaler
use, managing asthma, recognizing early warning signs, and
increasing awareness of asthma triggers (Objective Respiratory Disease [RD]-6, Objective RD-7.2, Objective RD-7.3,
and Objective RD-7.5, respectively). Achieving these objectives would result in attainment of Objective RD-2.2: reducing hospitalizations for asthma among children; Objective
RD-3.1: decreasing emergency department visits for asthma
among children; and Objective RD-5.1 decreasing missed
school days for children aged 5–17 with asthma.
1
Decker School of Nursing, Binghamton University, Binghamton, NY, USA
Corresponding Author:
Judith E. Quaranta, PhD, RN, CPN, AE-C, Decker School of Nursing,
Binghamton University, PO Box 6000, Binghamton, NY 13902, USA.
Email: jquarant@binghamton.edu
366
Since children in the United States attend school between
160 and 180 days per year (Education Commission of the
States, 2011), school nurses have greatest access and opportunity to care for the child with asthma, thus potentially
impacting asthma outcomes. However, for achievement of
these outcomes to become reality, school nurses must be
unfettered in their ability to perform the necessary behaviors
required for asthma management. Barriers that exist within
the school setting must be assessed to determine the extent to
which they impede the school nurse from carrying out those
behaviors necessary to adequately work with the child with
asthma.
Theoretical Framework
Because of the central concern for barriers, the health belief
model was chosen to gain an understanding of barriers
school nurses experience when performing asthma management behaviors. According to the health belief model, an
individual is likely to take health action if they believe that
action will reduce health risk, that they are susceptible to a
health issue, and that the health issue could have serious
consequences. The belief that a course of action is available
and that it would be beneficial in reducing either susceptibility or severity must be present. However, barriers may
preclude the individual from carrying out those behaviors
deemed beneficial (Champion & Skinner, 2008). Application of this model focused on the provision of care by a
health provider rather than on the individual taking a health
action. Quaranta and Spencer (2015) previously applied the
constructs of the model to asthma management by school
nurses. This study extends the understanding of this issue by
focusing on the impact of barriers on school nurse performance of asthma management behaviors. In addition, this
study assessed the role of barriers in asthma self-efficacy,
asthma attitude, and importance ratings of the asthma management behaviors.
Purpose
The purposes of this study were to (a) assess barriers present
in the school setting that impact school nurse asthma management, (b) determine the impact these barriers have on
actual performance of asthma management behaviors in the
school setting, (c) determine the impact these barriers have
on school nurse importance ratings of asthma management
behaviors, (d) determine the impact these barriers have on
school nurse asthma self-efficacy, and (e) determine the
impact these barriers have on school nurse asthma attitudes.
Literature Review
The role of the school nurse in asthma management has been
delineated. The National Association of School Nurses
(NASN, 2011) issued a position statement identifying health
The Journal of School Nursing 32(5)
care for chronic illnesses as a major focus of the role of the
school nurse. This role would include care of the student
with asthma. The school nurse is responsible for providing
health care to students, medication administration, healthcare procedures, and development of health-care plans. Case
management, referrals to primary care providers, collaboration with others to build student and family capacity for
self-management and learning, and providing healthrelated education to students and staff are included in the
role of the school nurse.
Barriers
Barriers confronting school nurses in performing asthma
management behaviors have been identified by many
researchers. The most frequently reported barriers were lack
of communication with parents, lack of supplies including
medications, and issues with the student with asthma. Student issues included the student not being aware of their
asthma symptoms, having poor asthma control, and not
knowing how to use their medications. The next most frequently reported barrier was a lack of teacher knowledge
about asthma and a lack of communication with healthcare providers. Lack of time, lack of asthma action plans,
and a lack of education programs for students, parents,
teachers, staff, and school nurses themselves were the next
most frequently identified barriers. Lack of support, lack of
involvement, and lack of knowledge of asthma policies by
administrators were also identified as barriers to asthma
management by the school nurse. Lack of funding was the
least cited barrier in the literature review (Anderson et al.,
2005; Ayala et al., 2006; Bartholomew et al., 2006; Borgmeyer, Jamerson, Gyr, Westhus, & Glynn, 2005; Dozier,
Aligne, & Schlabach, 2006; Engelke, Guttu, Warren, &
Swanson, 2008; Erickson, Splett, Mullet, Jensen, & Belseth, 2006; Forbis, Rammel, Huffman, & Taylor, 2006;
Gregory, 2000; Hillemeier, Gusic, & Bai, 2006; Kielb, Lin,
& Hwang, 2007; Liberatos et al., 2013; Neuharth-Prichett
& Getch, 2001; Price et al., 2002; Rodehurst, 2003; Snow,
Larkin, Kimball, Iheagwara, & Ozuah, 2005; Svavarsdottir
et al., 2013; Taylor-Fishwick et al., 2004; Winkelstein
et al., 2006).
A report from the Centers for Disease Control and Prevention on secondary schools substantiates that school
nurses continue to be confronted by barriers with subsequent
potential impact on performing asthma management behaviors (Demissie et al., 2013). Schools reporting access to
supplies and equipment ranged from 50% to 95.2%. The
percentage of schools with asthma action plans on file for
all students with known asthma ranged from 30.8 to 85.5.
School staff members’ requirement to receive training at
least once per year on recognizing and responding to severe
asthma symptoms ranged from 6.9% to 69.4% of schools.
The percentage of lead health education teachers receiving
professional development on asthma ranged from 4.8 to 48.
Quaranta and Spencer
However, schools where the lead health teacher wanted to
receive this training ranged from 37.9% to 70.3%. Providing
health information to increase parent and family knowledge
occurred in 16% of the schools. The percentage of schools
that provided referral to primary health-care providers for
students with poorly controlled asthma ranged from 30.2 to
85.8. Offering asthma education for students with asthma
ranged from 23.5% to 86%.
367
Research Questions
To understand the impact barriers place on school nurses’
performance of asthma management behaviors, the following research questions were asked for this study:
1.
2.
Asthma Self-Efficacy
School nurses who lacked confidence in their teaching ability declined conducting asthma education. Providing asthma
education to school nurses was successful in increasing selfefficacy among school nurses (Winkelstein et al., 2006).
Wisnivesky et al. (2008) found a positive relationship
between performance of asthma management behaviors and
self-efficacy among health-care providers.
Asthma Attitude
School nurses believe that asthma is more disruptive of the
school routine than other chronic diseases, which impacts
the student’s ability to participate in all-day school activities
including gym, recess, and keeping up with their peers (ORC
Macro, 2003). Increased education of school nurses was
found to improve asthma management and lead to better
student outcomes (Erickson et al., 2006; Gerald et al.,
2006). Buford (2005) found that parents wanted a provider
who was knowledgeable about asthma and who communicated directly with their child. Children with asthma wanted
more help from doctors and nurses managing their asthma.
Performance of Asthma Management Behaviors
Students who were taught asthma management by school
nurses had better outcomes (Berg, Tichacek, & Theodorakis,
2004; Levy, Heffner, Stewart, & Beeman, 2006; McWhirter,
McCann, Coleman, Calvert, & Warner, 2008; Taras, Wright,
Brennan, Campana, & Lofgren, 2004; Yang, Chen, Chiang,
& Chang, 2005). Engelke, Guttu, Warren, and Swanson
(2008) found significant improvement in quality of life and
asthma management for the student with asthma when
school nurses provided asthma case management. Gau, Horner, Chang, and Chen (2002) found that years of service
correlated with school management behaviors.
In summary, barriers to effective asthma management by
the school nurse were numerous. While several studies have
identified barriers to asthma management by school nurses,
no studies were found that identified the association of these
barriers with actual performance of asthma management
behaviors. The present study examined barriers to asthma
management and their impact on actual performance of
asthma management behaviors by the school nurse, asthma
self-efficacy, asthma attitude, and the ratings of importance
of asthma management behaviors.
3.
4.
Is there a relationship between barriers present in the
school setting and school nurse performance of
asthma management behaviors?
Is there a relationship between barriers present in the
school setting and school nurse asthma self-efficacy?
Is there a relationship between barriers present in the
school setting and school nurse asthma attitude?
Is there a relationship between barriers present in the
school setting and school nurse importance ratings of
asthma management behavior?
Method
Research Design
A descriptive–correlational design was used to investigate
the relationships of interest in this study. The study was
approved by the Binghamton University Human Subjects
Research Review Committee. Completion of the questionnaires constituted consent as explained in the invitation to
participate in the study.
Sampling Procedures
Inclusion criterion was school nurses should be members of
the NASN. The NASN provided a randomized list of 1,000
school nurses’ e-mail addresses. Computerized double randomization was conducted: A randomized list was created
from the membership; then, every third name was used.
These school nurses received an e-mail invitation to participate in the study; in addition, a link to the study was placed
on the NASN website. The last study question asked the
participant to indicate whether they joined in the study by
e-mail invitation or link. No participant indicated both; thus,
the researchers ruled out duplicate participants. The e-mail
invitation resulted in 291 responses, while the link resulted
in 246 responses for an overall 53.6% response rate.
Questionnaires
Development of the questionnaires used in this study was
previously discussed by Quaranta and Spencer (2015). Items
from existing asthma tools were modified with permission to
reflect the distinct needs of school nurses, to incorporate
asthma guidelines as recommended by the Expert Panel
Report 3, and to address issues identified in the literature
impacting asthma management of school nurses. Asthma
self-efficacy was based on Chiang, Hsu, Liang, Yeh, and
Huang (2009), Gau et al. (2002), Mesters, Meertens, Crebolder, and Parcel (1998), and Wigal et al. (1993) with
Cronbach’s as of .94, .92, .93, and .92 respectively. Asthma
368
attitude was based on Wigal et al. (1993) with a Cronbach’s
a of .92. Performance of Asthma Management Behaviors
Questionnaire and Asthma Management Behavior Rating
Questionnaire were original to this study but were of obesity
treatment and weight management tactics.
The Asthma Attitude Questionnaire consisted of 14 items
(Cronbach’s a ¼ .75). Response choices were 1 ¼ strongly
disagree, 2 ¼ disagree, 3 ¼ agree, and 4 ¼ strongly agree.
Scores were summed for this analysis. Higher scores indicate positive asthma attitude, equating to higher perceived
susceptibility and severity to asthma issues for the student
with asthma. The Asthma Self-Efficacy Questionnaire consisted of 19 items (Cronbach’s a ¼ .85). Response choices
were 1 ¼ mostly false, 2 ¼ false, 3 ¼ mostly true, and 4 ¼
true. Scores were summed for this analysis. Higher scores
indicate higher self-efficacy. Performance of Asthma Management Behaviors Questionnaire and Asthma Management Behavior Rating Questionnaire consisted of the
same 11 items (Cronbach’s a ¼ .83 and .61, respectively).
Response choices for Performance of Asthma Management
Behaviors were 1 ¼ does not perform the behavior and 2 ¼
performs the behavior at least 90% of the time for performance. Asthma Management Behavior Rating choices
were 1 ¼ not important, 2 ¼ important, and 3 ¼ very
important for the ratings. Greater importance ratings
equate to higher perceived susceptibility and severity. The
Barriers Questionnaire listed 12 barriers to asthma management from which school nurses could choose as well as an
option to indicate no barriers to asthma management or
barriers not listed. Respondents indicated 1 ¼ not a barrier
to asthma management and 2 ¼ is a barrier to asthma
management.
Content validity for the new tools was conducted. A
pediatric asthma and allergy specialist, a certified asthma
educator, two school nurse teachers, and one family nurse
practitioner reviewed each questionnaire. Each item was
rated on a 4-point Likert-type scale, with 1 ¼ not relevant,
2 ¼ unable to assess relevance without item revision or item
is in such need of revision that it would no longer be relevant, 3 ¼ relevant but needs minor alteration, 4 ¼ very
relevant and succinct. Ratings from the five reviewers were
added together for each item. Items receiving a score less
than 15 were excluded. The questionnaires were then pilot
tested with 11 school nurses from the local area with no
comments or suggestions for revisions given. The school
nurses indicated the questions addressed issues of asthma
management in the school setting.
Questionnaires were accessed through SurveyMonkey.
To ensure homogeneity of the responses from the e-mail
invitation and the link, t-tests for independent samples were
conducted. No statistically significant differences were
found for asthma attitude, t(462) ¼ .518, p ¼ .605; asthma
self-efficacy, t(432) ¼ 1.235, p ¼ .218; importance rating
of asthma management behaviors, t(450) ¼ 1.172, p ¼
.242; or performance of asthma management behaviors,
The Journal of School Nursing 32(5)
Table 1. Age and Educational Distribution of School Nurses.
Percentage
Frequency of Responses
Age
20–30 years
31–40 years
41–50 years
51–60 years
61þ years
Total
Educational level
Diploma
Associate degree
Bachelor of Arts/Bachelor of
Science (BS) other than nursing
BS in nursing
Master’s degree other than nursing
Graduate degree in nursing
Total
8
23
90
230
66
417
1.9
5.5
21.6
55.2
15.8
100
27
34
19
6.2
7.8
4.4
198
61
96
435
45.5
14
22.1
100
t(444) ¼ 1.332, p ¼ .183; indicating both groups were comparable. Thus, all participants were included in the analysis.
Data Analysis
Data analysis was conducted using IBM SPSS Statistics
Version 22 with a priori significance level of .05. Descriptive statistics described the sample characteristics. Frequencies and percentages were calculated for nominal and
ordinal data. Means were calculated for interval data. Pearson correlation was used to determine the relationship of the
number of asthma management barriers on asthma attitude,
asthma self-efficacy, importance ratings of asthma management behaviors, and the performance of asthma management behaviors. w2 was used to determine the relationship
between performance of asthma management behaviors and
barriers to asthma management.
Results
Participant and School Characteristics
Sample size was 537 school nurses. More than 99% were
female with four participants indicating male gender. Ages
ranged between 23 and 71 years (M ¼ 53.08, SD ¼ 8.219).
Most nurses were educated at the baccalaureate level (see
Table 1). Years in nursing ranged between 1 and 50 years
(M ¼ 26.56, SD ¼ 10.772). Years in school nursing ranged
between 1 and 37 years (M ¼ 13.30, SD ¼ 7.562). Reported
role indicated that 94% were school nurses, 4% were school
nurse teachers, and 1% were school nurse practitioners, while
30% were certified school nurses. Ninety percent of the
school nurses worked full-time and 10% worked part-time.
School nurses were responsible for a range of 1–5 schools
(M ¼ 1.71, SD ¼ 1.242). Sixty-eight percent of those nurses
worked in one school, 14% worked in two schools, 6%
Quaranta and Spencer
worked in three schools, 4% worked in four schools, and 8%
worked in five schools. Eighty-six percent of the school
nurses worked in public schools, with the remainder working
in private, parochial, and charter schools. Twenty-three percent of the school nurses were responsible for students in
prekindergarten to 12th grade, 39% were responsible for
elementary students, 12% were responsible for middle
school students, 11% were responsible for elementary and
middle school students, 8% were responsible for high school
students, and 8% were responsible for middle and high
school students. Number of students per school ranged from
32 to 5,600 (M ¼ 680, SD ¼ 532) in the school of primary
responsibility for each nurse.
Number of children diagnosed with asthma ranged
between 1 and 75 for each school (M ¼ 14.22, SD ¼
11.446), equating to an average of 14% children with asthma
at each school. Asthma action plans were on file for 33% of
students with asthma. About 85% of the school nurses
reported that students with asthma were able to self-carry
and self-administer their asthma inhalers, 73% had nebulizers available for use, and 72% had written asthma emergency plans in their schools. Seventy-six percent of school
nurses learned that a student had an asthma diagnosis from
parents/caregivers, while 36% gathered information from
school records, 23% gained information from health-care
providers, 12% assessed student symptoms, and 11% gained
information from student report.
Barriers to asthma management were identified. Eight
percent of school nurses reported no barriers to asthma management. Seventy-two percent of the nurses reported one or
more barriers to asthma management, 62% reported two or
more barriers, 46% reported three or more barriers, 28%
reported four or more barriers, 15% reported five or more
barriers, and 7% reported six or more barriers. The most
frequently reported barrier was lack of communication from
parents (55%). Lack of communication from health-care
providers was reported by 37%, while lack of time and lack
of equipment for asthma management were reported by 30%
each (see Table 2).
A Pearson correlation was computed to assess the relationship between the total number of barriers reported by
school nurses and (a) asthma management behaviors performed by the school, (b) asthma self-efficacy, (c) asthma
attitude, and (d) ratings of importance of asthma management behaviors. Questionnaire responses were summed for
this analysis. A negative correlation was found between the
number of barriers and performance of asthma management
behaviors (r ¼ .088, N ¼ 537, p ¼ .041). As the number of
asthma barriers increased, performance of asthma management behaviors decreased. No correlation was found for
asthma self-efficacy, asthma attitude, or ratings of importance of asthma management behaviors (see Table 3).
w2 for independence was performed to examine the relationship between performance of specific asthma management behaviors and barriers to asthma management. The
369
Table 2. Frequency of Reported Barriers to Asthma Management.
Barrier
% Yes % No
Lack of communication with parents
Lack of communication with health-care providers
Lack of time
Lack of equipment for asthma management
Lack of asthma action plans
Lack of funding for supplies
Lack of programs to teach students about asthma
management
Lack of knowledgeable faculty/staff
Lack of opportunity to attend continuing education
Lack of administrative support
Lack of communication with faculty/staff
Lack of school policies for asthma management
54.5
36.5
29.8
29.8
26.3
12.8
12.5
45.5
63.5
70.2
70.2
73.7
87.2
87.5
10.1
10.2
7.3
6.0
6.0
89.9
89.8
92.7
94.0
94.0
Table 3. Pearson Correlations for Barriers and Performance of
Asthma Management Behaviors, Importance Rating, Asthma SelfEfficacy, and Attitude.
Variable
Performance
SelfEfficacy
Attitude
Importance
Rating
.088*
.034
.025
.019
Total
barriers
*Correlation is significant at p < .05 (two tailed).
relationships between the following variables were significant: (1) assessing the student’s level of asthma control and
funding; (2) assessing the student’s awareness of asthma
triggers and lack of equipment and school policies; (3)
obtaining peak flow measurements and lack of knowledgeable faculty and staff; (4) providing asthma education to
students and lack of communication from faculty and staff,
knowledgeable faculty and staff, time, and administrative
support; (5) providing asthma education to parents/caregivers of students with asthma and lack of asthma action
plans and funding; (6) providing asthma education to faculty
and staff and lack of available programs; (7) assessing the
inhaler technique of the student with asthma and lack of
funding; (8) contacting the health-care provider for initiating
or updating the asthma action plan and lack of school policies and funding; and (9) referring the student to the primary
care provider when the student’s asthma is not in control and
there is lack of funding. School nurses were less likely to
perform these behaviors when confronted with the identified
barriers. Barriers were not found to impact the school
nurse’s ability to maintain an asthma action plan or track
school days missed due to asthma (see Table 4).
Discussion
This study demonstrated that school nurses are confronted
by barriers that interfere with performance of asthma management behaviors. Barriers, however, did not diminish the
370
The Journal of School Nursing 32(5)
Table 4. w2 for Relationship Between Asthma Management
Behaviors and Barriers.
Asthma Management Behaviors Barrier
Assessing student’s level of
asthma control
Assessing the student’s
awareness of asthma triggers
Obtaining peak flow
measurements
Providing asthma education to
students with asthma
Providing asthma education to
parents/caregivers of
students with asthma
w2a
p
Lack of funding for 6.539 .011
supplies for
supplies
Lack of equipment 5.143 .020
School policies
10.446 .001
Lack of knowledge 3.835 .050
faculty and staff
5.215 .022
Lack of
communication
from faculty/staff
Lack of knowledge 10.250 .001
faculty and staff
Lack of time
4.430 .035
7.060 .008
Lack of
administrative
support
Lack of asthma
5.099 .024
action plans
Lack of funding for 8.261 .004
supplies
Lack of available
5.222 .022
programs
Lack of funding for 4.754 .029
supplies
School policies
5.816 .016
Lack of funding for 10.216 .001
supplies
Providing asthma education to
school faculty/staff
Assessing the inhaler technique
of the student with asthma
Contacting the health-care
provider for initiating or
updating the asthma action
plan
Lack of funding for
Referring the student to the
supplies
primary health-care provider
when the students’ asthma is
not in control
6.839 .009
a
Degrees of freedom ¼ 1.
school nurse’s perception of how important these behaviors
were to perform or decrease their self-efficacy in performing
these behaviors or their attitude about asthma being an
important entity to control. As the results indicated, a negative correlation was found between the number of barriers
and performance of asthma management behaviors. As the
number of asthma barriers increased, performance of asthma
management behaviors decreased. No correlation was found
for asthma self-efficacy, asthma attitude, or ratings of
importance of asthma management behaviors. Thus, removing these barriers may allow the nurse to perform at the
highest practice level, enhancing the positive outcomes that
result from appropriate asthma management.
An interesting finding was the lack of relationship
between the frequency of reporting a barrier and its actual
impact on performing asthma management behaviors.
Despite communication with parents and communication
with health-care providers being the most frequently
reported barriers, these were not associated with the school
nurse performance of any asthma management behaviors. A
lack of funding presented as a barrier to most asthma management behaviors, yet this was reported by only 12.8% of
the school nurses. This might be attributed to insufficient
funds to pay for staff to cover the health office to free the
school nurse to engage in these behaviors. Lack of time was
attributed as a barrier to only one asthma management behavior, yet this was reported by one third of the nurses participating in the study. Lack of school policies was the least
reported barrier but impeded two management behaviors.
Despite barriers, most nurses are competent as assessed
by importance ratings, self-efficacy, and attitude. These
results highlight the need to address barriers confronting
school nurses. While these barriers have demonstrated their
impact on asthma management, these same barriers have the
potential to impact school nurse management for the multitude of other chronic diseases and issues impacting students
in the school setting. These results accentuate the need for
adequate funding and policies to guide and facilitate behavior. School nurses should not be impeded by avoidable
barriers.
Limitations
Participation was limited to school nurses who were members of the NASN. Thus, they may not be representative of
all school nurses. Data were self-reported. Lastly, the study
was limited to school nurses with computer access.
Implications for Nursing Practice
New national initiatives are underway that pose potential
opportunities as well as challenges to school nurses. While
the Affordable Care Act increases access to health care,
newly insured individuals need to be educated in how to
best use this new asset. Managing the student with asthma
in the school setting is greatly impacted by these new programs, with presenting either new barriers or opportunities
to manage asthma in the school setting.
Full implementation of the Affordable Care Act may
serve to reduce some of the barriers confronting school nursing. Section 2703 authorizes creation of health homes for
individuals with chronic conditions (American Nurses Association, 2014; Medicaid.gov, 2012). Health homes are
designed to provide comprehensive care management, care
coordination, and chronic disease management. The school
nurse should be a member of the health team, allowing for
seamless collaboration between health care and schools.
With more enhanced care for the individual with chronic
disease, students with asthma have the opportunity to
receive better management education in their health home,
reducing the burden on the school nurse to address this issue.
Students should have better asthma control and fewer health
issues if the tenets of health homes are realized.
However, increased access to health care may result in
additional diagnosed asthma cases in the school setting,
Quaranta and Spencer
increasing the number of students needing attention from
school nurses. School nurses need additional supplies, as
well as time, to address the issues of newly diagnosed students with asthma. As time and funding were associated with
a decrease in the performance of asthma management behaviors, emphasis needs to be placed on alleviating these
barriers.
School nurses can play an integral role in assisting
students with asthma and their parents in accessing the
health-care system. Health-care consumers may need resocialization in seeking medical care from a primary healthcare provider to avoid unnecessary, overuse of emergency
rooms. Since the induction of the Affordable Care Act, with
increased access to insurance through expanded Medicaid
and health exchanges, 28% of all emergency room visits
have reported increased visits, with severity increasing in
44% of visits or staying the same in 42% of visits (American
College of Emergency Physicians, 2015). This poses a
unique opportunity for school nurses to assist families in the
most efficient ways to access health care and facilitate
enrollment into a health home. This should result in better
disease management as a result of continuous health care,
leading to better outcomes for the student with asthma and
less reliance on the school nurse to provide primary health
care to address asthma needs.
Recommendations for Future Research
Research needs to continue to examine barriers to asthma
management and ways to empower the school nurse to overcome these obstacles. Many new social initiatives have been
initiated since most of the previous research was conducted,
namely, the Affordable Care Act with its multitude of provisions. It is vital to examine the impact of these major
changes and its subsequent effect on school nurse performance and outcomes for the student with asthma.
Conclusion
This study assessed barriers to asthma management and
additionally examined the impact of these barriers on school
nurse performance of specific asthma management behaviors. This study demonstrated that despite barriers, most
nurses are competent as assessed by importance ratings
of asthma management behaviors, self-efficacy, and attitude. This underlines the importance of removing barriers
to improve asthma outcomes for the student with asthma.
Removing these barriers will better the position of the
school nurse to address the new initiatives of the Affordable Care Act.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
371
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Author Biographies
Judith E. Quaranta, PhD, RN, CPN, AE-C, is an assistant professor in Decker School of Nursing, Binghamton University, Binghamton, New York.
Gale A. Spencer, PhD, RN, is State University of New York distinguished teaching professor and Decker Endowed Chair in Community Health Nursing.
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Copyright of Journal of School Nursing is the property of Sage Publications Inc. and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.