Now that you have considered the evidence and potential options to address the local site problem and project objectives, it is now time to describe the proposed design of your project, specific detai

Implementing an Asthma Education Program for Elementary School Staff

Student

Department of Nursing, University of Central Florida

NGR 7911C: Doctoral Project I

Dr. Valerie Martinez

Abstract

Introduction 5

Background and Significance 5

Organizational Needs Assessment 7

Description of the Sponsoring Organization 7

Stakeholder Analysis 9

Project Management Tools 9

Local Problem Statement 11

Literature Review and Synthesis 11

Purpose and Project Goals 14

Conceptual/Theoretical Framework 15

Methods 17

Project Design 17

Setting 17

Population 17

Intervention 17

Budget and Resources 17

Cost-Benefit Analysis 17

Outcome Measures 17

Data Collection 17

Data Analysis Plan 17

Ethical Considerations 17

Timeline for project completion 17

References 17

Appendices 20

Appendix C: Individual Evidence Summary Tool 20

Appendix B: Project Management Tools - Stakeholder Analysis and Communication Tool 23

Appendix B: Project Management Tools – Driver Diagram 24

Appendix B- SWOT Analysis 25

Data Collection Sheet/Instrument 27

Education Plan 27

Coded Data Management Sheet 27

Timeline Figure 27

Organization Letter of Support 27

Asthma is a leading illness among children and adolescents in the United States (Centers for Disease Control and Prevention [CDC], 2022). Asthma is a chronic disease characterized by inflammation and swelling of the airways (Asthma and Allergy Foundation of America [AAFA], 2022). Inflammation can be triggered by several factors such as smoke, allergens, cold air, viruses, dust, and a variety of chemicals. Asthma symptoms include shortness of breath, difficulty talking, coughing, wheezing, and chest tightness. There is no cure for asthma but with proper management asthma symptoms could be controlled and quality of life improved (AAFA, 2022).

Asthma affects approximately 10% of the pediatric population and is often debilitating (AAFA, 2022). As a result, more than half of missed school days are due to asthma in the United States (Ruvacalba et al., 2019). In the year 2013 alone, it accounted for more than 13.8 million missed school days (AAFA, 2022). School absenteeism affects most asthmatic school-aged children (59%) and is associated with lower academic performance (Hsu et al., 2016). It has a disproportionately higher prevalence in low-income populations, minority backgrounds, and African Americans, with a prevalence of 15.8% among these populations, while other racial and ethnic backgrounds report a prevalence rate of 7.8% (Rubacalva et al., 2019).

A huge burden is placed on both the family and the economic system due to asthma- related management and complications (Carpenter et al., 2016). Each year approximately 50% of children experienced at least one asthma attack (Getch et al., 2019). The average emergency room visit rate among the pediatric population was 88.1 per 10,000 population from the years 2010 to 2018 (CDC, 2021). The total economic impact of asthma among school-aged children is approximately $791 per child each calendar year and includes medical costs, loss of work productivity among parents, school absenteeism, and premature death (Carpenter et al., 2014).

Although children spend approximately half of their day in school and asthma is prevalent, relevant knowledge and resources among school personnel are limited (Lucas et al., 2012). Evidence points to limited education in asthma symptom recognition and management among unlicensed school staff (Anderson et al., 2005; Kawafha & Talbeth 2015; Reznik et al., 2020). A study done among schoolteachers in Illinois revealed that only 25% of teachers received any asthma training at their workplace (Lucas et al., 2012). Thus, recognition of asthma triggers and symptoms of an asthma attack are subpar (Al Aloola et al., 2017; Anderson et al., 2005). Furthermore, a lack of confidence in managing asthma exacerbations and increased anxiety in medication administration are common themes among school personnel (Al Aloola et al., 2017; Anderson et al., 2005; Reznik & Halterman, 2016). There is substantial evidence to argue that increased asthma knowledge can lead to increased confidence and reduced anxiety among school staff, which is needed to calmly respond in emergencies and to be more proactive in asthma management (Reznik et al., 2020).

“Asthma-Friendly Schools” is a CDC initiative that focuses on producing a safe environment conducive to learning for students with asthma and has been shown to improve asthma management (CDC, 2022). This is accomplished through providing asthma awareness programs for students and school staff, supporting evaluation of the programs and utilization of appropriate outcome measures, and providing school health services for students with asthma. In addition, using a collaborative approach in identifying students most in need of intervention contributes to ensuring a safe environment for students with asthma (CDC, 2022).

The goal of this project is to create a safe environment for all asthmatic students through the implementation of an asthma education program for school personnel and the establishment of a referral program for the identification of possible asthmatic students. Through increased knowledge, staff will be more confident and comfortable in asthma identification and management and be proactive facilitators in identifying possible undiagnosed students.

Imagine Schools at Town Center is a non-profit, public charter school founded in 2004 in Palm Coast, Florida. Its mission is to equip students for lives of leadership, success, and excellent character by offering high-quality education. The vision of the school is for every child to reach their full potential and find the path to lifelong success (Imagine Schools, 2022). For the past ten years, Imagine Schools at Town Center has employed a full-time certified nursing assistant (CNA) to run the nursing clinic. The purpose of the clinic is to improve the health of all people on campus and provide feedback to parents (S. Swanson, personal communication, September 16, 2022).

The school employs approximately 50 teachers and has 900 students from K-8th grade (S. Swanson, personal communication, September 16, 2022). There are currently only 14 students (2% of the student population) with diagnosed asthma which is considerably below the national average of 10% (AAFA, 2021) and indicates there are likely many undiagnosed students with asthma at this school. At the beginning of each school year, parents are required to indicate medical comorbidities and medication usage on admission forms. The CNA will then follow-up with each parent of an asthmatic student to develop an Asthma Action Plan and an Emergency Health Care Plan that are updated yearly. The completed Asthma Action Plans are kept in the clinic and with each teacher that has a student with asthma (S. Swanson, personal communication, September 16, 2022). However, for the past ten years, there have been no training for most of the school staff to address asthma identification and management, review current school policies, or use of Asthma Action Plans. Furthermore, there is no referral program set up for school staff to report asthma symptoms and collaborate with the school CNA to identify possible asthmatic students that have been missed (S. Swanson, personal communication, September 16, 2022).

The proposed project will incorporate different key stakeholders including the school principal, CNA, schoolteachers and staff, and parents, as identified in Appendix A. Each stakeholder carries a specific role in the implementation and can either contribute or impede the project through their influence. To engage key stakeholders, the benefits of asthma education and a referral program must be clearly presented and collaboration between each entity established. The school principal is responsible for approving the project. The CNA is responsible for collaborating with the project coordinator, school staff, and parents of each student referred to the asthma program. Staff’s responsibilities include attending an educational session and identifying and referring possible asthmatic students. Ease and usefulness of the program, in addition to convenient scheduling of the educational session, are critical factors in ensuring staff engagement. Lastly, parents are responsible for following up with their child’s provider for asthma screening and possible diagnosis. To ensure their participation, the referral process and the importance of following up with their child’s provider for asthma screening must be clearly explained to each parent.

Several project management tools were utilized to gain a clear picture of the project aim and to make project plans strategically. The driver diagram, as detailed in Appendix B, illustrates change ideas that will be implemented through this project, primary and secondary drivers, and the project aim. The project aim is to increase the staff’s confidence in identifying and managing pediatric asthma by at least 30% and have at least three students referred to the school clinic for further follow-up. The primary drivers include increasing staff confidence in asthma management and identifying possible asthmatic students. Secondary drivers include the staff’s lack of knowledge and confidence in identifying asthma triggers, asthma symptoms, and correct treatment. Other secondary drivers include the staff’s uncertainty about their school policy and the lack of a referral program. Change factors to facilitate project success include asthma identification and management training for the school staff, arranged collaboration between the school staff and the CNA, and establishment of a referral program.

The strength, weakness, opportunities, and threats (SWOT) analysis is also detailed in

Appendix B. Strengths of the proposed project include the following: 1) Support from the school administration and CNA, 2) Cost-effectiveness of the program, 3) Assurance of staff participation, and 4) Obvious need for the educational session. Weaknesses address the fact that the referral program will be based on the willingness of the school staff and CNA and the training will require their already limited time. Opportunities focus on improving students’ safety and health through asthma education and identification of undiagnosed asthma students through the referral program. However, an obvious threat exists to successful implementation as most of the school staff is not used to health education sessions and might not be open to an in-service.

Imagine School at Town Center for the past ten years has not offered an asthma educational session for most of its school staff. Thus, the school staff might lack the necessary knowledge and confidence to successfully prevent, identify, and manage asthma emergencies. Because the school’s asthma prevalence is much lower than the national and state average and there is no established referral program to identify possible asthmatic students, the health of many asthma students might be jeopardized as they remain undiagnosed and unmanaged.

Search Strategy

To address the need for school staff asthma education, a literature search was conducted to answer the following PICO question: “In school personnel, how does an asthma education program compared to no education program affect identification of possible asthmatic students and staff’s confidence in pediatric asthma identification and management?” The literature search was conducted through the EBSCOhost research platform using Medline, CINAHL Plus with Full Text, and APA PsycInfo databases. Search terms used included [“asthma educat*” OR “asthma program” OR “asthma intervention” OR “asthma referral*”] AND [“school personnel” OR teacher OR “school staff”]. An initial search yielded 146 articles from which 37 were excluded due to duplication. All peer-reviewed articles in the English language were then reviewed and included if they mentioned an asthma intervention or education program geared towards school staff. Hence, all asthma programs or educational sessions geared towards students, parents, or only school nurses were excluded. A total of eight articles were included in this synthesis as documented by Appendix C.

Synthesized Key Findings

The Need for an Educational Program

An emerging theme throughout the literature is the need for asthma identification and management education geared toward school personnel (Anderson et al., 2005; Carpenter et al., 2014; Reznik & Halterman, 2016). Most school personnel reported no asthma education classes or sessions offered in their school and thus decreased knowledge in identifying and managing asthma (Anderson et al., 2005; Kawafha & Tawalbeth, 2015; Reznik & Halterman, 2016; Ruvalcaba et al., 2019). Common misconceptions surrounded around recognition of asthma attack symptoms, steps to take during an emergency, current school policies, and medication use (Anderson et al., 2005; Reznik & Halterman, 2016; Neuharth-Pritchett & Getch, 2016). School personnel also demonstrated low confidence scores in identifying and managing asthma attacks (Al Aloola et al., 2017; Neuhartg-Pritchett & Getch, 2016; Reznik et al., 2020; Reznik & Halterman, 2016). Sixty-six percent of teachers felt uncomfortable helping students to manage an asthma attack and 44% worried about a potential asthma attack during their school day (Reznik & Halterman, 2016). High anxiety levels were present among many elementary school teachers as they worried about asthma attacks and medication administration (Reznik & Halterman, 2016).

Benefits and Content of the Educational Program

A standardized asthma education program has been shown to improve school personnel’s knowledge and confidence in asthma identification and management (Kawafha & Tawalbeth, 2015; Neuharth-Pritchett & Getch, 2016; Reznik et al., 2016; Ruvalcaba et al., 2019). Significant recognition of asthma symptoms and comfort assessing for an asthma attack were seen post- asthma-education interventions (Al Aloola et al., 2017; Kawafha & Tawalbeth, 2015; Reznik et al., 2020). Symptom recognition and identification, emergency management, and medication use were all vital components of an effective educational session (Al Aloola et al., 2017; Anderson et al., 2005; Reznik et al., 2020; Reznik & Halterman, 2016; Ruvalcaba et la., 2019). A successful educational session that was conducive to learning was interactive and often included visual aids, PowerPoint presentation, inhaler demonstration, case studies, question/answer session, and/or supplemental printed materials (Al Aloola et al., 2017; Neuharth-Pritchett & Getch, 2016; Reznik et al., 2020; Ruvalcaba et al., 2019). Another vital component of an asthma educational program that has been shown to improve staff’s knowledge and students’ asthma symptoms is reviewing current school policies regarding asthma emergencies and the role of the teacher (Carpenter et al., 2014 Reznik et al., 2020; Ruvalcaba et al., 2019).

Sustainability of the Educational Program and Practice changes

Lastly, a sustainable education program includes asthma practice or policy changes that are written, reviewed with the school personnel, and in collaboration with the school staff (Carpenter et al., 2014; Reznik & Halterman, 2016; Ruvalcaba et al., 2019). Any changes or additions to the current practice are based on the school’s individual need and discussed with the school staff (Carpenter et al., 2014). Evidence shows that practice changes focused on the assessment of students with asthma symptoms, in addition to educating the school staff, have been shown to improve asthma management (Carpenter et al., 2014). However, the practices of teachers are not always consistent with practice guidelines due to insufficient knowledge of existing policies and their processes, lack of written policies, and absence of collaboration between school personnel (Anderson et al., 2005 & Carpenter et al., 2014). Thus, successful implementation of a practice change should be clearly explained, easily accessible, and in collaboration with the school nurse (Carpenter et al., 2014).

The purpose of this project is to improve the confidence of the school staff in pediatric asthma identification and management. This will be accomplished through an educational session focused on asthma prevention, identification, and management within the school setting. The second aim of the project is to improve the safety and well-being of students by establishing a referral program for identifying possible undiagnosed asthmatic students.

Bandura’s Theory of Self-Efficacy is the theoretical framework guiding this project. The concept of self-efficacy is defined as an individual’s belief in their capabilities which determines how one will carry out actions to produce a certain desired outcome. The term self-efficacy and its impact on confidence, motivation, and empowerment was first described by Albert Bandura in 1986 (Bourne, 2021). Self-efficacy influences one’s efforts and subsequently their results (Bourne, 2021). People with higher self-efficacy aim for more ambitious goals, initiate action, and are more persistent in their efforts, even if actual capabilities do not match their beliefs at that time (Warner et al., 2020).

Current literature describes the need for self-efficacy in carrying out any role successfully (Bourne, 2021; Khan et al., 2021). Teacher self-efficacy is associated with motivation, initiative, and resilience, and thus, knowledge application, skill acquisition, and positive engagement of students (Bourne, 2021; Romjin, 2020). Khan et al., (2021) defines caregiver self-efficacy as being confident in their ability to support and take care of a loved one while maintaining emotional well-being and seeking support. Patient self-efficacy has been associated with better asthma disease control and outcomes (Reznik et al., 2020).

One of the goals of this project is to increase the staff’s confidence in preventing, identifying, and managing asthma attacks. Higher self-efficacy is associated with reduced anxiety and improved comfort, thus school staff will be more proactive in creating a safe environment for asthmatic students and managing emergencies (Reznik et al., 2020). Furthermore, they will feel more competent and empowered to make a difference in the lives of their students. As a result, the safety and health of asthmatic students will be improved within the school setting.

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Anderson E.W., Valerio M, Liu M, Benet DJ, Joseph C, Brown R, & Clark NM. (2005). Schools’ capacity to help low-income, minority children to manage asthma. Journal of School Nursing, 21(4), 236–242. https://doi.org/10.1177/10598405050210040901

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Hsu, J., Qin, X., Beavers, S. F., & Mirabelli, M. C. (2016). Asthma-related school absenteeism, morbidity, and modifiable factors. American Journal of Preventive Medicine, 51(1), 23–32. https://doi.org/10.1016/j.amepre.2015.12.012

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Aim Primary Drivers Secondary Drivers Change Ideas