A Review of School Nurses’ Self-efficacy in Asthma Care

Abstract

Asthma is the most common pediatric chronic respiratory illness and has a significant influence on children’s health, school attendance, and overall school success. Despite the effect of education and training, gaps remain in understanding school nurses’ self-efficacy in asthma care. The purpose of this integrative literature review is to gain a greater understanding of school nurses’ self-efficacy in asthma care. Themes and topics in the current school nursing literature regarding self-efficacy in asthma care include the value of continuing education, educational interventions and the use of resources in clinical practice such as the asthma action plan. This review indicates the importance of developing a greater understanding of the unique features of school nursing, the necessary resources, and the external factors that influence practice. Further research to establish a framework to evaluate how a change in practice may support school nurses’ self-efficacy and promote positive student health outcomes is needed.

Asthma, the school-aged child and the role of the school nurse

Asthma is a chronic lung disease that affects approximately six million children in the United States and accounts for nearly 14 million missed school days (Center for Disease Control (CDC), 2017). It may negatively affect academic achievement in school-aged children and lead to poor academic performance and increased dropout rates (Basch, 2011; Fowler, Davenport, & Garg, 1992). It is strongly associated with absenteeism (Cicutto, Gleason, & Szefler, 2014; Hollenbach & Cloutier, 2014), as approximately 36,000 children miss school each day due to asthma symptoms. Low-income students comprise a majority of children with asthma who miss school (Meng, Babey, & Wolstein, 2012). Proper asthma care management of children with asthma is vital for their social (Rhee, McQuillan, Chen, & Atis, 2017), emotional (Rhee et al., 2017), physical (Rhee et al., 2017), and intellectual outcomes (Basch, 2011).

The National Asthma Education and Prevention Program (NAEPP) advises clinicians on asthma management and provider behaviors that accompany asthma care. The goals and research commitments of NAEPP include raising the awareness of patients, health care practitioners, and the public about the seriousness of asthma; ensuring the timely recognition of symptoms; and increasing effective control between health care providers and patients through the utilization of modern treatment and education (U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, 2014a). Given that school nurses frequently provide care to children with asthma in the school setting, they must stay current on national guidelines, understand how the guidelines impact practice, and implement asthma management programs based on the guidelines (Gleason, Cicutto, Haas-Howard, Raleigh, & Szefler, 2016). It is also vital that nurses receive appropriate education that supports their ability to provide care (De Tratto et al., 2014). This education includes comprehensive and structured asthma-based learning that enhances understanding of evidence-based guidelines, with the intention of improving asthma-patient outcomes (Huss, Winkelstein, Calabrese, & Rand, 2001; Policicchio, Nelson, & Duffy, 2011).

The school nurse plays a vital role in providing care for acute, chronic, emergent, and episodic health issues, including asthma. In managing the needs of the child with a chronic illness at school, the nurse requires confidence in her/his ability to provide care to offer the best experience for the student (Lewallen, T.C., Hunt, H., Potts-Datema, W., Zaza, S., & Giles, 2015). By working with stakeholders, the school nurse can offer a comprehensive school health program and integrate health and education for students, parents, and school personnel.

The school nurse is uniquely well suited to provide quality asthma care which includes assessment, advice, support, and referral. The nurse offers asthma education to students, parents, and faculty; collaborates with community health providers to deliver asthma action plans (AAPs) and medication orders; and assists in the reduction of environmental triggers in the school setting. In addition, the school nurse has the power to address barriers to care, such as lack of communication between parents, health care providers and school staff, and also to advocate for students with asthma during the school day. School nurses can help prevent chronic symptoms, such as coughing or breathlessness after a physical education class. They can support the maintenance of normal pulmonary function (i.e., by recording daily peak flow readings and sharing the data with families and providers). In addition, they can encourage normal activity levels for the student, such as attendance at school and sporting events (U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, 2014a, 2014b).

More important, school nurses can advocate for a comprehensive school health program and integrated health education for students, parents, and school personnel. A comprehensive health program, along with strong health education, can reduce barriers to care. Therefore, school nurses’ performance of behaviors that support quality asthma care can reduce the risk of asthma exacerbations, which in turn can reduce emergency visits and hospitalizations and increase overall school attendance.

One major factor that affects performance of a behavior - in any workplace - is self-efficacy (SE). Self-efficacy influences how individuals act, feel, think and motivate themselves (Zulkosky, 2009). Studies have found that increased SE in workers can boost motivation and work-related performance (Bandura, 1997). In routine school practice, school nurses must handle and respond to a variety of health situations and unexpected emergencies. They must also provide routine and chronic care, including education, to students, families and school personnel. It is vital that school nurses exhibit confidence and be prepared to act - in a variety of circumstances that they may encounter in their work environment. An examination of school nurses’ SE in asthma care may help evaluate methods that increase SE, which in turn can affect performance and motivation and support both nursing and patient outcomes. This exploration can amplify school nurses’ voices in school health-policy development and performance of asthma management behaviors. This review will add to the existing school health literature. The literature demonstrates a positive relationship between school nurses’ SE and management of students’ diabetes (Fisher, 2006), and also between school nurses’ SE and care of students in a childhood obesity prevention program (Quelly, 2014). In a review of an obesity-prevention practice using measurement of body mass index, results showed that school nurses with a graduate degree reported higher levels of SE in performing obesity prevention behaviors for school-aged children than nurses with a bachelor’s degree or less (Hendershot, Telljohann, Price, Dake, & Mosca, 2008). These findings are relevant because it is important to encourage school nurses to actualize their potential in caring for children, no matter the diagnosis.

Overview and measurement of self-efficacy

Bandura’s social learning theory (SLT) (Bandura, 1977), renamed social cognitive theory in 1986, saw the inception of the term SE as a core construct (Bandura, 1986) and is defined as “belief in one’s capabilities to organize and execute the courses of action required to produce given attainments” (Bandura, 1997, p.3). Self-efficacy (SE) creates variance in how people think, feel and motivate themselves. Those with low SE tend to experience more stress, depression, anxiety, and helplessness while those with high SE tend to accept challenges without avoidance (Zulkosky, 2009). Higher levels of SE are correlated with goal-setting and significant commitment to those goals (Zulkosky, 2009).

Previous literature regarding SE suggests that role-modeling, positive feedback (Bandura, 1997), and supportive programs are useful methods for bolstering nurses’ SE (Cicutto et al., 2017). Nurses must believe that they can accomplish desired results. Otherwise, they may have little motivation to act (Bandura, 1997). With increasing acuity (intensity of nursing services required) of the student health population, rising poverty rates, and widening racial and ethnic health disparities, school nurses play a critical role in supporting the health of the pediatric population. If we appreciate the effect of school nurses’ SE on their provision of asthma care, we can increase the support they need to achieve desired health care behaviors. A review of the literature that explores the role of school nurses’ SE in asthma care and emerging themes is needed.

Gaps in current research

The number of children with acute and chronic disorders who attend school has rapidly changed the landscape of school health. Historically, children with more complex medical needs were cared for in institutions, hospitals or at home – where education may have been provided or provided in a limited manner. The Individuals for Disabilities Act (IDEA), ratified in 1975, stated that children with disabilities and chronic health conditions were entitled to receive a free and appropriate education while accommodating the disability (U.S. Department of Education, 2013). With the passage of IDEA and recent advances in medical technology, more children are allowed to attend school than in previous generations. School nurses with high SE are essential in the optimization of care and the ability to affect behavior and health outcomes for children, both with and without a chronic illness or disability (Fisher, 2006; Quaranta & Spencer, 2015; Quelly, 2014).

The National Association of School Nurses (NASN) advocates for more research and data-driven practice in school health and school nursing (Hootman, 2002; National Association of School Nurses, Maughan, E., Bobo, N., Butler, S., Schantz, S., & Schoessler, 2015). Hence, it is essential to review the existing literature on school nurses’ SE in asthma care, particularly the data on asthma knowledge, care, and management, to determine its contribution to the school nurses’ performance of asthma management behaviors.

Significance of the problem

While it is vital to understand the practice behaviors of school nurses, a better understanding of what supports those behaviors in the clinical setting is needed. Engelke, Swanson, & Guttu (2014) report that asthma management in schools is a complicated process. They found that school nurses were most concerned with the safety of children, making sure emergency procedures were established, educating staff and promoting self-care of students (Engelke et al., 2014). Quaranta & Spencer (2016) assert that school nurses who lack confidence in their teaching ability decline to conduct asthma education; decreasing barriers to practice and empowering school nurse to have higher SE in performing asthma-related behaviors can improve patients’ outcomes. School nurses are the health experts in the school system (Council On School Health, 2016) and, therefore, have to believe in their ability to provide expert quality care and feel comfortable with their knowledge, skill level and decision-making abilities (Zulkosky, 2009). It is essential that nurses exhibit confidence in their work when providing care and educating students, families and school personnel on asthma, trigger avoidance, peak flow monitoring, and proper use of an inhaler (U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, 2014b).

The significance of understanding the SE of school nurses in asthma care is that school nurses are generally the sole health provider in a school. In their clinical settings, school nurses have the potential to improve asthma care through asthma management behaviors that include education, standardization of and communication of school policies, use of an AAP, a clear policy regarding self-carried asthma inhalers in school, and assessment of environmental triggers for asthma exacerbations (Hollenbach & Cloutier, 2014). Unfortunately, while the school nurse is a vital ally for an active asthma management program, the nurse does not always establish school health policies, which may be set at the school board or administrator level (Cicutto, 2009). Therefore, an examination of school nurses’ SE in asthma care may help evaluate methods to increase their SE.

Methods

Design

A search of the literature was conducted with National Library of Medicine Medical Subject Heading (MESH) terms and keywords concerning asthma, SE, and school nursing in two databases: PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) with no restriction to years of publication. Papers reviewed included those from 1996–2017. The results of the search strategies are found in Table 1. Search terms included “asthma,” “school nursing,” “school health, “school health services,” “school nurse role,” “competence,” “professional competence,” “confidence,” “self-confidence,” “efficacy” and “self-efficacy.” Search methods were validated by a librarian affiliated with the authors’ University. The terms “confidence,” “competence,” and “professional competence” were included after an initial search of the literature found the terms to occur in addition to or instead of the word “self-efficacy.” An integrative review was chosen as it is a broad review done to understand a phenomenon (Whittemore & Knafl, 2005), generate new knowledge, and include a critique to examine inconsistencies in the literature (Torraco, 2016). The purpose of this integrative review is to gain a greater understanding of the construct of school nurses’ SE in asthma care.

Table 1.

Review of studies

Author and publication year	Study design	Sample size and population	Relevant findings	Strength of evidence	Description of measurement tool and sample assessment of the measurement
Borgmeyer et al., 2005	Descriptive analysis, Cross-sectional	n=76; Elementary school nurses (SNs) from the St. Louis Metropolitan area who attended an asthma conference	72% of SN reporting that they “agreed” or “strongly agreed” that having an AAP increased their confidence in caring for a child with asthma	Level III	Investigator developed; 0-5 scale of perceived comfort level in performing an asthma-related skill. i.e. School nurse comfort with performing a respiratory assessment
Bullock et al., 2002	Quasi-experimental	n=561; SN who had attended one of all of the six continuing education programs about diabetes management, asthma management, suicide prevention, mental health issues, seizure disorder and clinical skills (173 of 561) and other SN in Missouri (388 of the 561)	SN who completed the in-person asthma course had a higher level of perceived competency in practice than those who did not participate (p=0.0001). Total mail-in survey return rate was 36%	Level III	Investigator developed; 1-4 scale of perceived competence specific to asthma management behaviors of the nurse. i.e. Questions on school nurses’ asthma management
Chao et al., 2003	Quasi-experimental	n=793; SN in Taiwan who were part of the National Asthma Education Program	After the teaching sessions, significant improvements were noted for all items of a nurses’ SE for managing an asthmatic episode A five-item SE Likert scale employed for post-education assessments demonstrated significant improvements of nurses’ SE in the management of an asthmatic episode (from a mean of 32.5/50 to 43.23/50, p<0.001)	Level II	Designed as part of an educational assessment by the investigative team; 1-5 scale to measure efficacy in asthma management. i.e., Questions on how school nurses teach and assist students with a metered dose inhaler
Cicutto et al., 2017	Part 1: modified Delphi Part 2: Quasi-experimental	Part 2: n=40; SN in Colorado who had completed the Asthma and Allergy Foundation of America online course followed by a local face-to-face workshop	Part 2: Following the online course and local workshop, statistically significant improvements were found in knowledge, confidence and inhaler skills Self-confidence scores of nurses were lowest at baseline for the identification of at-risk status students with asthma and for providing care and education according to the identified care plan, but post-test scores showed improvement in self-confidence regarding asthma care and demonstrating inhaler technique (p=0.005). After the interventional workshop, which included a hands-on skill assessment of inhaler skill, there was a significant improvement noted in confidence (2.4-3.3, p=0,005). Possible scores ranged from 0-4, zero being not at all confident to four being completely confident.	Level II	Investigator developed; 0-4 scale to measure self-efficacy. i.e., Identify at-risk status for students with asthma
Gau et al., 2006	Cross-sectional	n=60; SN in Taipei, Taiwan. Schools covered range from preschool-college	When reviewing subscale scores between groups (divided by years of experience), there was a significant difference for those SN who had less than one year of experience as they reported feeling less confident in medication administration than those with more experience (F=3.12, p<0.05). There was also a significant difference on the total AMES for SN who had experience using peak flow monitoring (t=−5.37, p<0.001) as well as those who had experience with inhaled medication (t=−2.89, p<0.01).	Level III	Investigator developed; 7-point scale measuring efficacy. i.e., School nurse confidence with evaluating the peak expiratory flow rate
Hanson et al., 2013	Descriptive analysis, cross-sectional	Survey 1: n=65; SN in southeast Minnesota Survey 2: n=12	Survey 1(on-line): Having an AAP influenced SN SE in the timing of administration of asthma medication (52.5% of SN) and when to send a child for emergent care (50.8% of SN). Survey 2 (on-line): 11/12 nurses agreed or strongly agreed that the use of a portal to receive the AAP increase their confidence in contact the MD related to student asthma concerns.	Level III	Investigator developed; Likert scale and open-ended questions to measure perceived SE. i.e., The AAP helped the school nurse know when to provide medication to a student
Putman-Casdorph et al., 2011	Quasi-experimental/Pilot study	n=20 SN from 2 rural counties in West Virginia	Assessment of the intervention groups’ confidence levels pre and post education module via a questionnaire. The baseline and post-Asthma Distance Education Program (ADEP) scores in confidence differed between the intervention groups with the synchronous group (live intervention) having a better score than the asynchronous (pre-recorded intervention) (p=.017). Both groups were found to be effective in increasing competence and confidence of school nurses’ SE in asthma care (p=.005).	Level II	Used the School Health Personnel Questionnaire (SHPQ) developed by Winkelstein (see below) to measure SE. i.e., School nurse confidence in teaching peak flow skills to children
Quaranta et al., 2015	Descriptive, correlational design	n=537; SN recruited through NASN via email and website	A weak positive correlation between the perception of importance of AMBs and SE in asthma care (r=.232, p<.01), a moderate positive correlation between SE in asthma care and asthma attitude (r=.337, p<.01) and a weak positive correlation between asthma knowledge, asthma attitude with SE in asthma care, respectively, (r=.157 and .178, p<.01) was found.	Level III	Investigator developed; 4-point Likert scale measuring SE. i.e., I can correctly demonstrate how to use a peak flow meter.
Quaranta et al., 2016	Descriptive, correlational design	n=537; SN recruited through NASN via email and website	There was no significant correlation between barriers to asthma management reported by SN and SE in asthma care (r= −.034).	Level III	Investigator developed; 4-point Likert scale measuring SE. i.e., I can determine when to administer asthma medication when the student with asthma is having symptoms.
Winkelstein et al., 2006	Randomized control	Part 1= n=46 Part 2= n=41 (18 control, 28 intervention); 7 rural counties in Maryland	The intervention group had > SE scores at follow-up than the control nurses, but the differences were not statistically significant (p=0.55). There was no correlation between asthma knowledge and SE for either group at baseline or follow-up. Baseline knowledge scores: Intervention group 15.57/20 (n=26) Control group 17.47/20 (n=15), t=3.15, p=0.004 One year later telephone survey reported that only 7 out of 41 SN were interested in conducting an asthma education program independently. Time and lack of confidence in their teaching ability were the primary reasons.	Level 1	Investigator developed; 7-point Likert scale measuring SE. i.e., School nurses' confidence in teaching peak flow skills to children

Literature search and data evaluation

The broad search yielded 68 unique publications that were reviewed for relevance to the topic of interest (school nurses’ SE in asthma care). Publications included for analysis met the following criteria: (1) inclusion of school nurses in the sample (2) measurement of the school nurses’ SE, confidence or competence as either an outcome or a predictor variable (3) the measurement of the school nurses’ SE, confidence or competence was specific to asthma and (4) publication in peer-reviewed journals. Excluded from the review were articles that studied the children’s or parents’ SE, articles not written in English, articles that were not data-based, and articles with limited mention of school nurses, SE, and asthma. When the titles and abstracts of the 68 database publications were evaluated, ten met the criteria for inclusion. Full-text articles were reviewed for inclusion in the analysis, and all ten were accepted (Figure 1). Using the Whittemore and Knafl guidelines, study design, sample, study population characteristics, and key findings were assessed; and significant themes from the articles were categorized (Whittemore & Knafl, 2005). The themes were categorized as follows: the asthma action plan and its association with confidence and self-efficacy; and education and training to support competence, confidence, and self-efficacy.

Figure 1.

PRISMA flow diagram of the literature selection process

Using the Johns Hopkins Nursing Evidence-Based Practice (EBP) Evidence Level and Quality Guide, the evidence level was rated on a scale from Level I to Level V (Dearholt &Dang, 2012) (Table 1). Level I includes experimental and randomized control studies as well as systematic reviews of randomized control studies. Level II includes quasi-experimental studies which may include systematic reviews of randomized control studies and quasi-experimental studies or quasi-experimental studies only. Finally, Level III includes qualitative studies or non-experimental studies.

Results

Study characteristics and study population

The ten publications for this review included four quasi-experimental, two descriptive correlational studies, three cross-sectional, and one randomized-controlled study. For evidence level, the studies were rated as Level I, II or III. There was one Level I study or experimental design (randomized control), three Level II studies or quasi-experimental design and six Level III studies or non-experimental design. Many studies use the terms “perceived SE,” “SE,” “confidence,” or “competence” interchangeably. While SE reflects a level of confidence in one’s ability, the ideal is to keep these terms distinct. In their study evaluating the difference between perceived confidence and SE in the context of exercise, Rodgers, Markland, Selzler, Murray, & Wilson (2014), recognized that the terms “SE” and “perceived confidence” are often used interchangeably in the literature. Their findings support clarification of these terms and the use of accuracy of language in further research (Rodgers et al., 2014). This review of the literature will delineate between the specific terms used in each study.

The publications in this review lacked consistency in reporting demographic characteristics. Of the studies that reported demographics, the results indicated that ≥90% of the study population was female and study participants were predominantly White. Mean years of service as a nurse ranged from 7.92 to 26.5 years and years as a school nurse ranged from 1 to 13.3 years. Data collection was conducted with school nurses through an online survey or in-person questionnaire at a nursing conference or a distance learning course. Self-efficacy scores varied by the instrument that was used and with what aspect of asthma management behavior, skill or role of the nurse was being evaluated (see Table 1).

Measurement scales

Currently, there is no single, commonly-used SE scale for school nurses or nurses related to asthma care (Table 1). Most of the studies used investigator-developed tools with the exception of Putman-Casdorph & Pinto (Putman-Casdorph & Pinto, 2011) who used the tool designed by Winkelstein et al. (Winkelstein et al., 2006). Gau, Horner, Chang, & Chen (2002) developed an asthma-management efficacy scale (AMES) for use with measuring SE of school nurses. This scale consists of 15 items and uses a 7-point Likert scale with 1 as “no confidence” and 7 as “fully confident,” and higher scores indicating higher SE (Gau et al., 2002). A more recent tool designed to measure school nurses’ asthma SE (Asthma Self-efficacy Survey for School Nurses) consists of 19 items and uses a 4-point Likert scale. A higher score indicates higher SE (Quaranta & Spencer, 2015).

The asthma action plan and its association with confidence and self-efficacy

School nurses’ SE in asthma care was found to have a positive association with the presence of asthma action plans (AAPs) in the school setting. However, the reported studies used cross-sectional surveys, and thus it is not known whether those school nurses with higher levels of SE were more likely to have an AAP, for students with asthma, or the converse. Hanson, Aleman, Hart, & Yawn (2013) reported on school nurses’ (n=65) perceived value of AAPs and school nurses’ SE. They found that the presence of an AAP for a child at school influenced school nurses’ SE with regard to the timing of the administration of asthma medication in response to a student flare-up of asthma symptoms, as well as the timing of a call for emergency care, if any. In a follow-up survey, fewer than half of the nurses responded (12 out of 28). Those who did respond reported that the secure portal, designed for the electronic exchange of the AAP between providers and schools, increased the school nurses’ confidence in communicating with a physician about asthma-related concerns (Hanson et al., 2013). Another study reported positive results with AAPs; 72% of school nurses (n=76) stated that they “agreed” or “strongly agreed” that having an AAP increased their confidence in caring for a child with asthma (Borgmeyer, Jamerson, Gyr, Westhus, & Glynn, 2005).

Education and training to support competence, confidence, and self-efficacy

Studies have shown that continuing education and training on asthma care can increase nurses’ confidence and competence. Training can be done by mail, in person, and through live and pre-recorded educational online programs, all of which have positive effects (Bullock, Libbus, Lewis, & Gayer, 2002; Cicutto et al., 2017; Putman-Casdorph & Pinto, 2011; Winkelstein et al., 2006). Bullock et al. (2002) compared competence levels between a group of nurses (n=175) who took part in a continuing education program and those who did not (n=361). The group that enrolled and completed the course reported a statistically significant higher level (p=0.0001) of perceived competence than those who had not participated, although in this study the majority of those who received the survey did not respond. Studies of live and pre-recorded distance learning programs found both methods effective in increasing nurses’ SE in asthma care, although live educational segments led to higher scores (Putman-Casdorph & Pinto, 2011).

To evaluate a new asthma continuing education curriculum designed with input from school health team members, pre and post assessments were also used to measure school nurses’ (n=40) asthma care self-confidence (Cicutto et al., 2017). The nurses’ self-confidence scores were lowest at baseline for the identification of at-risk students with asthma, and for the provision of care according to the identified plan. Post-test scores demonstrated improved self-confidence regarding asthma care and demonstration of inhaler technique. Similarly, in a sample of 793 school nurses, Chao et al. (2003) found that during pre-test training, over 80% of school nurses reported a lack of confidence in their asthma medical knowledge. Post-training results demonstrated that instruction helped relieve school nurses’ stress and improve their confidence during asthma care.

Through a train-the-trainer model designed to increase asthma knowledge, SE, and documentation practices in school nurses (n=46), Winkelstein et al. (2006) found that school nurses who were randomized to a six-hour asthma-training session intervention group had higher SE scores than the control group nurses at follow-up. In a second study one year later, Winkelstein et al. (2006) found that only one-quarter of the nurses reported interest in conducting an asthma education program independently. They cited lack of confidence in their teaching ability and lack of time as reasons for refusing participation.

Additional factors that may influence confidence and self-efficacy

Quaranta & Spencer (2015) investigated the relationship between school nurses’ (n=537) asthma knowledge, SE in asthma care, asthma attitude, importance ratings of asthma management behaviors (the self-reported value assigned to perform a behavior), and performance ratings of asthma management behaviors. They found significant correlation between SE ratings in asthma care and asthma knowledge, asthma attitude, performance, and perceptions of the importance of asthma management behaviors. There was no significant correlation between SE in asthma care and perceived barriers to asthma management - demonstrating that the barriers did not present an obstacle to performance (Quaranta & Spencer, 2016). In a sample of 60 school nurses, Gau et al. (2002) found that nurses with <1 year of experience were significantly less confident in medication administration, peak flow monitoring, and use of inhaled medication than their more experienced counterparts.

Discussion

This integrative review examines school nurses SE in asthma care. Overall, this review of the literature found significant relationships between continuing education, educational-training sessions, and the use of resources (AAPs) and school nurses’ SE in asthma care. There is limited reporting on the predictors of or contributing factors to school nurses’ SE in asthma care. Similarly, there is little study on outcomes related to SE that could shed light on these influences and their role in practice behaviors.

The importance of asthma-focused education cannot be overstated regarding improving perceived confidence and competence of care for school nurses (Bullock et al., 2002; Chao et al., 2003; Cicutto et al., 2017; Putman-Casdorph & Pinto, 2011). A focus on continual training for nurses could strengthen self-confidence and achieve higher levels of SE beyond the post-test exposure (Kardong-Edgren, 2013).

The current SE in asthma care literature has limited research into SE’s relationship to student health outcomes and the practice behaviors of school nurses. There is minimal research specific to the personal and environmental factors that influence school nurses’ SE in asthma care. All studies used data that were self-reported or based on recall, and very few of the studies asked about prior exposure to asthma education before measuring competence, confidence, and SE. Additionally, the lack of randomized control trials with educational training and longitudinal investigations indicates a need for further study of school nurses’ SE in asthma care. This review discovered the following challenges: SE, confidence, and competence are used interchangeably, which may confuse readers and require a greater understanding of the relationships between these constructs. Due to the interchangeable use of terms, there is a lack of a unified metric for measuring school nurses’ SE in asthma care. Although the findings did not appear to differ between studies, the use of validated tools to evaluate school nurses’ SE in asthma care requires more consistent use.

This contribution to the state of the science concerning SE of asthma care indicates that distance learning technology is a viable solution for school nurses to acquire continuing education (Putman-Casdorph & Pinto, 2011). With continuing asthma education, nurses are well-positioned to provide evidence-based care and initiate and share asthma policies in the community and clinical settings (Cicutto et al., 2017). Additionally, distance learning may also address the needs of school nurses’ who drop out of traditional education programs. Yet, there are implications of data collection solely at conferences or through distance learning venues. Consideration must be given to information that is not collected due to those participants who are unable to attend conferences or distance learning courses. A range of data collection methods is necessary to reduce barriers and address drop-out rates of participants. Educators and researchers would be wise to consider creating a partnership with school nurses to support future projects, reduce barriers to participation, and continue to work toward improving student health outcomes. This type of partnership may serve as an exemplar to increase school nurses’ SE.

In a majority of the studies, change in perception was measured rather than actual change in practice. Research must move toward understanding existing school nurse practice models-including staffing mix and how it affects both nursing and student outcomes. Quaranta & Spencer (2016) address the barriers school nurses face in asthma management, which may support an investigation into staffing practices. Winkelstein et al. (2006) encourage a complete understanding of school nurses’ needs, which can lead to the successful implementation of asthma education in their work settings. In a novel Colorado-based project, the incorporation of workforce models was proposed (Cicutto et al., 2017). This project identified minimum competencies for differing roles in the school health care system, including unlicensed assistive personnel and school secretaries. Currently, many school systems in the United States do not have unlicensed assistive personnel or other school staff as a part of the health care team. Perhaps, it is time to argue for the addition of support staff to the school health care team to support nurses which will, in turn, sustain school nurses’ SE to provide evidence-based quality asthma management.

Nursing and student outcomes in school health need quantification. There are no unified metrics regarding nurses’ asthma practice, SE in asthma care, and school health. While one study looked at the presence of an AAP as an indicator of school nurses’ SE, the presence and adherence to an AAP is a way to measure outcomes of school nurse interventions. Therefore, continued investigation into the role of resources, such as the AAP, that may influence SE is warranted. Additionally, further study on existing tools in school nursing is encouraged, to measure nursing behaviors, student outcomes, and contribute to school health science.

Limitations

There are limitations of the literature included in this analysis. The samples may have been biased in individual studies as they selected nurses from a convenience sample or had a small sample size. In most of the reviews, information about the diversity of the sample was either not reported or reported in a limited manner. Finally, there were only ten studies that evaluated school nurses’ SE in asthma care, and of those ten studies, there was minimal consistency in the instrument used to measure SE.

Implications for School Nursing Research and Practice

Nursing and student outcomes in school health need quantification. There are no unified metrics regarding nurses’ asthma practice, SE in asthma care, and school health. Therefore, continued work on addressing and responding to the role that various circumstances play, and designing interventions is warranted. Further study on new and existing tools, scales, and frameworks in school nursing is encouraged to establish better validity, refinement, and generalizability to measure patient and nursing outcomes, and contribute to school health science.

Continued use of the AAP can positively influence SE and increase nurse confidence in asthma management (Borgmeyer et al., 2005; Hanson et al., 2013). By adopting changes in technology (i.e., a portal for receiving AAPs), we may be able to not only see the effect on how the child’s asthma is managed but how communication occurs between stakeholders. Research on school nurses’ SE in asthma care should further explore the inclusion of NAEPP guidelines, the effect of SE on student outcomes, and the role of predictors. Predictors must include workforce models that are designed to empower nurses in their individual settings. Research should also assess prior exposure of the school nurse to asthma experiences. These experiences include education, clinical experience, and policy work at the local and national level - regarding such topics as self-carry, self-administer, and environmental issues.

Future outcome research should explore whether school nurses with higher SE in asthma care are more likely to achieve results that include (1) performance of necessary skills, such as assessment of student’s level of asthma control or peak flow measurement skills; (2) development of a partnership with the student and family; (3) retaining an AAP for each child with asthma; (4) establishing a school-wide emergency asthma plan; (5) integrating self-management into asthma care and; (6) encouraging a partnership with a community provider (U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, 2014b). These outcomes will help build a strong nursing presence in schools, create a healthy school community, and support many of the NAEPP guidelines (Cicutto et al., 2016; Gleason et al., 2016). The NAEPP, coordinated by the National Heart Lung Blood Institute (NHLBI), aims to raise awareness about asthma and develop guidelines and resource materials based on the latest scientific evidence for clinical practice including schools and childcare centers (U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, 2014a). Program goals of NAEPP include raising the awareness of patients, health care practitioners and the public about the seriousness of asthma, ensuring the recognition of symptoms as well as effective control among health care providers and patients with modern treatment and education (U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, 2014a).

Conclusion

Evidence-based asthma management is an essential component of caring for children with asthma regardless of the care setting. Since asthma is a serious and prevalent disease in children and nurses care for children in schools, an inquiry into school nurses’ SE for children with asthma is necessary. Nursing schools should incorporate asthma management education into the curriculum, and continuing education is essential to the promotion of current knowledge and bolstering of positive behaviors.

On a daily basis, school nurses provide education, observe student technique regarding asthma management, and offer technical and emotional support. Therefore, an exploration of factors that may influence school nurses’ SE in asthma care has the potential to create optimal outcomes for students and effective use of health care resources. School health settings must champion the confidence and empowerment of school nurses to support improved child well-being.