Asthma Education for Rural School Nurses: Resources ... the asthma workshops that she conducted for the children and their parents/caregivers, and was avail-able to make home visits

RESEARCH ARTICLE

Asthma Education for Rural School Nurses:Resources, Barriers, and Outcomes

Marilyn L. Winkelstein, RN, PhD; Ruth Quartey, PhD; Luu Pham, MS;LaPricia Lewis-Boyer, LPN; Cassia Lewis, BS, CCRP; Kimberly Hill, BS; andArlene Butz, RN, ScD

ABSTRACT: This paper describes a school-based asthma education program for rural elementaryschool nurses. The program was designed to teach school nurses in 7 rural counties in Marylandhow to implement and to reinforce asthma management hehaviors in children with asthma andtheir caregivers. Rural nurses who participated in this program increased their mean asthmaknowledge scores more than nurses who did not take the program. The program also increasedself-efficacy among intervention school nurses, but the difference in self-efficacy between inter-vention and control nurses was not statistically significant at follow-up. No effects on documen-tation or communication behaviors were noted. Only 25'M) of the nurses reported an interest inimplementing future asthma educational programs for children with asthma. This study indicatesthe importance of understanding the unique characteristics of rural school nurses, the resourcesthey need, and the barriers and challenges they face in their practice.

KEY WORDS: asthma education, asthma research, barriers to teaching, rural school nurses, self-efficacy

INTRODUCTION

Rural children with asthma are at risk for increasedasthma morbidity due to environmental exposure tochickens, mice, cigarette smoke, pollen, molds, housedust mites, and fungi from silos, barns, and poultryprocessing plants (DoPico, 1996; Warren, 1989;Welch, Hogan, & Wilson, 2003). Recent studies ofchildren living in rural Iowa indicated that children

Marilyn L. Winkclstcin, HN, I'lil), is an iTidependent coiisiiltant iitJohns Hopkins University School of Nursing, Baltiinort', MD.

Ruth Qtiartiy, PhD, is research director, Department of Microbi-ology, Howard University College of Medicine, Washington, DC.

Lmi I'liuin, MS, is a research scientist at Johns Hopkins University,the Bloomherg School ot Public Health, Baltimore, MD.

Liil'ricia Lewis-Boyer, LPN, is a data manager at Johns HopkinsUniversity School of Nursing, Baltimore, MD.

(Msski Lewis, BS, CCRP, is research project director at Johns Hop-kins University School of Medicine, Baltimore, MD.

Kiitiberly Hill, BS, is research project director, Johns Hopkins Uni-versity School of Nursing, Baltimore, MD.

Arlene Biitz, RN, ScD, is associate professor at Johns Hopkins Uni-versitv School of Medicine, Genera! Pediatrics, Baltimore, MD.

from farm families have similar rates of asthma (about12-13.4%) and levels of morbidity comparable tothose of children from nonfarm families (Chrischilleset al., 2003; Merchant et al., 2004) and children in anurban environment (Amr et al., 2003). These authorsconcluded that triggers of asthma exacerbations aresignificant in the rural setting and strategies to im-prove asthma management in rural areas are essential.

Children spend approximately 35-50 hours perweek in school, and rural school nurses who care forchildren with asthma are in an excellent position toinfluence asthma outcomes (Bucher, Dryer, Hendrix,& Wong, 1998; Huss, Winkelstein, Calabrese, & Rand,2001). However, asthma management by rural schoolnurses is often less than optimal (Huss, Winkelstein,Calabrese, Nanda et al., 2001). Many rural schoolnurses do not use peak flow meters to assess asthmaseverity, do not have age-appropriate asthma educa-tional programs in their schools, and do not com-municate or collaborate adequately with parents andprimary health care providers in the management ofchildren with asthma (Calabrese, Nanda, Huss, Win-

170 The lournal of School Nursing June 2006 Volume 22, Number 3

kelstein, Quartey, & Rand, 1999; Huss, Winkelstein,Calabrese, Nanda, et al., 2001).

The school-based asthma education program wasan important component of a larger research projectdesigned to improve the quality of life of rural school-age children with asthma and their caregivers {Butz,Pham, Lewis, Hill, Walker, & Winkelstein, 2005). Theasthma education was designed to teach rural schoolnurses how to improve asthma management of chil-dren in the school setting. This paper describes thiseducational intervention and discusses the resourcesand barriers encountered in the implementation ofthe program and the effectiveness of the program inincreasing asthma knowledge, self-efficacy, and docu-mentation practices of rural school nurses.

BACKGROUND

The Precede health behavior model (Green, Kreuter,Deeds, & Partridge, 1980) provided the theoreticalfoundation for the education program. The Precedemodel is based on the assumption that health prob-lems (such as asthma) are linked to behaviors that areinfluenced by predisposing, enabling, and reinforcingfactors that precede or influence specific health be-haviors (Figure 1). Predisposing factors that could in-fluence asthma management in rural schools are in-sufficient knowledge of asthma care and limited self-efficacy on the part of school nurses. Enabling factorsare limited educational and community resources re-garding teaching asthma self-management skills. Re-inforcing factors are educational programs in theschool setting, social support, and availability ofhealth care services in the community. All of thesefactors can potentially influence the asthma manage-ment behaviors of rural school nurses. The goal of theasthma education program was to reinforce asthmamanagement behaviors by providing rural schoolnurses with the education, resources, and consultationthey need to provide improved asthma managementfor children with asthma and their parents/caregivers.

Resources

Community resources and social support are im-portant enabling and reinforcing factors for asthma

lleallh Behaviors(knowledge, useof peak tloivmeier. elc.)

Healthoutcomes(Qualily ill"life, reduced

scKiiiilabsences.eic.l

Figure 1. Precede Model Applied to Asthma Management

health behaviors in rural school nurses. Several spe-cific resources were developed to enhance asthma ed-ucation for rural school nurses, including conveninga local advisory board. This board was assembled bytbe research team and met before the implementationof the asthma education program. The board identi-fied resources in the rural community that would fa-cilitate asthma education in the elementary schoolsand provided baseline information about cultural andeconomic values of tbe community and local patternsof access to health care. Board members includedcounty school health nursing supervisors, countyhealth department representatives, a pediatric aller-gist, and an agricultural scientist. All individuals hadexpertise in asthma or environmental risk factors as-sociated with asthma morbidity in the rural popula-tion. Members of the board provided scientific over-sight and clinical insight for program developmentand assisted in validation of the study protocols andstrategies. Board members reviewed and approved allthe educational materials used in the asthma educa-tion program.

Another resource was the School Health PersonnelTraining Manual developed by the research team afterconsultation with the local advisory board. This man-ual contained information about the asthma educa-tion program and content on basic asthma patho-physiology, asthma medications, factors infiuencingasthma care, environmental control measures, com-munications with the caregivers and primary care pro-viders, adherence, cultural and ethnic sensitivity,home visit guidelines, and community resources. Eachsection had individual learning objectives and a list ofreferences. All school nurses in the intervention groupreceived a copy of the resource manual at the begin-ning of the program.

A third resource was the Rural Nurse Consultant(RNC), a registered nurse from one of tbe rural coun-ties who was recruited for the asthma education pro-ject. The RNC provided continuity, support, and com-munication with the rural community. She was re-sponsible for implementing the asthma education forthe children with asthma and their parents/caregiverswho were enrolled in the larger research project. Shewas certified as an asthma educator by the NationalAsthma Educator Certification Board and supervisedthe delivery of the asthma education program to theschool nurses. She used a "train-the-trainer" approachin her interactions with the school nurses.

After delivering the asthma education to the schoolnurses, the RNC served as a resource and consultantto nurses in the intervention group. Not only was shealways available by telephone, but she made frequentvisits to the intervention nurses at their schools. Shereinforced specific asthma management behaviors inthe schools, such as encouraging the nurses to obtainand use asthma action plans (AAPs) and peak flow me-ters. She encouraged the school nurses to participate

Volume 22, Number 3 June 2006 The journal of School Nursing 171

in the asthma workshops that she conducted for thechildren and their parents/caregivers, and was avail-able to make home visits to any of the interventionchildren with asthma and their caregivers if the nursesrequested.

Barriers

Several barriers to conducting the educational pro-gram for the school nurses were encountered over thestudy period. Barriers to implementation of the inter-vention varied from county to county. However, timeconstraints for providing the educational workshopsto the intervention nurses were present in all thecounties. The school nurses had limited time for ed-ucation, and most of the workshops had to coincidewith their professional development days scheduled atthe beginning of the school year. Finding a workshoplocation tbat was convenient to all school nurses wasa major hurdle in several counties. Because schools inthe rural communities often were located many milesapart, many school nurses had to travel 1-2 hours be-tween tbeir schools and the workshop location. Dis-tance was such a significant barrier that the workshopshad to be scheduled far in advance to accommodateschool schedules and to enable the nurses to plan forattendance.

Other barriers to implementation included the de-mand that the county receive monetary compensa-tion for the time spent by school nurses at the edu-cational workshops, as well as the restriction thatschool nurses complete research questionnaires onlyduring their free time and not during school workhours. This constraint meant that members of the re-search team often made several additional telephonecalls to the school nurses in the evenings and onweekend days, sent reminder cards, and drove longdistances to pick up study questionnaires. In some cas-es, these constraints interfered with adherence to theoverall timeline for the research project.

Another barrier to implementation occurred duringthe recruitment phase. The Institutional Review Boardof the Johns Hopkins Medical Institutions approvedall aspects and procedures of this study, and informedwritten consent was obtained from every parent/care-giver and school nurse who volunteered to participatein the study. However, to maintain confidentiality ofschool health records, recruitment of the childrenwith asthma and their parents/caregivers was con-ducted by the rural school nurses in the schools andcounties involved in the study. The research team pro-vided permission slips to the schools and the schoolnurses sent the slips home to the parents/caregivers.To be included in the study, children had to meet thefollowing inclusion criteria: (a) have physician-diag-nosed asthma, (b) take prescription medications forasthma, (c) have at least one asthma symptom (i.e.,wheezing, shortness of breath, nighttime cough.

wheezing with exercise or colds) within the past year,and (d) awaken at night within the past 6 monthswith coughing, wheezing, shortness of breath, or chesttightness. Some schools applied their own additionalcriteria for recruitment. For example, in one school,the nurses only sent information about the study andpermission slips to families of children who wereknown to have severe asthma or to children who vis-ited the health room on a regular basis, rather thandistributing information and permission fortns to allchildren who met the inclusion criteria. Becauseschool participation was voluntary, the school prin-cipal and/or school nurse in each school could decidewhether or not they wished to participate. Conse-quently, in one county, only 2 school nurses out of 16chose to participate in the study.

Transfers of nurses from school to school and res-ignations made it difficult for the research team to es-tablish prolonged contact with the nurses and hin-dered communication between the nurses and theRNC. This lack of communication made it difficult todetermine motivators for participation in the educa-tional training program. Although the research teamoffered continuing education units (CFUs) to allschool nurses who participated in the training, earn-ing CEUs did not serve as a motivator, because con-tinuing education is not a requirement for state li-cense renewal or job security. However, providingbreakfast and lunch, as well as time to socialize at theeducational training program, was an important mo-tivator for the school nurses and was appreciatedgreatly by them.

METHODS

Selection of Subjects

School nurses and health assistants were recruitedfrom boards of education or county health depart-ments. Prior to starting the study, the research teammet several times with the board of education orcounty health department personnel in each countyto inform them of the study and to obtain their ap-proval and support. Seven rural counties volunteeredto participate; there were no significant demographicdifferences among the counties (Table 1). The countieswere randomized to either intervention or controlgroup hy the research statistician. Randomization wasdone at the county level to eliminate potential con-tamination of the sample, because some school nursesworked at several schools in the same county. Forty-one elementary schools volunteered to participate.Letters containing an invitation to participate, an in-formed consent form, and a baseline questionnairewere sent to all school nurses and health assistants inthe participating schools. If a school nurse or assistantwished to participate, they returned the informed con-sent and baseline questionnaire in a prepaid, return-addressed envelope. Sixty-four school nurses were el-

172 The journal of School Nursing June 2006 Volume 22, Number 3

igible for participation, but 14 nurses in one countyelected not to participate because of time constraints.As a result, 50 school nurses consented, and 4 did notreturn their completed questionnaires. Thus, 46school nurses were enrolled at baseline for an overallresponse rate of 72%. Eighteen school nurses were inthe control group and 28 were in the interventiongroup. There were no significant demographic differ-ences between the groups at baseline, but nurses inthe control group worked with significantly more chil-dren and cared for more children with asthma (Table2).

Asthma Educational Workshop

Intervention school nurses attended a 6-hour train-ing session designed to teach them asthma manage-ment skills for the school setting. The session con-tained content on asthma pathophysiology, rural en-vironmental triggers and irritants, and current infor-mation about asthma medications and delivery

devices. The train-the-trainer model provided the ba-sis for educating the school nurses, and hands-on

Intervention school nurses attended a6-hour training session designed to teachthem asthma management skills for theschool setting.

demonstrations were an essential part of the program.During the training program, school nurses practicedusing peak flow meters, placebo asthma medications,and delivery devices {i.e., metered dose inhalers, spac-ers, and nebulizers) until tbey could demonstrate pro-ficiency with these devices. At the training session, theRNC stressed the importance of encouraging all par-ents/caregivers of children with asthma to obtain anAAP from their primary care provider. Each interven-tion nurse was given a dollhouse to use in the healthsuite to help children to identify environmental asth-

Table 1. Selccfcd Demographic Characteristics of Rural Counties

Characteristic

Total population'

Race'CaucasianAfrican AmericanOther

Median household income''Poverty status'"Asthma prevalence'

(bounty 1

30,861

81.7%14.8%3.5%

$38,14210.4%6.7%

County 2

30,612

69.4'K)28.4%

$33,44813.5%7.{)%

County 3

44,108

%9%8.8'Ki2.2%

$S9,8545.6%6.4'M.

County 4

92,746

93.4%3.9%2,7%

$51,2937.3'Ki8.1%

County S

19,680

79.6'Ki17.4%3.0'K.

$40,41210.3%

7.3%

County 6

34,670

82'Ki15.4%2.6'M.

$46,6377.9%5.3%

County 7

49,604

81.2%16.7%2.1%

$40,5659.4%8.8%

' From U.S. Census Bureau (2i;)();5|.'' From U.S. Census Bureau (2()(K)).' From State of Maryland Department of Health and Mental Hygiene (2003).

Table 2. Demographic Characteristics of School Nurses at Baseline

Characteristic

GenderWomenMen

Mean ageRace CaucasianNurses with Asthma

Job titleNurse practitionerRegistered nurseLicensed practical nurseHealth room assistant

Educational levelHigh schoolAssociate degreeBachelor's degreeMaster's degreeUnspecified

Mean number of years in school nursingNumber of schoolsMean number of children in schoolMean number of children with asthma

Intervention (« = 28)

27 (96%)1 (A"/o)

46 years28 (100%)

1 (4%)

20 (71%)8 (29%J

1 (4'M.)5 (18%)

10 (35%)1 (4%)

11 (39%)7.41

42530

Control in = 18)

18(100%)

45 years18 (100%)2 (11%)

1 (6'!̂ .)13 (71%)1 (6'K))3 (17%)

3 (17%)5 (28'M.)6 (33%)2 (11%)2 (11%)7.71

54342

Statistical Significance

chi-square = 0.05p = .82

t - -0.39, p = .70

chi-square = 0.16p = .68

chi-square - 6.22p = .10

chi-square = 6.70p - .15

t = .18, p = 89t= -1.40,p = .17t = 2.44, p - .02t = 2.39, p = .02

Volume 22, Number 3 lune 2006 The journal of School Nursing 173

ma triggers and an Environmental Protection Agencyschool kit to help them to identify, to solve, and toprevent indoor air quality problems in their school.Finally, intervention school nurses received a resourceguide with a directory of services provided hy localgovernmental and private agencies; the School HealthPersomiel Trainitig MatUHil; the National Heart Lungand Blood Institute videotape, Making a DifferenceAsthtna Matiagemctit in Schools; a booklet entitled Nurs-es: Partners in Asthma Care; peak flow meters for use inthe school health suite; and the consultation servicesof the RNC.

During the training program, schoolnurses practiced using peak flow meters,placebo asthma medications, and deliverydevices until they could demonstrateproficiency with these devices.

School nurses in the control group received the re-source guide; the Makittg a Differetice Asthma Matiage-ment in Schools videotape; the Nurses: Partners in Asth-ma Care booklet; and peak flow meters. No education-al training was provided, and they did not receive anyconsultation with the RNC.

Study Instruments

All school nurses completed a baseline question-naire with questions relating to demographic charac-teristics, asthma knowledge, asthma self-efficacy, andasthma documentation and communication practicesat the beginning of the study before the asthma edu-cational training was delivered to the interventionnurses. All school nurses completed the same ques-tionnaire at follow-up 1 year later.

Asthma knowledge was measured by a 20-itemquestionnaire that contained items related to the in-struction presented in the training session and theSchool Health Personnel Training Mamial. Each question-naire item had four response options with one correctanswer. Total asthma knowledge scores could varyfrom 0-20 points. A score of 16 correct answers (80%)was considered passing. Content validity for this ques-tionnaire was high, as reported by an expert panelconsisting of a pediatric allergist and two pediatricnurse practitioners. Cronbach's alpha reliability of theknowledge questionnaire was moderate at .67.

Asthma self-efficacy was measured by a 15-itemquestionnaire that contained items designed to reflectthe components of the training session and the degreeof confidence that the school nurse had in performingasthma management activities such as teaching chil-dren how to use a peak flow meter. Participants pro-vided responses on a 7-point Likert scale ranging from1 (indicating "never confident") to 7 (indicating "ex-

tremely confident"). Total scores could vary from 15-105 points, with higher scores indicating greater con-fidence. Cronbach's alpha reliability for this instru-ment was .73.

Documentation of asthma management and com-munication activities was measured by a 17-item ques-tionnaire designed to measure how frequently theschool nurse performed specific asthma managementor communication activities, such as using peak flowmeters in the health suite and telephoning caregiversor primary care providers. Participants provided re-sponses on a 5-point Likert scale ranging from 1 (in-dicating "never") to 5 (indicating "all the time") foreach activity or communication. Total scores couldvary from 17-85 points, with higher scores represent-ing more frequent documentation and communica-tion.

RESULTS

Asthma Knowledge

After the educational program, the mean asthmaknowledge score of the intervention school nurses in-creased from 15.57 points to 17.15 points, whereas themean score of the control nurses remained at 17.47.The increase in asthma knowledge for the interven-tion nurses was statistically significant. Despite the in-crease in asthma knowledge scores for interventionnurses, the difference between the groups was not sta-tistically significant at follow-up. Examination of thenumber of correct knowledge items between baselineand follow-up indicated that intervention nurses hada greater increase in the number of correct answersfrom baseline to follow-up than control nurses had.Individual item analysis also indicated that more in-tervention nurses answered the item relating to im-mediate management of an asthma episode in theschool setting correctly than did nurses in the controlgroup (Table 3).

Despite the increase in asthmaknowledge scores for intervention nurses,the difference between the groups wasnot statistically significant at follow-up.

Asthma Self-Efficacy

Although the intervention school nurses had great-er self-efficacy scores at follow-up than the controlnurses had, the difference between the groups was notstatistically significant (Intervention mean = 5.67;Control mean = 5.52; f = - . 6 ; p = .55). There was nocorrelation between asthma knowledge and self-effi-cacy for either group of nurses at baseline or follow-up. No significant differences between the groups in

174 The journal of School Nursing lune 2006 Volume 22, Number 3

total mean documentation scores were noted at base-line or follow-up.

Evaluations From School Nurses

A telephone survey of all school nurses {n = 41) wasconducted 1 year after the research project was fin-ished to obtain their evaluations of the education pro-gram. A standardized interview questionnaire wasused, and responses were obtained from 28 (68%)school nurses. Eighty-five percent of the nurses listedthe education training session as the best part of thestudy. Seventy percent said they used the workshopinformation about peak flow meters, spacers, metereddose inhalers, asthma medications, how to commu-nicate with children, and how to obtain AAPs fromthe primary care providers in their nursing practice inthe schools. However, only 7 (25%) of the school nurs-es said they would be interested in conducting anasthma education program independently in theirschools in the future. Time constraints and a lack ofconfidence in their teaching ability were the primaryreasons that the school nurses were not interested inconducting an asthma education program.

Seventy percent said they used theworkshop information about peak flownneters, spacers, metered dose inhalers,asthma medications, how to communicatewith children, and how to obtain AAPsfrom the primary care providers in theirnursing practice in the schools.

DISCUSSION

These results indicate that providing education torural school nurses can increase their asthma knowl-edge, because intervention nurses who received theasthma education increased their knowledge scoressignificantly from baseline to follow-up. However, it

must be noted that the two groups had significantlydifferent mean knowledge scores at baseline (Table 3).This is a limitation of the study and may have beenrelated to the fact that school nurses and health assis-tants in the control group were responsible for moretotal children and took care of more children withasthma. It is also interesting to note that although thecontrol nurses had higher knowledge scores at bothbaseline and follow-up, almost half of them (47%) an-swered the question about management of an asthmaepisode in the school setting incorrectly at follow-up,whereas 88% of the intervention nurses answered thisquestion correctly.

Although the difference in self-efficacy between thegroups was not significant at follow-up, data indicatethe asthma education program was successful in in-creasing self-efficacy among school nurses in the in-tervention group. This finding is congruent with aprevious study indicating that education programscan increase school nurses' self-confidence in manag-ing asthma (Bullock, Libbus, Lewis, & Gayer, 2002).

IMPLICATIONS FOR SCHOOL NURSING PRACTICE

The results of this study indicate that more schoolnurses who received the asthma education programanswered a critical thinking question about asthmamanagement correctly (Table 3). This is important be-cause caring for children during asthma episodes isone of the most frequent activities that school nursesperform (Borgmeyer, Jamerson, Gyr, Westhus, &Glynn, 2005; Bucher, Dryer, Hendrix, &t Wong, 1998;Calabrese, Nanda, Huss, Winkelstein, Quartey, &Rand, 1999). It is essential that school nurses knowhow to respond during these episodes and that theyfeel comfortable implementing nursing interventions.Management of acute asthma episodes was empha-sized in the education program, and special effortswere made to teach intervention nurses how to usemetered-dose inhalers, spacers, and nebulizers to ad-minister asthma medications. The school nurses whoreceived this education indicated that it was very im-

Table 3. Analysis of Asthma Knowledge Scores and Individual Knowledge Items

MeanIntervention Group

(H = 26)-Control group

(n = 15)- Statistical Signiflcauce

Mean total score at baseline (range - 0-20) 15.57 (78%)Mean totai score at follow-up (range = 0-20) 17.15 (86%)Mean change in total score (baseline to follow-up) 1.58

Critical thinking item: A child with moderate persistentasthma comes to the health room with wheezing thatstarted while running on the playground. The first thingthe school nurse should do is have the child: (a) drinkseveral glasses of water; (b) relax by taking several fastdeep breaths; (c) take his/her controller medication; (d)take his/her quick reliever medication.'" 23

17.47 (87%)17.47 (87%)

-0.07

7 (47%)

t = 3.15, p = .004r = 0.64, p = .53Wilcoxon rank sum = 107,

p = .03

chi-square = 6.469p = .01

•* Diita unavailable at baseline or follow-up for two control nurses and three intervention nurses.'' Correct answer.

Volume 22, Number 3 lune 2006 The journal of School Nursing 175

portant to them; 7{Wa stated they used informationfrom the workshop in their daily nursing practice.

Although the train-the-trainer modelsuccessfully increased asthma knowledgeand self-efficacy, the model was notsuccessful in empowering rural schoolnurses to provide educational programs tochildren with asthma and their parents/caregivers. Only 25% of these nurseswere interested in providing asthmaeducation independently in the future.

Although the train-the-trainer model successfullyincreased asthma knowledge and self-efficacy, themodel was not successful in empowering rural schoolnurses to provide educational programs to childrenwith asthma and their parents/caregivers. Only 25%of these nurses were interested in providing asthmaeducation independently in the future. Although theystated that they had learned new asthma managementskills and were applying these skills in their practice,many school nurses were not comfortable incorporat-ing their new knowledge and skills into formal edu-cational programs for children and their parents/care-givers. This result is especially interesting becausehealth teaching is an expectation of the school nurseand an important part of the Scope and Standards ofSchool Nursing Practice {National Association ofSchool Nurses [NASN] & American Nurses Association,2005). It is essential that school nurses feel comfort-able teaching children and their parents/caregiversnot only about asthma, but other health issues as well.A lack of comfort suggests that rural schooi nursesmay need continuing education programs that pro-vide them with the opportunities and confidence thatthey need to actually develop, teach, and manage for-mal health education programs.

. . . many school nurses were notcomfortable incorporating their newknowledge and skills into formaleducational programs for children andtheir parents/caregivers. This result isespecially interesting because healthteaching is an expectation of the schoolnurse and an important part of the Scopeand Standards of School NursingPractice.

a formal asthma education program in their schools.In their evaluations of the asthma program, manynurses stated that their hours had been cut back re-cently and they had no time for education. Previousstudies of school nurses have indicated they havemany responsibilities and little time and few resourcesto help them implement education programs (Hea-man & Estes, 1997). However, recent reports of edu-cational programs implemented by school nurses in-dicate that such programs are successful and have thepotential to produce substantial results {Gregory,2000; Mooney, 2005).

Lack of time was another reason thatrural school nurses reported they wouldnot be able to implement a formal asthmaeducation program in their schools.

Lack of time was another reason that rural schoolnurses reported they would not be able to implement

Future research should explore specific opportuni-ties to provide rural school nurses with protected timeand the resources they need to provide education inthe school setting. For example, one study recom-mended the use of trained volunteers and nursing stu-dents to help schooi nurses (Heaman & Estes, 1997).The use of volunteers may be particularly relevant andappropriate in the rural setting, because studies haveindicated that rural individuals are self-reliant and ac-customed to relying on lay resources and a network ofrelatives and neighbors for help (Scharff, 1998). Nurs-ing students would be a valuable resource, becausenursing instructors are frequently in need of clinicalpractice sites, and rural elementary schools are an ide-al setting for students to implement health educationprograms that are frequently required by child andcommunity health undergraduate and graduate cours-es. Another resource for rural nurses is the School NurseAsthma Managemetit Progtatn Resource Manual devel-oped by the NASN {2004). This manual providesschool nurses with the tools that they need to pro-mote optimal asthma management for their studentsand provides an excellent foundation for rural schoolnurses and educators who wish to develop school-based asthma education programs.

Many nurses who participated in this researchstudy commented that they lacked specific materialsto provide adequate asthma education, and they weregrateful that the research team had provided peak flowmeters to the schools and the children enrolled in thestudy. School nurses should approach their local com-munity leaders and businesses to determine whetherthese individuals and organizations are interested inbuying peak flow meters and asthma devices, such asspacers and nebulizers, for their schools. Providingcomputers and access to computerized informationsystems on asthma and e-mail contact with asthma

176 The journal of School Nursing June 2006 Volume 22, Number 3

experts, such as the RNC used in this study, are otherresources that could be used by rural school nurses.

SUMMARY

. . . rural elementary school nursescontinue to need time, educationalmaterials, and confidence to implementasthma education programsindependently.

This research study indicated that school-basedasthma education can increase asthma knowledge andself-efficacy among rural school nurses. It also foundthat rural school nurses value such education and in-corporate the knowledge and asthma managementskills gained from these programs into their nursingpractice. However, rural elementary school nursescontinue to need time, educational materials, andconfidence to implement asthma education programsindependently.

. This study was funded through a grant from the Na-tional Instilutf of Nursing Research, National Institute of Health, 1-ROl-NR05062-1.

REFERENCES

Amr, S.. Bollinser, M. E., Myers, M., Hamilton, R. G., Weiss, S. R., Ross-man, M., Osborne, I.,, Timmins, S., Kimes, D. S., Levine, E. R., &Blaisdell, C. J. (2003). Environmental allergens and asthma in urbanelementary schools. Annuls of Allergy; Asthniu, & hnmunology, 90(1),:H-4O,

Borgmeyer, A,, Jamerson, P., Gyr, P., Westhus, N., St Glynn, E. {2005).The school nurse role in asthma management: Can the action planhelp? jouriuil of School Nursing, 2!|1), 23-30.

Bucher, I.., Dryer, C, Hendrix, E., & Wong, N. (199H), Statewide assess-ment of school-age children with asthma in Delaware, lournal ofSchool Hmlth, 68(7), 276-2S\.

Bullock, L. F., Libbus, M. K., Lewis, S., & Gayer, D. (2002). Continuingeducation: Improving perceived competence in school nurses, lournalof School Nursing, 18(6), 360-363.

Butz, A., Pham, I,., Lewis, L., Lewis, C, Hill, K., Walker, |., fi Winkelstein,M. (2005). Rural children with asthma: Impact of a parent and childasthma education program, lournal of Asthma, '^2(101, 813-821.

Calabrese, B. J., Nanda, J. P., Huss, K., Winkelstein, M., Quartey, R. L, 8:Rand, C. S. (19yy). Asthma knowledge, roles, functions, and educa-

tional needs of school nurses, journal of School Health, 69(6), 233-238.

Chrischilles, h., Ahrens, R., Kuehl, A., Kt'lly, K., Thorne, P., Bermeister,L., k Merchant, J. (2(X)4). Asthma prevalence and morbidity amongrural Iowa school children, lournal of Allergy and Cliniciil hnnmnology,113, 66-71.

DoPico, G. A. (1996). Lung (agricultural/rural). Otahiryngology-HeuLl tunlNeck Surgery, 114, 212-216.

Green, L. W., Kreuter, M. W., Dteds, S. G., tt Partridge, K. B. 11980), Healtheducation planning: A diagnostic iipjmhicli. Palo .Altt), CA: Mayfield Pub-lishing Co.

Gregory, E. K. (2000). Empowering student-S on medication tor asthmato be active participants in their care: An exploratory study, journalof School Nursing, 76(1), 20-27 .

Heaman, D.J., & Estes, J. (1997|. The free-running asthma screening test:An approach to screening for exercise-induced asthma in rural Ala-bama, journiil of School Health, 67(3), 83-88.

Huss, K., Winkelstein, M., Calabrese, B., Nanda, J.. Quartey, R., Butz, A.,Resto, M., Huss, R., Si Rand, C. S. (2001). Rural school nurses asthmaeducation needs, journal of Asthma, 38{3), 253-260.

Huss, K., Winkflstein, M., Calabrese, B., & Rand, C. (2001). Roie ofschool nurses in asthma management. PuetlUitric Drugs, 3{S), 321-328.

Merchant, J, A., Naleway, A. L., Svendsen, E. R., Kelly, K. M., Burmeister,L. K, Stromquist, A. M., Taylor, C. D., Thornu, P. S., Reynolds, S. j . ,Sanderson, W. T., ts: Chrischilles, L. A. (2004). Asthma and farm ex-posures in a cohorl of rural Iowa children. Eiivironmetital health per-spectives, /i3(3), 350-356.

Mooney, B. (2005) Fighting fat in schooi. Advance for Nurses, 7(14|, 36-40.

National Association of School Nurses (NASN). (2004). Resource manualfor comprehensive school-based asthma management. Castle Rock, CQ:Author.

National Association of School Nurses (NASN) & American Nurses As-sociation (ANA), (2005). 5i:7i(»u/ nursing: Scope and standards of practice.Washington, DC: Author,

Scharff, J, E. (1998), The distinctive nature and scope of rural nursingpractice: Philosophical bases. In H. J. Lee (Ed.), Conceptual basis forrural nursing (pp. 19-38), New York: Springer Publishing.

State of Maryland Department of Health and Mental Hygiene, (2003),Asthmu in Maryland 2003. Baltimore: Department of Health and Men-tal Hygiene, Retrieved August 2005 from http://www.Ilia,state.md,us/mch/pdf/.'\sthma_in_Maryland.2003,pdf

U.S, Census Bureau. (2(J(J0), Small Area Income and Poverty Estimates.Washington, DC: Housing and Household Economic Statistics Divi-sion. Retrieved August 2005 from http://www,census.gov/ftp/pub/hhes/www

U.S, Census Bureau. (2003), Maryland QuickFacts. Washington, DC: U.S.Census Bureau. Retrieved August 2005 from http://quickfacts.census,gov/qfd/statcs/24000.html

Warren, C.P.W. (1989). Qvcrview of respiratory health risks in agricul-ture. In J.A. Dosman fk D,W, Cockcroft (Eds.) Principals of health andsafet}' in agriculture (pp. 47-49), Boca Raton, FL: CRC Press.

Welch, J, L, Hogan, M, A,, & Wilson, N, W, (2003). Mouse allergy amongasthmatic children from rural Appalachia. Annals of Allergy Asthma &Immunology, 90, 223-225.

Volume 22, Number 3 June 2006 The journal of School Nursing 177