Leading change

School nurses from Shropshire Community Health NHS Trust addressed unwarranted variation in the support and treatment of children with asthma in schools by developing and implementing asthma management guidance. This has led to improved knowledge and confidence in school staff, which has improved the care and treatment of children with asthma, leading to better health outcomes.

The School Nursing Team at Shropshire Community Health NHS Trust is made up of specialist community public health nurses, school staff nurses and school nurse support workers, who work together to promote and support the health and wellbeing of all school aged children aged 5-19 years old.

Where to look

Asthma is the most common long term medical condition among children and young people in the UK and is the most common reason for urgent admissions to hospital in children and young people in England. Asthma UK (2013) reported that there are 1.1 million children diagnosed with asthma in England, representing at least two children per classroom. Asthma is responsible for 12 deaths per year in children under the age of 14. The Healthy Child Programme (Department of Health (DH), 2009) emphasised that a child who is in the best possible health will have the ability to flourish and achieve at school. Good health in children is further associated with increased attendance and attainment. This view is mirrored by the Public Health Outcomes Framework (DH, 2012), which stresses that children who are in good health will have fewer school absences, leading to better educational outcomes for that child. Asthma contributes to many missed school days, with 33% of children with asthma feeling that they have missed out in school (Asthma UK, 2014).

Asthma UK (2016) stated that the use of Volumatic spacers in moderate-to-severe asthma attacks is as effective as treatment with a nebuliser. It is further recommended that children use spacer devices for administration of all their asthma medication (National Institute for Health and Care Excellence (NICE), 2012).

What to change

School nurses from Shropshire Community Health NHS Trust led an audit of primary and secondary schools across the county, which identified significant unwarranted variation in asthma management. The results indicated that 10% of pupils with asthma had an asthma care plan in place, 44% of schools had written guidelines on managing an acute asthma episode, 57% of schools had received education and training to support them to manage children with asthma conditions, and 50% of asthma inhalers kept by schools weren’t appropriate for pupils to use efficiently during an attack. The nurses recognised an opportunity to enhance the asthma management support provided in schools to address this variation.

How to change

The school nurse manager and professional lead set up a local steering group that was led in partnership by the School Nursing Team and the Acute Trust. Guidance on asthma management in schools was developed to enhance the confidence of school staff in managing acute and chronic asthma. This highlighted some core principles:

• Schools should have an identified asthma lead who will act as a key contact and take responsibility in ensuring oversight and coordination of the guidance principles into practice, as well as staff education, training and support;
• School staff should ensure that children with asthma have their relieving medication with them in school and take steps where this isn’t the case to maximise safety;
• Children with asthma should have easy access to their relieving medication at all times while in school;
• Children with asthma should have an individual healthcare plan highlighting their specific triggers and symptoms;
• School staff should document when children take their medication, self-administered or otherwise; and,
• School staff should be equipped and trained to manage an acute asthma attack within the school setting.

The guidance was rolled out to schools across the county with members of the School Nursing Team promoting and delivering asthma management training.

Adding value

Better outcomes – A post implementation audit provides evidence of improvements:

• 5% of schools have a written asthma policy;
• 5% of schools have written guidelines on the management of an acute attack;
• 5% of schools have staff trained on asthma by the school nursing team;
• 2% of schools have an identified asthma lead;
• 4% of schools reported that their students had an individual asthma care plan;
• 9% of schools have access to an emergency Ventolin inhaler; and,
• 91% of schools have an emergency Volumatic spacer.

Better experience – All schools now have a member of staff with specialist knowledge about asthma management. This includes the use of equipment to help children’s breathing in an acute asthma attack. Qualitative feedback demonstrates parental satisfaction with the schools’ ability to manage their child’s asthma:

• ‘’I feel happier knowing if there were any more problems he would be cared for properly by those members of staff”,
• “I feel they are more confident now, therefore I’m happier”
• “I believe there are two members of staff with training to deal with my son if any problems with his asthma occur”.

Better use of resources – The confidence and skills of school staff to manage acute and chronic asthma has been enhanced. This has had a positive impact on children’s attendance and health at school, as well as supporting a whole system approach to management of the children’s long-term conditions.

Challenges and lessons learnt for implementation

It is important that the whole team have ownership of the change and work together in every element of public health work being delivered for our population.

Find out more

For more information contact:

• Jo France, School Nurse Manager and Professional Lead, Shropshire Community Health NHS Trust, Jo.france@nhs.net
• Kirsten Ellmore, Specialist Community Public Health Nurse, Shropshire Community Health Care Trust, kirsten.ellmore@shropcom.nhs.uk