Temple Challenges of Asthma Management for School Nurses Paper

Temple University

Question Description

I’m trying to learn for my Health & Medical class and I’m stuck. Can you help?

Dr. Penny Liberatos will be discussing her article on Asthma.

Please read, complete the brief synopsis of the article, and be prepared to discuss with Dr. Liberatos.

In a 300-400 words (not counting the title and journal details):

  1. Background
  2. Method
  3. Results: analysis, statistics, tables and figures, interpretations of findings
  4. Discussions: strength, limitations, comparing with other studies, policy implications, future research directions
  5. Conclusions

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RESEARCH ARTICLE Challenges of Asthma Management for School Nurses in Districts With High Asthma Hospitalization Rates PENNY LIBERATOS, PhD a JENNIFER LEONE, MPH, RD, CHESb ANN MARIE CRAIG, RN, BSN, SPHN, MPHc ELIZABETH MARY FREI, MPHd NATALIE FUENTES, MPHe INDIA MARIE HARRIS, BSN, RN, MPHf ABSTRACT BACKGROUND: School nurses play a central role in assisting elementary school children in managing their asthma, especially those in higher-risk school districts that are at increased risk of uncontrolled asthma. Study purposes are to (1) identify barriers to asthma management by school nurses in higher-risk school districts; and (2) assess the extent to which National Asthma Education and Prevention Program (NAEPP) recommendations are followed in these districts. METHODS: School districts containing at least one zipcode with high asthma hospitalization rates among children (0-14 years) in a New York State county were identified. Nurses in 44 elementary schools were surveyed about asthma management during 2008. Both quantitative and qualitative data were collected. RESULTS: Study nurses learned of children with asthma mainly through school records and when students presented with symptoms rather than through parents. The major obstacles to asthma management were communication with parents and parental support. Reluctance of some physicians to diagnose asthma in these children presented a barrier and contributed to the nurses’ ability to gain parental cooperation. Adherence to the NAEPP school recommendations was inconsistent. CONCLUSIONS: Improvement in the communication among parents, school nurses, and providers is critical to the improvement of asthma management for children in high-risk school districts. Keywords: asthma; school nurses; compliance; hospitalizations. Citation: Liberatos P, Leone J, Craig AM, Frei EM, Fuentes N, Harris IM. Challenges of asthma management for school nurses in districts with high asthma hospitalization rates. J Sch Health. 2013; 83: 867-875. Received on November 18, 2011 Accepted on December 21, 2012 A s one of the most common chronic conditions in children, asthma affected approximately 7 million US children in 2009 for a prevalence rate of 9.6%, representing a 10% increase since 2001.1,2 Asthma is a major cause of school absenteeism, with an estimated 14.4 million school days lost in 2008.2 As the third leading cause of hospitalizations among children <15 years and with more than 500,000 annual emergency department visits, asthma also has major consequences for US health care costs.2 The highest rates of asthma among those <18 in 2009 occurred among boys (11.3% vs. 7.9% girls), African Americans (17.0% vs. 8.5% Whites), and the poor (13.5% vs. 8.3% nonpoor).1 Furthermore, African-American children had a 49% increase in asthma prevalence since 2001.1 Although the overall prevalence for Latino children was similar to that for non-Hispanic whites, Puerto Rican children had rates that were 140% higher.3,4 In addition, poorly managed asthma tends to occur more often in low socioeconomic status (SES) communities.5,6 In New York State (NYS) (including New York City, NYC), 491,000 children (<17) were reported to have asthma in 2006-2008 for a prevalence rate of 11.0%.7 Because children spend a substantial portion of their day in school, elementary school nurses in particular assist children in managing their asthma, a key role that can help to effectively manage the condition and positively influence child health.8 For example, there is evidence that the presence of a full-time school nurse a Assistant Professor, (penny_liberatos@nymc.edu), Department of Epidemiology & Community Health, New York Medical College, School of Health Sciences & Practice, Valhalla, NY 10595. bQuality and Performance Improvement Manager, (jennyk8@msn.com), Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467. c Orange County Department of Health, (acraig@co.orange.ny.us), Division of Intervention Services, Supervising Public Health Nurse, ICHAP Coordinator, 124 Main Street, Goshen, NY 10924. Journal of School Health • December 2013, Vol. 83, No. 12 • © 2013, American School Health Association • 867 can significantly decrease the total number of missed school days for children with asthma compared to a part-time nurse.9 Understanding the barriers faced by school nurses who manage childhood asthma, is one step toward developing programs and resources that can support them, particularly for those who work in schools with high asthma rates. The National Asthma Education and Prevention Program (NAEPP) has developed recommendations for schools and school nurses to implement regarding asthma management. Schools should have (1) a system by which students with asthma can be identified, assessed, and monitored; (2) asthma-related plans in place (individual, school-wide emergency, medication management); (3) care coordination for students with significant asthma morbidity; (4) provision of asthma education to students, families, and school staff; and (5) provision of a safe, healthy school environment (not discussed in this article).10-12 These guidelines are consistent with standards of practice from professional associations for school nurses.8,13 A few previous studies have examined how asthma is managed in public schools. Snow et al12 surveyed 156 professional staff in 5 elementary schools in NYC. They asked questions regarding the NAEPP school recommendations and found poor adherence and lack of a consistent approach in managing students’ asthma. Forbis et al14 conducted focus groups with 33 school nurses in Dayton, OH. They identified 3 sources of difficulty regarding asthma management: schoolrelated (eg, lack of supplies/medications), parentrelated (eg, difficulty contacting parents, lack of education about asthma), and medical (eg, no asthma plan, no asthma diagnosis). A study by Kielb et al15 surveyed 1550 elementary school nurses in NYS (excluding NYC) in 2003 (out of 2557) with at least one school per school district participating. They reported that lack of time and funding for supplies were the main barriers to asthma management. Approximately one fourth of students with asthma had an asthma plan, but the majority reported that asthma-related equipment was available at the school. Their study also found varying degrees of compliance with the NAEPP school guidelines. In summary, although some previous work has examined challenges that school nurses encounter in managing asthma, they have not focused on schools with higher rates of asthma or uncontrolled asthma (an indicator of which is the rate of asthma hospitalizations).1,3 If some schools have higher rates of asthma, especially uncontrolled asthma, how does that affect asthma management by school nurses? The purposes of this study were to (1) identify barriers to asthma management by elementary school nurses in higher risk school districts; and (2) assess the extent to which the NAEPP recommendations are followed in schools with higher asthma rates. METHODS Participants This study focused on school districts in Westchester County, NY (just north of NYC) with high rates of asthma hospitalizations in elementary school-age children. The county has about 1 million residents, with 232,689 children (<18 years) who are 53.2% White (non-Hispanic), 15.9% African American and 23.9% Latino.16 As a measure of possible uncontrolled asthma, asthma hospitalization rates were obtained for ages 014 by zipcode of residence for the period 2004-2006.17 The highest quartile of asthma hospitalization rates (ie >22.6 per 10,000 population) included 18 zipcodes. Five of these had <11 asthma hospitalizations and were not included due to the instability of the small numbers.17 The remaining 13 zipcodes were mapped to their corresponding school districts. Larger districts included both high- and low-risk zipcodes. As children may attend any school in some districts, all zipcodes comprising a school district were included in the study. This added 6 more zipcodes for a total of 19 zipcodes selected for the study (Table 1). The 19 zipcodes mapped to 7 school districts, of which 6 (85.7%) agreed to participate. The other was in the midst of an educational review and declined. School nurses at each of 56 elementary schools constituting the 6 districts were contacted. Of these, 44 (78.6%) agreed to participate. The main reason given by the 12 nonparticipating nurses was lack of time; many indicated that they were understaffed. Procedure A letter was sent to each school district superintendent explaining the study and requesting permission to contact the nurses in all elementary schools in their district. Once superintendent approval was received, each elementary school nurse was contacted by telephone to solicit study participation. Those who agreed were sent a questionnaire and an appointment for a telephone interview (see below) was scheduled dMPH Graduate, (emfrei@yahoo.com), Department of Epidemiology & Community Health, New York Medical College, School of Health Sciences & Practice, Valhalla, NY 10595. e Corporate Quality Improvement Manager, (nafuentes65@gmail.com), APS Healthcare INC., 44 South Broadway, White Plains, NY. f MPH Graduate, (inurse@juno.com), New York Medical College, School of Health Sciences & Practice, Department of Epidemiology & Community Health, Valhalla, NY 10595. Address correspondence to: Penny Liberatos, Assistant Professor, (penny_liberatos@nymc.edu), Department of Epidemiology & Community Health, New York Medical College, School of Health Sciences & Practice, Valhalla, NY 10595. 868 • Journal of School Health • December 2013, Vol. 83, No. 12 • © 2013, American School Health Association Table 1. Asthma Hospitalization Rates (ages 0-14 years) for School Districts in Westchester County, NY∗2004-06 School District Bedford Hills Elmsford Mt. Vernon New Rochelle Ossining White Plains Yonkers Zip Code 10507 10523 10550 10552 10553 10801 10804 10805 10562 10601 10603 10605 10606 10607 10701 10703 10704 10705 10710 Number of Discharges Asthma Hospitalization Rate 12 18 108 33 13 66 34.7 39.2 46.2 32.3 20.2† 30.2 ‡ ‡ 9.6† 22.7 26.8 24.9 12.2† 16.4† 35.3 47.1 38.4 17.3† 33.8 28.2 8 36 14 22 14 15 13 194 49 26 86 35 Data source: New York State Department of Health, 2004-200617 . Highest quartile was defined as rates of 22.7 and above. ∗ Rates are per 10,000 population, ages 0-14 years. Only school districts that had at least one zipcode with an asthma hospitalization rate falling in the highest quartile (indicating highest risk) are included. † Hospitalization rate is below cut off for high risk quartile, but was included because other zipcodes in school district fell into the high risk quartile. ‡ Data suppressed by NYS Department of Health for confidentiality purposes, but zipcode was included because other zipcodes in school district fell into the high risk quartile. approximately 2.5 weeks later. This allowed time for the completed questionnaire to be returned so that any questions/unanswered items could be reviewed during the interview. To gain a better understanding of some topics, especially obstacles and support for asthma management, telephone interviews were conducted with the school nurses. All interviews were conducted by 9 MPH student interviewers and tape-recorded to assist with accurate response completion and oversight. The interviewers were trained in qualitative interviewing skills and completed the National Institutes of Health course in the protection of human subjects. Data collection for the study was conducted during November 2008 to January 2009. Instruments The school nurses completed a questionnaire consisting of 33 items (23 closed-ended/10 open-ended); some of these items were drawn from a similar survey of NYS school nurses conducted in 2003 and described earlier.15 Topics included here are how nurses learn which children have asthma, access to medications/equipment in school, adequacy of communication and time to meet student needs, obstacles Journal of School Health • they face in managing these children in school, school asthma education provided, and participation on a school health committee. Most closed-ended questions were multiple-choice; most open-ended questions required the nurses to enter the number of children who fell into that category or explain a response category (eg, Other). The questionnaire had numerous revisions and was pretested on 30 nurses and school nurses not involved in the study and revised accordingly. A guide consisting of 16 questions (12 open-ended/4 closed-ended) was used for the telephone interviews which averaged about 25 minutes. Most of the openended questions allowed the nurses to further explain their responses to the survey. Data Analysis Participating schools were compared with nonparticipating and NYS schools to address potential nonparticipation bias and provide context for study results using demographic data obtained from the NYS Education Department18-20 including subsidized lunch program eligibility-used as a proxy for SES. Furthermore, asthma prevalence for nonparticipating schools was obtained from data collected through a NYS-funded program at a local hospital21 and from the Kielb study15 for NYS schools. Responses to the closed-ended questions in the questionnaire and interview were entered into Excel (Microsoft, Redmond, WA) and then imported into SPSS (Chicago, IL) for analysis. Descriptive statistics are presented for all responses. The open-ended responses from the interviews were reviewed by the authors and content-analyzed for common themes. RESULTS Characteristics of Study and NYS Schools Comparing demographic characteristics for participating and nonparticipating schools showed that both groups had student bodies where at least two thirds were African American/Latino, half received reduced/free lunch, and 16% had a parent with limited English proficiency (LEP); however, a larger proportion of students in nonparticipating schools possessed these characteristics (especially for race/ethnicity and SES). Nonparticipating schools also had a larger average student enrollment and average number and proportion of students with asthma, indicating a likely greater workload for their school nurses. This pattern is consistent with the reasons that nonparticipating school nurses gave for why they could not participate in the study, that is, they had no time. Comparing participating study schools with NYS schools, the former have much higher proportions of students who are minority, have low SES, have parents with LEP, and have asthma (Table 2). December 2013, Vol. 83, No. 12 • © 2013, American School Health Association • 869 Table 2. Characteristics of Study and NYS Schools Westchester Elementary Schools Characteristic Enrollment Number of students per school Range Race/ethnicity % White % African American % Latino % Other % ‘‘Minority’’§ Socioeconomic status % Reduced/free lunch Parental English proficiency % Limited proficiency Students with asthma N % Participating∗ Mean‡ Nonparticipating∗ Mean‡ 493.8 (272-1089) 540.5 (195-953) 464.1 — 26.8 31.0 37.0 5.3 68.0 10.3** 46.3 40.2 3.3 86.5 51.7 19.4 20.8 8.1 40.2 54.2 68.3* 44.1 16.8 22.2 7.3 65.2 13.5 85.4 16.4 — 8.5 NYS Schools† Mean‡ NYS, New York State. ∗ Participating schools = 44 schools with 21,728 students; 1 full-time nurse per school; nonparticipating schools = 12 schools with 6486 students. † NYS data for race/ethnicity, SES, and English proficiency include all schools. Enrollment data based on—2483 elementary schools with 1,152,335 students. Asthma prevalence data based on 1550 elementary schools with 629,765 students.15 ‡ Values are means across all schools in each group; participating/nonparticipating school. Comparisons performed by t-test; * p < .05; ** p < .01. § ‘‘Minority’’ designates African American and Latino. — Data not available. Data Sources: Students With Asthma Data—Participating schools drawn from this study; nonparticipating schools drawn from St. John’s Riverside Hospital data;21 NYS elementary schools drawn from Kielb et al study.15 All Other Data From NYS Report Card —Westchester elementary schools—2007-2008;18 NYS schools—2007-2008.19,20 on file for about 31.8% of students with asthma (averaged across 39 schools). However, more than 7 of 10 nurses reported having a school-wide asthma emergency plan (33/39 = 84.6%) and nebulizers (44/44 = 100%)/spacers (30/43 = 69.8%). On average, approximately 1 in 16 children with symptoms (6.4% averaged across 39 schools) could not go home because no one could pick them up. More than three fourths (34/44 = 77.3%) of study nurses provided asthma education to students with asthma and almost half (21/44 = 47.7%) of nurses also educated their parents. Teachers and others were less likely to receive education. Characteristics of School Nurses and Students With Asthma (Table 2) The majority of study nurses were >50 years (32/44 = 72.7%), with three fourths (33/44) selfidentifying as White (6/44 = 14% as African American or Latino), almost two thirds (28/44 = 63.6%) had >10 years experience as a school nurse, and all were either registered nurses (RNs) or nurse practitioners (43 RNs, 1 NP) and worked full time in their elementary schools (1 nurse per school). More than half (25/44 = 56.8%) spoke only English, about one third (14/44 = 31.8%) spoke Spanish, with the rest speaking other languages. Of the 21,728 students in participating elementary schools, 2928 were reported to have asthma, for a prevalence rate of 13.5% during 2007-2008. Obstacles to Asthma Management (Table 4) More than 7 of 10 study nurses indicated that poor communication with parents (33/44 = 75%), parental support (33/44 = 75%), and asthma-related supplies from families (31/44 = 70.5%) were the most common obstacles to asthma management. These quantitative data were supported by the following derived from the qualitative interviews (Table 4). Poor communication with parents was a major source of frustration for study nurses (24/39 = 61.5%). Language barriers were frequently cited as a factor (11/44 = 25%), but so was the limited support that nurses felt they received from the parents (11/44 = 25%). According to the nurses, parents often did not Asthma Management and Education (Table 3) Study nurses identified children with asthma predominantly through school records, followed by parents and students presenting with symptoms. It is notable that nurses learned of a student’s asthma as often by the student presenting with symptoms as parents informing her (31/44 = 70.5%). A doctor’s medication order was also a top source of identification for study nurses (Table 3). Despite the use of medication orders to identify some students, study nurses only had such orders 870 • Journal of School Health • December 2013, Vol. 83, No. 12 • © 2013, American School Health Association Table 3. Asthma Management and Education Table 4. Obstacles to Asthma Management Participating Elementary Schools∗ Characteristic Source of asthma information† School records Parents Student presents with symptoms Doctor order/medication form Other Asthma management practices Has asthma plan‡ Has doctor order for quick-relief medicine‡ Uses peak flow meter‡ School-wide emergency plan exists† School has† Nebulizers Spacers Consequences of asthma‡ Student visits to health office Student dismissed early Student stayed in school because no one could pick them up Who receives asthma education† Students (all) Students with asthma Parents of children with asthma Teachers Classroom Physical education Others Total Number of Schools N % 37 31 31 26 4 84.1 70.5 70.5 59.1 9.1 44 44 44 44 44 — — 31.8 33.9 39 39 — 33 19.5 84.6 38 ...
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Final Answer

Ok, here you go!Let me know if you like it 😇 The word count is 431 but that is including the reference and title, so the actual word count is around 390!

Article Discussion of “Challenges of Asthma Management for School Nurses in Districts
With High Asthma Hospitalization Rates”
Since asthma is such a prevalent disease in the U.S. and it causes a significant
level of disruption in the education industry for children, the study’s purpose was to
evaluate the potential issues that school nurses may face when treating students with
asthma as understanding this is essential to creating us...

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