I attached the article and the grading criteria for the critical analysis of an article.

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). Hospi- talization 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 (Akin- bami 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 appropri- ately. 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 aller- gic 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 objectiv es 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 Respira- tory Disease [RD]-6, Objective RD-7.2, Objective RD-7.3, and Objective RD-7.5, respectively). Achieving these objec- tives would result in attainment of Objective RD-2.2: reduc- ing 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.

1Decker 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: [email protected] The Journal of School Nursing 2016, Vol. 32(5) 365-373ªThe Author(s) 2016Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840516641189jsn.sagepub.com 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 oppor- tunity 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 manage- ment 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 suscept- ibility or severity must be present. However, barriers may preclude the individual from carrying out those behaviors deemed beneficial (Champion & Skinner, 2008). Applica- tion 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 perfor- mance 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 man- agement behaviors.

Purpose The purposes of this study were to (a) assess barriers present in the school setting that impact school nurse asthma man- agement, (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-effi cacy, 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 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, health- care procedures, and development of health-care plans. Case management, referrals to primary care providers, collabora- tion with others to build student and family capacity for self-management and learning, and providing health- related education to students and staff are included in the role of the school nurse.

Barriers Barriers confronting school n urses 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. Stu- dent 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 fre- quently reported barrier was a lack of teacher knowledge about asthma and a lack of c ommunication with health- care 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 liter ature review (Anderson et al., 2005; Ayala et al., 2006; Bartholomew et al., 2006; Borg- meyer, Jamerson, Gyr, Westhus, & Glynn, 2005; Dozier, Aligne, & Schlabach, 2006; Engelke, Guttu, Warren, & Swanson, 2008; Erickson, Splett, Mullet, Jensen, & Bel- seth, 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-Fishwic k et al., 2004; Winkelstein et al., 2006). A report from the Centers for Disease Control and Pre- vention on secondary schools substantiates that school nurses continue to be confronted by barriers with subsequent potential impact on performing asthma management beha- viors (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. 366 The Journal of School Nursing 32(5) 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 %. Asthma Self-Efficacy School nurses who lacked confidence in their teaching abil- ity declined conducting asthma education. Providing asthma education to school nurses was successful in increasing self- efficacy 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 educ ation 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 communi- cated 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, Hor- ner, 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. Research Questions To understand the impact barriers place on school nurses’ performance of asthma management behaviors, the follow- ing research questions were asked for this study: 1. Is there a relationship between barriers present in the school setting and school nurse performance of asthma management behaviors? 2. Is there a relationship between barriers present in the school setting and school nurse asthma self-efficacy? 3. Is there a relationship between barriers present in the school setting and school nurse asthma attitude? 4. 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 question- naires 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 ran- domization 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 partic- ipate 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, Cre- bolder, and Parcel (1998), and Wigal et al. (1993) with Cronbach’s as of .94, .92, .93, and .92 respectively. Asthma Quaranta and Spencer 367 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 a¼ .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 indi- cate positive asthma attitude, equating to higher perceived susceptibility and severity to asthma issues for the student with asthma. The Asthma Self-Efficacy Questionnaire con- sisted of 19 items (Cronbach’s a¼ .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 Man- agement Behaviors Questio nnaire and Asthma Manage- ment Behavior Rating Quest ionnaire consisted of the same 11 items (Cronbach’s a¼ .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 perfor- mance. Asthma Management Behavior Rating choices were 1 ¼ not important ,2 ¼ important ,and3 ¼ very important for the ratings. Greater importance ratings equate to higher perceived sus ceptibility and severity. The Barriers Questionnaire listed 12 barriers to asthma manage- ment from which school nurses could choose as well as an optiontoindicatenobarrierstoasthmamanagementor 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 rele- vant ,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 si gnificant differences were found for asthma attitude, t(462) ¼ .518, p¼ .605; asthma self-efficacy, t(432) ¼ 1.235, p¼ .218; importance rating of asthma management behaviors, t(450) ¼ 1.172, p¼ .242; or performance of asthma management behaviors, t (444) ¼ 1.332, p¼ .183; indicating both groups were com- parable. 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. Descrip- tive statistics described the sample characteristics. Frequen- cies and percentages were calculated for nominal and ordinal data. Means were calculated for interval data. Pear- son correlation was used to determine the relationship of the number of asthma management barriers on asthma attitude, asthma self-efficacy, importance ratings of asthma manage- ment behaviors, and the performance of asthma manage- ment behaviors. w2was 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 % Table 1. Age and Educational Distribution of School Nurses. Frequency Percentage of Responses Age 20–30 years 8 1.9 31–40 years 23 5.5 41–50 years 90 21.6 51–60 years 230 55.2 61 þyears 66 15.8 Total 417 100 Educational level Diploma 27 6.2 Associate degree 34 7.8 Bachelor of Arts/Bachelor of Science (BS) other than nursing 19 4.4 BS in nursing 198 45.5 Master’s degree other than nursing 61 14 Graduate degree in nursing 96 22.1 Total 435 100 368 The Journal of School Nursing 32(5) 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 per- cent 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 nebuli- zers available for use, and 72 % had written asthma emer- gency 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 man- agement. 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 rela- tionship between the total number of barriers reported by school nurses and (a) asthma management behaviors per- formed by the school, (b) asthma self-efficacy, (c) asthma attitude, and (d) ratings of importance of asthma manage- ment behaviors. Questionnaire responses were summed for this analysis. A negative correlation was found between the number of barriers and performance of asthma management behaviors ( r¼ .088, N¼537, p¼.041). As the number of asthma barriers increased, performance of asthma manage- ment behaviors decreased. No correlation was found for asthma self-efficacy, asthma attitude, or ratings of impor- tance of asthma management behaviors (see Table 3). w2for independence was performed to examine the rela- tionship between performance of specific asthma manage- ment behaviors and barriers to asthma management. The relationships between the following variables were signifi- cant: (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 knowledge- able 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/care- givers 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 poli- cies 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 man- agement behaviors. Barriers, however, did not diminish the Table 2. Frequency of Reported Barriers to Asthma Management. Barrier % Yes % No Lack of communication with parents 54.5 45.5 Lack of communication with health-care providers 36.5 63.5 Lack of time 29.8 70.2 Lack of equipment for asthma management 29.8 70.2 Lack of asthma action plans 26.3 73.7 Lack of funding for supplies 12.8 87.2 Lack of programs to teach students about asthma management 12.5 87.5 Lack of knowledgeable faculty/staff 10.1 89.9 Lack of opportunity to attend continuing education 10.2 89.8 Lack of administrative support 7.3 92.7 Lack of communication with faculty/staff 6.0 94.0 Lack of school policies for asthma management 6.0 94.0 Table 3. Pearson Correlations for Barriers and Performance of Asthma Management Behaviors, Importance Rating, Asthma Self- Efficacy, and Attitude.

Variable Performance Self- Efficacy Attitude Importance Rating Total barriers .088* .034 .025 .019 *Correlation is significant at p< .05 (two tailed). Quaranta and Spencer 369 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 neg- ative 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, a sthma attitude, or ratings of importance of asthma management behaviors. Thus, remov- ing 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 wa s 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 man- agement 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 beha- vior, yet this was reported by one third of the nurses parti- cipating 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 multi- tude 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 beha- vior. School nurses should not be impeded by avoidable barriers.

Limitations Participation was limited to school nurses who were mem- bers 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 pro- grams, 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 nur- sing. Section 2703 authorizes creation of health homes for individuals with chronic conditions (American Nurses Asso- ciation, 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 asth ma 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, Table 4. w2for Relationship Between Asthma Management Behaviors and Barriers.

Asthma Management Behaviors Barrier w2a p Assessing student’s level of asthma control Lack of funding for supplies for supplies 6.539 .011 Assessing the student’s awareness of asthma triggers Lack of equipment 5.143 .020 School policies 10.446 .001 Obtaining peak flow measurements Lack of knowledge faculty and staff 3.835 .050 Providing asthma education to students with asthma Lack of communication from faculty/staff 5.215 .022 Lack of knowledge faculty and staff 10.250 .001 Lack of time 4.430 .035 Lack of administrative support 7.060 .008 Providing asthma education to parents/caregivers of students with asthma Lack of asthma action plans 5.099 .024 Lack of funding for supplies 8.261 .004 Providing asthma education to school faculty/staff Lack of available programs 5.222 .022 Assessing the inhaler technique of the student with asthma Lack of funding for supplies 4.754 .029 Contacting the health-care provider for initiating or updating the asthma action plan School policies 5.816 .016 Lack of funding for supplies 10.216 .001 Referring the student to the primary health-care provider when the students’ asthma is not in control Lack of funding for supplies 6.839 .009 aDegrees of freedom ¼1. 370 The Journal of School Nursing 32(5) 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 stu- dents with asthma. As time and funding were associated with a decrease in the performance of asthma management beha- viors, 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 reso- cialization in seeking medical care from a primary health- care 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 acc ess 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 over- come 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 pro- visions. It is vital to exami ne the impact of these major changes and its subsequent effect on school nurse perfor- mance 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 beha- viors. This study demonstrated that despite barriers, most nurses are competent as assessed by importance ratings of asthma management behavi ors, self-efficacy, and atti- tude. 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 n ew initiatives of the Afford- able 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. Funding The author(s) received no financial support for the research, author- ship, and/or publication of this article.

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Gale A. Spencer , PhD, RN, is State University of New York dis- tinguished teaching professor and Decker Endowed Chair in Com- munity Health Nursing. Quaranta and Spencer 373 Copyright ofJournal ofSchool Nursing (SagePublications Inc.)isthe property ofSage Publications Inc.anditscontent maynotbecopied oremailed tomultiple sitesorposted toa listserv without thecopyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use. Copyright ofJournal ofSchool Nursing isthe property ofSage Publications Inc.andits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.