Asthma and absenteeism

First-year PreSpecialty students Abby Smith (center) and Ankith Donthi (right) help second grader Saray Caravajal Hernandez identify and manage her asthma symptoms. Photo by Susan Urmy.

During the past school year, Napier Enhanced Option Elementary School in Nashville had the second largest population of elementary school-aged children with asthma in the district.

The ranking is one that Vanderbilt University School of Nursing (VUSN) Assistant Professor Natasha McClure, MSN’11, DNP, CPNP, knows she cannot change. So she wants to do the next best thing — provide knowledge to initiate asthma care at an earlier stage.

In 2015, an estimated 6.2 million children in the United States had asthma and nearly half reported having one or more asthma attacks a year, according to the U.S. Centers for Disease Control and Prevention’s 2015 National Health Interview Survey.


Social determinants
The neighborhood where you grew up and the stability of your home life impact your health. So does whether you are poor or well-off, own a car or have to walk, or go to a struggling school or a high-achieving one. These social determinants of health — the social, economic and physical conditions in the environments in which people live, learn, work, play, worship and age — create challenges for health care providers. Sometimes providers can help change the conditions. Sometimes they need to find creative, judgment-free and compassionate solutions that allow them to provide care.

Asthma continues to be a serious public health concern and a leading cause of school absenteeism, McClure said. It accounts for about 14 million absences each school year, or one-third of all days of missed instruction.

Armed with national and local asthma-related data, McClure developed a pilot asthma education program at Napier, a metropolitan public school where 98 percent of its students are considered economically disadvantaged based on household income and the surrounding neighborhood struggles with crime, unemployment and poverty.

She enlisted students enrolled in VUSN’s Enhancing Community and Population Health Nursing course to help. In 2014 Green Means Go was launched in hopes of reducing the number of asthma-related absences.

Now in its fourth year, the program has seen a host of changes — both in outcomes and how the program functions.

Adapt and retool

“I had thought that the best way to implement the program was to do what school nurses do — provide direct care to students. We envisioned coming into the school and being able to manage a child’s asthma by screening for symptoms and intervening with a referral for either medication administration or reaching out to parents to alert them of the need for medicines,” McClure said. But it didn’t work that way.

“What we soon discovered was that Napier, like most schools across the nation, doesn’t have a full-time school nurse, and only 12 out of 91 students had inhalers at school. That was a huge barrier.”

She redirected the program’s approach.

“Napier school has about twice the national and twice the state average of kids with asthma. The school doesn’t have the resources to manage this so we needed to figure out how best to help these students,” she said. The solution: engage VUSN nursing students to teach Napier students how to evaluate their own asthma health.

“Now we have a multi-tiered approach that not only educates but empowers children and we are seeing considerable progress,” McClure said.

‘My chest feels tight’

The first objective of Green Means Go is education.

Nursing students engage with first-through fourth-grade students to teach them how to self-assess, self-monitor and self-report.

Every child enrolled in the program, currently about 60, has a folder that includes a list of self-assessment questions, a journal to record symptoms and an action plan card that provides clear directions on how to proceed based on the symptoms they are experiencing.

“We teach children to do a daily symptom check and to report their symptoms to an adult,” McClure said. “We hope that by initiating care earlier at school, it will reduce the number of asthma-related school absences.”

Assistant Professor Natasha McClure helps J’Brein Crawford evaluate his asthma. He’s one of approximately 60 children at Napier who participate in the asthma assessment program. Photo by Susan Urmy.

Teachers and other school personnel are also included in the education and received training to be prepared to assist the students.

Green Means Go uses a simple stop light model for assessments: Green is good — go ahead with activities. Yellow is hold on — slow down and assess. Red means alert — stop and take necessary measures. Criteria for assessment are easily understood by the children. “I can run and play” is a green response. “My chest feels tight” or “I wake up at night coughing” are yellow responses. “I can’t sing Happy Birthday” or “It feels hard to breathe” are red — and triggers to go  to the Napier office, where an adult will determine the appropriate action for that child.

“I think that schools are the biggest opportunity for improving a child’s health, but in Middle Tennessee we are not making the most of those opportunities because our school nurse-to-student ratio is one to 3,000,” she said. Because of that reality, health care for school children has to adapt, sometimes creatively.

“We have to recognize that sometimes our system of health care does not work for the people who need it the most,” said McClure. “It is important to keep thinking of how we can deliver care to vulnerable patients living in underserved communities in ways that might not match our traditional models.”

That lesson is one McClure and other VUSN faculty want nursing students to take to heart. Circumstances in the places or culture where people are born, live, learn and work have an impact on health just as surely as heredity and behavior do. Poverty, unsafe neighborhoods, limited access to healthy food, lack of transportation and unemployment all contribute to health problems and are all negative social determinants of health.

“Our nursing students may or may not have experience with poverty or other social determinants but in the course of their careers they will meet and care for people who have,” McClure says. “It’s important that these future providers learn to look at the whole person and their entire circumstances when determining care, and then adapt or find solutions that meet that person’s needs.”

A noticeable change in absenteeism 

The nontraditional route to asthma care works for Napier’s students — and it’s caught the eye of the local juvenile court magistrate whose court is filled with the truancy, educational neglect and loitering cases of Davidson County students.

Juvenile Court Magistrate Jennifer Wade oversees the Metro Student Attendance Center, a partnership between the Davidson County Juvenile Court, Metro Nashville Police Department and Metro Nashville Public Schools. Her caseload teeters between 1,600 to 2,500 petitions a school year.

“This program has brought a great awareness to the courts and has educated us on the nature of asthma issues,” Wade said. “Green Means Go has had a great impact on my court. This program has given me an additional tool in making decisions about truancy. Having it as a resource has been so beneficial.”

The magistrate reached out to McClure after seeing improvements in truancy at Napier. Since meeting with McClure, Wade has learned how asthma affects students and the role it has played in student absenteeism. Her newfound knowledge has influenced how Wade interacts with petitioners in her court.

Juvenile Court Magistrate Jennifer Wade on the bench at the Metro Student Attendance Center, where she works on truancy, educational neglect and loitering cases for Metro Nashville Public School students. She says the Green Means Go program has made a positive impact on her court. Photo by John Russell.

“Prior to learning about this program, I was asking the wrong questions to my students and families,” admitted Wade. “In the past I’d ask if they had gone to the doctor and if so, did they get a doctor’s note for school to explain why they were absent.

“Now I am asking if they are getting the appropriate treatment on a daily basis and maintaining the treatment protocol or if they have an inhaler and medications to manage their illness. I feel like I am able to ask the right questions to help the students and empower the parents.”

Wade commends VUSN for partnering with Napier. “Green Means Go is innovative,” she said. “I wish every school had a program like this. It just might keep some of these cases from getting this far. That would be a big win.”

Parents on board

The program is making a difference at Napier, according to Chelsey Reardon, the Napier site manager for Community Achieves, a Metro Nashville Public School initiative that provides resources and support to parents, students and the community.

“Green Means Go has been very well received at Napier,” Reardon said. “The beauty of this program is that it allows the child to be more knowledgeable and more familiar with their own body and aware of when they are at risk for something more serious.”

Not only are the students being educated, but the parents have begun to advocate and talk to their providers regarding medications for the child to be given at school, Reardon said. “That’s a shift and an important piece of the whole program because then they are on board and taking the next steps necessary to improve their child’s health.”


A New Perspective
Sometimes the realities our patients face are far from what we ourselves have experienced. Read more »

McClure is pleased with how the program is progressing, but said there is still much work to be done.

“Because there are barriers to health care access, we still need to keep asking questions — how do we make health care more accessible? How can we do a better job of bringing health care to the people who need it the most?

“Napier is full of people who show up every day and want to make change happen. They are innovators. They are willing to try new things,” she said. “You have to have that if you are ever going to change the paradigm.

“I love being a part of what is going on there. It’s not easy work, but it is important work.”

Since launching Green Means Go at Napier, McClure has been working with MNPS and Jennifer David, MSN’14, a new Community Health faculty member at VUSN, to initiate a second Green Means Go site with the largest population of elementary-age children with asthma in Nashville.

by Jessica Pasley