School Nursing Emergency Response Study: A National Convergent Parallel Mixed Methods Cross-sectional Survey.

Every state in the United States has passed legislation allowing students to self-carry rescue inhalers in the school setting. Many organizations are stakeholders in respiratory issues, school health issues, and pediatric issues, recommending the support of this practice. Students’ ability to self-carrying rescue inhalers in the school setting has been impacted by school nurse perceptions and decision-making. This study addressed the questions: (a) What are school nurse perceptions and attitudes in regard to children self-carrying inhalers in the school setting? (b) How do school nurses decide whether children can self-carry inhalers in the school setting? and, (c) Are school districts and school nurses aware of the laws and guidelines regarding children self-carrying inhalers in the school setting? In this grounded theory study, 20 elementary and high school nurse participants were interviewed. The taped interviews were transcribed and analyzed utilizing grounded theory methods. The data were categorized into a conditional matrix that addressed context, conditions, actions, and consequences. From this analysis, a substantive theory was developed, “Balancing decisions about the self-carry practice: Powerful influences.” Various factors weighed on the nurses’ decision-making, such as laws, policies, school characteristics, student characteristics, trust, knowledge deficits, teachers, safety nets, control, nursing philosophy, internal policies, praxis, and assessments of students. The consequences included elementary school nurses manipulating the situation and micromanaging; and high school nurses manipulating the situation, letting it go, and fostering independence and empowerment. Elementary school nurses neither encouraged nor facilitated the self-carrying of rescue inhalers unless the parent was adamant about the need to self-carry. Conversely, high school nurses encouraged and facilitated the self-carry practice. These findings have implications for nursing practice, nursing science, and policy development that could enhance self-carry practices. Based on these implications, future study could address many areas of limited research, such as manipulation of the self-carry situation, appropriate practices to support or prepare students for the self-carry practice, legislative evaluation, and outcomes with students who self-carry.

Journal of School HealthVolume 49, Issue 6 p. 313-316 Task Differentiation Among Elementary, Middle and High School Nurses* Susan Gilman MSHA, Corresponding Author Susan Gilman MSHA Susan Gilman, MSHA, Evaluation Coordinator of School Health Programs, University of Texas Medical Branch, 1202 Market Street, Galveston, TX 77550 (Corresponding author).Evaluation Coordinator of School Health Programs, University of Texas Medical Branch, 1202 Market Street, Galveston, TX 77550Search for more papers by this authorMildred C. Williamson RN, Mildred C. Williamson RN Mildred C. Williamson, RN, Coordinator of Health Services, Galveston Independent School District, P.O. Drawer 660, Galveston, TX 77550.Search for more papers by this authorPhilip R. Nader MD, Philip R. Nader MD Philip R. Nader, MD, Director of School Health Programs, Department of Pediatrics and Psychiatry, University of Texas Medical Branch, 1202 Market Street, Galveston, TX 77550.Search for more papers by this authorSandra Dale RN, MS, Sandra Dale RN, MS Sandra Dale, RN, MS, Assistant Professor of Nursing, University of Texas Medical Branch, School of Nursing, Galveston, TX 77550.Search for more papers by this authorRosemary McKevitt RN, EdD, Rosemary McKevitt RN, EdD Rosemary McKevitt, EdD, University of Texas Nursing School at San Antonio, Health Science Center, San Antonio, TX 78284.Search for more papers by this author Susan Gilman MSHA, Corresponding Author Susan Gilman MSHA Susan Gilman, MSHA, Evaluation Coordinator of School Health Programs, University of Texas Medical Branch, 1202 Market Street, Galveston, TX 77550 (Corresponding author).Evaluation Coordinator of School Health Programs, University of Texas Medical Branch, 1202 Market Street, Galveston, TX 77550Search for more papers by this authorMildred C. Williamson RN, Mildred C. Williamson RN Mildred C. Williamson, RN, Coordinator of Health Services, Galveston Independent School District, P.O. Drawer 660, Galveston, TX 77550.Search for more papers by this authorPhilip R. Nader MD, Philip R. Nader MD Philip R. Nader, MD, Director of School Health Programs, Department of Pediatrics and Psychiatry, University of Texas Medical Branch, 1202 Market Street, Galveston, TX 77550.Search for more papers by this authorSandra Dale RN, MS, Sandra Dale RN, MS Sandra Dale, RN, MS, Assistant Professor of Nursing, University of Texas Medical Branch, School of Nursing, Galveston, TX 77550.Search for more papers by this authorRosemary McKevitt RN, EdD, Rosemary McKevitt RN, EdD Rosemary McKevitt, EdD, University of Texas Nursing School at San Antonio, Health Science Center, San Antonio, TX 78284.Search for more papers by this author First published: June 1979 https://doi.org/10.1111/j.1746-1561.1979.tb07720.xCitations: 4 * This study was supported in part by the Robert Wood Johnson Foundation. AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume49, Issue6June 1979Pages 313-316 RelatedInformation

To identify new and accelerated modes of practice used by school nurses during the COVID pandemic. To create a quick reference infographic bringing together experiential evidence on the range and considerations regarding different modes of practice for use by the school nursing community of practice. A descriptive qualitative secondary data analysis of open-ended questions in a survey, and focus groups with school nurses. The pragmatic aim was to focus on changes in school nurse modes of practice to ensure continued engagement with children and young people, and school nurses' experience of the benefits and challenges of these modes of practice. Data were collected from 98 school nurse participants across a United Kingdom-wide survey (n78) in April to May 2022, and focus groups (n20) in June to July 2022, within the School Nursing in the Time of COVID project. Data from the seven open-ended questions in the survey and four questions from the focus group were analysed using the framework approach. Modes of practice fell into two categories: individual assessment and support (video-calling platforms, telephone contact, virtual messaging, walk-and-talks and home visits) and group support (wellbeing approaches, social media). Considerations for these modes rooted in school nurses' experience are described. Interpretations were used to create the summarising evidence-based infographic as a quick reference resource for school nurses. There was no 'one size fits all' approach. The modes used by school nurses were adopted or developed out of necessity or resource availability and in response to the specific needs of individuals or groups. The developed infographic provides a quick reference guide to deliver the expressed need for knowledge exchange within the school nursing community by participants in the original studies and can be used to inform current school nurse practice. The developed evidence-based infographic has stand-alone value. It has the potential to raise awareness of the range of different strategies that can be used to facilitate and/or enhance engagement with children and young people, equip school nurses with knowledge to foster innovative and responsive practice and aid critical reflection in a complex post-pandemic landscape. The infographic is a unique resource and is a first step in knowledge exchange based on experiential learning. The resource will be used as the foundation for future work to develop a co-created training resource for school nurse students (undertaking the Specialist Community Public Health Nurses course) and/or continuing professional development resource for established school nurses. This study has been conducted and reported in accordance with COREQ guidelines for qualitative research. A consultation group was closely involved with the planning, conduct and analysis of the original studies. This group consisted of representatives from professional organisations SAPHNA (School and Public Health Nurses Association) and the CPHVA (Community Practitioners' and Health Visitors' Association), a school nurse and a member of the public. SAPHNA have continued in their consultative role for this study and has provided content and usability feedback regarding the infographic. Early findings have been presented to the SN community of practice, and feedback invited, through presentation separately at the CPHVA and SAPHNA annual conference.

PURPOSE: The purpose of the present study was to assess knowledge, attitudes, and communication and referral behaviors of U.S. high school nurses about the Female Athlete Triad. METHODS: A random sample of 1000 U.S. high school nurses who are members of the National Association of School Nurses were contacted by email and invited to participate in an online survey about student health. Survey questions assessed knowledge, attitudes and communication behaviors with coaches and athletes with respect to disorders of the Triad. Content areas covered included knowledge about the Triad, communication and referral behaviors, school policies, information needs, and demographics. RESULTS: Three hundred and seventy nurses answered survey questions, for a response rate of 37.0%. Only 19% of the nurses were able to identify the three components of the Triad, and only 25% reported that they work proactively with coaches to help prevent health issues among their female athletes. However, over 95% of the nurses surveyed expressed interest in learning more about the Triad. Results also indicate substantial between-nurse variability in knowledge, and a consistent interest in learning more about the Female Athlete Triad. CONCLUSIONS: The school nurses responding to our survey demonstrated a lack of knowledge about the Female Athlete Triad and the interrelatedness of the components of the Triad, but indicated their desire to learn more about the topic. Based on the results of this study, we believe that school nurses should be provided with educational resources and specific guidelines for recognizing, screening, and treating student athletes who present to them or are referred by coaches with concerns of the Triad. Nurses with a strong foundation of knowledge in this area would be able to act proactively to help educate the coaches and female athletes at their schools, to help prevent, recognize, and treat Triad related health consequences.

LBGTQ+ students often miss the support and information they need in the school nursing, but little is known about junior high school (JHS) nurses' work with LGBTQ+ students. 15 JHS nurses were interviewed in focus groups about their perceptions of supporting LGBTQ+ students. Four interconnected themes were identified with inductive thematic analysis: (1) JHS nurses' professional identity and practice; (2) Recognition of sexual and gender diversity in school; (3) Family acceptance process; and (4) LGBTQ+ students as school nursing clients. JHS nurses self-identified as accepting professionals, but having limited skills, knowledge, and education needed in supporting LGBTQ+ students. Supporting LGBTQ+ students is a complex phenomenon, and to enhance JHS nurses' competence in providing care for these students, sexual and gender diversity needs to be included in evidence-based nursing information sources, covered in nursing education, and the school needs to be secured as LGBTQ+ safe place.

OF DISSERTATION THE ROLE AND IMPACT OF SCHOOL NURSES AND INTENTIONS TO DELEGATE DIABETES-RELATED TASKS AMIDST BUDGET CUTS AND LEGISLATIVE CHANGES As the percentage of school children with chronic conditions such as diabetes continues to rise, funding for school nurses to keep those students healthy and safe is decreasing. This dissertation includes three studies: (1) a systematic review of the literature on the role and impact of American elementary school nurses, (2) a focus group study that further examined the role of Kentucky school nurses and described their reaction to a new regulation that necessitates delegation of diabetes-related nursing tasks to unlicensed assistive personnel (UAP), and (3) a quantitative study that examined Kentucky school nurses’ past behaviors and future intentions regarding the delegation of diabetes-related tasks. A systematic review of the literature revealed that activities of school nurses can be conceptualized into four major areas: (a) health promotion and disease prevention; (b) triage and treatment of acute issues (e.g., injuries and infectious diseases); (c) management of chronic conditions; and (d) psychosocial support. School nursing activities are associated with increased attendance, higher quality schools, and cost savings. Focus groups in three regions of Kentucky found that Kentucky school nurses fulfill the same major roles as their counterparts across the nation, and face similar challenges such as lack of time, limited resources, language barriers, and communication issues with families. School nurse participants described their biggest impact on students as identifying and addressing students’ physical and psychosocial barriers to learning. While recent legislation was passed in Kentucky necessitating the delegation of insulin administration to UAP, school nurses had not experienced many changes at the time of the focus groups. However, some nurses said that their districts were not planning to delegate insulin administration and intended to keep a nurse in every school. Others appreciated the prospect of having more trained staff in schools to recognize signs of distress in chronically ill students. A statewide survey of 111 Kentucky school nurses indicated that nurses’ past delegation behaviors and future intentions related to delegation are rooted in the level of skilled decision-making that must occur and the risk to the student if the wrong decision is made. Unfortunately, school nurses’ intentions to delegate higher-stakes tasks (e.g. carbohydrate counting, insulin dose verification, and insulin administration) were significantly stronger than their support for (attitude related to) delegation of those tasks, which is disconcerting both for the safety of students as well as for the liability retained by delegating nurses. This disparity between support and intentions indicated that school nurses anticipate that they will have to delegate certain tasks to UAP despite their discomfort with delegating them, most likely due to high workload and lack of resources. Additional studies should be undertaken to determine the impact of legislative changes on the delivery of school health services in Kentucky and other states, particularly once school districts and nurses have had adequate time to adjust to new laws. Such studies should investigate to whom nurses are delegating health services, what tasks are being delegated, and the extent and process of training that UAP receive. Future surveys should utilize perceived behavioral control items that assess situational control (e.g. policy, workload) over delegation rather than, or in addition to, efficacy of individual skills required for delegation of nursing tasks. Researchers must further explore the discrepancies between attitude and intentions; that is, why are nurses planning to delegate tasks to UAP if they do not support the delegation of those tasks? Kentucky school nurses are champions of health promotion for children, not only in their provision of health services and health education, but also in the area of school health policy. School nurses should train UAP so that more school staff can recognize signs of distress in students with diabetes, but at the same time should continue to advocate and seek funding for a nurse in every school with the help of the Every Student Succeeds Act.

The current tenuous status of public education funding requires that school nurses be proactive in advocacy efforts on behalf of their school nursing programs. Advocating for nursing practice within an educational setting presents unique challenges. Lack of state or national consensus for support of school nurse services creates an opportunity for school nurse advocates to develop quantitative tools to evaluate their school nurse program. Identifying commonalities and differences between school administrators' and school nurses' perceptions of the school nurse role will provide information that can be used to strengthen programs and facilitate the understanding of school personnel about what school nurses do. This study compared school administrator and school nurse perceptions of the role of the school nurse using a tool based on the National Association of School Nurses' "Advocacy Talking Points." Analysis of responses identified specific areas in which schools could improve their school nurse program and enhance school administrators' understanding of the school nurse role.

Annotated abstract

Pediatric health-care providers may be unaware of how best to partner with their patients’ schools to create asthma-friendly environments in which patients’ asthma health needs are communicated clearly, school heath staff are empowered and equipped to react to asthma exacerbations appropriately, and school personnel reinforce asthma health maintenance messages with families.After completing this article, readers should be able to: More than 5.5 million school-age children in the United States are diagnosed as having asthma. (1) This equates to almost 1 in 10 school-age children, making asthma the most common chronic childhood condition in the country. More than half of all children with a diagnosis of asthma have at least 1 asthma exacerbation each year. Particularly concerning, rates of pediatric asthma deaths have been increasing. In 2018, 156 children aged 5 to 17 years died of asthma. Non-Hispanic black children have a 6 times greater mortality rate from asthma complications than Hispanic white children and a 7 times greater rate than non-Hispanic white children. (1) Deaths that occur outside the clinical setting account for 13% of all asthma deaths in children.Asthma can affect a child’s academic attendance and education. Children with asthma miss more school than those without asthma and are at greater risk for missing more than 10 school days per year, a degree of absenteeism that may put them at risk for grade retention. (2)(3) Almost half of all students with asthma miss at least 1 day of school each year due to related symptoms, accounting for 13.8 million lost days. (4) Absences occur most frequently during colder months, among students with persistent rather than intermittent asthma, and among students attending a school with a part- versus full-time nurse on staff. (3)(5) Studies suggest that 1 of the peak times for ambulance-treated pediatric asthma exacerbations is around 1 pm (ie, in the middle of the school day), further underscoring the importance of school factors in contributing to students’ asthma outcomes. (6)A recent policy statement from the American Academy of Pediatrics highlights the importance of coordination of care between community-based pediatricians and other child health-care providers (hereafter referred to collectively as pediatricians) and school health staff. (7) This review article focuses on the role of pediatricians in supporting and contributing to high-quality school-based asthma management. By gaining an understanding of the challenges that schools face in promoting asthma wellness, and of how to partner with students, families, school nurses, and school staff to overcome these challenges, pediatricians can help ensure that their patients with asthma are safe, healthy, and primed to learn.The Centers for Disease Control and Prevention (CDC) Healthy Schools and the CDC’s National Asthma Control Program (NACP) have developed strategies to guide school personnel and other stakeholders in creating asthma-friendly schools. (8) Asthma-friendly schools are defined as environments that are safe for children with asthma and have policies and practices in place that support children and their caregivers in managing their asthma. The NACP recommends multiple evidence-based strategies to address asthma in schools, including supporting students in asthma self-management, educating school staff and caregivers, improving school air quality, linking students to medical providers for asthma health maintenance, allowing students to self-carry quick-relief medication (such as albuterol), and having schools stock a supply of albuterol for communal student use.In interventional studies, school-based asthma management programs have typically involved a combination of interventions designed to improve schools’ ability to identify students with asthma and assess their level of symptom control, educate high-risk students on disease management, link students to primary care providers, and/or develop protocols for managing asthma emergencies. (9)(10)(11)(12) School-based asthma interventional trials have achieved varying levels of success in terms of improving students’ quality of life and reducing their number of hospitalizations and emergency department visits. Results suggest that strong partnerships among schools, families, and health-care providers are key to programmatic success, and limitations in available resources for program implementation are a primary barrier. (12)Note that interventional trials are typically conducted in relatively highly resourced school settings with engaged stakeholders. Depending on local context, the level of medical support that can be provided to students at any given school may be very different. Although US federal laws mandate that all children have access to health services at school, individual states determine the minimum qualifications for school nurses, which may or may not include a baccalaureate degree, nursing certification, registered nursing license, and minimum amount of experience. (13) States also regulate which activities, such as administering medications, can be performed only by a registered nurse versus a licensed practical nurse. Although the American Academy of Pediatrics strongly endorses a minimum of 1 full-time registered nurse in every school, this standard is not always met. (14) Access to school nurses has been associated with improvements in chronic disease management, including reduced frequency of asthma exacerbations and absenteeism due to asthma. (14) Nonetheless, only 63% of schools have full-time nursing coverage, 19% have part-time coverage, and 18% have no nursing coverage. (15) Approximately 80% of public schools have support from a registered nurse, either full- or part-time, whereas among private schools the percentage is much lower at 35%. In addition to nurses, nearly 1 in 5 schools use volunteers, and nearly 3 of 4 schools use teachers or school staff to supplement nursing activities, including performing health promotion education.Most assessments of barriers to asthma care management at school have exclusively included schools with nurses on staff. Presumably schools without nursing staff experience even greater obstacles to the provision of quality care to students. In a survey of school nurses that sampled from a national database, 78% of respondents reported that albuterol was available at their school. (16) However, because most schools do not stock albuterol for communal student use, it is unclear how many of the respondents were simply reporting that at least 1 student at their school had access to a personal supply of albuterol brought from home. (17) In another survey of nurses from 36 predominantly urban schools in Alabama, respondents collectively reported that only 14% of students with asthma had an albuterol inhaler at school. (18) Another survey of 126 nurses from a different urban school district found that nearly three-quarters of the respondents agreed that “asthma is one of the biggest health problems I deal with among students in my school,” and “most of the kids who have to be dismissed early because of asthma symptoms could go back to class if they had an inhaler at school.” (19) These results underscore the perceived impact of asthma on student health and suggest that some asthmatic children with mild symptoms and no inhaler are being sent home, leading to higher rates of absenteeism.Beyond limited access to albuterol, school nurses have also reported that their efforts to manage students’ asthma are hampered by inadequate nurse staffing and time, limited support from school administrators, and challenges in communicating with parents and pediatricians. Other barriers cited by school nurses include a lack of knowledge about asthma management guidelines among students, parents, teachers, school personnel, pediatricians, and school nurses, as well as a lack of appreciation for school nurses’ expertise. (20)Pediatricians’ efforts to partner with schools on asthma management should begin with self-evaluation to determine whether personal clinical practice adheres to guidelines for asthma diagnosis and management. In 2007, the National Heart, Lung and Blood Institute’s National Asthma Education and Prevention Program (NAEPP) established age-based criteria for the classification of asthma based on patients’ level of risk for severe exacerbation and degree of daily impairment. (21) In 2020, the NAEPP published focused updates across 6 topic areas to the original guidelines. (22).Assessing asthma risk involves considering all of a child’s significant asthma exacerbations in the preceding year, and assessing asthma impairment involves considering all of the child’s daily symptoms in the past 2 to 4 weeks. Risk and impairment are used to classify a child’s asthma severity (intermittent, mild persistent, moderate persistent, and severe persistent) and control (well controlled, not well controlled, or very poorly controlled). The NAEPP guidelines provide standardized recommendations for therapy initiation, escalation, and de-escalation based on the child’s risk and impairment classification at the time of the assessment. For more details on asthma diagnosis and management, see the article “Asthma” in the November 2019 issue of Pediatrics in Review and the 2007 and 2020 NAEPP recommendations. (21)(22)(23)NAEPP guidelines emphasize the importance of patient and family education regarding asthma diagnosis, symptom recognition, and management. Pediatricians should provide families with asthma self-management education at the time of diagnosis and reinforce key messages routinely at follow-up visits. Messages should be tailored to a child’s level of comprehension and developmental stage to encourage engagement. Proper use of inhalers should be repeatedly reviewed using the teach-back method, with parents and older children demonstrating their ability to administer medication. Asthma education initiated in the medical home should establish concepts and language that transcend care setting.Beyond following evidence-based guidelines in caring for individual patients with asthma, pediatricians can also leverage the functionality of their electronic medical record system to optimize asthma management on a practice or population level. Specifically, pediatricians can use medical record search tools to identify their at-risk patients and patients with asthma who have had gaps in care (eg, missed appointments or lack of prescription for an indicated controller medication).Guidelines dictate that all patients with asthma have an asthma action plan that is individualized. The written asthma action plan provides individualized instructions and a roadmap for education at school to reinforce appropriate medication use by families. The treatment plan should be developed through a joint decision-making process among the pediatrician, the patient, and the patient’s family. Input from a child’s school nurse may also be helpful for proper execution of the plan at school. Coordinating educational messages via the asthma action plan and other health records shared with school health staff allows the pediatrician to be sure that families receive consistent advice across care settings.Key elements of the asthma action plan include the following (24): Many pediatricians and school systems have adopted asthma action plans with these important components. These plans often use a stoplight format designating green, yellow, and red zones to indicate the actions needed when a child is doing well, should be monitored for worsening symptoms, or requires emergency medical intervention, respectively. Helpful asthma action plan examples in English and Spanish are available for download from the American Lung Association website. (25) Of note, some schools and school districts only accept their own, approved asthma action plan as the official form authorizing school health staff to administer asthma medication to students.A 2012 survey of 1,412 health-care providers (including adult-focused health-care providers and mid-level providers) found that only 16.4% of primary care providers “almost always” gave asthma action plans to patients, and 17.6% “never” gave them to patients. (26) A 2013 CDC survey found that only half (50.8%) of parents of a child aged 0 to 17 years with asthma recalled ever having received an asthma action plan. (27)Giving an asthma action plan to a family at medical visits does not guarantee that the form reaches school health staff. Manual delivery of asthma action plans to the school nurse by families has not been found to be reliable. (28) Faxing or mailing forms to the school are other options but require accurate school information and appropriate labeling of documents because they contain protected health information that should not be shared with non–health personnel at the school. Sharing of medical forms using electronic medical record interfaces, portals, and direct secure messaging should be explored as options for communicating with schools as these tools become more widely available.Communication between pediatricians and school health staff must comply with federal privacy laws governing the exchange of protected health information. Local school districts and health organizations may have additional regulations. Misconceptions regarding the requirements of these laws and regulations pose a barrier to effective care coordination across sectors.The Health Insurance Portability and Accountability Act (HIPAA) is a US federal law that protects the privacy of patient health information held by “covered entities.” (29) Pediatricians are considered covered entities, and thus, signed parental consent for the disclosure of a child’s protected health information by the pediatrician is required; however, there are exceptions. The exchange of protected health information with other health-care providers for treatment purposes is one of those exceptions permitting pediatricians to discuss a student’s medications and plan for the provision of care with the student’s school health staff without the written authorization of the student’s parent. (30)The Family Educational Rights and Privacy Act (FERPA) is a US federal law that protects the privacy of students’ personal records held by educational agencies or institutions that receive federal funds under programs administered by the US Secretary of Education. (31) School health records are maintained as part of the students’ educational records and are, therefore, governed by FERPA, not HIPAA. Under FERPA, school health staff is not allowed to disclose information in a student’s educational record to any party outside the school without written consent from parents. As such, school health staff can request documents and forms from the pediatrician but may not share information about asthma symptoms and medication use at school, absenteeism, or school performance without parental authorization. (32) In other words, HIPAA allows the pediatrician to communicate with the school nurse regarding the child’s health without written consent. However, FERPA requires parental consent for the school nurse to share any educational record information, including student health data, with the pediatrician.Bidirectional health information exchange between pediatricians and school health staff is a key component of creating an asthma-friendly school. Obtaining parental consent for this exchange needs to be standard procedure and, ideally, should be documented in the asthma action plan. Supplementary consent documents or treatment orders can also be used. Beyond the asthma action plan, standardized forms or documents to facilitate communication between school health staff and pediatricians can be used to streamline information exchange, particularly for children with poorly controlled asthma and/or chronic absenteeism due to asthma. Such a form may include space to document details about a student’s hospital admissions, emergency department visits, urgent care visits, school health suite visits, school days missed, whether the student has an asthma action plan and medication at school, and how both health-care parties prefer to exchange documents in the future. A standardized form may also include a place to document parental consent to permit bidirectional communication between the school and the pediatrician if consent is not already captured in the asthma action plan.In 2004, the US Congress passed the Asthmatic Schoolchildren’s Treatment and Health Management Act, which gives states preference for certain sources of federal funding if they enact local laws requiring schools to permit students to access their asthma medications during the school day. (33) Complying states must require public schools to authorize students to self-carry and self-administer asthma medication if 1) a health-care provider prescribed the medication for use during school hours; 2) the student demonstrates to the health-care provider and school nurse (if available) the skill level necessary to use the medication; 3) the health-care provider has written a treatment plan guiding medication use and asthma management (ie, an asthma action plan); and 4) the student’s parent or guardian has submitted to the school the asthma action plan and any other documents required by the school related to liability. Per the Act, students must have immediate access to their asthma medication while 1) at school; 2) at school-sponsored activities, including sporting events; and 3) traveling to or from school or school-sponsored activities. The asthma action plan, any other related documents, and backup medication, if provided to the school, must all be kept in a location at school to which the student and staff have immediate access in case of emergency. The medication authorization can apply only to the school for which it was granted, and it must be renewed by the parent each school year.All states and the District of Columbia now have albuterol self-carry laws for students. Nonetheless, states differ in the amount of detail included in their local laws. Those with less-detailed legislation rely on individual schools and school systems to determine the specific policies used to implement the mandate. It has been found that schools and school systems often create policies that add restrictions beyond what is minimally required. (34) For example, school systems may require the submission of extra forms beyond the asthma action plan. They may dictate that backup medication must be new and unopened, or accompanied by the asthma action plan at the time it is received rather than working with families to collect all the necessary items piecemeal. These policies effectively limit the number of asthmatic students with access to lifesaving treatment at school. Local variation in medication access rules can also cause confusion for parents and pediatricians in terms of knowing what items need to be submitted for which school.There are multiple prerequisite steps for a student to have access to a personal supply of quick-relief medication at school: Depending on when parents initiate the process and the time it takes for all the steps to be completed, a student may not gain access to albuterol at school until the winter or spring. In such cases, it is helpful for the pediatrician to alert the family that the process will need to be repeated again in the fall for the new school year.Access to albuterol remains low despite every state passing laws allowing students access to their self-supplied asthma medications at school. (18)(19) As a result, the NACP, professional organizations such as the National Association of School Nurses, and advocacy groups such as the American Lung Association all maintain the position that schools should stock albuterol inhalers for students who experience asthma symptoms or emergencies at school and lack access to their own medication. (8)(35)(36) In addition to the inhalers, schools need spacers to ensure effective delivery of medication. School policies and procedures need to minimize any contagion risk related to the use of medications and delivery devices.Most successful legislative efforts to enact so-called stock albuterol policies for schools have been modeled on existing stock epinephrine laws. (37) Currently, all states and the District of Columbia allow or require schools to stock epinephrine. In contrast, fewer than 20 states have passed laws or provided guidelines for stock albuterol in schools, and legislative efforts at the federal level have not been successful thus far. Important considerations for creating and implementing stock albuterol policies include the following: Toolkits and recommendations are available to help guide efforts to enact stock albuterol policies and programs, including from the American Lung Association (https://www.lung.org/), the National Association of School Nurses (https://www.nasn.org/home), and state agencies that have succeeded in such efforts. (35)(38)(39)(40)Some early adopters of stock albuterol policies have found promising results. For example, the state of Missouri enacted its stock albuterol legislation in 2012. Data collected in the 2013–2014 school year revealed that 981 students received stock albuterol, with 86% of those students returning to the classroom. (41) A low-income urban district in Arizona saw a 20% reduction in 911 calls and a 40% reduction in medical transports to the emergency department after implementing a stock albuterol policy that delivered 222 albuterol doses to 55 children at 22 schools. (42)Importantly, establishing a stock albuterol program does not replace the necessary components for the appropriate clinical diagnosis and management of asthma, such as effective communication between pediatricians and school health staff, use of an asthma action plan, and ongoing asthma self-management education for patients and families. Rather, stock albuterol should be viewed as 1 important tool among many in the toolbox for creating asthma-friendly school settings.Daily use of inhaled corticosteroids, with or without concomitant long-acting beta2-agonist (LABA) therapy depending on age and asthma severity, is recommended for many children who meet the NAEPP’s definition of having persistent asthma. (21) add Ref: National Asthma Education and Prevention Program Expert Panel. 2020 Focused Updates to the Asthma Management Guidelines. National Heart Lung and Blood Institute; December 2020. Poor adherence to prescribed use of a daily inhaled corticosteroid as a controller medication among children with persistent asthma is associated with lower quality of life and increased frequency of asthma exacerbation, sleep disruption, and school absence. (21)(43) Nonetheless, mean adherence among children with their prescribed inhaled corticosteroid regimen is likely less than 50%. (44)(45)(46) The school nurse may be an underused resource for achieving asthma control for students with persistent asthma, poor adherence to an inhaled corticosteroid regimen, and high asthma morbidity. In addition to providing outreach to families to educate them about the need for improved asthma control, school nurses may administer daily inhaled corticosteroid medication to students.To implement school-based asthma controller therapy, the pediatrician prepares an asthma action plan with separate for inhaled corticosteroid use or without on school days versus to be shared with the student’s family and school nurse. school the student to the health suite on that typically be daily is administered all at by the school nurse. and on other days that school is not in students or parents administer and doses of the controller medication at to of school-based asthma controller therapy are School-based asthma controller therapy is only at schools with an nurse to administer In plans must be to the of 2 controller medication at a Although most will only 1 per without some will authorize the of a for school use for children with a of high health-care for asthma school nurses and parents must be able to maintain an of communication because the parent must supply the school nurse with a new controller medication each Pediatricians can parents that the US delivery of medications, and parents can for to go to the school. delivery to the school needs to be and with school staff. all the school-based asthma controller therapy is most for students with very poor asthma control who are at high risk for morbidity. In such cases, it can be well the necessary to for school-based asthma controller therapy because multiple trials have it to be associated with fewer and symptoms, a greater number of days without any symptoms, and albuterol use and frequency of urgent care visits.

These are difficult, demanding times for Schools of Nursing and Health Services worldwide. In addition to pressures of COVID-19, there are now perfectly understandable demands to end discrimination and to promote greater racial equality. Such demands place nursing and health services and reputation managers in a difficult position. I have been fortunate to draw on the work of Sir Humphrey Appleby GCB KBE MVO for this paper via his consultancy company, ‘Brilliant Strategies Consulting Ltd’ or ‘BS’ as it is known throughout healthcare and education. So well recognised is his work that colleagues have recognised his cut-through thinking immediately, commenting to me, ‘That's pure BS’. In this ‘modest proposal’ (Swift, 1729/2008, Chapter 1, p. 5), I outline strategic steps that all schools and health services can adopt, to be at least seen to ‘take decisive action’. It is vital that organisations balance the need to make their positions clear and timely through declarations of support for racial equality and making fulsome denunciations of racist abuse, against the need to ensure smooth continuation of ‘business as usual’. ‘Disruptive Innovation’ has many marketable, income-generating qualities, but such disruption should not be mistaken for drastic action or the interruption of existing excellence that would negatively impact every nurse and student, regardless of race or ethnicity. As Margaret Thatcher noted in 1975, considerable economic damage can be caused by ‘the relentless pursuit of equality’. Great care must be employed to ensure that steps taken towards ending racism do not weaken any other long-established systems, processes or structures that the health and university sectors rely upon so heavily. In an evidence-based era, it is vital that large amounts of the best possible evidence are gathered and assessed before making any changes that could lead to actual change. Boards and Executive groups must be certain that proposed changes related to any racial dimension of services are based on the most extensive research, consultation and deliberation. This cannot occur overnight and may take several executive group lifetimes to be finalised. Considerable research already exists of course on every aspect of racism, its effects, and how to dismantle it, but such studies are often from other cities or worse, other countries and so may not be suitable for your organisation's particular agenda. Valuable research strategies that organisations could employ, following extensive internal discussions, stakeholder engagement and in-depth consultations are as follows: A Report or White Paper can be commissioned to explore disparities, in less threatening ‘general terms’, within the organisation. A combined broad brush and deep dive approach is essential that acknowledges possible ethnic and racial disparities as potential co-contributors to an organisational culture where equity and equality may, at times, be deemed by some, to be less than optimal. Such a report should ideally be undertaken internally, by existing senior staff with a sound working knowledge of and affinity with the organisation, its values and its culture. It is important to include Black, Asian and Minority Ethnic (BAME) or BIPOC (Black, Indigenous and People Of Colour) staff somewhere in any report, possibly in an advisory role where their opinions can be canvassed, if this is ever thought necessary. Organisations have a responsibility, however, to avoid accusations of tokenism and to maintain the principle of meritocracy, where the best possible staff are assigned to such a report team, regardless of professional background, gender or ethnicity. It is vital that this team is afforded sufficient time to produce a report of acknowledged quality and that this process is not rushed. It is also vital of course that organisations and staff refrain from making any comments, announcements or statements of principle regarding ‘racism’, as these will invariably be taken out of context. Nor must any organisational changes regarding any aspect of racism or discrimination be made while such inquiries are progressing, to avoid pre-empting any findings or conclusions. A modern health service or school of nursing will appreciate the importance of today's social media world and its leading role in shaping public understanding and perception. It is crucial therefore that the Public Relations Department works hand in glove with the Executive Group to manage all aspects of the narrative of any inquiry or initiative. Social media affords organisations numerous ways to proclaim their implacable opposition to racism and to signal other organisational virtues. The viral success of the UK’s ‘Clap for Heroes’ initiative should inspire everyone here. Campaigns can be launched involving all front-line staff in the organisation's drive to raise awareness of racism. A suitable hashtag can galvanise staff to be photographed holding placards, making pledges, forming heart shapes with their fingers or even dancing, using subsequent posts on social media channels to raise even more awareness. For example, #WePledgeToEndIndividualActsOfRacism or #StampOutRacismInNursing are powerful statements that everyone can readily support, easily write and share online, thus actualising the organisation's values. Such campaigns also incorporate clear success measures, such as the number of ‘likes’ and ‘shares’ that can demonstrate the success of what Sir Humphrey himself has suggested could be healthcare's ‘We Are the World’ moment to Boards and CEOs. Even greater whole-of-organisation, if not national impact, can be achieved by designing visual campaigns showcasing selected staff as ‘champions’ of the organisation's commitment to raising yet another level of awareness of racism. Ribbon days are now extremely popular, and any school or health service could brand itself a thought leader by designating a special ‘Nurses Enthusiastically United To End Racism & Ethnic Discrimination’ (NEUTERED) day. A staff competition, with cupcakes and certificates, to design the most appealing ribbon, would further promote engagement. A national anti-racism award scheme could also stimulate organisations to devote significant resources to the winning of such a prestigious award. This has proved most popular in the university sector in relation to gender equity and teaching excellence, and there seems no reason why schools and health services leaders could not task their coal-face staff to compile similarly impressive nominations. If award winners were announced at a gala dinner, this functions as an additional motivator and organisational reward for executives who could be invited along as funded guests to thank them for their support of such key anti-racism initiatives. Health services and schools of nursing rightly focus on individualised patient care and personalised learning for students. ‘Person centeredness’ and aversion to ‘mass processing’ are guiding principles of health and education service. Consequently, an organisation's efforts to combat discrimination must also concentrate upon individuals, rather than some amorphous ‘system’. Systems are, it has been repeatedly shown, composed of individual people. When BAME colleagues complain of discrimination or racist abuse, such actions are almost always committed by individual people and it is upon these people that organisations must focus their efforts. Individual staff development is also paramount in signalling concern for racial equity. For example, workshops on promotion are valuable when aimed at remediating BAME staff whose applications are often poor and unsuccessful. Organisations must make key appointments to facilitate the work of ending discrimination on campus and in health services. Transparency demands that every hospital, service and university appoint a Diversity and Inclusion Officer. This role can often be undertaken as an enhanced responsibility to the existing role of a staff member who seeks greater executive experience and who appreciates the importance of working smarter, not harder. The appointment should be made purely on merit rather than on any subjective and potentially biased notion of ‘best fit’. This appointment and the process involved clearly signals that the organisation takes discrimination, whether racial or otherwise, very seriously indeed. Such appointments represent excellent value for money as an operating budget for the incumbent is not required and the organisation subsequently has a clearly identifiable and accountable figure who is now responsible for all aspects of race and diversity within the school or service and to whom all inquiries or complaints can be directed. Organisations must invest in carefully targeted staff training if racism is to be recognised and avoided. Such mandatory and auditable training demonstrates to external funding bodies that organisations have fully met their responsibilities to ensure that all customer-facing and ancillary staff understand racism and discrimination. It would be an imprudent use of scarce resources to include managers and executives in such mandatory training as they will already have considerable recent experience of driving numerous rafts of organisational changes. A clear register of diversity training attendees will allow the organisation to identify any staff who fail to comply with policy and fall short of the organisation's expressed anti-racism values. Managers can then determine what further remedial or disciplinary action is required to ensure staff have learned all of the required learnings that such learning opportunities afford. Such anti-racist training can be uncomfortable and challenging for some, but this is not inevitable. A skilled facilitator or teacher can ensure that the majority of staff present are relaxed, unconcerned and equally accepting of any ideas expressed. BAME staff have often shared the important lesson of how excluded, uncomfortable and marginalised they have been made to feel in some training and meeting spaces. It is incumbent therefore on trainers and facilitators to ensure that discomfort is never allowed to become an element of mandatory training for any staff present, regardless of race, gender, ability or viewpoint. ‘We are all in this together’ is a powerful message for all health staff to internalise. Innovative experiential learning approaches such as involving staff in sari-wrapping, hair braiding, preparing and tasting foods from other cultures or sharing experiences of how everyone, at some time, has probably experienced some sense of difference because of their nationality or accent, can help staff focus on all of the factors that unite, rather than divide them. This paper has outlined additional pressures that call to end racial and ethnic discrimination represent, but I am confident that our systems and organisations can show they are discussing how to plan to meet these challenges. This approach calls for individual and organisational level reflection on the mission-critical components of how organisations can demonstrate their full commitment to raising awareness of racism and take the initial steps towards considering how best to address this blight on our health and university sectors. Specifically, I propose a broad strategy including the following: generating sufficient research and data to undergird future action, creating innovative and powerful social media campaigns, focusing clearly on individual responsibility to eschew racism and tackling proven instances of individual racial abuse, establishment of key diversity and inclusion appointments, and initiating mandatory training for all non-executive staff. Given this extensive suite of strategic approaches designed to recognise and tackle Schools of Nursing and Health Service racism, it is difficult to imagine what else an organisation can do to achieve everything mentioned in the title of this paper (Garmendia, 2018).

Comparing 2018 to 2022, active shooter incidents (ASIs) increased by over 66% from 30 to 50 shootings, respectively. There are limited data on the effectiveness of currently available active shooter preparedness programs. This quality improvement (QI) project evaluated the effectiveness of the 2022 active shooter training (AST) for staff and faculty of a large southeastern university's School of Nursing (SON). Survey participants were SON faculty and staff recruited via emails sent pre- and post-AST. An online survey was used to obtain the participants' demographics, knowledge regarding the recommended actions for responding to ASI, and confidence in their ability to react appropriately. Data were analyzed using descriptive statistics. Information was obtained from 141 survey responses (80 pre- and 61 post-survey responses). Overall, group confidence in the ability to react to ASIs increased from pre- to post-training. Correct responses to knowledge-based questions based on the training increased by 7.8% in the post-training survey. Post-survey respondents indicated a 33.6% increased accurate response to the question, "What is the correct response to an active shooter?" The SON AST effectively improved the readiness and confidence of the trainees in case of such a future shooting incident. Future AST should integrate didactic and simulation aspects into programs for further efficacy. Active shooter incident instruction in the workplace and further evaluation of the effectiveness of training programs should become a national priority. Occupational health nurses are well suited to help evaluate and improve AST effectiveness.

Background: School administrators are responsible for the oversight of school nurse roles, responsibilities, and staffing levels. However, administrators may not be fully aware of the scope and standards of school nursing practice or student healthcare needs. The purpose of this study was to identify the educational administrator’s understanding of the school nurse role. Method: Q methodology was used to explore quantitatively the subjective, shared opinions of school administrators about the school nurse role. Data regarding administrator personal characteristics and environmental factors were looked at as possible contributing factors in role perception. Participants (N=25) completed demographic and Q-sort surveys using an online platform. Results: Seven factors representing unique viewpoints were identified explaining 70.8% of the study variance. Though the most common school administrator perception of school nurses is that of a medical-model nurse with a prioritization of physical health needs of students, several other perceptions were identified. The factors identified were Medical-Model School Nurse, School Nurse as a Health Liaison Within the School, School Nurse as a Trusted Professional Liaison to the Community, School Nurse as an Educator, School Nurse as a Collaborator and Provider of Guidance, School Nurse as a Manager of Student Mental Healthcare, and School Health Leader. Conclusions: Outcome data related to actual school nurse role functions should be compared with the prevailing perceptions of school administrators to determine congruency or highlight areas of lesser recognized functions of the school nurse role. This study will help to guide and refine future efforts toward a clearer understanding of the school nurse role. Based upon a more complete understanding of the school nurse role, administrators may increase support and advocacy for revision of assigned duties and enhanced staffing levels.

School nurses provide a vast number of health services for students, teachers, and staff. Despite school nurses' important contributions to the health status of students, through the years their positions have been gradually supplemented by Unlicensed Assistive Personnel (UAP)/ Health Clerks. With the number of UAPs increasing in the school setting, roles and responsibilities of school nurses and UAPs need to be clearly differentiated in order to utilize the UAP's services legally and efficiently. This research used a descriptive survey to investigate the perceptions that differentiate the role of school nurses and UAPs among school administrators, nurses, UAPs, secretaries, and office clerks in a selected Northern California school district. The study described their views about the responsibilities of school nurses or UAPs for specific tasks in health services. A job description was developed based on the results of the survey to provide clear guidelines of the UAP's responsibilities to school personnel.

School nurses are often sources of health-care support for teens with sexually transmitted infections (STIs) and unintended pregnancies. However, providing prevention (e.g., condoms) and teaching technical skills (e.g., condom use) needed to reduce high-risk sexual behavior may require a change in perceptions and policies. This study used a cross-sectional study design to assess nurses' perceptions of condom availability accompanied by sex education programs among high school nurses (n = 87) in Kansas. Results showed that school nurses in this study supported condom availability, were comfortable providing condoms, and felt condom availability was within the scope of their job but were less likely to provide condoms because of external barriers. Common barriers include administration, parents, cost, community support, and policies. School nurses, by virtue of their access to the majority of Kansas' adolescents, have the potential to provide sex education and tools such as condoms, so young people can prevent STIs and unintended pregnancies.

BackgroundSchools are described as important arenas for health promotion interventions. Despite the critical role of school nurses in health promotion, limited research specifically examines school nurses’ perceptions of providing health promotion.AimWe aimed to describe both ratings and descriptions of school nurses' capability, opportunity, and motivation to provide health promotion beyond the individual health dialogues in Swedish schools.MethodThis convergent mixed-methods study used national cross-sectional data collected in May 2023 from a web-based survey and qualitative narrative data from an open-ended question in the same survey. In total, 596 school nurses in Sweden answered the web survey, and 354 described their experiences in the open-ended question. Data were analysed and interpreted through three commonly used theoretical domains in behaviour change research: capability, opportunity, and motivation.ResultsSchool nurses’ perceived motivation and capability to provide health promotion were generally rated as high, whilst the perceived opportunities to provide health promotion was rated as lower. Individual factors and the local work environment seemed to influence school nurses' perceived capability, opportunity, and motivation to provide health promotion. In a positive work environment, school nurses were confident in colleagues’ expectations and how to assess health promotion needs. In addition, there was a joint agenda, structure, and interprofessional collaboration in such a school, where health promotion felt important, enjoyable, and rewarding. In a negative work environment, school nurses were not expected to provide health promotion, and their time was prioritised to include other tasks primarily. Moreover, there was a lack of perceived adequate knowledge, skills, and tools to provide health promotion.ConclusionA positive work environment for school nurses, including a joint health promotion agenda, interprofessional collaboration, and clear expectations and structure, seem to be essential for providing health promotion activities to school-aged children.