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Amber Blankenship
Abstract
knowledge by the child and parent, as well as a lack of resources for school nurses. Due to this
inadequate control, asthmatic children often miss school. Frequent absenteeism can lead to poor
academic performance and create social strain with peers. School nurses can provide care to
limit school days lost and allow the child to lead a more normal life. Many nurses report
challenges as simple as identifying those diagnosed with asthma and communicating with
families and primary care providers. This review appraises asthma care guidelines and their
effects on children, kindergarten through fifth grade, and school absenteeism. After careful
search via CINAHL and PubMed using keywords, studies were identified to support the use of
asthma action plans with co-interventions including educational opportunities for stakeholders,
case management, and addressing environmental needs. These studies provide evidence to
support the claim that implementing asthma care guidelines will reduce the number of school
days missed. This review addresses the need for case management to help families address
socio-economic essentials for healthcare and quality of life; as well as, improve team
collaboration between the school nurse, community provider, and family by improving asthma
awareness within the community. These two interventions are the foundation to a globally
Keywords: Asthma, attendance, asthma care guideline, Asthma Action Plan, school-aged
children.
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 3
Asthma is a reactive airway disease which causes inflammation and muscle constriction,
leading to decreased airflow and available oxygen to vital organs. This disease affects both
adults and children alike. In 2015 it was estimated that 6.2 million children of the US population
suffered from asthma. In 2013 approximately 13.8 million lost school days reported were related
to asthma (American Lung Association, 2017). If poorly controlled, asthma can be debilitating,
decreasing abilities to participate in activities similar to peers. If properly managed through the
appropriate use of medications and avoiding triggers, a quality of life may be preserved.
Children spend an average of eight hours per day, five days per week at school.
Consequently, having poor control of asthmatic symptoms during school hours places these
students at greater risk for exacerbations, hospitalizations, and even mortality. It is vital that
symptoms be recognized and managed. Multiple asthma care guidelines have been developed to
address symptom control and provide both staff and student support during exacerbations. Will
school-age asthmatic children, kindergarten through fifth grade, with a standardized asthma care
guideline in place, have improved attendance records in comparison to school aged asthmatic
Purpose
This paper aims to review available research to identify best practices and up-to-date
guidelines for managing childhood asthma within the school environment. This review will
assess the implementation of such guidelines and evaluated their effect on student attendance.
Methods
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 4
An online literature search was initiated employing the Western Washington University
OneSearch database using terms Asthma action plan AND attendance OR absenteeism AND
school-aged children." Close to 2000 articles populated. Inclusion criteria were abstracts
referencing asthma programs and attendance records, full-text access, peer-reviewed journals,
and studies published after 2012. Articles dating before 2012 were included if studies were
relative and of an essence. Exclusion criteria were studies focusing on medication brands or
Search was then routed to Google Scholar, PubMed, and CINAHL databases where
search criteria, attendance OR absenteeism were removed and further studies were identified.
Intra-article citations were evaluated. These citations directed search to the National Association
of School Nursing (NASN) and National Heart, Lung and Blood Institute (NHLBI) websites,
where current best practice guidelines were visited. A peer-reviewed journal, The Journal of
Findings
Based on the Evidence Hierarchy, these articles provide strong, high-level research
evidence: a systematic review, two randomized control trials (RCT), and a quasi-experiential
study. Two qualitative studies, although provide a lower level of evidence, illustrate
phenomenology and processes. Research also identified two literature reviews to include in this
discussion.
Absenteeism
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 5
This search identified four studies which provided strong evidence addressing asthma
care and school attendance. Three of these studies clearly supported improved attendance records
after the implementation of an asthma action plan (AAP) coupled with other co-interventions. A
third study elicited no direct statistical changes on school attendance in the asthmatic student
population. However, on closer review, this same study noted differences in absentees between
asthmatic students who received care in the health office, and those who did not. This study,
completed by Splett, Erickson, Belseth, & Jensens is a randomized control trial (RCT) which
focused on care coordination with medical providers, developing AAP, the creation of resource
nurse positions, staff training, and student education. (Splett et al., 2006). A second RCT
implemented case management to assist with screening, family referrals, and collaboration with
medical providers. This study provided strong evidence illustrating a decrease in school days
missed of approximately two days (Moricca, Grasska, BMarthaler, & Weismuller, 2013). Liptzen
et al. developed and trialed a step-up program which encompassed case management, screening,
collaboration and student and staff education. This study illustrated improved outcomes and
supported a decrease in absentees (Liptzin et al., 2016). The fourth article examined an
assortment of care plans and their effects on symptom control and attendance. This study also
The National Heart, Lung, and Blood Institute (NHLBI) and the National Association of
School Nurses (NASN) provide evidence-based guidelines supporting nurse case managers
(Schantz & Maughan, 2015) (National Heart, Lungs, and Blood Institute, 2014). Although these
previously researched guidelines provide the strongest level of evidence, this review identified
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 6
supported case identification using a nurse case manager as an agent for implementation. The
Splett et al study monitored students visits to the health office. Those students who had more
than one visit per week with asthmatic symptoms qualified for further assessment by case
management. If merited, parents were contacted and referred to a community care provider for
follow-up (Splett et al., 2006). The second and third study used questionnaires to screen students
at risk. Students parents fill out these questionnaires upon school enrollment and every three
months throughout the academic year (Lipzin et al., 2016). Case managers then contact families,
explain results, and make appropriate referrals. These nurses act as a liaison for collaboration
between family, school, and primary care providers (PCP); as well as address family needs,
NHLBI guidelines acknowledge the need for access to medications and a partnership
with families and community providers, to ensure a plan is in place for prevention and crisis
management. (National Heart, Lungs, and Blood Institute, 2014). In both qualitative studies,
Nurses expressed communication challenges with families, and a lack of provided asthma action
plans. In one study nurses reported an approximate 28% of asthmatic students had an AAP
(Borgmeyer, Jamerson, Westhus, & Glynn,2005). Of these same nurses, 72% agreed or strongly
agreed that AAPs provided a guidance tool and improved in the nurses self-confidence in caring
for these students. One study addressed AAP with built-in consents for medication administration
and acknowledged the need for systems for community providers to share AAP with the school
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 7
district. The results of this study exhibited more AAP on file, more medications were available
Education
Each study addressed education for student, family, and staff. The step-up program provided
evidence-based asthma education titled Open Airways for School (OAS)(Liptzin et al., 2016).
This six, forty minute-session program educated students, 3rd through 5th grade, on proper
inhaler use and basic disease knowledge. On evaluation, students were shown to have improved
inhaler technique and symptom management. A second study addressed education for school
staff following National Institutes of Health (NIH) (which equates to NHLBI) guidelines. A half
day training was provided and regularly reinforced (Splett et al., 2006).
asthma action plans implemented during school hours. However, there are few studies which
provided a consistent recipe of co-interventions for implementation. Two of three studies clearly
confirmed an improvement in attendance after guidelines became enacted; whereas a third study
indirectly affected the number of days missed. Evidence-based guidelines from NHLBI and
NASN agree. These three studies with national guidelines provide the strongest level evidence
to support the implementation of an asthma action plan coupled with co-interventions. All studies
appraised coordinated other interventions to augment and support AAP; though each study had
differences, common themes surfaced overall. These topics included policy development, case
identification, education, case management, and addressed barriers perceived by school nurses;
many of which mirror those of national institutions such as the NHLBI and National Association
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 8
of School Nurses (NASN) (Schantz & Maughan, 2015) (National Heart, Lungs, and Blood
Institute, 2014).
An asthma action plan, prepared and tailored by the child's pediatrician promotes control
of the disease, avoids exacerbations, and maintains a quality of life for the student. With a proper
action plan in place, staff [nurses, teachers, and administration] have the tools needed to help
these students participate in activities with their peers and maintain a quality of life; yet many
school nurses claim to have few AAP on file. This lack of AAP is a compromise to student
safety. A student must have access to their medications. Although students are permitted to carry
their inhalers, until they demonstrate proper use, there is need for assistance. Without an action
plan, schools lack consent to share health information if an emergency were to occur (Cicutto,
There is a need to improve communication between parents, nurses, and primary care
providers (PCP). A major concern for nursing is that they are not always aware of which students
have asthma, or who have undiagnosed asthmatic symptoms; despite surveys and phone calls as
these are not always returned (Nadeau & Toronto, 2016). Nurses report a disconnection with
parents; possibly related to distrust due to misunderstanding of school nurse level of education,
or due to management preferences (Nadeau & Toronto, 2015). Naturopathic remedies have gain
popularity and communities, like the one here in the Bellingham school district, prefer these
practices. Due to HIPPA law's, PCP's are not allowed to share information with school boards,
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 9
unless permitted by the parent, as action plans are establish between the parent and provider, a
process needs to be implemented to share this information with the school district.
School nurses are spread thin and often have multiple schools to visit. In the Bellingham
school district, each nurse has 1500 students each, despite a recommended ratio of one nurse to
750 students by NASN and acknowledged by U.S Department of Health and Services
(Dolatowski et al., 2015). Due to a lack of available time, these nurses are unable to address
student needs thoroughly. Our research revealed strong evidence supporting positions for case
management. Many families may not have access to healthcare; a case manager provides insight,
skill, time to address concerns and make referrals as needed; as well as provide a bridge of care
serving the important role of liaison between all stakeholders, assuring full collaboration.
Education
Creating awareness for each stakeholder addresses many barriers discussed. Research
supports implementation of OSA to provide a foundation of knowledge for the student who can
then share with family. As the family gains experience and has a sense of support from the
school, miss-trust towards the nurse, improves. Substantial evidence supports staff education. If
a child has an AAP in place, ancillary staff can follow the plan as written; however, providing
staff with tools can assist with prevention. An understanding of their role and early symptom
recognition avoids a delay of care and improves outcomes for these students; as well as provide
support for case identification. Further education will allow staff to address other environmental
needs such as dust, plants, and perfumes, which may act as triggers for the student.
Recommendations
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 10
Nurses report communication with both parents and primary care providers to be the
most frustrating challenge (Nadeau & Toronto, 2016). It is believed that the cause of these
(Cicutto et al., 2014). Education should then be provided to improve knowledge of students,
family, and ancillary staff. Evidence-based programs such as OAS have been proven
opportunities for all staff and families, lead to less asthma exacerbations, as evident in the Step-
Up study. This increased awareness will also help to build trust in school nursing practice by
community members.
insurance coverage, access to primary care, and address educational needs. Case management
positions may not be realistic for current school budgets. However, the evidence is strong enough
Room visits by uninsured families, versus the cost to employ a case manager. Looking further at
potential downstream affects, if children are frequently missing school, which leads to decreased
academic performance and increased dropout rates, a reliance on social systems is promoted
Applying the above two recommendations will improve access to care, health literacy,
and parent compliance to care plans. These factors will increase the number of asthmatic
students with asthma action plans, available medications, and provide direction for staff to
BEST PRACTICES FOR ASTHMA CARE GUIDELINES 11
improve student outcomes. However, the need for funding to establish case management
Conclusion
School nurses are stretched thin to provide care for hundreds of children, sometimes
dispersed between two or greater schools. A requisition testified by these nurses, is that of
and crisis management. If properly managed, asthmatic children can lead healthy lives alongside
their non-asthmatic peers. Asthma care guidelines and asthma action plans will provide nursing
with the tools and knowledge to support these students. With support, students will have less
symptomatic days and fewer missed days of school, thus creating better opportunities to thrive
academically.
References
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