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Achieving the educational mission: are Connecticut K-12 school nurses valued?

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Achieving the Educational Mission:
Are Connecticut K-12 School Nurses Valued?
by
Janene Batten

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2021

ii

© Copyright by Janene Batten 2021
All Rights Reserved

iii

The Committee for Janene Batten certifies the approval of this Dissertation

Alexandra Wilcox, Committee Chair
Monique Datta
Briana Hinga

Rossier School of Education
University of Southern California
2021

iv
Abstract
Background: Healthy students are better learners is central to the K-12 education mission to
graduate students successfully. School nurses support students’ educational success by taking
care of their immediate health needs, coordinating care for students’ chronic health conditions,
and promoting healthy behaviors. This study uses a knowledge, motivation, and organizational
gap analysis framework to evaluate how Connecticut school nurses perceive their role and
practice in the educational environment are valued to further the educational mission.
Methods: A qualitative phenomenological design was used. Fourteen Connecticut school nurses
were interviewed via Zoom in January 2021. Data from interviews was analyzed using thematic
analysis.
Results: Although school nurses believe that they bring value to students by providing equitable
access to healthcare and wellness education, they felt that the organization did not recognize how
indispensable they are to meeting the educational mission. School nurses identified four areas of
opportunity: advocacy skills that enables the organization to recognize the alignment of the
school nurse expertise with the educational mission; belief in their ability to advocate to change
workload levels to ensure the provision of safe healthcare; and an advocacy platform within the
organization to convey their value as essential to the educational mission.
Recommendations: Empower school nurses to advocate how and why their role is indispensable
to the K-12 educational mission.
Keywords: school nurses; K-12 education

v
Dedication
to all School Nurses
This is your time to be heard.
To school nurses - you have known for a century what the broader community is just
acknowledging. And that is that the COVID-19 pandemic laid bare the inherent problem that the
social determinants of health fuel the nation’s healthcare disparities. Your practice was founded
on knowing that disparities existed and then meeting the needs of underserved children, families,
and communities. Today, continuing to witness firsthand family’s enduring hardships (and
enjoying privilege), your practice is grounded in care coordination, ensuring all children have
equitable access to the care that they need.
To school nurses - for a century, you have been doing what the wider community is calling for.
And that is to have conversations to find solutions and develop partnerships to solve the
inequities and invest in educational, nutritional, transportation, and economic needs that support
health in our community. Today, your interdisciplinary and intersectoral efforts find specialist
healthcare for children, food and housing for needy families, transportation for parents to get
children to medical appointments, and clothing to keep children warm.
To school nurses - every day you witness and act on the profound connections between health
and a child’s education. School nurses, your presence in schools where the nation’s children are
and your longstanding and successful efforts to address their needs not only means that you are
thought leaders, it also means that you will get it done. Be courageous!
Seize this moment to be heard. Change cannot happen without you.

vi
Acknowledgements
I want to acknowledge and give special thanks to my dissertation chair, Dr. Alexandra
Wilcox, for dedication, guidance, leadership, and always challenging me to do even better. Your
commitment to me and this topic during the development and completion gave this project the
life it merited.
Adoration goes to those I thrust various iterations of bits and parts of the doctoral
manuscript in front of and who painstakingly reviewed, read, edited, and offered feedback.
Sincere thanks to Dr. Don Murphy, whose reading offered insights that evolved into clarity and
focused this study at pivotal moments along the way. Appreciation to my committee, Dr.
Monique Datta and Dr. Briana Hinga, whose conviction in the topic's significance gave
invaluable perspectives strengthening what this has become.
Special thanks and immense gratitude go to all my nurse colleagues who were a source of
reflection and constant encouragement along my EdD journey. Your belief continually
reinforced that this was a valuable topic. You continually deepen my understanding and
appreciation for the exceptional and tireless caring that nurses lovingly provide.
Loving appreciation goes to my family and friends whose journey this has also been. I
could not have taken on this degree without your love, support, and unending encouragement.
Thank you for listening and reflecting with me about my passion for school nurses.
Thank you to my Cohort 13 classmates for sharing the learning space allowing me to
experiment and grow. Your support throughout our coursework gave me precisely what I was
looking for from this program – the perspectives and insights from talented professionals who
were different from me. Fight On Trojans!
And finally, the author acknowledges there are no conflicts of interest.

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Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables ................................................................................................................................. xi
List of Figures ............................................................................................................................... xii
Chapter One: Introduction .............................................................................................................. 1
Background of the Problem ............................................................................................................ 3
Importance of Addressing the Problem .......................................................................................... 8
Field Context and Mission .............................................................................................................. 8
Field Global Goal .......................................................................................................................... 12
Description of Stakeholder Groups ............................................................................................... 13
Stakeholder Group of Focus for the Study ................................................................................ 14
Purpose of the Study and Questions ............................................................................................. 15
Overview of the Conceptual and Methodological Framework ..................................................... 15
Definition of Terms....................................................................................................................... 17
Organization of the Project ........................................................................................................... 19
Chapter Two: Review of the Literature ........................................................................................ 20
History of School Nursing – Public Health Focus ........................................................................ 21
How Legislation Shapes School Nursing Practice........................................................................ 24
Federal Legislation .................................................................................................................... 25
Elementary and Secondary Education Act ............................................................................ 26
Individuals with Disabilities Act (IDEA) .............................................................................. 27
Connecticut State Legislation.................................................................................................... 27
The K-12 Education Milieu .......................................................................................................... 29
Education Dollars Fund School Nurses .................................................................................... 29
School Principals ....................................................................................................................... 31
School Nurse Supervisors ......................................................................................................... 32
School Nursing Workforce ........................................................................................................... 33
School Nurses Knowledge Sources........................................................................................... 36
School Nursing Practice ................................................................................................................ 38
Care Coordination ..................................................................................................................... 39

viii
Public Health ............................................................................................................................. 40
Leadership ................................................................................................................................. 41
Quality Improvement ................................................................................................................ 41
The Clark and Estes (2008) Gap Analytic Conceptual Framework ............................................. 42
Stakeholder Knowledge, Motivation, and Organizational Influences .......................................... 43
Knowledge and Skills................................................................................................................ 43
Knowledge Updates for Clinical Practice [Factual] .............................................................. 43
Alignment of School Nurse Role and the Education Mission [Conceptual] ......................... 45
Convey the Value of the School Nurse to the Education Community [Procedural] ............. 46
Responding Effectively to Influences of the Education Setting [Metacognitive] ................. 47
Motivation ................................................................................................................................. 51
Self Determination Theory .................................................................................................... 52
Self-Efficacy .......................................................................................................................... 53
Organizational Influences ......................................................................................................... 55
Cultural Model Influence 1: A Sense of Belonging .............................................................. 57
Cultural Model Influence 2: Empowered to Convey Their Value to Others in the School .. 58
Cultural Setting Influence 1: Access to the Support of Other Healthcare Professionals ...... 59
Cultural Setting Influence 2: Professional Development Opportunities ............................... 60
Conceptual Framework: Interaction of Stakeholders’ KMO Influences ...................................... 63
Conceptual Framework Details ................................................................................................. 63
Conclusion .................................................................................................................................... 66
Chapter Three: Methodology ........................................................................................................ 68
Purpose of the Project and Research Questions ............................................................................ 68
Overview of Methodology ............................................................................................................ 69
Data Collection, Instrumentation, and Analysis Plan ................................................................... 70
Interviews .................................................................................................................................. 71
Instrumentation ...................................................................................................................... 73
Data Collection Procedures ....................................................................................................... 74
Data Analysis ......................................................................................................................... 74
Credibility and Trustworthiness ............................................................................................ 75
Ethics and Role of the Researcher ................................................................................................ 77
Positionality ............................................................................................................................... 77

ix
Ethics ......................................................................................................................................... 78
Consent and Confidentiality for Study Participants .................................................................. 79
Compensation ............................................................................................................................ 80
Chapter Four: Results and Findings .............................................................................................. 81
Purpose of the Project and Research Questions ........................................................................ 81
Participant Stakeholders ............................................................................................................ 82
Interview Administration .......................................................................................................... 87
Data Analysis ............................................................................................................................ 87
Data Validation ......................................................................................................................... 87
Results and Findings ................................................................................................................. 88
Results and Findings: Knowledge Results ................................................................................ 89
Factual Knowledge. ............................................................................................................... 90
Conceptual Knowledge. ......................................................................................................... 93
Procedural Knowledge. ......................................................................................................... 95
Metacognitive Knowledge. .................................................................................................. 102
Summary of Knowledge Results ............................................................................................. 105
Results and Findings: Motivation Results ............................................................................... 106
Self-Determination Theory .................................................................................................. 107
Self-Efficacy ........................................................................................................................ 117
Summary of Motivation Results ............................................................................................. 122
Results and Findings: Organizational Results ......................................................................... 123
Cultural Model Influence 1. ................................................................................................. 124
Cultural Model Influence 2 .................................................................................................. 127
Cultural Setting Influence 1 ................................................................................................. 132
Cultural Setting Influence 2 ................................................................................................. 137
Summary of Organizational Influence Results ....................................................................... 140
Summary of Knowledge, Motivation, and Organizational influence (KMO) results. ............ 141
Chapter Five: Recommendations and Discussion....................................................................... 145
Findings and Results ................................................................................................................... 145
Knowledge Strengths .............................................................................................................. 146
Motivational Strengths ............................................................................................................ 146
Organizational Strengths ......................................................................................................... 147

x
Knowledge, Motivation, and Organizational Needs ............................................................... 148
Recommendations for Practice ................................................................................................... 149
Knowledge Influence Recommendations................................................................................ 149
Procedural Knowledge Recommendation ........................................................................... 150
Motivation Influence Recommendations ................................................................................ 152
Self-Efficacy Recommendation ........................................................................................... 153
Organizational Influences Recommendations ......................................................................... 155
Organizational Recommendation ........................................................................................ 157
Integrated Knowledge, Motivation, and Organizational Recommendations .......................... 159
Implementation and Evaluation: Fully Empowering School Nurses to Convey Value.............. 160
Proposed Implementation Strategies ....................................................................................... 160
Proposed Evaluation Plan........................................................................................................ 161
Limitations and Delimitations ..................................................................................................... 164
Recommendations for Future Research ...................................................................................... 165
Conclusion .................................................................................................................................. 166
References ................................................................................................................................... 168
Appendix A: Interview Protocol ................................................................................................. 209
Appendix B: Crosswalk Showing KMO Assumed Influence, Data Collection, and Research
Question ...................................................................................................................................... 216
Appendix C: Zoom Instructions.................................................................................................. 225
Appendix D: Communications ................................................................................................... 226
Appendix E: Participation Survey .............................................................................................. 230
Appendix F: Information Sheet for Exempt Research ................................................................ 234

xi
List of Tables
Table 1: Stakeholder Performance Goals……………………………….………………………..14
Table 2: Assumed Knowledge Influences…………………………………………….………….50
Table 3: Assumed Motivational Influences………………………………………………………55
Table 4: Assumed Organizational Influences…………………………………………………….62
Table 5: Participant Characteristics………………………………………………………………84
Table 6: Aggregated Participant Characteristics………………………………………………….86
Table 7: Summary of School Nurse Knowledge Influences………………………………………89
Table 8: Summary of Assumed Motivation Influences…………………………………………106
Table 9: Summary of Assumed Organization Influences………………………………………..123
Table 10: Summary of Assumed Influences and Validation Status……………………………...141
Table 11: Summary of “Gap Validated” from Assumed Influences…………………………….142
Table 12: Summary of Knowledge Needs and Recommendations…………………………...…149
Table 13: Summary of Motivational Needs and Recommendations…………………………….152
Table 14: Summary of Organizational Needs and Recommendations…………………………..155
Table 15: Proposed Implementation and Evaluation Plan…………………………………162-163

xii
List of Figures
Figure 1: School District: Personnel Structure……………………………………………………12
Figure 2: Conceptual Framework………………………………………………………………...65

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Chapter One: Introduction
Nurses and their work bring value to society. The nursing workforce is the largest
healthcare profession, with more than 3.9 million nurses nationwide (U.S. Bureau of Labor
Statistics, 2019; U.S. Bureau of Labor Statistics & U.S. Department of Labor, 2020a, 2020b).
Since the beginning of 2020, the global COVID-19 pandemic shone a bright light on the health
care sector and, most significantly, the valor of nurses as invaluable to navigating the care of
millions of patients (Brenner, 2020; Stockton & King, 2021). They are front-line healthcare
professionals who make a multitude of patient-care decisions every day (Clarke & Donaldson,
2005; Institute of Medicine, 2011; O’Keeffe et al., 2015). Their essential role means that they are
responsible for delivering best practices to ensure quality patient care (Institute of Medicine,
2011) and meet clinical quality and safety guidelines (National Association of School Nurses,
2017, 2020; The Joint Commission, 2019).
School nurses are distinct nurse specialists who work in the K-12 educational
environment. As with all nurses, school nurses graduate with an undergraduate degree that
prepares them to be nursing generalists (Craven et al., 2013). Nurses working in the K-12
education sector become school nurse specialists through navigating the unique and complex
health care needs by working with the school-aged child and their families in the community
setting. To become a school nurse prepared to address the quality of care essential to care for
students, the 4-year baccalaureate nursing degree (BSN) is preferred over the shorter 2-year
associates nursing degree (ADN) (American Federation of Teachers, 2009; Council on School
Health, 2016; National Association of School Nurses, 2016a). The BSN is preferred for the
safest student care because it qualifies the nurse to perform duties that an ADN is not trained to
do. However, the BSN is not mandated, so as many as 47% of the nation’s school nurses have an
2

ADN training (Willgerodt et al., 2018). To certify their role as school nurse specialists some
nurses choose to attain national- or state-level professional school nurse certification which
involves having experience in direct clinical practice in the K-12 setting beyond their BSN
preparation (Aroke, 2014; Cruise, 2020; National Association of School Nurses, 2016a; NBCSN,
2021). In a national survey of 3,108 school nurses, 15.9% were nationally certified and 33.8%
were certified at the state-level (Davis et al., 2018).
Specialization in school nursing is recommended because of the unique healthcare roles
and responsibilities that school nurses face in this community setting. They support students’
educational achievement by taking care of students’ immediate health needs, coordinating care
for students’ chronic health conditions, and promoting healthy behaviors (Council on School
Health, 2016; National Association of School Nurses, 2015a). Situated in the community means
that school nurses are front-line health care professionals for students whose families come from
all socio-economic circumstances. A national school-nurse survey revealed that 79.8% of school
nurses work in schools where more than 25% of students receive reduced-price lunches (Davis et
al., 2018). School nurses address the social determinants of health such as income, housing,
transportation, access to health insurance, and environmental health (National Academies of
Sciences, 2021; National Association of School Nurses, 2016b). With social determinants
identified causing 80% of health concerns, including many chronic conditions (Cockerham et al.,
2017; Paul et al., 2021; Sereni et al., 2016; Shantz & Elliott, 2021), school nurses are essential as
their core focus is uniquely as front-line health care professionals.
As with all nurses, the expectation is that school nurses fulfill their healthcare role using
best practices for healthcare quality outcomes (National Association of School Nurses, 2017).
However, in contrast to nurses in hospital and outpatient clinic settings, school nurses do not
3

work in the healthcare milieu of the proximity to collaborative support from nurses or other
healthcare professionals (Denke & Winkleblack, 2020; Helleve et al., 2020). School nurses work
in isolation and without underlying culture and communication infrastructure of knowledge
sharing vital to the success of nursing practice (Davis et al., 2018; Maughan, 2018; Simmons,
2002; Smith & Firmin, 2009; Yonkaitis, 2018). Instead, they are embedded in the organizational
ethos of education where health, although vital for students’ success in school, is not the main
priority (Allison et al., 2019; Bayik Temel et al., 2017; Biag et al., 2015; Kruger et al., 2009). As
a result of the isolation from the support of health care professionals and working in a setting
where health is not the primary concern, school nurse’s practice is often undervalued, and as a
result, they are unable to practice to their full scope (Adams & Barron, 2009; Vela, 2017). Even
though the educational mission’s focus is to ensure students succeed in school, compromising the
school nurse role can be an antecedent for low health care quality for students. The problem of
practice that this study seeks to evaluate is how Connecticut K-12 school nurses perceive their
role and practice in the educational environment are valued in furthering the education mission
by ensuring that students are healthy and ready to learn.
Background of the Problem
In K-12 schools, the mission is to focus on the student’s successful academic
achievement. The school nurse has a shared stake in this mission because their specialized
practice centers on ensuring students are healthy and ready to learn (National Association of
School Nurses, 2017). Nevertheless, individuals in the educational environment often do not
value that school nurses are integral to that mission (Kruger et al., 2009).
There are unique challenges that school nurses face due to being situated in the education
setting. The school nurse is often the only health care professional in the building, and so is
4

isolated and unable to collaborate and gain knowledge from other clinicians (Adams & Barron,
2009; Schweikhard, 2016; Smith, 2004). Unable to talk over student health issues with other
nurses may compromise the provision of essential and quality healthcare, especially if the nurse
is unsure of the best care for a student’s health condition (Pufpaff et al., 2015; Schweikhard,
2016).
School nurses are front-line and often become the student’s only care provider available
to address the medical and social needs. The school nurse is available to a child without barriers
such as insurance and transportation, fees, and appointments (Fleming, 2011). While this is true
in all schools where a school nurse is, it is particularly true in schools with underserved and low-
income children. With COVID-19 highlighting the deep inequities in the health system with the
critical problem that the health system does not value the social determinants of health, school
nurses are invaluable in their communities (National Academies of Sciences, 2021). The social
determinants of health are a particular issue for the vulnerable populations which includes
children as they rely on adults to care for them. In 2018, 16.2%, or one in six children lived in
poverty, 11.1% of households are food insecure, and every year 2.5 million children experience
homelessness (poverty.org, 2021). Health care organizations and policymakers have identified
how social factors and poor living conditions impact children’s health (Centers for Disease
Control and Prevention, 2018). Social factors such as low household income lead to a higher
burden of disease (Assari & Hani, 2018; Clark et al., 2019; K. Hughes et al., 2017; Racine, 2016)
such as childhood developmental disorders (K. Hughes et al., 2017), unmet dental care needs
(Assari & Hani, 2018), and poorly controlled chronic conditions such as asthma (Bellin et al.,
2018). Low household income also results in food insecurity, which means that by not having
enough to eat, and being hungry, the child’s ability to perform at school decreases (Jyoti et al.,
5

2005; Shankar et al., 2017) as well as decreases their psychological well-being and increases
emotions such as a sense of hopelessness and suicide ideation (Belsky et al., 2010; Brinkman et
al., 2020). Access to highly nutritious foods is essential for a child’s healthy development
(American Academy of Pediatrics, 2015). Food insecurity also leads to other adverse health
outcomes (Cook et al., 2013; Kral et al., 2017; Larson et al., 2020; Rose-Jacobs et al., 2008) such
as being overweight, particularly in girls (Cook et al., 2013; Kral et al., 2017; Larson et al., 2020;
Rose-Jacobs et al., 2008). The disruption of appropriate nutrient intake can lead to lasting effects
such as appreciably low IQ and being at developmental risk and high levels of behavioral and
emotional problems (Belsky et al., 2010). In the unique role of being present in communities,
school nurses are responsible for influencing and informing issues around social determinants of
health, such as food insecurity, or housing, or transportation, when dealing with a child, the child
and their family, or the community at large (National Academies of Sciences, 2021).
As part of the K-12 educational community, a school nurse’s availability ensures that all
school-aged children have equitable access to a health care provider. In areas with
disproportionate numbers of low-income families, access to health care providers is often
inadequate (Anderson, 2017, 2018; Sherry et al., 2021). There is a positive association between
residential segregation and access to physicians (Anderson, 2018) and other healthcare providers,
including dentists, mental health providers, podiatrists, optometrists, physical/occupational/
speech therapists, and chiropractors (Anderson, 2017). The lack of access to health care
providers in the immediate community is a troubling barrier for families when it comes to their
child’s health. The difficulty is even more worrying for a parent who does not have access to a
private vehicle or needs to take time off work (H. K. Hughes et al., 2017). As a result of access
6

barriers to healthcare, the school nurse becomes the pseudo-primary care provider and is
perfectly positioned to first recognize undiagnosed health conditions and concerns.
School nurse caseloads leave little time to do anything more than take care of students’
immediate health needs. School nurses are often responsible for caseloads that number in the
hundreds, and often in the thousands of students, many who have chronic and potentially life-
threatening conditions (Baxley, 2016; Endsley, 2017; Jameson et al., 2018; Schweikhard, 2016).
Also, caseloads can be immense because the school nurse is responsible for students across
multiple schools, often traveling between the schools on any given day (Baxley, 2016;
Willgerodt et al., 2018). The health acuity, or the complexity of the health needs of students, is
also a burden to the caseload for school nurses (Dolatowski et al., 2015; Jameson et al., 2020).
Caseloads are particularly concerning in schools with underserved and low-income children, as
the school nurse may be the only primary care provider for a disproportionate array of increased
health concerns (Assari & Hani, 2018; Clark et al., 2019; K. Hughes et al., 2017; Racine, 2016).
School nurses are grappling with increasing numbers of students with a broader range of
physical, developmental, behavioral, and emotional challenges (Endsley, 2017; Jameson et al.,
2018; Leroy et al., 2017). Due to the Individuals with Disabilities Education Act (IDEA)
(Individuals with disabilities education act (idea), 2004), which mandates that students with
special needs attend schools, school nurses see increasing numbers of their patient populations
are children with disabilities. The National Center for Education Statistics (2020b) shows an
increase in students with special needs from 8.3 percent in 1976-77 to 13.8 percent in 2015-16
school years. Children with special health care needs often require medication administration,
acute/chronic care, mental health care, care coordination, and other increasingly complex tasks,
all of which fall under the school nurse’s responsibility (Pufpaff et al., 2015; Willgerodt et al.,
7

2018). Providing essential and quality healthcare care is critical for all students, and especially so
for students with special needs. The school nurse is at a disadvantage when working alone and
within time constraints to ensure that all students get the quality care that they need.
Funding for school nurse programs is reliant on education dollars (Leachman et al.,
2017). As a result, when there are reductions in school funding, school administrators are forced
to prioritize spending. As healthcare is not the central priority in the education setting, school
nurses are often likely to be impacted (Blad, 2020; Leachman & Mai, 2014; Leachman et al.,
2017; National Council on Disabilities, 2018). Impacts of low prioritization for funding school
health include inadequate staffing or low compensation (Cygan et al., 2019; Jameson & Bowen,
2020) or forcing administrators to let school nurses go because their position is not mandated
(Wang et al., 2014). Funding also affects whether or not the school nurses have access to
necessary healthcare supplies in which to run a practice (Kruger et al., 2009; Maughan & Adams,
2011; Wang et al., 2014). And typically, funding directly impacts school nurses’ access to
ongoing nurse education (Kruger et al., 2009). School health funding shortfalls can result from
school administrators not connecting the school nurse’s role to the educational mission (Asada et
al., 2020; Kruger et al., 2009; Resha, 2010), often due to not being entirely aware of their scope
of practice. For instance, school nurses’ time can be misappropriated, including being
responsible for tasks that do not fall into the nurse’s scope, such as fire drills (McIntosh &
Thomas, 2015). Also, where their professional skills could bring perspective, they may often be
left out of conversations, for instance, not being included in decision making when planning for
special needs children (Kruger et al., 2009).

8

Importance of Addressing the Problem
Valuing that school nurses are essential to the educational mission is critical because
“healthy students are better learners” (Centers for Disease Control and Prevention, 2021, para.
1). Central to the educational mission, school nurses bridge healthcare and education, ensuring
that students can optimally learn. Schools are where children and adolescents go every day,
which puts the school nurse in the best place to provide equal access to health care where the
students are (National Association of School Nurses, 2017; Racine, 2016; Robert Wood Johnson
Foundation, 2010a). Research shows that there are strong connections between student’s health
and academic achievement (Basch, 2011; Best et al., 2018; Centers for Disease Control and
Prevention, 2018; Michael et al., 2015; Willgerodt et al., 2018). Ensuring students have
uninterrupted schooling is achievable because the school nurse is readily on hand to meet all
acute and chronic healthcare needs (Fleming, 2012; Leroy et al., 2017). Keeping students in
school is possible because the school nurse’s role includes well-health tasks such as conducting
periodic child health assessments, developing long term health education and promotion, and
planning for the school’s emergency preparedness (Willgerodt et al., 2018). An appreciation of
the school nurses’ centrality to students’ health, ensuring successful learning is imperative in
furthering the educational mission.
Field Context and Mission
The study’s context is the K-12 educational setting where school nurses are situated,
providing leadership to bridge healthcare and education, ensuring students develop to their full
potential (National Association of School Nurses, 2016b).
K-12 education’s mission is to ensure students receive equitable access to a high-quality
education that ensures academic achievement and well-being in order to lead successful lives
9

(National Association of Elementary School Principals, n.d.; The School Superintendents
Association, 2018; U.S. Department of Education, 2011). School nursing’s priority aligns with
the K-12 educational mission in that school nursing practice “protects and promotes student
health, facilitates optimal development, and advances academic success” (National Association
of School Nurses, 2017, p. 1).
The context for school nurses within Connecticut’s educational setting is that they work
in one of the 1,508 Connecticut public elementary, middle, or high schools (Connecticut State
Department of Education, 2020b). They tend to the daily health needs of approximately 528,000
students (Connecticut State Department of Education, 2020b), and are often the only healthcare
provider in the educational setting (National Association of School Nurses, 2017). There is no
single employer for school nurses in Connecticut, so there is no accurate data for the number of
school nurses that work at the elementary, middle, or high school level.
Each school is a part of one of the 205 school districts in Connecticut (Connecticut State
Department of Education, 2020b). Each school district has a superintendent and, depending on
its size, potentially, an assistant superintendent. The superintendent is the top executive of the
school district responsible for day-to-day programming, staffing, and financial decisions (Stand
for Children, 2012). With student needs as the focus, the superintendent is charged with meeting
the district’s goals and implementing the school board’s vision. The town or city’s constituents
elect the school board within the school district’s town or city. The school board makes policy
and strategic planning decisions for the district, sets the budget and spending priorities, and hires
and manages the superintendent (Stand for Children, 2013). Each school within the district has a
principal and potentially assistant principals, teachers, and other support staff, including the
school nurse. The school’s principal reports to the superintendent, hiring and supervising
10

teachers and staff, and the school’s day-to-day operations, including developing and building a
culture of learning (Stand for Children, 2013).
The school health program within a school district includes one school nurse supervisor
who oversees the school nurses working in each school in that district. In Connecticut, the school
nurse supervisor is employed by and reports to an administrator at the school district level. The
school nurse supervisor is responsible for coordinating the student health needs across the
district, including personnel policies and procedures for special needs students (Connecticut
State Department of Education, 2020a). Most Connecticut school districts have a nurse
supervisor who may or may not have the additional task of providing direct care to students.
Because there is no single employer, there is no accurate data for the number of school nurse
supervisors working in Connecticut K-12 schools. The most recent annual non-mandatory survey
sent to school districts (2017-2018) shows that 170 out of 205 districts responded (Connecticut
State Department of Education, 2020b). The survey showed 185 nurse supervisors in
Connecticut, 139 who have school assignments providing care for students, and 46 who do not
provide direct care (Connecticut State Department of Education, 2020c). Hiring the school
nurses often falls to the school principal or the district’s school nurse supervisor. The survey data
shows approximately that within the 1,508 Connecticut schools, there are 1,386 school nurses
(Connecticut State Department of Education, 2020c). The survey also shows that there are 262
health services support staff who assist the school nurses.
The Connecticut State Department of Education has oversight of education across the
state through legislative acts. The Department also provides 37.8% of state tax revenue to fund
school districts (School and State Finance Project, 2021a). Connecticut school health’s
governance is mandated by the Connecticut General Statutes Chapter 69 – School Health and
11

Sanitation (2019a). According to the Connecticut State Department of Education School Nurse
Program, the mandate for school nurses is to ensure the well-being, academic success, and life-
long achievement of the students (Connecticut Department of Education, n.d.). While
Connecticut school nurses do not report to anyone at the state level, the Connecticut school nurse
educator provides coordination of school health services and advises school nurses on school-
related matters and coordinates appropriate training.
Figure 1 shows a model of the educational context within which school nurses work.

12

Figure 1
School District Reporting Structure
Note: School district reporting structure showing the relationship between school health, and
school nurses, in the educational context. This structure may vary between school districts
depending on size and personnel makeup.

Field Global Goal
Even though the school nurse is integral to student academic achievement, individuals in
the education milieu do not necessarily understand the complexity of the school nurse’s role or
their value to the educational mission. The school nurse’s value as part of the education team
needs to be acknowledged and embraced (Peña, 1998). The field global goal is that by June
2023, 100% of Connecticut K-12 school principals will implement best practices to provide
13

school nurses with a culture of support that empowers them to perform at their full scope of
practice ensuring students are healthy and ready to learn.
Description of Stakeholder Groups
Several stakeholder groups are fundamental to the achievement of this goal. Key
stakeholders for the achievement of this field goal are as follows:
• School principals and administrators because they have ultimate responsibility for
student well-being and all education team members.
• The district’s school nurse supervisor, who plays a healthcare leadership role
supervising the school nurse and ensuring their practice’s success in supporting
healthy students.
• The Connecticut Department of Education and the School Nurse Advisory
Council, as an advisor to the Commissioner of Education and Public Health about
school nurse professional development needs.
• The Connecticut K-12 school nurse, whose role and practice are essential to
furthering the educational mission by ensuring that students are healthy and ready
to learn.

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Stakeholder Group of Focus for the Study
All stakeholders' commitment is integral to valuing school nurses as central to students’
health, which is imperative in furthering the educational mission. However, school nurses are
accountable for safe and effective nursing care that ensures students are healthy and ready to
learn. With this in mind, Connecticut K-12 school nurses, as central to student health, will be the
stakeholder of focus in this study. The school nurse’s integration as an empowered professional
in the education milieu aligns with the school’s mission to graduate students to lead productive
and successful lives. Table 1 describes the stakeholder performance goals.

Table 1
Stakeholder Performance Goals
Mission
K-12 education’s mission is to ensure students receive equitable access to a high-quality education that
ensures academic achievement and well-being in order to graduate and lead successful lives.
K-12 School Principal/School Administrator
By June 2023, 100% of Connecticut K-12 school principals will implement best practices to provide
school nurses with a culture of support that empowers them to perform at their full scope of practice
ensuring students are healthy and ready to learn.
School Nurses School Nurse Supervisor
Connecticut State
Department of Education
By December 2022, 100% of
Connecticut K-12 school nurses
will convey to individuals in the
educational environment the
value of the nurses' role and
how it furthers the educational
mission in order for the
community to appreciate and
advocate for each school to
have a full-time nurse onsite
daily.
By June 2022, each district school
nurse supervisor will mentor,
provide tools, along with clear,
current, and challenging goals that
enable school nurses to have a
sense of mastery for their full scope
of practice so they can convey their
value to individuals in the local
educational environment.

By January 2022, the
Connecticut Department of
Health will provide K-12
school nurses with the tools
required to enable nurses to be
empowered to share
information about their role
and practice so they can
convey their value to
individuals in the local
educational environment.
15

Purpose of the Study and Questions
The purpose of this qualitative phenomenological study is to evaluate how Connecticut
K-12 school nurses perceive their practice and role in the educational environment are valued in
furthering the education mission, ensuring students are healthy and ready to learn.
The study will focus on the school nurse’s knowledge, motivation, and organizational
influences in the educational environment affecting their ability to convey how and why their
practice and role furthers the educational mission.
The questions that will guide this study are as follows:
1. How does working in the educational environment impact the school nurse’s ability
to convey the value of their contribution to the education mission?
2. What are the knowledge, motivation, and organizational influences that facilitate or
impede the school nurses’ ability to convey to individuals in the educational
environment the value of their role and how it furthers the educational mission?
3. What are the knowledge, motivation, and organizational resource recommendations
for Connecticut K-12 school nurses to be able to convey to individuals in the
educational environment the value of their role and how it furthers the educational
mission?
Overview of the Conceptual and Methodological Framework
Goal achievement is dependent on the combination of the appropriate knowledge,
motivation, and organizational and contextual influences in place to ensure success (Rueda,
2011). Success is dependent on accounting for any gaps in any of these three influences on goal
achievement. The conceptual framework for this study uses the gap analysis process described
by Clark and Estes (2008). The gap analysis identifies the school nurse’s knowledge, motivation,
16

and organizational influences that impact their ability to be empowered in the educational
environment to convey the value of their role in meeting the educational mission by ensuring
students are healthy and ready to learn.
The researcher’s ontology is through the constructivist lens, recognizing that an
individual’s knowledge forms through lived experiences and interactions with others in society
(Lincoln et al., 2017). The constructivist lens means that the researcher participates in the
research process with the study participants. With this lens, the study’s methodological
framework is a qualitative phenomenological study, where participants describe the common
meaning of a concept from their experience (Creswell & Poth, 2018). The study method
included the hermeneutic cycle of the data collection, followed by data interpretation, spurring
action based on the data (Lincoln et al., 2017). Data collection in this study was via interviews
that collected the constructed meaning of school nurses’ lived experiences working in the
educational environment. Through interview questions, school nurses were encouraged to
identify and voice experiences about working in the context of an educational environment and
how it influences their ability to convey the value of their role (Creswell & Creswell, 2018). This
qualitative approach analyzed and made meaning of the perceptions school nurses share through
patterns that emerged from understanding their knowledge, motivation, or organizational
influences in the educational environment.

17

Definition of Terms
Best Practice in nursing is a “directive and quality-focused concept, which describes a set of
recommendations or a desired standard (outcome), incorporates translation of current evidence
into practice, and promotes a high level of performance/ effectiveness” (Nelson, 2014, p. 1512).
Care coordination is the “function and product of a team approach to providing seamless, safe,
quality care for an individual by linking systems and people to improve health outcomes … [and]
where the nurse is integral to the care coordination model in helping patients overcome barriers
to health care and reach their healthcare goals” (Prokop, 2016, p. 273).
Caseload is the school nurse’s workload, or the number of students that are assigned to a
registered school nurse (Jameson et al., 2020) .
Clinical reasoning is “a complex cognitive process that uses formal and informal thinking
strategies to gather and analyze patient information, evaluate the significance of this information
and weigh alternative actions. Core essences of this concept include cognition, metacognition
and discipline‐specific knowledge” (Simmons, 2010, p. 1155).
Evidence-based practice Evidence-based practice (EBP) is a widely accepted process in
healthcare for making clinically valid decisions integrating three things: the best available
research evidence, the clinician’s expertise, and the patient’s expectations for their clinical care
(Porter-O'Grady, 2010; Rycroft-Malone et al., 2004; Sackett et al., 1996).
Full Nursing Potential is a “dynamic state in which government regulations, institutional
policies, adequate education, personal experience, environmental factors, and personal traits
culminate to foster the essence of nursing, enabling nurses to deliver high-quality, patient-
centered care and promote equitable social systems” (Aroke, 2014, p. 278).
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Advanced Practice Nurses / Nurse Practitioners Advanced practice nurses, also known as
nurse practitioners, work as primary care providers in school-based health centers. In
Connecticut, these nurses provide outpatient healthcare to students in one of the 93 state-funded
school-based health centers across 25 different Connecticut communities (Patterson Janicek et
al., 2019).
Patient Safety is the prevention of harm to patients where there is a “critical contribution of
nursing to patient safety, in any setting, [by having] the ability to coordinate and integrate the
multiple aspects of quality within the care directly … and across the care delivered by others in
the setting” (Mitchell, 2008, para. 6).
Public health is concerned with protecting the health of entire populations and specifically “is
the science of protecting and improving the health of people and their communities … by
promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing
and responding to infectious disease” (CDCFoundation, 2020, para 1).
School-Based Health Centers (SBHC) are “comprehensive primary care facilities located in or
on the grounds of schools. In Connecticut these facilities are licensed by the Department of
Public Health as outpatient or hospital satellite clinics. SBHCs assure that students, particularly
those that are uninsured and underinsured, have access to comprehensive health and preventative
services” (Connecticut State Department of Public Health, 2020b, para. 1).
School Health Services is the “comprehensive efforts of developing, implementing, and
evaluating services, both within the school and the community, that provide each and every
student with the resources needed to thrive within a healthful environment. School Health
initiatives should work to promote inclusive environments in which students can learn together
about, and develop, healthy behaviors overtime” (American School Health Association, 2020).
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Scope of Practice is the “ full range of roles, responsibilities and functions that nurses are
educated, competent and authorized to perform” (White et al., 2008, p. 45).
Social Determinants of Health are conditions in the places where people live, learn, work, play,
worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and
risks (Centers for Disease Control and Prevention, 2020a).
Organization of the Project
This study contains five chapters. Chapter One provides the reader with a brief overview
of the importance of valuing school nurses as central to students’ health as imperative in
furthering the educational mission. Chapter One also introduces the key concepts and
terminology, the goals, the stakeholders, and the framework for the study. Chapter Two provides
a review of the current literature surrounding the scope of the study. Topics about the school
nurse’s history and role within the education setting highlight the issues surrounding school
nurses’ work in the educational environment. Chapter Two also presents the framework
underpinning this study, which focuses on the influences on school nurses’ knowledge,
motivation, and organizational and contextual factors in which they work. Chapter Three details
the methodology concerning the choice of participants, data collection, and analysis. Chapter
Four includes data assessment and analysis. Chapter Five provides recommendations and future
research.
20

Chapter Two: Review of the Literature
Social research seeks to understand the reality of a social phenomenon (Mertens, 2009).
This chapter grounds the reader in the complexities of the social phenomenon at the heart of this
study, which are the influences in the educational environment that affect how school nurses
convey how their role furthers the educational mission. The chapter aims to contextualize the
school nurse as a distinctive healthcare professional situated within the K-12 education
environment. The chapter begins by describing the history of school nursing to understand why
there are nurses in schools. The chapter then explains how legislation has impacted the school
nursing profession. The chapter provides an overview of today’s school nurse workforce,
including an outline of their practice exigencies, and where school nurses derive their knowledge
for practice. A brief overview of the school nursing practice framework illuminates the value that
nurses bring to the educational mission through their accountabilities to the educational
environment and the community.
The chapter concludes by reviewing the relevant research associated with the conceptual
and methodological framework for the study. The Clark and Estes (2008) gap analysis is used in
this study as the lens for identifying nurses’ perceptions about any knowledge, motivation, and
organizational influences impacting their ability to adequately convey how their role and practice
furthers the educational mission.
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History of School Nursing – Public Health Focus
“A sensible school nurse, with good judgement, discretion, and
enthusiasm may be a powerful factor in the general improvement
in the community” Lillian Struthers (1917).
School nursing practice was a fortuitous unintended consequence of an experiment in
1902 to decrease children’s absence from school. It began in New York City, which, at the time,
was a dirty, crowded, and unhealthy place to live and work (Philips, 1999; Vessey & McGowan,
2006). These conditions often saw the fast spread of disease among the population. This fear of
the spread of illness meant that sick children either did not go to school or were sent home from
school. In an attempt to protect children from disease transmission, the Board of Health in New
York City put the “rule of exclusion” into place, and children who were sick or potentially
contagious were sent home, but without any return to school follow up (Rogers Struthers, 1917;
Vessey & McGowan, 2006). Each New York City school would often see 15-20 children per day
sent home for health-related reasons (Allender et al., 2013).
During this time, Lillian Wald, an 1891 nurse graduate from the New York Hospital
School of Nursing, considered nursing as integral to the community’s health. Wald’s nursing
work focused on aid needy populations, including people living in poverty and crowded
conditions (Philips, 1999). She recognized that their sickness was rooted in a more extensive set
of social problems and was often beyond the individual’s control. Her work amongst the poorest
in New York City “resulted in nursing practice that went beyond caring [for ill patients to]
encompassing an agenda for reform in health, industry, education, recreation, and housing.”
(Buhler-Wilkerson, 1993, p. 1780). Wald instigated the term “public health nurse” and argued
that the nurse linked the family’s social, economic, and health needs to services required to
22

maintain and enhance their health (Buhler-Wilkerson, 1993). Wald founded the Henry Street
Nurses’ Settlement, one of the first community health-care programs in the world (Philips,
1999). This mission of the humble yet formidable group of nurses was to serve the working-class
welfare, catering to the community’s health and social needs.
The chairman of the New York City Board of Education became aware of Wald’s
community work, especially recognizing her active campaigning for child health and welfare
(Vessey & McGowan, 2006). In 1902 he sought Wald’s help with the problem of children’s
absences from school. Thus, the beginnings of having a nurse in schools were set in motion.
Wald’s recommendation was to place a nurse in schools with additional in-home follow-ups for
children sent home (Philips, 1999). Lina Rogers, one of the Henry Street nurses, became the first
school nurse. The intention was for a one-month trial period, with monitoring of the program’s
accomplishments. With limited space and supplies, Rogers began working in four schools with
the largest number of children who were excluded from school (Rogers Struthers, 1917; Zaiger,
2000). Rogers inspected all sick children, treating those who posed no risk to others so they
could return to class, as well as sending home children with contagious diseases with follow up
visits to their homes (Vessey & McGowan, 2006).
At the end of the month trial period, children were returning to school sooner than before
(Zaiger, 2000). This success led to twelve more trained nurses being hired into schools by the
New York City Board of Health, and the promotion of Lina Rogers to be the first Superintendent
of School Nurses (Rogers Struthers, 1917; Vessey & McGowan, 2006). Overseen by Rogers, the
program of nurses focusing on children’s health in schools was so successful that the numbers of
children excluded from school went from 10,567 in 1902 to 1,101 in 1903 (Struthers, 1917, as
cited in Pollitt, 1994, Figure 1; Rogers Struthers, 1917). Furthermore, at that time, the Board of
23

Education granted an appropriation of $30,000 for the program and hired 15 more school nurses,
totaling 27 in all (Rogers Struthers, 1917). Besides caring for the sick, under Roger’s
administration, “health education concerning [children’s] growth and development, health,
hygiene, and nutrition” (Vessey & McGowan, 2006, p. 256) was introduced, along with school-
based wellness programs, including dental and hearing screening.
The need for the care for school children’s health saw the spread of school nurses across
the nation to Los Angeles in 1904, Boston in 1905, Seattle in 1907, and Philadelphia in 1908
(Zaiger, 2000). Like New York City, children in rural areas also suffered poor health conditions
due to unsanitary conditions. In rural areas where health needs were of great concern (Houlahan
& Deveneau, 2019), school nurses would travel on horseback to schools where they would
perform duties such as health screenings and infection control (Johnson, 2017). For instance, in
Virginia, with the state’s health commissioner declaring that education funds were wasted on
children unable to learn, public health nurses were deployed to rural schools with the expectation
that community health and sanitation be improved (Houlahan & Deveneau, 2019). However,
communities often misunderstood the need for this healthcare role (Houlahan & Deveneau,
2019). Rural Virginians, did not view the role as an opportunity for citizens’ health and welfare,
and resisted the notion of public health nurses in schools as an unwanted government mandate
(Houlahan & Deveneau, 2019). While some communities such as New York saw the value and
as such gave funding, for the most part school nurses were an underfunded profession. Again, in
the initial stages of the school nurse role in Virginia, funding was not valued for their education
and employment. Support did not come from public funds, as teacher’s salaries did, but through
“women’s clubs, private donations, and selling refreshments at county fairs” (Ranson, 1917, as
cited in Houlahan & Deveneau, 2019, p. 5).
24

School health and school nursing practice continued to grow over the decades with
nurses’ interactions with children and their families, echoing Wald’s foundations of the public
health nurse role as integral to the community she serves. Throughout the 20
th
century, there
have been significant impacts on the practice due to federal legislative acts aiming to reduce
children’s poor health, ultimately thrust the responsibility into the venue where children spend
the most time – that is in schools. The historical recognition of placing school nurses in the
education setting as an appropriate and convenient way to address school-aged children’s health
care needs has led to the reliance on school nurses to ensure that students are healthy and ready
to learn.
How Legislation Shapes School Nursing Practice
Expectations of the K-12 educational mission, and the school nurse’s role as central to
furthering that mission has evolved in response to social, cultural, political, and legal influences
(Morse et al., 2020). “The public-school system costs taxpayers two-and-a-half times more than
it did half a century ago – far outstripping changes in enrollment over that time. … The increase
reflects an array of policy shifts, changes in student demographics, state and federal mandates”
(Education Week, 2020, para 1).
Social programs resulting in legislation over the past several decades have placed the
burden of caring for students’ health in the education setting. As a result, the school nurse has
become accountable to legislation at both the federal and state levels. The legislation has meant
an expansion of the school nurse’s role to include critical tasks such as chronic disease
management, emergency preparedness, behavioral health assessment, and health education
(Davis et al., 2018; Morse et al., 2020). In a study by Davis and colleagues (2018), school nurses
were asked to identify the top three factors that impacted their ability to practice nursing to the
25

full scope of practice. Of the items identified, three were legislative and policy-related: 37.6%
found that state laws and policies made their practice difficult; 34.5% identified school district
laws and policies; 20.1% identified the State Nurse Practice Act.
Federal Legislation
Over the later part of the twentieth century, federal government legislation enacting the
protection of children’s rights and ensuring equal access to education has substantially impacted
school nursing (Cruise, 2020). The trend for equality began with the 1954 decision by the U.S.
Supreme Court that racial segregation of school was unconstitutional, followed by the 1964 Civil
Rights Act strengthening the laws against discrimination (Cruise, 2020). These decisions paved
the way for the 1973 Section 504 of the Rehabilitation Act, requiring educating children with
disabilities in public schools, which then receives assistance through federal funding. A more
recent Act is the 2010 Healthy, Hunger-Free Kids Act of 2010, establishing minimum nutrition
requirements for food on school grounds and acknowledging the benefits of students’ nutrition,
physical activity, and school wellness (Cruise, 2020). All three of these legislative Acts give
school nurses grounds to provide leadership for equal access to health for the students in the
educational environment (Cruise, 2020). Other legislation impacting schools also directly affects
school nurses, and two federal legislative acts have majorly impacted school nurse’s work. The
first is the 2015 Every Student Succeeds Act (ESSA), which replaced the No Child Left Behind
Act (NCLB), which authorizes state-run programs for school districts eager to raise academic
achievement by addressing the complex challenges for students who live with disability,
mobility problems, learning difficulties, poverty, transience, or who need to learn English (U.S.
Department of Education, n.d.). The second is the 1975 Individuals with Disabilities Act (IDEA),
which ensures students with disabilities receives free appropriate public education as well as
appropriate special education services (Individuals with disabilities education act (idea), 2004;
26

U.S. Department of Education, 2020b). Central to both Acts is the student attending public
school who has a health issue highlighting the school nurse’s necessity as integral to ensuring
students have access to a health professional in the environment where they spend most of their
day. Having the school nurse in place guarantees follow-through accountability, substantiating
the value of having a healthcare professional in the school to ensure students are healthy and
ready to learn. A short description of these and how they impact the school nurse follows.
Elementary and Secondary Education Act
In an effort to address poverty issues, the Elementary and Secondary Education Act,
1965, mandated funds to schools for equal access to quality education (Paul & Social Welfare
History Project, 2014). A positive outcome of this Act was that it included funding that tripled
the number of school nurses; however, it added to their responsibilities. School nurses became
responsible for case coordination of students’ health and meeting each state’s mandate
requirement for screening and immunizations (Gustafson, 2005). In 2001 the Act became known
as the No Child Left Behind Act, with the express purpose of raising all students’ achievement
and closing the achievement gap (U.S. Department of Education, 2020a). Reauthorization of the
Act every five years saw the most recent (2015) rename the Act to Every Student Succeeds Act
(ESSA) (Paul & Social Welfare History Project, 2014). The Act’s latest iteration includes the
requirement to promote safe and healthy students, with school nurses named explicitly as being
accountable for providing instruction in healthy lifestyles and chronic disease management
(Cruise, 2020).

27

Individuals with Disabilities Act (IDEA)
The Education for All Handicapped Children Act, passed in 1975, required all school-
aged children with a disability to attend public schools. The inclusion of disabled children in
schools meant that the population of children with special needs now became the school nurse’s
responsibility (Cruise, 2020). Revised in 1990 to the Individuals with Disabilities Act (IDEA),
all children up to the age of 21, regardless of their physical or cognitive disabilities (Cruise,
2020; Dang, 2010) have access to, at the public expense, free and appropriate public education
(FAPE). The number of students who received special education services under IDEA has
steadily risen from 6.3 million in the school year 2000–01, which at the time was 13% of the
public school enrolment, to 7.1 million in 2018-19, or 14% of public school enrollment (National
Center for Education Statistics, 2020b). Although the inclusion of students with disabilities in
schools is federally mandated, federal dollars to states cover less than half of the additional cost
to educate and provide healthcare for a disabled child (Blad, 2020; Robert Wood Johnson
Foundation, 2010b). Congress periodically reviews IDEA, and in 2017 it found that although 40
percent of IDEA funding should come from the federal government, school districts nationwide
receive a mere 8 percent in support of their budgets (Cruise, 2020). As a result, this program’s
financial burden is falling to school districts to cover the costs (Blad, 2020). Underfunding this
program often means larger caseloads for school nurses without additional resources resulting in
inadequately caring for special needs students and diminishing their educational experience
(Knauer et al., 2015).
Connecticut State Legislation
School nurses in Connecticut must abide by state Statutes that pertain to both health and
education, as well as individual school districts may impose policies that the school nurse must
follow. The state of Connecticut has legislation that school nurses must abide by. The Nurse
28

Practice Act (State of Connecticut, 2019d) outlines the scope of practice that a registered school
nurse must comply with. Per the Connecticut Board of Examiners for Nursing, school nurses
must be licensed and registered to practice within the state (Connecticut State Department of
Public Health, 2020a). The requirements for school nurses’ practice are included in the
Connecticut Statutes. For instance, Chapter 169 - School Health and Sanitation (State of
Connecticut, 2019a), many other regulations, includes guidance for school nurses on
immunizations and vaccinations (Sec. 10_204a), administering medications (Sec 10-212a), and
the requirement on occasion to act as visiting nurses in their town (Sec 10-212).
An added complexity for school nurses is that they span both the health and education
sectors. For instance, Connecticut Statutes, Chapter 170 – Boards of Education (State of
Connecticut, 2019c), includes guidelines for blood glucose testing by students.
Enacted legislation impacts the educational environment, thus students’ education and
often the necessities of their health (Butler et al., 2020; DeFosset et al., 2020; McIsaac et al.,
2019). School nurses bring value to the educational environment as healthcare professionals
who interpret, make others aware of policy requirements, implement, and monitor requirements
(Budd et al., 2012; Butler et al., 2020; Cruise, 2020). As an advocate for healthy students, school
nurses are proficient in clarifying any regulatory requirements and how they impact student
health and the school’s mission s (Lineberry et al., 2018; Willgerodt et al., 2018) .

29

The K-12 Education Milieu
The U.S. Constitution does not include education as a fundamental right (School and
State Finance Project, 2021b). In the absence of a national mandate, each state assumes the
responsibility for K-12 education. Within each state are school districts that put into action the
educational objectives of that district. Connecticut has 205 school districts, 1,508 schools, and
approximately 528,000 students (Connecticut State Department of Education, 2020b).
School districts in Connecticut, and most nationwide, are multilayered organizational
structures where decisions must often be agreed upon by the several bureaucratic layers. Each
school district has a school board, consisting of community members, who create priorities and
formulate its district’s goals. Within each school district is a superintendent who, along with the
staff, makes the budget, which is then approved by the board (U.S. Department of Education,
2019). All health services for the school district, including healthcare staffing, are decided within
this organizational structure and often without input from someone with health expertise (School
and State Finance Project, 2021a).
Education Dollars Fund School Nurses
Each local school district in Connecticut is funded through a combination of local, state,
and federal tax dollars (School and State Finance Project, 2021a). In 2018, nearly $11.4 billion
was spent in public education, with approximately 58% coming from each district’s local
property taxes, 37.8% from state taxes, and 4.2% from federal taxes. Each city or town’s
governing body approves the school district’s budget. And within that budget is the
responsibility for providing health services for students, including funding for the school health
program and the school nurses.
Due to the disparate nature of each Connecticut city or town owning the funding
responsibility for its school district, there is no centralized data about how much funding is
30

allocated to school health. However, on a national level, according to the School Nurse
Workforce Study (Willgerodt et al., 2018), the nationally aggregated data for school health
funding shows 76.7% of funding for school nursing services comes from local education dollars;
17.2% from state monies; 11.4% from health departments; 12.0% from federal monies; and 3.6%
from foundations and hospitals. These percentages differ from state to state, and within the
school districts within that state. As already noted, because each school district decides how
much they spend on school health services, there is no equivalent state-level data that includes
percentages spent on school health services or school nurse salaries.
Limited education budgets mean that school boards and administrators must decide how
much of their finite budget to spend on school health services (Leachman & Mai, 2014; Robert
Wood Johnson Foundation, 2010b). Education budget cuts often result in eliminating the school
nurse, reducing the number of school nurses causing high nurse-to-student ratios, or to reduce the
school nurse’s hours (Lineberry et al., 2018; Willgerodt et al., 2018). Even as school districts cut
funding to health services within schools, there are still legal obligations such as the IDEA Act
and Section 504 of the Rehabilitation Act to provide appropriate school health care. Some states
have passed legislation allowing non-licensed school personnel to provide health services to
continue to provide health services to students (Lineberry et al., 2018). This state legislation runs
the risk of providing unsafe or inappropriate healthcare to students (National Association of
School Nurses, 2015a, 2015b).
However, research shows that “schools, families, local health care providers, the public
health system, and the community at large all reap the benefits” of having a school nurse (Robert
Wood Johnson Foundation, 2010b). A cost-benefit analysis study, conducted in Massachusetts,
determined that when a full-time school nurse is present, the community gains $2.20 for every
31

dollar invested in a school nurse (Wang et al., 2014). A different study showed that after a school
nurse was added to the staff, there was a decrease in time spent on health-related issues of 57
minutes for the principal, 46 minutes for clerical staff, and 20 minutes for a teacher (Baisch et
al., 2011).
School Principals
School principals affect the success of a school’s effectiveness and student outcomes
through creating the vision and setting goals (Leithwood & Jantzi, 2006), providing individual
support (Leithwood & Riehl, 2005) engaging in professional development with other educators
(Bamburg & Andrews, 1991), initiating collegial discussions among the school community
members (Heck, 1992). The school principal is responsible for ensuring student safety and
adequate staffing levels so that every student who requires specialized healthcare procedures
receives them (Blackburn & Apesoa-Varano, 2018). School principals are often the gatekeepers
for health services, including hiring and evaluating the school nurse (Blackburn & Apesoa-
Varano, 2018; Willgerodt et al., 2018). As one of the community leaders, the principal can assist
the school nurse’s endeavors to partner with community health agencies to expand or improve
health programs for students through education (Blackburn & Apesoa-Varano, 2018).
The school principal’s oversight of the student population’s health needs assumes that the
principal has a close connection with the school nurse. A study on the school nurse’s job
satisfaction revealed that 64% of the study nurses lacked support from principals and other
school administrators (Fleming, 2012; Jameson & Bowen, 2020; Junious et al., 2004; Kruger et
al., 2009). This disconnect could be attributed to the fact that administrators, educators, and even
families often do not understand the variety of tasks the school nurse does (Kruger et al., 2009;
Simmons, 2002). Perception is that the school nurse is primarily focused on medication
administration, and has a similar role to the “lunch lady” (Maughan & Adams, 2011). However,
32

principals also have frustrations about how their days are spent. Principals report that their
workdays are consumed with managerial activities leaving little time to motivate, enable, and
support their team to develop their practice (Huang et al., 2020). However, the development of
relationships with good communication between the school nurse and the principal, and other
educators shows there is much greater understanding and value of the nurse’s role in student’s
health (Biag et al., 2015; Maughan & Adams, 2011).
School Nurse Supervisors
Due to the size of some school districts and the number of school nurses in the district,
coordination of the school health services falls to a school nurse supervisor (Connecticut State
Department of Education, 2018). The school nurse supervisor is responsible for providing
clinical support and guidance on student health conditions, providing training, ensuring clinical
practice standards, figuring out budgeting and billing, and ensuring compliance with state and
district health policies (Blackburn & Apesoa-Varano, 2018). Throughout the 205 school districts
in Connecticut there are 185 nurse leaders in Connecticut, 139 who have school assignments
providing care for students, and 46 who do not provide direct care (Connecticut State
Department of Education, 2020c). School nurses benefit from having access to a school nurse
supervisor. It has been shown that nurse’s practice is more successful when there are
collaborative opportunities for a nurse leader to mentor and share experience and wisdom with
other nurses, particularly novices (Dryden-Palmer et al., 2020; Gallagher-Ford et al., 2020; Ost et
al., 2020; Tucker et al., 2020).
While the nurse leader’s responsibilities facilitate ensuring the school nurse is prepared to
care for students’ health needs, the school nurse supervisor often lacks power and is
marginalized by the organizational decision making. Blackburn and Apesoa-Varano’s (2018)
investigation of school nurse supervisors’ work showed that they are not empowered to say how
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the school health services are funded and often must continually negotiate for the money even
when it is already allocated. Despite this dismissal of the nurse leader’s authority, participants in
Blackburn and Apesoa-Varano’s study (2018) reported being in a constant state of educating
administrators, principals, and the school boards about how the school nurses improve student
health and school attendance, promote student safety, and prevent district liability. The school
nurse supervisor often has limited power in the school district. However, when hiring a school
nurse, the task will often fall to the school nurse supervisor.
School Nursing Workforce
The importance of having a school nurse as part of the educational environment should
not be understated. Research shows that the school nurse is instrumental for furthering the
educational mission by ensuring students achieve academic success by keeping students healthy
and ready to learn (Davis et al., 2018; McDaniel et al., 2013; National Association of School
Nurses, 2020; Robert Wood Johnson Foundation, 2010b). Health-related problems have been
shown to contribute to academic underachievement (Belsky et al., 2010; Council on School
Health, 2016; K. Hughes et al., 2017; Rose-Jacobs et al., 2008). For example, physical and
emotional health problems account for chronic absenteeism, which often results in failing to
complete school (Allison et al., 2019). As well, the presence of a school nurse guarantees health
equity enabling all students to have regular access to a healthcare provider (Anderson, 2017,
2018; Centers for Disease Control, 2017a; Centers for Disease Control and Prevention, 2018;
Racine, 2016).
The presence of a school nurse ensures that teachers and other school staff can focus on
their work by reducing up to an average of 13 hours per day across all that staff previously
dedicated to student health concerns (Baisch et al., 2011). Also, a school nurse’s presence
34

rewards the district by reducing the financial healthcare cost significantly to communities (Wang
et al., 2014). The school nurse is also often the only voice advocating for the student’s health and
social needs (Rodriguez et al., 2011; Solum & Schaffer, 2003). Despite these positive effects,
there is a shortage of school nurses in schools (Education Law Center, 2013; Willgerodt et al.,
2018).
The nationwide School Nurse Workforce Study of public and private schools estimates
that there are 95,800 full-time equivalent school nurses (>30 hours a week), with a further 36,500
part-time time school nurses (Willgerodt et al., 2018). Most states do not mandate school
nursing, resulting in school nurses’ deployment ranging from adequate coverage to meet the
school’s needs to distressingly insufficient coverage (Robert Wood Johnson Foundation, 2010b).
Connecticut has approximately 1,386 school nurses, including 185 school nurse supervisors. As
well, there are approximately 262 nursing support staff, including 57 licensed practicing nurses,
and 158 health aids (Connecticut State Department of Education, 2018).
It is recommended by the National Association of School Nurses (2015a) that every
school has a school nurse ensuring the best care for students. However, the Workforce Study
shows that only 39.3% of schools across the country employ a school nurse full-time (>35 hours
per week), 35.3% employ part-time school nurses (< 35 hours per week), and 25% of schools do
not employ a school nurse at all. Research shows that even if a school nurse is employed full-
time, they may be assigned to more than one school, with over half (55.9%) covering two or
more schools (Maughan & Bergren, 2016). There are regional differences across the country,
with the Northeast more likely to have a full-time school nurse, and the West more likely to have
one nurse covering multiple schools (Willgerodt et al., 2018). Connecticut state law mandates
35

that “each local or district board of education appoints at least one school nurse” (Spigal, 2008,
para. 6).
In acute care hospital settings, appropriate staffing, known as nurse staffing ratios, is a
federal law required to ensure better and safer patient care (Shin et al., 2018; State of
Connecticut, 2008). Contrary to this, there is no federal law for the education setting to mandate
nurse to student ratios. School nurses are less likely to safely and effectively carry out all of their
tasks when they have high work caseloads (Davis et al., 2018; Jameson & Bowen, 2020), which
can lead to low job satisfaction and burnout (Jameson et al., 2018).
The National Association of School Nurses (2015a) and the American Academy of
Pediatrics (Council on School Health, 2016) recommend for the safest care for students, the
maximum ratio should be one school nurse to no more than 750 students. In some states,
legislation has been passed that complies with this sentiment, recommending that school districts
have a school nurse. However, these laws do not attach funding, which means that schools
cannot be mandated to comply (Houlahan & Deveneau, 2019), and few schools consistently
achieve these ratios (Davis et al., 2018; Guttu et al., 2004; Willgerodt et al., 2018). The School
Nurse Workforce Study shows that only 15 states (30%) meet or fall below this recommendation
(Willgerodt et al., 2018), with huge variations between states. For instance, Vermont reports that
there are 275 students to a school nurse, and in Utah, there are about 4,800 students to one school
nurse. In Connecticut, the majority of schools meet or fall below the recommended ratio. Only
10.5% of schools have a ratio greater than one nurse to 750 students; 23.6% have 501-750
students to one nurse; 50% have 251-500 students to one nurse; and 16.3% have less than 250
students (Connecticut State Department of Education, 2018).

36

School Nurses Knowledge Sources
The value of the school nurse in the educational environment is enhanced when they have
the skills and the knowledge to perform their work to their full scope of practice. The knowledge
that school nurses use in their practice varies from formal knowledge learned as part of their
nursing degree program (National Association of School Nurses, 2016a) to maintaining
competency through professional development (Estabrooks et al., 2005; Morse et al., 2020;
Rosenblum & Sprague-McRae, 2014) and informal settings in conversations with nurses and
other healthcare colleagues (Estabrooks et al., 2005). School nurses most often practice alone,
and so need adequate education to practice safely by themselves in increasingly complex
situations (Jameson & Bowen, 2020), and be motivated to continue increasing their knowledge
(Praeger & Zimmerman, 2009).
Undergraduate education prepares the school nurse to become a generalist in nursing. A
4-year baccalaureate degree is recommended as a minimum education requirement for school
nurses (American Federation of Teachers, 2009; Council on School Health, 2016; National
Association of School Nurses, 2016a), but is not mandated (Costante, 2002). As a result, only
nine states require the BSN to practice as a school nurse (Praeger & Zimmerman, 2009), and
nationwide only 53.0% of school nurses hold a baccalaureate degree (Willgerodt et al., 2018),
and 60% of Connecticut school hold that degree or higher (Connecticut State Department of
Education, 2018). Orientation programs help bridge any gaps in the universal nursing program to
help them understand the school nursing nuances and complexities (Knutson, 2019). In addition
to formal education programs, the National Association of School nurses also recommends that
school nurses achieve school nurse certification through either the state or the national school
nurse certification programs (National Association of School Nurses, 2016a).
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School nurses require professional development as an important way to stay current with
healthcare practices and innovations. There is often a required minimum number of professional
development hours that school nurses must participate to stay registered as a nurse (Craven et al.,
2013), with requirements varying from state to state (Praeger & Zimmerman, 2009). To maintain
licensure in Connecticut, the school nurse requires a minimum of 10 hours of professional
development every two years (Connecticut State Department of Public Health, 2020a).
However, even though the school nurse ensures students stay healthy and in school, financial
support for professional development is not a priority for school districts (Baxley, 2016).
Participation becomes incumbent on the school nurse to financially support attendance (Adams,
2009). School nurse workloads require that they be in school when the students are, meaning
that it is difficult for school nurses to participate in professional development opportunities on a
school day (Baxley, 2016). For that reason, school nurses often turn to their colleagues as a
practical, readily available source of information.
Nursing knowledge comes from sharing between nurses what is known about clinical
experiences (Benner et al., 1997; Estabrooks et al., 2005; Quinn & McAuliffe, 2019). Sharing
information among nurses is valued for several reasons: nurses trust the information they get
from peers; they need information in a timely manner for immediate patient needs; and they feel
greater affirmation and more supported from their nurse colleagues than others (Estabrooks et
al., 2005). When they talk with others, nurses feel better informed about a clinical situation
because narrative allows the listener to connect with the storyteller, and have an emotional
response, leading to remembering the information (Benner et al., 1997; Denning, 2011).
Working in isolation restricts peer-to-peer support for school nurses (Baxley, 2016). School
nurses report that they need more networking opportunities to ensure their practice is of the
38

highest quality (Adams, 2009; Adams & Barron, 2009). In a study about an online journal club’s
effect on raising awareness of evidence-based practices, Sortedahl’s study (2012) showed that
school nurses appreciated the connection to network with colleagues.
School Nursing Practice
For students to be successful learners, they must have their healthcare needs met. When
school nurses practice quality health care, they contribute to the educational mission by ensuring
that students are healthy and ready to learn. The National Association of School Nurses (NASN)
Framework for 21
st
Century School Nursing Practice represents a student-centered approach to
school nursing and its fundamental principles (Maughan et al., 2015). The framework supports
the idea that school nursing provides healthcare that is grounded in evidence-based practice.
Evidence-based practice is a process that improves the school nurse’s knowledge through critical
thinking about how they practice and provide safe, quality care (Titler, 2008). School nurses’
interventions with positive outcomes are linked to evidence-based practices for life-threatening
diseases such as asthma and diabetes, and emotional issues such as anxiety and bullying (Best et
al., 2018).
Besides centering practice on evidence-based practice, the Framework includes five
principles: care coordination, public health, leadership, quality improvement, and practice
standards (Maughan et al., 2015). The Framework offers a lens to examine the complexity of the
work of school nurses. Reviewing these principles examines how critical the presence of school
nurses is to impacting students’ health and educational outcomes. A broad overview of the
principals is key to understanding the link between the school nurse’s role and positive health
and education outcomes essential to furthering the educational mission.

39

Care Coordination
Care coordination requires school nurses to organize, facilitate, and deliver patient care
activities in the school environment (Camicia et al., 2013). The school nurse spends a great deal
of time coordinating care for students, including direct care, chronic disease management, and
case management (Best et al., 2018). Direct care includes students’ acute and urgent health
needs, including first aid, administering prescribed medications, and caring for emotionally
affected students. This care ensures that students return to the classroom without excessive delay
(Daughtry & Engelke, 2018; Leroy et al., 2017; Rodriguez et al., 2013). The nurse also sees
students with chronic health conditions such as diabetes or asthma (Guttu et al., 2004), referring
students to other healthcare providers for conditions such as HIV and physical and sexual abuse
(Maughan & Bergren, 2016). The school nurse is also pivotal in providing care for students with
significant mental health issues, neurodevelopmental disorders, congenital abnormalities, and
other conditions reliant on medical technology for daily living (Morrison-Sandberg et al., 2011).
The number of children with special health care needs (CSHCN), including both chronic as well
as medically complex conditions, has increased 400% between 1960 and 2000 (Perrin et al.,
2014) and now accounts for 20 percent of all students (Centers for Disease Control and
Prevention, 2020b). Students with chronic issues absorb a great deal of the school nurse’s time
due to necessary ongoing medical attention (National Center for Chronic Disease Prevention and
Health Promotion, 2020), but being involved has a positive effect on reducing chronic
absenteeism (Leroy et al., 2017). School nurses do their best to be involved in collaborating to
develop individual student education and healthcare plans ensuring positive health and academic
outcomes (Lehr, 2020; Morrison-Sandberg et al., 2011; Willgerodt et al., 2018); however, they
are often overlooked (Anderson et al., 2018). In fact, only 71.5% of school districts indicate they
require school nurses to participate in the development of Individualized Education Programs,
40

and 76.5% require a school nurse to attend for the development of 504 plans (Centers for Disease
Control, 2017b).
Public Health
Community and public health responsibilities have always been central to the school
nurse role (Maughan et al., 2015). The nurse is alert to recognizing the student’s health equity
needs, connecting students to healthcare resources, financial resources, and in some cases, shelter
and food (National Association of School Nurses, 2016b). The school nurse often serves as the
healthcare safety net because access to convenient healthcare providers and health care facilities
is often inadequate in low-income areas (Anderson, 2017, 2018; Anderson et al., 2018). Students
who live in poverty are frequent visitors to the school health office for minor complaints, and
nurses may find deeper concerns that need dealing with (Smith & Firmin, 2009). When both
parents are working, mothers tend to rely on school nurses to take care of their child’s health
needs (Smith & Firmin, 2009). In the school nurse’s office’s safe space, the student finds a
caring and trustworthy person who listens and is alert to broader issues facing the student, such
as abuse, neglect, and depression (Berryman, 2008; Lineberry et al., 2018; Robert Wood Johnson
Foundation, 2010b; Smith & Firmin, 2009). School nurses also provide primary prevention
coordination, ensuring that immunizations are up to date (Baisch et al., 2011), and offering
education in obesity prevention, asthma, tobacco control, and substance abuse (Council on
School Health, 2008). School nurses are pivotal in secondary health prevention for early
detection of visual or hearing issues (Anderson et al., 2018; Council on School Health, 2008;
National Association of School Nurses, 2016b; Willgerodt et al., 2018) and screening students
for any condition that can impact their learning (National Association of School Nurses, 2020).
Screening visual or hearing defects, as well as issues. (Anderson et al., 2018; Willgerodt et al.,
2018).
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Leadership
As often the only health professional in the school, school nurses are inherently the leader
for improving health in children, families, and the community. School nursing leadership
involves becoming an advocate for the health of the students and their families, a change agent, a
systems-level leader, and a life-long learner (Maughan et al., 2015). Well-health means that
school nurses develop school and district policies for health-related issues and prepare for
school-wide and community emergencies (Anderson et al., 2018; Willgerodt et al., 2018). School
nurses also advocate for student families by referring them for health insurance, such as assisting
with health care costs (Connecticut State Department of Education, 2018). Leadership also
means remaining current with practice changes through professional growth and professional
development. School nurses also take the lead in developing health education and wellness
programs outlined in the Every Student Succeeds Act (ESSA) requirements. School
administrators have reservations about investing resources in health prevention programming and
are often reluctant to have students miss class time (Morrison-Sandberg et al., 2011). As Asada
and colleague’s (2020) study regarding the school superintendent’s perspectives about local
wellness policies, there was no mention of the school nurse being integral to supporting these
federally funded wellness mandates.
Quality Improvement
As part of their professional practice, school nurses continually reflect on the care they
provide to students, and through quality improvement, enhance the ways care is delivered
(AHRQ, 2013). Quality improvement comes from reviewing nurse-sensitive outcomes data, such
as school health office visits, early dismissal of a student, and medications administered to
determine what activities have the most significant impact on effective care and health outcomes
(Bergren, 2016; Maughan et al., 2015). Data collection is time-consuming and given the large
42

and complex caseloads school nurses deal with, this is a recognized gap in school nurse practice
(Bergren, 2016; Davis et al., 2018). Without data it is difficult for school nurses to show the
value their practice brings to improved health and academic outcomes for students (Maughan &
Yonkaitis, 2017). Advocating for school nurse practice based on positive outcomes data is the
measure that all stakeholders, including principals, school boards, and boards of health, can
apply to budgets (Maughan & Yonkaitis, 2017).
The Clark and Estes (2008) Gap Analytic Conceptual Framework
The intent of this study is to evaluate the influences in the educational environment that
affect how school nurses can adequately convey how their role and practice further the
educational mission. To best address this, the researcher needs to gain increased knowledge
regarding any facilitators and barriers that influence the school nurse in the context of their
educational environment. Organizations, and in this case the educational environment, are
complex and require an all-encompassing lens that systematically focuses on understanding why
there is an inability to perform as expected (Rueda, 2011). The lens, or framework, for this study
is the Clark and Estes’ (2008) Knowledge-Motivation-Organizational (KMO) process. The KMO
framework uses what is known as a gap analysis to examine variances between organizational
expectations and a person’s performance. The gap between personal and organizational
expectations can often be attributed to the misalignment between the two. According to Clark
and Estes (2008), three factors can be attributed to the misalignment: the knowledge and skill
influencing a person’s performance; motivation influencing their performance; and
organizational supports and barriers that are an influence in helping them achieve the expected
performance.

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Stakeholder Knowledge, Motivation, and Organizational Influences
This review of the literature on stakeholder knowledge, motivation, and organizational
influences (KMO) focuses on the factors impacting the school nurse. This section addresses the
KMO considerations associated with the goal that 100% of school nurses will convey to
individuals in the educational environment the value of the nurses' role and practice and how it
furthers the educational mission.
Knowledge and Skills
There are four types of knowledge associated with learning: factual, conceptual,
procedural, and metacognitive (Krathwohl, 2002). Anderson and Krathwohl (2001) describe
factual knowledge as discrete bits of information and details that must be known in order to
perform a task; conceptual knowledge is knowing how things are interconnected and interrelated
within a system; procedural knowledge is the sequence, the process, or the steps needed to
accomplish a task; and metacognitive knowledge is the awareness of the cognitive process, of
knowing when or why to do something, or to be aware of and to self-reflect of one’s thinking.
Factual and conceptual knowledge represents the “what” of knowledge. In contrast, procedural
knowledge represents the “how” in one given topic or field, and metacognitive knowledge
includes knowledge from across many topics or fields (Anderson & Krathwohl, 2001).
This review examines all four types of knowledge associated with evaluating how school
nurses will attain the performance goal of conveying to individuals in the educational
environment the value of the school nurse and how it furthers the educational mission.
Knowledge Updates for Clinical Practice
For school nurses to convey how their practice helps the organization meet its mission,
they need to be current in the way they practice nursing. A more detailed account of the school
nurses’ source of knowledge has already been addressed. Alliteration here is the recognition that
44

the expectation that all school nurses need to stay abreast of current practices using the process
of evidence-based practice (National Association of School Nurses, 2017). Evidence-based
practice is the widely accepted process in healthcare that integrates a critical thinking approach
to make clinically accurate decisions for safe patient care (Estabrooks et al., 2005; Porter-
O'Grady, 2010; Taylor, 2016). Evidence-based practice necessitates the clinician’s knowledge
about, and motivation to, effectively integrate three things: the best available research evidence,
the clinician’s expertise, and the patient’s expectations, concerns, and desires for their clinical
care (Porter-O'Grady, 2010; Sackett et al., 1996). Evidence-based practice is central for nurses to
meet quality and safety outcomes (American Nurses Credentialing Center, n.d.).
The volume of healthcare information and the continual advancement of healthcare
practice requires the school nurse to seek knowledge purposefully. School nurses believe that
evidence-based practice is essential; however, few use it in their clinical practice (Adams, 2009;
Baxley, 2016; Cruise, 2013; Yonkaitis, 2018). School nurses report that they are unaware of
available research and often lack convenient access to journal articles (Barnes, 2012; Yonkaitis,
2018). They are also unlikely to use a research database nor a librarian to find research (Adams
& Barron, 2009; Vela, 2017; Yonkaitis, 2018).
Institutional support is pivotal for nurses to apply the evidence-based practice process
(Melnyk et al., 2018; Rycroft-Malone et al., 2013). Evidence-based practice is successful when
there are opportunities for nurses to share experience and wisdom (Dryden-Palmer et al., 2020;
Gallagher-Ford et al., 2020; Ost et al., 2020; Tucker et al., 2020). The integration of the
evidence-based practice process into nursing practice establishes a noticeable engagement in
nurses’ practice, creating better patient outcomes (Boamah, 2018; Williamson et al., 2015).

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Alignment of School Nurse Role and the Education Mission [Conceptual]
For school nurses to convey how their practice helps the organization meet its mission,
they need to be both aware of the mission and know how their role helps achieve it. Within the
frame of the school district, the overarching mission is providing the students’ outstanding
education for them to succeed, graduate, and go on to live productive, healthy lives. The school
nurse’s role aligns with this mission in that its focus is to use standards of practice for care
coordination and provide leadership for the healthcare needs of students (National Association of
School Nurses, 2017). The school nurse is often the sole healthcare provider in the school, which
allows them to see themselves as, and take the lead with influencing perceptions and policies
within the school district (Bergren, 2017; Shalala, 2014). Leaders set directions by identifying
and articulating the vision (Leithwood & Riehl, 2005). In setting the direction, the school nurse
aligns the value of student health with the mission to successfully graduate students to allow
educators to understand the connection better.
While there are reports from nurses that educators do not see the connection between
health and academic success (Anderson et al., 2018; Green & Reffel, 2009; Maughan & Adams,
2011), distinct community commitments stand in support of the school nurse’s efforts. The
Whole School, Whole Community, Whole Child initiative (Centers for Disease Control and
Prevention, 2020c) calls for great alignment between education leaders and health sectors to
“improve each child’s cognitive, physical, social, and emotional development” (para. 1). The
model for this initiative has shown in some states to prioritize student health within the education
sector, but more work needs to be done (Chiang et al., 2015).

46

Convey the Value of the School Nurse to the Education Community [Procedural]
In a focus group of school nurses identifying their use of public health interventions, one
nurse stated, “the challenge is the administrative system not understanding the health need”
(Anderson et al., 2018, p. 199). It is problematic that key stakeholders in the educational
environment do not connect that the school nurse is the bridge to ensuring that students are
healthy, and therefore, ready to learn (Green & Reffel, 2009; Maughan & Adams, 2011). The
school nurse needs to communicate the connection to show there is a clear correlation between
good health and school attendance (Allison et al., 2019) and student's academic outcomes
increase when a school nurse is present (Green & Reffel, 2009; Johnson, 2017; Yoder et al.,
2014).
Communication is essential when conveying a message of change, as it serves to help
how people construct what is being asked of them (Lewis, 2019). The factors within an
organization often constrain how the communicator can convey their message (Lewis, 2019, p.
119). The school nurses need to reflect on the effective communication methods within the
school when essential changes are being conveyed. These considerations will shed light on
choosing how best to communicate (Lewis, 2019). As the implementers of a change in the
educational environment, school nurses also need to be sensitive to poor communication
problems to avoid them (Lewis, 2019). Some of the problems are that the vision is not clearly
communicated, that follow-through is poor, or that top management support is lacking.
The act of communication is difficult for some. According to Denning (2011), the
simplicity of a well-constructed narrative told in the form of a story creates an emotional
response from the audience often evoking the listener to embrace the message and make the
change. Storytelling captures and holds the heart and minds of people through evoking the
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“sights and sounds and smells of the context in which the story takes place” (p. 7). Storytelling
helps the listener create a shared understanding of events through facts, events, and experiences
(Lewis, 2019). Denning (2011) suggests using a springboard story to motivate others into action.
Creating a springboard story develops from an idea that will resonate with people’s hearts. It
starts with an incident where a change has already happened and is told as a hero’s journey
where the protagonist is not unlike someone in the audience. The story fully embodies the
change idea to help the audience connect and then relay the alternative to remind people what
will happen if the change does not occur. School nurses have many stories that, when sensitively
created, with a carefully developed narrative that creates emotion for greater awareness among
the school community about their role in the school’s mission.
School nurses may not regularly cross paths with school community members (Green &
Reffel, 2009), so it is important they advocate for conditions that improve their ability to meet
the mission. It is incumbent, as one school nurse put it, “to toot [their] own horn and tell what we
do and how much time we save the teachers; how much time we keep the kids in their desk at
school” (Anderson et al., 2018, p. 199).
Responding Effectively to Influences of the Education Setting [Metacognitive]
For school nurses to convey how their practice helps the organization meet its mission,
they need to think through how they learn and connect with others to bring about a shared
understanding of the school nurse role. Nurses use metacognitive processes to continually reflect
and critically think about issues in the education setting and manage matters that confront them if
it does not align with their scope of practice (Flesner et al., 2010). Through metacognitive
thought, people assess their motivation, values, and the meaning of their life (Bandura, 2001). As
professionals, metacognitive thought occurs as they think about their practice adjusting so that
48

their care always meets the community’s needs (Rodgers, 2002). Equally, the metacognitive
process of reflection needs to also happen between themselves and other education professions
as patient care quality has been shown to correlate with effective relationships among
professionals (Hallin et al., 2011; Ndoro, 2014).
Successful interprofessional collaborations between the school nurse focusing on
students’ health and others in the education environment focusing on the students’ academic
achievement are imperative to achieve the school mission. Nonetheless, there is often a lack of
connection between the school nurse and others in the education environment because of the
different foci for their day-to-day responsibilities (Green & Reffel, 2009).
Through metacognition, interprofessional work can enhance the organization’s goals
(Wilhelmsson et al., 2012). Metacognition, essential for successful learning, is defined as active
control over the cognitive process (Anderson & Krathwohl, 2001). From an organizational
perspective, the metacognitive process allows each professional to bring their perspective and
expertise when planning, monitoring, and evaluating the task at hand (Wilhelmsson et al., 2012).
Inherent in the metacognitive process is reflection. Reflection serves the purpose of being
a rigorous yet straightforward way of thinking that occurs when interacting with others (Dewey,
1910/1933, as cited in Rodgers, 2002). Reflection creates a connection between experiences and
ideas that create a more in-depth understanding. Metacognition to achieve interprofessional
competency uses reflection as part of the continuous evaluation by the players of actions and
workplace results (Wilhelmsson et al., 2012).
Reflective-in-action and reflection-on-action (Schön, 1987, as cited in Ferry & Ross-
Gordon, 1998) are the basis for evaluation during the interprofessional metacognitive process.
First, interprofessional competency requires individuals to use reflection-in-action (Wilhelmsson
49

et al., 2012). Reflection-in-action is thinking while doing a task and applying tacit knowledge to
the situation, which brings about a continuous development of professional expertise. Second,
professionals develop interprofessional competency through reflection-on-action amongst
thought task alignment with each other as they together seek to meet the organization’s goals
(Wilhelmsson et al., 2012). Reflection-on-action is the review of the decision-making process to
reconfigure how the decisions to act are put together (Ferry & Ross-Gordon, 1998). Third,
reflection-for-action requires that the interprofessional team process and translate other
experiences into meeting the organization’s goals (Wilhelmsson et al., 2012).
The school nurse also uses metacognition to think about their practice in educational
settings, learn from what has gone before, and adjust so that their care always meets the
community’s needs (Rodgers, 2002). Nurses need to reflect and critically think about issues in
the education setting and manage matters that confront them if it does not align with their scope
of practice (Flesner et al., 2010). Equally as necessary, the metacognitive process of reflection
with other education professions needs to happen as patient care quality has been shown to
correlate with effective relationships among professionals (Hallin et al., 2011; Ndoro, 2014).
Table 2 identifies the four knowledge influences (knowledge, conceptual, procedural, and
metacognitive) that will gain insights into the school nurse’s knowledge about conveying to
individuals in the educational environment about how the school nurse’s role furthers the
educational mission.

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Table 2
Assumed Knowledge Influences
Stakeholder Goal – School Nurses
By December 2022, 100% of Connecticut K-12 school nurses will convey to individuals in the
educational environment the value of the nurses' role and how it furthers the educational
mission in order for the community to appreciate and advocate for each school to have a full-
time nurse onsite daily.
Assumed Knowledge Influences Knowledge Type
School nurses need to know about nursing procedures,
regulations, and legislation that affect the students in their
care, and update their practice as any of these evolve.
Factual
School nurses need to know and understand the alignment
between their nursing practice and the educational mission
in order to help students lead productive and successful
lives.
Conceptual
School nurses need to know how to effectively convey to
the K-12 education community the school nurse’s role and
the value that they bring.
Procedural
School nurses need to know what factors in the educational
setting influence their clinical practice and to work with
others to ensure that their healthcare role continues as a
strength for the education community.
Metacognitive

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Motivation
Motivation is the energy that drives someone to want to start a learning task, persist at it
once they have started, and invest the adequate mental effort to succeed (Clark & Estes, 2008;
Clark & Saxberg, 2019; Elliot et al., 2017). Motivation is also the force behind what someone
wants to accomplish, how they will accomplish it, and how hard they will work to achieve it and
when they will stop (Meyer et al., 2004). People’s motivation is enhanced when they are
working on something they value and can connect to, either because it interests them and
stimulates them intellectually, or it is a skill they consider essential to their role (Ambrose et al.,
2010; Clark & Saxberg, 2019). People also need to feel they have self-efficacy, or the capacity to
do the task at hand with the expertise they currently have (Ambrose et al., 2010; Clark &
Saxberg, 2019). Motivation is also heightened if the environment is supportive of the task at
hand (Ambrose et al., 2010). At the heart of motivation is goal setting, whether self-generated or
assigned by others (Clark & Estes, 2008; Meyer et al., 2004). Even in a supportive environment,
there can be diminished motivation if there is no commitment to the purpose or the value of the
goal. There can likewise be a lack of motivation if the person is feeling negative emotions such
as anxiety or anger or cannot identify why they are struggling with a task or think the struggle is
beyond their control to fix (Clark & Saxberg, 2019).
This study will focus on two motivational influences that potentially affect school nurse’s
ability to convey to individuals in the educational environment the school nurse’s value in the
education setting and furthers the educational mission. These motivational influences are self-
determination theory and self-efficacy.

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Self Determination Theory
For school nurses to convey how their practice helps the organization meet its mission,
they need to have the opportunity and feel that they can influence the outcome. Deci and Ryan’s
(1985, as cited in Elliot et al., 2017) self-determination theory states that a person’s intrinsic
motivation is satisfied when they take care of three innate needs. Consideration of all three when
thinking about motivation will help explain why people do what they do. First, people need to
feel competent (Ryan & Moller, 2017). Competence refers to being able to do a task. As nursing
generalists, there is a great deal that school nurses know to practice successfully, and intrinsically
they are motivated to stay abreast of changes in healthcare delivery (Heckhausen & Kay, 2017).
However, staying abreast of all the needed information can be problematic if the organization
does not allow for career development opportunities and does not invest in their learning
(Bolman & Deal, 2017).
Second, school nurses need to have autonomy and ownership over their actions (Ryan &
Moller, 2017). Autonomy refers to being empowered and being in control through the self-
determination of what one does (Choi et al., 2016). Often as the only health care professional in
the building, the nurse typically has a great deal of autonomy in work practice. With this
autonomy, the school nurse can self-regulate her practice and stay appropriately engaged
(Heckhausen & Kay, 2017). When there are lapses in autonomy, motivation to continue with
work is affected (Bolman & Deal, 2017). That can mean inadequate care for students and
possible medical errors (Endsley, 2017; O’Keeffe et al., 2015).
Third, school nurses need to feel connected to the people and the environment in which
they work (Ryan & Moller, 2017). Connected and relatedness refers to have a sense of
connection and to belong to a group. School nurses often work alone, isolated from colleagues.
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While they practice autonomously, there is a lack of support and healthcare leadership that are
essential aspects of effective clinical care (Adams, 2009). For the novice school nurse, the
contradiction of autonomy and lack of connectedness to colleagues leads to feelings of self-doubt
and the fear of making mistakes (Kruger et al., 2009; Simmons, 2002). Another indicator of not
feeling connected is the lack of understanding of the nurse’s role, which often leads to non-
inclusion, where their expertise would be beneficial for the student’s health (McIntosh &
Thomas, 2015). Organizations that encourage participation and promote meaningful team-based
opportunities are incentives to keep people engaged (Bolman & Deal, 2017).
Self-determination theory acknowledges that by nature, people are self-motivated and
eager to succeed, but equally, it acknowledges that people can be alienated, passive, and
disaffected (Berryman, 2008). The social context in which people operate can shape these
motivation differences. When the social environment supports a person’s intrinsic motivational
needs, positive outcomes will ensue. Social contexts that do not support these needs have adverse
effects on a person’s well-being.
Self-Efficacy
For school nurses to convey how their practice helps the organization meet its mission,
they must have a sense of self-efficacy. Self-efficacy is to have a positive expectation for success
for a task (Zimmerman et al., 2017). One’s measure of self-efficacy is based on five beliefs about
themselves. First, if they perceive they are capable of undertaking the task; second, if they think
that goal-mastery of the task is attainable; third, how they rate their predictive success to
complete the task; fourth, what success looks like given the context of the task; fifth, can success
improve over time (Zimmerman et al., 2017).
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Self-efficacy for tasks that school nurses may not be familiar with increases when given
the right skills and training for that task (Gormley, 2019). Achieving success enhances
professional fulfillment when improving patient health (National Academies of Sciences, 2016).
Feeling a sense of self-efficacy also comes from learning from others and through positive
feedback they receive from others (Zimmerman et al., 2017). Learning from others is especially
true as nurses report gaining a great deal of knowledge through informal social interactions
(Estabrooks et al., 2005). However, peer-to-peer support is problematic for the school nurse in
the K-12 education setting because they are usually the sole provider for one or more schools. As
a result of their isolation and limited contact with other professionals, school nurses lack
professional networks (Baxley, 2016). Lastly, self-efficacy feelings improve if anxiety and stress
are minimized (Zimmerman et al., 2017). Levels of workload that lead to emotional exhaustion
and burnout are problematic for school nurses (Jameson et al., 2020; Van Bogaert et al., 2017)
which can lead to an anticipation of failure if the level of cognitive input for a new task seems
high (Clark & Saxberg, 2019; Meyer et al., 2004). The school nurse can advocate for conditions
that improve their ability to meet the mission. An example is the impact that the school nurse’s
workload has on student outcomes, nurse outcomes, and organizational outcomes (Daughtry &
Engelke, 2018; Lineberry et al., 2018). Heaving nursing workloads lead to job dissatisfaction,
increased burnout, and inadequate care for students (Jameson & Bowen, 2020; Liu et al., 2018).
Table 3 identifies two motivational influences that focus on self-determination theory and
self-efficacy. These influences will be used to fully understand the school nurse’s motivation to
convey to individuals in the educational environment the school nurse’s value and how it furthers
the educational mission.

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Table 3
Assumed Motivational Influences
Stakeholder Goal
By December 2022, 100% of Connecticut K-12 school nurses will convey to individuals in
the educational environment the value of the nurses' role and how it furthers the educational
mission in order for the community to appreciate and advocate for each school to have a full-
time nurse onsite daily.
Assumed Motivation Influences Motivation Type
K-12 school nurses need to believe that by creating
awareness of their value in the education setting, they are
empowered to achieve role competency, practice autonomy
within the school, and be integral to the school community.
Self Determination Theory
K-12 school nurses need to believe that they are of value to
the education setting and can effectively share the
significance of their value to their school community.
Self-Efficacy

Organizational Influences
“Every culture is nested in some larger culture and can only do
what the larger culture affords, tolerates, or supports” (Schein &
Schein, 2010, p. 181)
This section will review the organizational influences that affect school nurses’ ability to
convey to people in the educational environment how the school nurse’s role and practice
furthers the education mission.
Organizational culture is a source of collective identity and commitment, is grounded in
history and tradition, and it provides order and rules to organizational existence (Ehrhart et al.,
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2014; Gallimore & Goldenberg, 2001). Culture is the internal beliefs, values, and attitudes that
are generally automated and are unnoticeable to those within that culture. While culture seems to
apply to macro-level environments such as organizations, on the micro-level, occupations also
develop cultures (Schein & Schein, 2010). People within occupations share values and beliefs as
part of their professional role, which remains strong even when they do not work with
occupational peers.
Gallimore and Goldenberg (2001) propose that reflecting on two factors when analyzing
culture, first, cultural models, and, second, cultural settings. A cultural model is the shared
understanding of how things work, which have evolved and developed as a result of shared
assumptions. The cultural model is the shared internal beliefs, values, and attitudes that are
generally automated and invisible and unnoticeable by those of that culture. What is noticeable
to those outside of that group are the cultural group’s core values, goals, beliefs, emotions, as
well as group norms and its identity and images of self (Clark & Estes, 2008; Schein & Schein,
2010). A cultural setting is where all actors come together to perform their work and accomplish
the things that they value as individuals and as an organization. Cultural settings are the visible,
concrete manifestations of the cultural model that appear within the activity setting.
Gallimore and Goldenberg (2001) note that both the cultural setting and the cultural
model are limited and facilitated by the environment in which they exist. Examining both the
organization’s cultural model and the cultural setting reveals the influences that affect the school
nurse’s ability to convey to individuals in the educational environment how the school nurse’s
role and practice furthers the education mission.

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Cultural Model Influence 1: A Sense of Belonging
According to Bolman and Deal (2017), an organization’s efficiency depends on its
structure, including ensuring that there is the appropriate grouping of people in place to enact the
mission. Organizational performance is enhanced and becomes more efficient when specialist
roles align with its mission and goals. Moreover, in cases where the person’s specialization is
unique to the organization, they usually know more about their work than others. Their unique
expertise in the school nurse’s case means they expect to work autonomously and prefer
reporting to a professional colleague (Fleming & Willgerodt, 2017). However, the dilemma of
autonomy is that it can leave people feeling isolated and unsupported (Kruger et al., 2009;
Simmons, 2002).
Within the school milieu, Mintzberg’s (1979) organizational model of the education
setting (as cited in Bolman & Deal, 2017), the school nurse is classified as a supporting role,
with teachers forming the operating core, and principals and superintendents making up the
administrative role. On the one hand, the school nurse as support aligns with the expectation to
support students in being healthy and achieve academically. However, as the only health
professional in the school, the nurse is integral to the operating core, and is expected to lead
health-related issues (National Association of School Nurses, 2016b). As the only health
professional in the building, their practice can be demanding and challenging (Fleming, 2011;
Maughan & Adams, 2011; Simmons, 2002). As the health care specialist, the school nurse has a
great deal of autonomy over their practice. However, along with that comes the sense of
isolation, loneliness, and a lack of support, especially acute for the novice school nurse (Kruger
et al., 2009; Simmons, 2002).
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The lack of support often extends to inadequate funding to support school health and the
school nurse practice. Education dollars fund the school nursing practice, and in times of budget
reductions, nursing services are affected because only a few states mandate that schools employ
a school nurse (Cygan et al., 2019; Wang et al., 2014). Compensation for school nurses is usually
on a lower pay scale than teachers (Kruger et al., 2009). In times of budget constraints, the focus
is usually on academics rather than ensuring that clinical care basics and specialized supplies are
taken care of, even though teachers receive a stipend for classroom supplies (Kruger et al.,
2009). In times of extreme budget limitations, even school nurses’ hiring is compromised
(Maughan & Adams, 2011). Professional development, a requirement for license renewal, is
often inadequately supported and not acknowledged in the way it is for teachers. As a result,
school nurses often attend professional development programs on their own time and pay for it
themselves (Kruger et al., 2009).
Cultural Model Influence 2: Empowered to Convey Their Value to Others in the School
Organizations benefit from maximizing the skills, attitudes, energy, and commitment of
the people within it (Bolman & Deal, 2017). Education leaders who support each member’s
performance within the organization strengthening the school’s culture, ensuring that everyone
shares the school community’s norms, values, beliefs, and attitudes (Leithwood & Riehl, 2005).
A healthy school culture strengthens trust and mutual caring, bringing staff together to work
toward the shared mission (Leithwood & Riehl, 2005). Also, the participation of a variety of
leaders across the school community improves the school’s quality and performance as a whole
(Leithwood & Riehl, 2005). Team-based interactions encourage diverse thinking
interprofessional interactions to enhance reflective practice and critical thought, when necessary,
to bring theoretical and practical concepts into practice (Barley, 2012). When the culture is
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welcoming, the school nurse’s skills, knowledge, expertise, and scope of practice, receive an
appropriate acknowledgment (Davis, 2018). To educate others about their value, school nurses
should build relationships formed on trust and acceptance (Davis, 2018).
Cultural Setting Influence 1: Access to the Support of Other Healthcare Professionals
School nurses predominantly work in isolation of other health care professionals where
natural networks are absent. Creating connections is imperative because nurses obtain practice
knowledge from information exchanges during formal and informal interactions with other
nurses. Estabrooks et al. (2005) categorized nurse’s sources of knowledge and report four that
they bring to their practice: experiential knowledge, a priori knowledge, documentary sources,
and social interactions. While all knowledge sources are essential in nursing, Estabrooks et al.
identified that communication, information exchange, and professional associations
predominantly form as a result of social interactions between school nurses. These exchanges
occur due to the trust and confidence in other nurses to assist with immediate patient care issues.
The knowledge may not always be new but may affirm what a nurse already knows, offering
reassurance for a clinical decision (Estabrooks et al., 2005). Knowledge relating to patient care
also comes from formal venues such as conferences, seminars, workshops, and short courses.
Another way nurses gain support in their practice is to encourage peer-to-peer exchanges
between mentors who guide novices through new processes (Clark & Estes, 2008). Exchanging
knowledge in this way benefits the mentor and the protégé (Carmeli et al., 2009; Janssen et al.,
2018). From an organizational perspective, the support and sharing of information increase
organizational knowledge creation (Bryant, 2005). These support opportunities also benefit the
organization by having happier employees, reducing staff turnover, and increasing efficiencies
("The importance of mentoring for individuals and organizations: Mentoring: A mutually
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beneficial relationship between mentor and mentee that serves to create strong organizational ties
while offering networking opportunities," 2010; Janssen et al., 2018). In the school nurse
population, there is evidence that shows that a mentor helps facilitate the implementation of
evidence-based practice (Adams, 2007; Baxley, 2016). However, a mentoring program’s success
requires the support of the organization’s leadership and concerted nursing staff involvement
(Abdullah et al., 2014). Barriers within the organizational setting that hinder a mentor program
for implementing evidence-based practice are a lack of mentors available (Farokhzadian et al.,
2015).
Cultural Setting Influence 2: Professional Development Opportunities
Learning is the sustainable competitive advantage that keeps the organizations successful
(Schein & Schein, 2010). Success for school nurses means to have access to continuing
education to stay abreast of continually evolving healthcare practices and health technology
(Greiner & Knebel, 2003; Heckhausen & Kay, 2017). It also means continually updating skills
and specialized training required to work with particular populations (Maughan & Bergren,
2016). For school nurses, this requires knowing the latest clinical evidence to effectively assess
and treat students (National Academies of Sciences, 2016).
The school nursing professional standards recommend that school nurses look for
knowledge and learning opportunities that ensure their practice reflects up to date competencies
and anticipates future needs (National Association of School Nurses, 2017). Fulfillment of this
professional development requirement varies from state to state (Praeger & Zimmerman, 2009).
However, in Connecticut, to maintain nursing licensure, the school nurse requires at least 10
hours of professional development every two years (State of Connecticut, 2019d). However,
even though having school nurses available is valuable for ensuring that students stay healthy
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and in school (Allison et al., 2019; Best et al., 2018; Johnson, 2017), they face barriers to taking
part in educational opportunities (Baxley, 2016). Financial support for continuing education is
not a priority for school districts (Adams, 2009), and school nurses often lack time to attend
(Baxley, 2016).
Individuals feel a great deal of satisfaction when they focus on their self-development in
order to achieve self-actualization in their work (Schein & Schein, 2010). Maintaining
competency through professional growth and continual learning is imperative for school nurses
to remain current with practice changes. To realize this, investment by the school nurse’s
employer requires ensuring career development opportunities for school nurses’ to develop new
skills (Bolman & Deal, 2017)
Table 4 identifies the cultural model influences and the cultural setting influences that
will be used to understand school nurse’s motivation to convey to individuals in the educational
environment how the school nurse’s role and practice furthers the education mission.

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Table 4
Assumed Organizational Influences
Stakeholder Goal
By December 2022, 100% of Connecticut K-12 school nurses will convey to individuals in the
educational environment the value of the nurses' role and how it furthers the educational
mission in order for the community to appreciate and advocate for each school to have a full-
time nurse onsite daily.
Organizational Influence Organizational Influence
Category
K-12 school administration needs to foster an
environment where school nurses have a sense of
belonging that respects their professional capacity to
contribute to the educational mission’s success.
Cultural Model Influence 1
K-12 school administration needs to foster an
environment where school nurses are fully empowered to
convey their value to others.
Cultural Model Influence 2
K-12 school administration needs to provide school
nurses with access to the support of other healthcare
professionals.
Cultural Setting Influence 1
K-12 school administration needs to provide adequate
professional development opportunities for school nurses.
Cultural Setting Influence 2

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Conceptual Framework: Interaction of Stakeholders’ KMO Influences
According to Grant and Osanloo (2014) the conceptual framework represents the
researcher’s understanding of the problem to be explored and the relationships among the study
variables. Like a map, the conceptual framework offers a visual image showing a logical
structure connecting the concepts or ideas within the study and how they relate to each other
(Miles et al., 2020; Rallis, 2018). The conceptual framework develops the argument and
establishes what will be studied (Miles et al., 2020), but is malleable evolving as entities and
relationships become more clearly discernable (Ravitch & Riggan, 2012) The conceptual
framework consisting of three elements: the researcher’s personal experience and viewpoints,
existing knowledge about the phenomena, and the theoretical positions regarding the phenomena
(Miles et al., 2020; Rallis, 2018; Ravitch & Riggan, 2012).
The conceptual framework in Figure 2 represents the contextual and individual
influences, as perceived by the researcher, that empowers the school nurse’s ability to convey the
value of their role and practice in the educational environment.
Conceptual Framework Details
The first element in the conceptual framework, the study’s significance, stems from the
researcher’s understanding that school nurses are healthcare workers who are central to
achieving the educational mission. The challenge of being situated in the educational
environment is that their practice is isolated from other healthcare professionals. Being the only
healthcare practitioner often means they lack the support for their practice that could benefit
adequate healthcare delivery to students. In Figure 2, the nurse is the central figure connecting
healthcare to the educational mission. When the assumptions of the contextual and individual
influences are met, school nurses are empowered to convey their value as essential to furthering
the educational mission by ensuring students are healthy and ready to learn.
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The second element, or the body of knowledge about the phenomena, has been discussed
throughout Chapter Two. The discussion centers on the embeddedness of the school nurse in the
educational milieu. The complexities of their role are outlined, and how there is often a lack of
awareness of the school nurse’s value in furthering the educational mission. Chapter Two
discusses the fact that school nurses bring their professional healthcare knowledge and expertise,
to their work, as well as their professional intrinsic motivation. Knowledge of healthcare
practices, as well as motivation to apply these practices are central to ensuring that students are
healthy and ready to learn in the educational environment. Figure 2 depicts the complexity and
interrelatedness of the contextual and individual influences that need to be aligned to ensure that
students healthy and achieving academically.
The third element in the conceptual framework is the theoretical lens of the phenomena.
This study uses the lens of Clark and Estes’ (2008) knowledge, motivation, and organizational
(KMO) influences as central to meeting the needs of the organization’s goal. Figure 2 shows the
assumed organizational (contextual) influences in the educational setting that empower the
school nurse’s ability to convey their value. Similarly, the figure shows the assumed knowledge
and motivation influences that empower their ability to convey their value. It is important to note
that the KMO influences are not mutually exclusive, so all need to be considered interconnected
when thinking about influences that affect the achievement of any goal (Rueda, 2011).

65

Figure 2
Conceptual Framework
Note: Conceptual framework showing the influences on school nurses that empower them to be
able to convey their value in furthering the educational mission of successful education of
students for them to achieve their full potential.

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Conclusion
This chapter reviewed the literature related to school nurses in the K-12 educational
environment. School nurse practice began early in the 20
th
century, and during that century,
legislation has influenced school nurse practice within the educational environment. School
nurses often operate as the only health care provider in a school within a school district. The
district’s education funding decisions impact school-based health, ultimately impacting the
school nurse. The chapter discussed that the school nurse workforce positively impacts students
in schools by keeping them healthy and ready to learn. The chapter highlighted the school nurse
practice framework, which is the context for their ability to perform to their full scope of
practice.
Following this literature review about school nurses, the review outlined the school
nurse’s knowledge, motivation, and organizational and contextual influences that impact their
ability to convey the value of their role in meeting the educational mission by ensuring students
are healthy and ready to learn. Key assumed knowledge influences included four things:
knowledge of nursing procedures, regulations, and legislation; how school nurse practice aligns
with the educational mission; effectively conveying their value; and knowledge of reflection in
response to influences. There are two assumed motivational factors: school nurses’ self-efficacy
in believing they can share their value in the educational environment; and, self-determination
theory, where they are empowered within the educational environment. There are four assumed
organizational factors: the cultural model influence of administration fostering a sense of
belonging; and the cultural model influence where school nurses are empowered to convey their
value to others; the cultural setting influence where school administrators provide school nurses
access to other health care professionals; and the cultural setting influence where school nurses
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have access to professional development opportunities. The framework focused on the
knowledge and motivational factors of school nurses as the primary stakeholder, conveying to
others in the educational setting the value of the nurse’s role in furthering the educational
mission. Chapter Three will present the methodological approach to explore and understand the
assumed knowledge, motivation, and organizational influences on the school nurse population in
the educational environment.

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Chapter Three: Methodology
Purpose of the Project and Research Questions
The purpose of this qualitative phenomenological study was to evaluate how Connecticut
K-12 school nurses perceive their practice and role in the educational environment is valued in
furthering the educational mission by ensuring students are healthy and ready to learn. Chapter
Two outlined the context in which school nurses work, highlighting areas that influence their
ability to convey the value. While a complete evaluation of the school nurse’s educational
environment milieu would focus on all stakeholders, for practical purposes, the stakeholder focus
for this study was K-12 school nurses. This study’s lens was the knowledge, motivation, and
organizational influences (KMO) in the educational environment that affect how school nurses
can adequately convey how their role and practice furthers the educational mission.
Through the lens of the KMO model (Clark & Estes, 2008), the research questions are as
follows:
1. How does working in the educational environment impact the school nurse’s ability
to convey the value of their contribution to the educational mission?
2. What are the knowledge, motivation, and organizational influences that facilitate or
impede the school nurses’ ability to perform at their full scope of practice ensuring
students are healthy and ready to learn?
3. What are the knowledge, motivation, and organizational resource recommendations
for Connecticut K-12 school nurses to convey their value in the educational
environment?

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Overview of Methodology
The researcher used the constructivist approach to this study. This approach gains an
understanding of the phenomena by interpreting participant perceptions knowing that there are as
many realities as there are participants (Lincoln et al., 2017). Using the constructivist
perspective, this study used a qualitative phenomenological approach to understand how school
nurses perceive their experiences working in the educational environment. Qualitative
phenomenological research attempts to interpret and make sense of how someone describes their
experience of a phenomenon in their world as they see it (Creswell & Creswell, 2018; Creswell
& Poth, 2018). In qualitative research, the researcher becomes the critical instrument situating
themselves in the study’s natural setting. The participant’s understanding of the phenomena was
the focal point as the expert sharing opinions, interpretations, and meanings about their
experience (Creswell & Creswell, 2018; Merriam & Tisdall, 2016).
This study used one-on-one semi-structured interviews as the data collection tool. The
semi-structured interview allowed the researcher to ask questions to prompt the conversation
about the phenomenon, yet allowed the participant latitude to respond with their insight about
what they interpret from the question (Merriam & Tisdall, 2016).
In qualitative phenomenological studies, the what and how of the participant’s experience
is interpreted and given meaning by the researcher (Creswell & Poth, 2018; Lincoln et al., 2017).
Data collection incorporated the hermeneutic cycle where data is collected, then interpreted,
leading to further data collection to help make meaning of the phenomena (Lincoln et al., 2017).
Qualitative research employs an emergent design to analyze the participant’s responses, which
means using an inductive approach to reveal patterns and build themes from the information
brought to light by the participant (Creswell & Creswell, 2018). This study of the school nurse’s
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work experiences in an educational setting analyzed the interpretations to give meaning to
insights from knowledge, motivation, and organizational perspective. These interpretations were
used to recommend meaningful next steps and an action agenda for all stakeholders identified as
influential in school nurses achieving the goal of articulating the value of their role in the
educational environment (Creswell & Poth, 2018)
The interview protocol (see Appendix A) was designed to gather participants’ responses
using the study research questions as a guide. See Appendix B for a detailed matrix showing the
crosswalk relationship between the interview protocol, the study research questions, and the
knowledge, motivation, and organizational (KMO) influences.
Data Collection, Instrumentation, and Analysis Plan
The study used interviews to learn about the school nurse’s experiences and perceptions
about working in an educational environment (Merriam & Tisdall, 2016). The study data were
the school nurse’s words reflecting the feelings, thoughts, and emotions describing the
phenomenon of practicing in the educational environment (Creswell & Poth, 2018). Interviews
allowed the researcher to question and probe participants about their experiences.
The interviews were conducted using Zoom videoconferencing (Zoom Video
Communications Inc., 2020), a cloud-based platform that allows for online group meetings.
Online interviews are an increasingly valuable way to collect data as geographically dispersed
participants can easily connect (Archibald et al., 2019; Iacono et al., 2016; O’Connor & Madge,
2003). Participants did not need an account and connected easily to the session via a web
browser on a computer or an app on an electronic device. Participants were given detailed
instructions about using the Zoom platform and an assurance of confidentiality as part of the
interview instructions. See Appendix C for participant instructions about using Zoom.
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Qualitative research design requires that the researcher choose a sample population
representative of the population under study (Creswell & Poth, 2018). The study participants
were recruited from the Connecticut K-12 school nursing community. Purposive sampling was
used to select school nurses who could provide the most information about the study phenomena
(Creswell & Poth, 2018). Participant recruitment was through invitation via email sent by the
researcher.
Interviews
Qualitative phenomenological research uses interviews to gain an understanding of the
school nurse’s experience. The purpose of the interviews was to discover what cannot be
observed and to see the phenomena of interest from the other’s perspective (Patton, 2002).
Participants were included based on being knowledgeable about the topic of interest to describe
as part of their experience. Interview data collection typically continues until data saturation,
with no new information forthcoming (Merriam & Tisdall, 2016). With deference to this
recommendation, the researcher interviewed 14 school nurses at which time data saturation was
reached.
Participants
Qualitative research design includes a sample population representative of the population
under study (Creswell & Poth, 2018). Qualitative research also employs small sample sizes, but
large enough to be sure data collected is information-rich (Moser & Korstjens, 2018). This study
focused on the Connecticut school nursing community, selecting participants from the state's K-
12 school nursing community.
With qualitative research aiming to collect rich data (Creswell & Poth, 2018), purposive
sampling was used to select school nurses who could provide the most information about the
study phenomena. Purposive sampling included iterative decisions to select participants who
72

offered alternative perspectives to give the data its richness (Guetterman, 2015). Connecticut’s
eight county boundaries were used as the basis for sampling school nurses from different regions
across the state equitably. To ensure maximum variation, the inclusion of diverse individuals in
terms of characteristics was important to the study (Creswell & Poth, 2018). The participant
selection goal was to include up to two nurses from each county. To achieve this, the researcher
sampled school districts from each county based on the communities with profiles for either
lowest or highest socioeconomic circumstances relative to that county. This sampling technique
ensured the inclusion of school nurses who work with students from diverse socioeconomic
circumstances. The sampling was based on data from the Small, Rural School Achievement
Program and the Rural Low-Income School Program FY2012 (ed.gov, 2012), which shows the
percentage of students from families below the poverty line. To diversify participants
representing each school district, the researcher sent emails to school nurses working in
elementary, middle, and high schools in each community. The researcher sent three separate
rounds of email, recruiting several nurses through each round. See Appendix D for
communications to the participants. Of the 14 school nurses who responded, all were included in
the study. There were only two counties where only one nurse was represented. After the 14
interviews the researcher noted that saturation was reached with no new information coming
from each participant (Moser & Korstjens, 2018).
To collect anonymous demographic information, each participant was asked to complete
a short survey that includes demographic details about them and their place of work (Appendix
E). The survey platform is Qualtrics
XM
(Qualtrics, Provo, UT) online survey software. The
survey software and the data collected is password protected on a secure server. Survey
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information is confidential and is password protected. Only 13 of the 14 school nurses in the
study completed the survey.
Instrumentation
This study used a semi-structured interview protocol with open-ended questions to
maintain data collection consistency in all school nurses’ interviews. Semi-structured open-
ended interview questions allowed the interviewer to build the conversation around the area of
interest by asking relevant questions probing interviewees’ responses (Merriam & Tisdall, 2016;
Patton, 2002).
The use of an interview protocol ensured the line of questioning is the same for each
participant (Merriam & Tisdall, 2016), especially as there was a limited time frame for each
interview (Creswell & Creswell, 2018). It proved useful to include different types of questions in
the protocol as it created a fluid conversation with the school nurses (Krueger & Casey, 2015).
This study’s interview protocol included various questions including an opening question,
transition questions, and key and ending questions. To add to the quality of the information
received during the interview, Patton’s (2002) six question types were included: experience and
behavior, opinion and values, feelings, knowledge, sensory, and background and demographic.
To fully engage the participant, probes were used to deepen the conversation asking who, what,
when, and where questions, allowing the interviewee opportunities to expand on their
experiences and opinions (Merriam & Tisdall, 2016). During the study’s data analysis phase, the
interview protocol acted as a guide to what the participant was referring to (Patton, 2002). See
Appendix A for this study’s interview protocol, which includes the crosswalk of the interview
questions corresponding to Patton’s questions types (2002).

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Data Collection Procedures
Data for this study was information provided through the participant interviews. Also, the
researcher took notes during the interview to capture anything that happened other than what was
said, such as a non-verbal reaction to a question (Merriam & Tisdall, 2016). Interviews with
school nurses took place via the Zoom video conferencing platform (Zoom Video
Communications Inc., 2021) at a convenient time. Each interview lasted approximately 60-
minutes.
With participant permission, each interview was audio- and video-recorded for later
verbatim transcription. Audio recording was the preferred method for ensuring that the
interviewer’s exact words were captured (Merriam & Tisdall, 2016). Zoom recording was
disabled upon entry into the meeting. The Zoom software required each participant to consent to
the recording once the recording started electronically. Zoom recordings for each interview are
held in a secure file and will be destroyed after this study. School nurses are assured
confidentiality as Zoom recordings are password protected for both the sessions’ audio and video
components (Zoom Video Communications Inc., 2021). The recording was an essential feature
allowing the researcher to quickly recall the interview, noting things missed during the time with
the participant (Merriam & Tisdall, 2016).
Data Analysis
Data is the information that is collected as a part of the research study. The data for this
study is the words of the participant in the form of the interview transcripts. Transcription
software was used to transcribe the Zoom interview recording. Editing the transcript was
necessary as the transcription software misinterpreted words. As well, participant’s details were
edited within the transcript. For security purposes, the coding for participant pseudonyms are
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kept in a separate file from the study materials. It is also recommended that the transcript include
sequential line numbering for easy tracking (Merriam & Tisdall, 2016).
Data analysis was started after all interviews were complete (Creswell & Creswell, 2018).
The transcripts were uploaded into ATLAS.ti 9 qualitative data analysis software (ATLAS.ti 9
Windows, 2021). ATLAS.ti is computer-assisted qualitative data analysis software (CAQDAS)
enabling ease of use to store and organize the transcripts and the information within them
(Creswell & Creswell, 2018). The software allowed the researcher to conveniently code the
participant transcripts, as well as allowed for easy querying and analysis of the detail. Coding the
data was a process of creating apriori codes and n-vivo codes (Saldaña, 2013). The coding
allowed the researcher to summarize and distill the information collected from each participant
(Saldaña, 2013). The data analysis process included reading all transcript data and identifying
chunks that represented categories (Creswell & Creswell, 2018). The KMO framework was used
to develop apriori code categories in the initial coding cycle. The researcher then created
subcategories based on themes revealed from within the KMO code categories.
Credibility and Trustworthiness
Credibility and trustworthiness, also known as reliability and validity, in a qualitative
study refer to the confidence that the study’s findings are true and accurate from the perspectives
of the researcher, the participant, and the readers (Creswell & Creswell, 2018). Credibility, or
reliability, of a study, was measured through two things: transparency of the way the study was
conducted; and the reporting of results that match the study’s intent (Merriam & Tisdall, 2016).
Achieving transparency was possible by keeping documentation throughout the study, recording
all decisions. The reliability of the data also came from checking Zoom transcripts for accuracy.
The voice recognition translator in Zoom contained errors, so the transcripts were read and
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edited for accuracy. Transparency of code development comes from using a codebook, including
a description of each code and an example (Saldaña, 2016). The development of the codebook
was instrumental in keeping coding on track as the codes accumulated and changed.
There were several ways that trustworthiness, or validity, was incorporated into this
study. As Merriam and Tisdale (2016) advised, the first was using peer debriefing before the
commencement of the study, and during the study. For instance, the interview protocol and the
methods for selecting study participants were peer-reviewed by qualitative research experts.
Also, before the study started, the faculty reviewed the study for completeness. During the study,
consultation continued with qualitative research experts to discuss strategy for data analysis.
Second, to ensure trustworthiness, there was a review of the interview protocol (Merriam &
Tisdall, 2016). While the protocol is the tool and guide used to gather the data, the interviewer is
the instrument, and the value of the information gathered depends on the interviewer (Patton,
2002). The interview protocol was piloted with three school nurses prior to the study beginning.
Piloting the survey ensured that questions were as straightforward as possible and were
understandable to the participants. Third, efforts to ensure study trustworthiness occurred during
the data collection phase (Merriam & Tisdall, 2016). The study used member checking by asking
participants to review the transcripts for accuracy and to be sure their answers represented what
they meant (Creswell & Creswell, 2018).
This study employed methods to ensure that the results are credible and trustworthy. As
the qualitative researcher is the data collection instrument, the credibility of a study depended on
the researcher checking their bias as the study developed and acknowledging their positionality
during the process (Creswell & Creswell, 2018). Allowing the reader to know how the researcher
fits into the study is a central component of the study’s credibility and reliability.
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Ethics and Role of the Researcher
Ethics within a research study include the interaction between the researcher and the
participant, as well as the effect that the study has on the population in the study (Lincoln et al.,
2017). Constructivist research occurs when both researcher and participant have equal control
over the process, and both share how the research is produced and used (Lincoln et al., 2017).
Positionality
The researcher is a medical librarian who supports the practice of nurses in both clinical
and academic settings. Deeply involved with this cohort, the researcher continually witnesses
nurses’ dedication to their profession and thinking about doing things better in their practice.
Because of these interactions, the researcher knows about the work of nurses in creating a
patient-centered culture in the clinical setting. The basis for the researcher’s values and axiology
(Saunders et al., 2019) influencing and framing this study, is that nurses influence the clinical
milieu’s effectiveness.
In addition to working with hospital clinical nurses, the researcher has done outreach to
school nurses to assist them with their information needs. Through this outreach, the researcher
is aware that school nurses do not have access to the same support nor resources as hospital
clinical nurses. There is an abundance of other clinicians in hospital clinical settings that nurses
can seek help as needed. Conversely, school nurses are situated in education settings and often
work alone. Importantly, though, the researcher’s professional philosophy is that patient care is
more effective when healthcare professionals have access to support and information needed for
healthcare. In addition, the researcher is not a nurse and must approach this study with humility
to better understand how the school nurses interpret their professional world as they live it
(England, 1994). As the researcher approaches this study’s population, there is a necessity to stay
open to their voices about their world and their values relating to this topic.
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In the researcher’s doctoral inquiry journey, although clear about the problem of practice,
the researcher naively presumed that “research itself leads to change” (Tuck & Yang, 2018, p.
13). Tuck and Yang (2018) describe how novice researchers often embark on research that tells
and retells disenfranchised communities’ stories, reinforcing that something is broken. While the
KMO model frames research around a gap, the researcher’s viewpoint is that while gaps may be
evident, there is always an opportunity to build on the strengths of what is currently in place
(Cooperrider et al., 2005). With this in mind, the researcher developed this qualitative study with
the ethical perspective that qualitative research contains an action agenda that addresses all
stakeholders with the intent for sustainable reform for the school nurses (Creswell & Poth, 2018;
Lincoln, 2009; Wolf et al., 2009).
Ethics
Ethical issues are considered in any study that involves human subjects (Creswell &
Creswell, 2018). Qualitative research intrudes on the study participants’ lives, which means that
the researcher has an obligation to their study population to avoid harm, gain informed consent,
protect their privacy, and ensure the welfare of the people and communities in the research
(Ntseane, 2009).
The first step was to gain access to the research site to collect the data by obtaining
permission from the human subjects review board (Creswell & Poth, 2018), in this case, the
University of Southern California Institutional Review Board (IRB). Confirmation was obtained
after the researcher’s dissertation committee approved the study proposal. The IRB approval was
noted in all correspondence and documentation made available to the study participants. For this
study, permission to access a site to find participants was not necessary as the participants took
part in the research independent of their workplace.
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For complete transparency about the research, an important step when conducting the
research is to disclose the study’s purpose to participants (Creswell & Poth, 2018). In all
communications with participants, the purpose of the study was outlined. Language was also
included to assure the recipient of the communication that participation is voluntary, and at any
time, they can stop participating without penalty or harm.
When gathering data, it was also necessary to respect the researcher and the participant’s
potential perceived power imbalance (Creswell & Poth, 2018). During the interview process, all
attempts were made to create an atmosphere of trust and openness (Creswell & Poth, 2018).
Consent and Confidentiality for Study Participants
All due respect in terms of confidentiality and privacy was afforded to study participants
(Creswell & Poth, 2018). Confidentiality began with data collected and followed through to data
storage, data analysis, and reporting and publishing the report. All data is stored on a secure
password-protected hard drive and thumb-drive.
As deemed acceptable by the Institutional Review Board, the study participants gave
verbal consent to participation before collecting any data (Creswell & Creswell, 2018). Because
the interviews were via Zoom obtaining written consent was not done. With explicit notification
to the participant about their rights, IRB allows verbal consent in lieu of written consent. The
participant was advised about their rights, and the nature of the study through all
communications. Email communication included the Information Sheet for Exempt Research
(Appendix F) which fully outlined the purpose of the research as well as information about who
to contact if more information is needed. The participants consented verbally to the study and to
being recorded at the beginning of the interview. The reasons for the study, as well as its
benefits, were outlined in all email communications and at the time of the interview. At the time
of the interview, it was also explained to participants why were also chosen to participate. As
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well, each participant was assured that their participation was voluntary and that they will not be
put at undue risk (Creswell & Poth, 2018). It was also made clear that the participant may leave
the study without penalty or harm at any time.
Qualtrics
XM
(Qualtrics, Provo, UT) online survey software was used for survey delivery.
Accessing the Qualtrics platform and the data stored from the survey is via password protection.
Consent for the survey participation was part of the survey introduction and included language
that the completing the survey means that the respondent is consenting to participate. It was also
expressly stated that participation is voluntary, and if questions cause discomfort, items do not
have to be answered, or that survey completion can be discontinued.
Compensation
Participants did not receive compensation for study involvement.

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Chapter Four: Results and Findings
Purpose of the Project and Research Questions
This qualitative phenomenological study evaluated how Connecticut K-12 school nurses
perceive their practice and role in the educational environment are valued in furthering the
education mission, ensuring students are healthy and ready to learn. The study focused on how
the school nurse’s knowledge, motivation, and organizational influences in the educational
environment affected their ability to convey how their practice and role furthers the educational
mission. The questions that guided this study were as follows:
1. How does working in the educational environment impact the school nurse’s ability to
convey the value of their contribution to the education mission?
2. What are the knowledge, motivation, and organizational influences that facilitate or
impede the school nurses’ ability to convey to individuals in the educational
environment the value of their role and how it furthers the educational mission?
3. What are the knowledge, motivation, and organizational resource recommendations
for Connecticut K-12 school nurses to be able to convey to individuals in the
educational environment the value of their role and how it furthers the educational
mission?
As discussed in Chapter Three, the study methodology used was one-on-one semi-
structured interviews enabling the researcher to understand the participant’s perceptions about
the phenomena of interest. In addition, a pre-interview survey was conducted to gather
demographic information about the participants.
This chapter begins by describing the stakeholders who are Connecticut K-12 school
nurses, followed by a discussion of how the interviews were conducted. The methods for data
analysis and validation are also described. The results and findings are then presented. An
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analysis of the results is based on the knowledge, motivation, and organizational influences that
affect the school nurse’s ability to convey their value in the educational environment. The finding
section follows with findings for the research questions.
Participant Stakeholders
This study focuses on the Connecticut K-12 school nursing community. Qualitative
research design includes a small sample population representative of the population under study.
Connecticut’s eight-county boundaries were used as the basis for sampling school nurses from
different regions across the state equitably. This selection method was chosen to include school
nurses working in school districts within each county representing varying student population
sizes and make-up. The final sample interviewed included two nurses from each of six counties
and one school nurse from each of two counties. There were 14 participants interviewed before a
preliminary review of the data determined that saturation had been reached, so interviewing
came to an end.
The participants were recruited by email based on being a school nurse in one of the eight
Connecticut counties. There were three separate rounds of emails that were sent to request
participation. To ensure the participation of school nurses serving diverse community
populations, two school districts from each county were selected in each round. School districts
selected reflected, for that county, either predominantly low or high socioeconomic family
demographics. An email was sent to an elementary school nurse, a middle school nurse, and a
high school nurse for each school district. Not all school districts had all grade levels because
the district was small, so the email was sent to the grade level represented in that school district.
The first email (November 30, 2020) was sent to 42 school nurses, and five agreed to
participate. The second email (December 15, 2020) was sent to 48 school nurses, and seven
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agreed to participate. The third email (January 26, 2021) was a targeted email to elicit
participation from school nurses who represented school districts and student age range
demographics not yet participating in the interviews. There were 12 emails sent, and two school
nurses agreed to participate. For each round of emails, two weeks after the email was sent, the
researcher sent a reminder email.
Of the 14 school nurses included in the study, nine were from elementary schools (PK-6
grade); three were from middle schools (5-8 grade); and two were from high schools (9-12
grade). School nurses worked in schools with student populations that ranged from
approximately 100 students to as many as 2,000 students. As assigned per selection criteria, eight
school nurses interviewed represented schools in communities with low socioeconomic (SES)
demographics, and six were from schools within high socioeconomic communities. SES data
was found by reviewing school district statistics in the National Center for Education Statistics
(NCES) (National Center for Education Statistics, 2020a). Another indicator of SES is
percentage of families receiving supplemental nutrition assistance program (SNAP) benefits, and
this data was also found in the NCES. Table 5 shows that in some counties a “low” SES district,
defined as percentage of families below the poverty line, was not that much different from a
“high’ SES district in another county. Nonetheless, this study recognized high SES districts when
less than 8% of families are below the poverty line, and less than 10% are receiving SNAP
benefits. Conversely, low SES districts included 11% or more of families who fall below the
poverty line, with 16% or more receiving SNAP benefits. Table 5 shows the characteristics of the
participants of the study.

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Table 5
Participant Characteristics
Participant
School
Nurse
Experience
(years)
Grades
Predominant
Family SES
(High/Low)
ab
[% families with
children in public
school below poverty
line]
District %
families
with SNAP
benefits
b
District
School
Nurse
Supervisor
Present
(Yes/No)

Nurse Smiley 10 PK – 2 High [0%] 0% Yes
Nurse Hansen 2 PK – 2 High [8%] 10% Yes
Nurse Winfrey 12 PK – 4 Low [2%] 17% Yes
Nurse Garcia 11 PK – 4 Low [2%] 17% No
Nurse Fernandez 3 K – 5 Low [31%] 44% Yes
Nurse Smith 15 K – 5 Low [29%] 46% Yes
Nurse Bond 1 3 – 6 High [4%] 2% No
Nurse Taylor 5 3 – 6 Low [22%] 26% No
Nurse Janssen 4 4 – 6 High [1%] 8% Yes
Nurse Carter 9 5 – 8 High [5%] 5% Yes
Nurse Swain 25 6 – 8 High [3%] 2% Yes
Nurse Ender 5 6 – 8 Low [11%] 16% Yes
Nurse Mallory 12 9 – 12 Low [16%] 24% Yes
Nurse Aarons 4 9 – 12 Low [38%] 48% Yes
a
High/Low factored relative to all school districts in that county;
b
National Center for Education
Statistics

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Before each interview, school nurses were asked to complete an anonymous online
survey using Qualtrics
XM
(Qualtrics, Provo, UT) to gather primary demographic data. Of the 14
participants interviewed 13 responded to the survey. All survey respondents said they had
worked in a clinical setting other than a K-12 school prior to becoming a school nurse.
Information gathered from the interviews found that eleven of the 14 school nurses have a school
nurse supervisor in their district. Only five school nurses indicated having nursing education of a
bachelor’s degree or above, with eight indicating they have an associate degree. Only one school
nurse in this study has national certification as a school nurse. Seven nurses acknowledged
belonging to the Association of School Nurses of Connecticut, and five belong to the National
Association of School Nurses. Table 6 shows aggregated demographic data collected from the
participants.

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Table 6
Aggregated Participant Characteristics (N=13)
School Nurse Characteristics Average (range)
Total Years Nursing
School Nurse 8.5 (1 -- 25)
Registered Nurse 15 (1 – 35)
n
School Nurse Supervisor Present 11
a

School-Based Health Clinic Present 5
Employer
Board of Education 11
Local Health Department 2
Employment Status
Full-time 9
Part-time 2
Other 2
Highest Degree
Associates 8
Bachelors 4
Masters 1
National School Nurse Certification 1
Association Membership
ASNC
b
7
NASN
c

5
a
Data from interviews;
b
Association of School Nurses of Connecticut;
c
National Association of
School Nurses

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Interview Administration
A qualitative semi-structured interview was used to gather the data from participants. The
interviews, each lasting for approximately 60 minutes, were conducted remotely using the Zoom
video conferencing platform (Zoom Video Communications Inc., 2020). The interviews took
place at the school nurse’s convenience during January and February 2021. With the participant’s
permission, each interview was video- and audio-recorded.
Data Analysis
After each interview, the transcripts were downloaded, edited to remove timestamps, and
formatted into a question-and-answer conversation-type transcript. Transcripts were also
checked for discrepancies between the Zoom auto-transcript format and the participant’s words.
After interviews were completed, the transcripts were uploaded and coded in Atlas.ti software
(version 10 Windows). All recordings and transcripts were held in a secure password-protected
computer and in an electronic password-protected file. After the completion of the 14 interviews,
the researcher used deductive reasoning to apply KMO a priori codes developed from the
literature and conceptual framework to all interview responses using Atlas.ti. The a priori codes
were then reviewed for emerging themes within the data and recoded accordingly. Analytic codes
served as data points that supported or refuted the KMO need assumption under evaluation.
Data Validation
Interview data was validated considering the school nurse’s perception of their ability to
convey that their practice and role are of value and are integral for the educational mission.
Findings from the interviews were interpreted and summarized according to the assumed
knowledge and motivation needs and organizational influences identified in Chapter Two.
Assumed needs and influences have been established as a gap validated or gap partially
validated (both indicating an area for improvement) or a gap not validated (indicating an area of
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strength lacking evidence as an area for improvement). Gap validated was concluded if four or
more of the school nurses did not have the necessary knowledge, motivation, and organizational
support related to the assumed influence. When an assumed influence showed that nurses had
some but not all the required knowledge, motivation, and organizational support, the influence
was assigned the rating of gap partially validated. Assumed influences were concluded as gap
not validated if ten or more of the 14 school nurse participants have the necessary knowledge,
motivation, and organizational support related to the assumed influence. A detailed discussion of
the critical themes from the data sources for each knowledge, motivation, and organizational
influence follows.
Results and Findings
The general literature review in Chapter Two explored school nursing practice as a
unique specialty embedded in the K-12 educational environment. Discussion centered on how
the school nursing practice role aligns with the educational mission ensuring that students are
healthy and ready to learn. The chapter then focused on the knowledge, motivational, and
organizational influences that impact the school nurse’s ability to convey the value of their role
in meeting the educational mission. The conceptual framework (see Figure 2) displays how these
assumed influences were used to guide this study.
This chapter discusses the results of the interviews with school nurses in the context of
the assumed influences, using the data validation gap analysis as the frame for the findings
(Clark & Estes, 2008). Gap analysis is the foundational structure for these results. In March
2020, the COVID-19 global pandemic abruptly affected the K-12 educational community in
ways that continue to evolve. All school nurses interviewed had school closures early in the
pandemic, but at the time of the interview, some were beginning to see the schools in their
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district return to in-person classes, often with a modified schedule. All worked either full-time in
the school or a hybrid situation working at home and school. The results include details of their
work before the pandemic and how their work shifted and evolved during the pandemic.
Results and Findings: Knowledge Results
For people to function effectively in any endeavor, they need to know what is required to
successfully achieve the task at hand (Rueda, 2011). For school nurses to achieve the goal of
conveying their value in contributing to the educational mission, there were four assumed
knowledge influences for this study. Table 7 is the summary of the findings for all four assumed
knowledge influences.

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Table 7
Summary of School Nurse Knowledge Influences
Assumed Knowledge Need
Gap Validated
Yes / No
Factual –
School nurses need to know about nursing procedures, regulations, and
legislation that affect the students in their care, and update their practice as
any of these evolve.
Not Validated
Conceptual –
School nurses need to know and understand the alignment between their
nursing practice and the educational mission in order to help students lead
productive and successful lives.
Not Validated
Procedural –
School nurses need to ensure that school administrators understand why their
role and practice is essential bringing value to the K-12 educational setting.
Partially
Validated
Metacognitive –
School nurses need to know what factors in the educational setting influence
their clinical practice and to work with others to ensure that their healthcare
role continues as a strength for the education community.
Not Validated

Factual Knowledge. School nurses need to know about nursing procedures, regulations, and
legislation that affect the students in their care, and update their practice as any of these
evolve. This gap is not validated.
For school nurses to successfully convey their value, they need to have factual knowledge
about their nursing practice. Two factual knowledge themes emerged from the interviews with
school nurses. Fourteen out of 14 school nurses described first having clinical knowledge to care
for students and secondly having regulatory knowledge about their practice.
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Clinical Knowledge. School nurses described situations where they had adequate
knowledge to clinically assess and determine a healthcare plan of action for many health issues
that students present. Nurse Garcia illustrated the breadth of the health issues that she needed
knowledge for when she stated,
Kids come to me for everything from a bellyache to a broken arm or a seizure … we
administer medicines, we write emergency plans for kids with significant medical
diagnoses … [and we do] physical assessment, you know, to determine if they need
further care.
Besides knowing about routine health care needs, Nurse Carter explained the continual
need for clinical knowledge for students with special needs when she said, “now that more and
more [special needs] children are coming in and being mainstreamed into schools, I mean, my
gosh, now you have to know what’s going on medically for these kids.” These examples show
that school nurses indicated having sound clinical knowledge for their practice in the educational
setting.
School nurses explained knowing where to find information to stay current in their
practice. They mentioned attending professional development, searching Google, watching
YouTube videos, and relying on nursing books from their schooling. Nurse Fernandez
commented that to stay in touch with clinical knowledge, she is a big reader for her practice
saying, “I'm always hyper-critical of myself, so I'm like … what if this situation happens and I'm
not prepared for it.” School nurses also commented that they reached out to other school nurses
in the district for knowledge that they may not have. Nurse Bond, a school nurse with only one
year of experience, illustrated the importance of his peers as a resource for knowledge when he
pointed out, “I feel like I have great resources and support for the things that I don't know a lot
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about … the nurse at the other school has been a school nurse for many years and has worked in
different school environments. … so, she's a great resource.” The school nurses recognized that
clinical knowledge needs to be current to provide the best clinical care for students. They
perceived that their level of clinical knowledge and their ability to stay current conveyed the
value of their role of meeting the educational mission by keeping students healthy and ready to
learn.
Practice Knowledge. Besides having clinical knowledge, school nurses reported that
they know the regulations surrounding their scope of practice. For instance, they know that they
“cannot diagnose” or “do physicals,” and therefore when needed to refer students for further
care. Nurse Taylor explained that “as far as the kid’s healthcare … I can recommend, I can
advise, [but] I can't manage people's primary care.” Having current knowledge with legislative
changes was also described by the nurses as paramount. Nurse Swain, a nurse for 25-years,
described routinely attending the State Department of Education’s new school nurse orientation
to learn about legal and regulatory changes that affect her practice. She noted that “they’ll
change a law in July that we have to implement in September, and you can’t say that you were
ignorant of the law. You can’t say that I didn’t know that it passed.” Staying current with shifting
health regulations during COVID-19 was a task appropriately for which school nurses took
responsibility. All school nurses described being constantly preoccupied with gathering
information about the pandemic to guide their community and practice. Nurse Swain noted that
she always watched the Tuesday weekly Governor’s briefings and made sure that the most
current regulations were on hand. At the time of the interview, she explained, “there are like nine
or ten addendum’s ... so I'm printing them out, and I have them literally on my desk behind my
head … all of the addendums, especially addendum five, which is specific about schools … in
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terms of cleanliness.” She noted that “they’ll change a law in July that we have to implement in
September, and you can’t say that you were ignorant of the law. You can’t say that I didn’t know
that it passed.” School nurses verified that they knew about their scope of practice and were
familiar with pertinent and timely regulations and legislation affecting the school nurses and the
environment in which they worked. Having an awareness of practice regulations and staying
with changes was perceived by school nurses as conveying the value of their healthcare role in
the educational setting.
Conceptual Knowledge. School nurses need to know and understand the alignment between
their nursing practice and the educational mission in order to help students lead productive
and successful lives. This gap is not validated.
For school nurses to successfully convey their value, they need to have a conceptual
understanding of how their role aligns with the mission of the K-12 organizational environment.
The interviews showed that 14 out of 14 school nurses dedicate their healthcare role to care
coordination efforts to keep students in the learning environment as much as possible. This
alignment was exemplified when Nurse Smiley said that her efforts are directed toward “keeping
[the student] in class, not taking them away from learning.” As a care coordinator, the school
nurses described assessing the student's situation to succeed in the school day. They described a
sense of vigilance in thinking about "the whole child" and being instrumental in connecting
health and the student's school achievement. Nurse Smiley expressed her role as, “it’s sort of like
you basically do first aid, and the rest of your job is leadership and coordinating.” School nurses
described taking the lead and connecting students with community healthcare providers for
necessary health issues. Care coordination was described as following up gaps in the annual
health care documentation with the family to determine if they could assist in any way. For
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instance, school nurses recognized the importance of health insurance as a facilitator for getting
adequate medical care. As Nurse Garcia said when students, and especially low-income families,
do not have health insurance, “we provide [the family] information on the HUSKY plan …to
take advantage of that if they want to.” Similarly, if the school nurse discovered the student
faced an access barrier to any community health provider, school nurses said they would become
the “middle person” connecting the student, and their family, with health resources. The need for
eyeglasses for students was raised by five of the 14 school nurses, often being alerted by teachers
that they did not see well enough to do their work in the classroom. Nurse Smith described her
advocacy on behalf of low-income families in her school to coordinate care for students by
finding them eyeglasses. She explained,
The Lions Club comes once a year, and they do all our vision checks … they’ll give us
the names of kids that need help …and if they don’t have insurance, and they are having
some problem, then I will research and find out where they can get them for the cheapest
and where they can get them right away.
During the COVID-19 schools were closed to avoid the spread of the virus, with schools
transitioning to online learning (State of Connecticut, 2020, March 10). School nurses described
how care coordination shifted during this time. Nurse Aarons explained, “I am like the
middleman of kids that are being isolated and quarantined and how they're going to continue
with school. We're keeping kids together … even though we're distance. We're still supporting
them as much as we can.” While they had to remain vigilant to student-focused health care
coordination, school nurses took on more significant school-wide health issues, all of which were
new to everybody. They described developing protocols for the transition of students and staff
who were to return to in-person classes. The school nurses spoke of developing and instituting
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health issue protocols abiding by the state’s recommended social distancing, masking, and
quarantine time frames. Nurse Bond described, “we were trying to figure out when we can
reopen schools safely … and to develop training videos for [staff and students] about hand
hygiene and how to put on a mask properly and what masks to wear.” School nurses spoke at
length about how deeply their work has been affected and how their interaction with students has
changed but that through it all their commitment to student wellbeing has remained steadfast.
Nurse Mallory lamented how deeply she as a nurse was affected by the lesser interaction she
now has when she said:
Right now, I don’t feel like I can be the nurse I want to be … This pandemic has wrecked
everything … I want to be able to talk with them, hear about their day, and not have to be
brief with them … and when I see their faces, I want them to see my face.
School nurses verified that their conceptual knowledge and understanding of how their
role and practice aligns with the educational mission. Facilitating connections to community
resources illustrates the school nurse’s coordination role as instrumental in paving the way for
students to be as healthy as possible to attend school successfully. During the COVID-19
pandemic, school nurses continued to use their health experience to engage themselves with the
school’s mission by supporting students and their families, with the end goal of ensuring students
were successfully learning.
Procedural Knowledge. School nurses need to ensure that school administrators understand
why their role and practice are essential in bringing value to the K-12 education setting. This
gap is partially validated.
For school nurses to successfully convey their value, they need to know how and when to
share, integrate, and transfer their clinical knowledge to affect the educational community's well-
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being. Fourteen of 14 school nurses described how they seize opportunities to integrate their
health and wellness experts in the school's activities. The two prominent themes emerged that
explain how effectively nurses convey their clinical knowledge: first, school nurses actively
teach health and wellness, and second, they integrate health knowledge during meetings about
planning individual student’s learning. The gap in the assumed procedural knowledge is that the
organization has not fully aligned the value of the school nurse’s position and expertise as
indispensable to the organization meeting the educational mission.
Teaching Health and Wellness. School nurses described how intertwined the oversight
of student healthcare is with education about health and wellness. As Nurse Janssen said,
“teaching and nursing are the same thing … you [just] tailor your message [to the recipient].”
School nurses interviewed spoke about how they "teach" about health issues to teachers,
students, parents, and administrators, in group and one-on-one settings.
Teaching School Personnel. School nurses described that they appreciated the
opportunities to convey clinical aspects about students’ health to the school’s staff, both one-on-
one and in group settings. As a result of COVID-19, school nurses said they had taken an even
more significant part in educating and planning student well-being, primarily because of the
uncertainty, leading to increased anxiety levels among the educational community. Nurse
Janssen’s clinical knowledge about COVID-19 was instrumental as he described, “in general we
educated the teachers at the beginning of the year that … a kid should only be showing up if
they're 100% healthy and ready to be here. If the kids are showing up with sniffles and coughs …
you need to call me.” Since student health needs vary by individual, school nurses explained they
meet one-on-one with classroom teachers. Nurse Ender spoke about educating individual
teachers to let them know “that they're going to be receiving a child or have a child that's got a
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condition that maybe they didn't have last year …you do that kind of education with them.” With
respect to small group teaching, four school nurses specifically described speaking with certified
school staff and sports coaches about medication administration. As part of the responsibility of
transferring this knowledge, school nurses said they are required to evaluate the staff they teach
because, as the certified health professional they hold ultimate authority as medication
administrators. Nurse Garcia described how critical this training is because “technically they’re
working under our license so we have to feel comfortable that they can give the medication
appropriately … I have them go over it again with me to show their competency.” The school
nurses indicated they valued training opportunities with school staff to blend their health
expertise into the school environment. Seizing opportunities to transfer critical medical
intervention skills to the educational team's key members conveys the value of the school nurse
by bridging their role as the healthcare expert as integral to student health.
Teaching Students. School nurses also spoke about educating students in health classes
and one-on-one. These opportunities allowed the school nurse to transfer age-appropriate
information to educate students about their health. Involvement in teaching health classes drew a
variety of responses from the school nurses. Nurse Aarons said that in her elementary school, “I
did education [on] washing your hands … how long do you wash your hands for?” School nurses
mentioned they dedicate one-on-one time talking with students who come to their health office
about their health issues whether they are big or small. Nurse Winfrey described how her role
went beyond treating the students saying,
In my role [it is] important to for the kids to feel empowered to take care of their own
body, so I think it's important for them to learn … if they come in and they're wheezing
… I like to let them listen to their breathing and have them hear the wheezing and try to
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understand it … I like to take the time teaching them about what kinds of things can
cause a headache, or a stomach ache or … and not just try to fix it.
School nurses said they enjoyed collaborating with students and parents when sharing
health care information. Nurse Ender described how she communicates with students “as they
transition to becoming young adults … more collaboration, I think, is required oftentimes to get
them help or get them on a healthier path.” School nurses also reported communicating with
parents to collaborate and educate about their role in the school as integral to their child’s health.
As Nurse Hansen described, “I do call a lot of parents to let them know what’s going on … I
keep the lines of communication open with parents because I want them to be able to come to me
with issues … I’m only as good as the information I’m given.” The school nurses indicated they
took time to effectively communicate through teaching health and wellness to students and their
families. Teaching opportunities that connect the school nurse’s role as a healthcare provider to
the student’s health and well-being shine a light on their value in the educational environment.
Health and Wellness Knowledge Integration. School nurses also reported bringing
value and ensuring well-being by integrating health knowledge into the educational community
and individual students. Fourteen out of 14 school nurses said that during COVID-19, because of
the uncertainty around COVID-19, there were increased anxiety levels among the educational
community. All of the school nurses described taking a proactive role in offering reassurance
across to their community. Nurse Winfrey described how her role as a healthcare provider
changed noticeably, extending to everyone in her community:
Before we were really there to help, you know, there as a school nurse … but I think with
COVID it's not only the children but the staff. Some of the staff have mental health or
anxiety about it, [as well] family members and therefore the extended community.
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Offering comfort was possible because they had actively educated themselves and
became a calming influence through integrating their knowledge. School nurses talked about the
anxiety levels and how they took a lead role in developing strategies to make sure the
educational environment was safe to function. Nurse Carter described how she communicated
pandemic-specific knowledge into her school:
Over this past summer I had to search and get all the PPE supplies we felt the school
would need, do walk-throughs to be sure the school was looking clean … to be sure that
everything was going to be attended to.
The school nurse was readily available as the source of COVID information and became
the center for compassion conveying the value of their role to the educational community.
On a one-on-one basis, school nurses describe the integral knowledge they brought to the
student’s “504” or special education “Planning and Placement Team” (PPT) meetings by
providing the health care plan for that student. Nurse Mallory explained,
These meetings are for students who are having issues … maybe a new diagnosis that's
interfering with their schoolwork … I always request the medical documentation … from
that I can give input on suggestions for accommodations that would help them at school
... I do make individualized health care plans for students.
The importance of having the school nurse at these meetings is to communicate their
expertise and to be sure that the school has all the information needed to care for the student.
Nurse Carter openly stated,
I can ask the questions that everybody needs to know when everybody is so afraid and so
politically correct that they won't ask. So I'm helping everybody to get what they all need.
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And I've been told that too by teachers. Like, I'll hear, thank God you were there and
thank God you did this or that. So, I know they appreciate that.
All participants described the inclusion of the school nurse in these student planning
meetings as critical. Communicating their healthcare expertise verbally during planning meetings
and developing health care plans incorporated into the student’s learning conveys the value of the
school nurse in the educational setting.
School Nurses are Perceived as Dispensable. School nurses know and demonstrate
their value revealing they are experts and integral to the mission. School nurses described
opportunities to speak to their community about what they do explicitly; their comments
indicated that the administration does not fully understand the value of their expertise as being
essential to the educational mission. Statements from school nurses that revealed this disconnect
were descriptions about how the organization sees the school nurse role as non-essential and
often dispensable. School nurses described that there are schools in Connecticut that do not have
a school nurse. As a substitute nurse in some of these schools, Nurse Fernandez, described the
difficulties of dealing with student health issues without the school nurse. She explained,
“administration was in that role … making sure the kid’s okay. So for an administrator to be
running a whole school and have to do that, that’s really hard on them.” The organization’s
dismissive view of the value of school nurses was also revealed during COVID-19 when school
districts, who were either not in session or doing remote learning, stopped paying school nurses.
Nurse Swain identified that she knew of a school district where the school nurses “had to start
unemployment, they never paid them.”
School nurses revealed that there are times when the organization “forgets” about them or
does not value their role as integral in helping the meet the educational mission. Nurse Ender
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described how during COVID-19 when students were learning remotely without the necessary
equipment her work was hampered:
Right now, I think, giving us access to our electronic medical record …. like give us all a
laptop with that access to that when we're not in school, we can still effectively help
students from home, you know … or even have … like a day like today, if I could access
my voicemail or my phone or … I could work.
The explicit connection of the organization seeing the school nurse role as essential to the
educational mission was described by school nurses as being left out of the decision-making
process. Nurse Hansen stated that prior to COVID-19 school nurses were “not a huge part of the
decision making process in the community … we are kind of an afterthought … it’s not like I’m
part of a group … I was like the last to know.” The sense of feeling unimportant to the
educational mission also extends outside of the school. Nurse Fernandez, employed by a health
department and not a school district highlighted how her employer “sometimes [they look at us
as] numbers, you know, public health nurse one, public health nurse two. And I think we just get
lost in translation … they recognize us when it’s beneficial to them.” These examples show that
although school nurses are influential in keeping students healthy, they also report a disconnect
by the organization regarding their essential and indispensable role. There is a gap in their ability
to convey how their expertise is central and vital within the educational setting.
School nurses verified how they could clinically connect their role and practice to the
educational setting, ensuring that students are healthy and ready to learn. Communicating
health-related information through teaching one-on-one and in group settings illustrates how
school nurses convey their value by engaging in the educational environment. However, the
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implicit act of being an effective nurse is shown not to be enough to explicitly convey to the
organization that it must secure the school nurse position within its structure.
Metacognitive Knowledge. School nurses need to know what factors in the educational setting
influence their clinical practice and to work with others to ensure that their healthcare role
continues as a strength for the education community. This gap is not validated.
Through reflection to develop and improve practice in the educational environment, the
school nurse can think through when and why they would position themselves into the
educational environment. During the interviews, 14 of 14 school nurses gave evidence about
self-reflection on their interactions with students (reflection-on-action) and thinking about
collaborative work with others (reflective-in-action).
Reflection-on-Action. Deliberately engaging in self-reflection was described as inherent
in the school nurse’s day as they recognized the importance of the care they provide and its
impact on everyone. Nurse Garcia summed it up the value of taking the time when she described
why self-reflection is vital for ensuring sound clinical practice by saying, “you have to be to be a
good nurse … you learn from those mistakes, or those thoughts.” School nurses said that they
reflect on their practice by bouncing ideas off peers. Nurse Bond, who has been a school nurse
for only a year, said he found reflection especially valuable when he considered his practice with
his health office nursing assistant. He said, “we will talk through, like … how do we think that
went with that student? Did I handle that the right way? Did I miss anything? You know, what
should I have asked?” Nurses who described their self-reflective practices said they often spend
time doing it at the end of the day, such as on the way home in the car, by taking a nap, or
through exercise. Nurse Hansen explained that she followed up with her supervisor to get
feedback, “I’ll go back the next day and call my supervisor and be like so this happened
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yesterday, and I thought about it and this is what I think, what do you think?” School nurses
described how they are continually thinking about their practice to ensure that students are
getting the care they need. This past year, because of the dynamic nature of the pandemic, nurses
were continually reflecting on what their practice looked like, what the needs of the students and
educational community were, and how to always improve what had come before. As Nurse
Janssen noted about reflection on his practice:
It happens in real-time ... we do that as a trio of nurses … like when we're each working
on something or situation comes up, we send a quick email to all three. Or, you know, a
quick phone call … hey I had this idea, what about this let's try this … especially this
year we're inventing systems and sharing resources.
Nurses described reflection-on-action as simply being a part of their day and the essence
of being an effective nurse. The school nurses interviewed perceived that through reflection-on-
action, they conveyed to themselves and others that they bring value through continual learning
about improving their clinical practice. Continually evolving their healthcare practice aligns with
the educational mission and ethos of ensuring that students receive access to the highest
educational experience possible.
Reflective-in-Action. School nurses described that by the very nature of being a sole
health professional deeply intertwined with a student's education, they are continually
collaborating to bring clinical and education attributes together. Nurse Smith described that
always in the front of her mind is the motto, “it takes a village to teach a child.” The melding of
the school nurse as the trusted partner and health expert in the educational environment was
epitomized when Nurse Taylor explained that she:
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Consider[s] the teachers’ opinions and thoughts on the kids … I let them know that
they're like the most important part of the puzzle because I see the kids, for these
snapshots, but they're with the kid all the time. So, if a teacher tells me that someone's
behavior is radically off from their baseline or something, I take that seriously and
proceed from there.
These collaborations are opportunities for school nurses to work with other stakeholders
in the educational environment, reflecting on aligning their expertise with the mission of
successfully educating students.
School nurses explained that they applied and shared their clinical knowledge in
collaborative settings, bringing reflective-in-action processes to ensure that students can
successfully participate in their education. Fourteen out of 14 school nurses reported using their
clinical knowledge to deliver health care plans outlining how a student’s chronic condition
affects their learning and how educators can ensure maximum learning. Nurse Smiley reported
how she was relied upon to be the source of health information to support a student describing,
“we had a seizure child … I was asked my opinion and to look things up and add things [to the
student’s educational care plan].” The nurses spoke about how the educational team appreciates
that their clinical knowledge is invaluable, taking it into account to ensure a student’s positive
learning experience. Nurse Carter believed that her medical care plan was integral to the
educators’ work with the student when she said, “I think teachers and the guidance counselors
respond and agree with my decisions because they know that they're science-based.” School
nurses described using reflective-in-action opportunities to integrate healthcare into the
interdisciplinary setting. Using their clinical knowledge to think critically about the student’s
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learning needs showed the value of their role by guiding the education team from a health needs
perspective.
School nurses verified how they use metacognitive processes to connect their healthcare
role and practice to the educational setting. School nurses described how reflection-on-action
develops their practice and ensures that students receive the best health and wellness care at
school. Reflective-in-action opportunities existed through collaborations with others, creating a
more in-depth understanding of how the healthcare and the educational roles intersected and
enhanced the student's educational experience. The use of these metacognitive processes
illustrates how school nurses convey their value to enhance students' experience in the
educational setting.
Summary of Knowledge Results
The four categories of knowledge that determine the success of the school nurses ability
to convey value in the K-12 educational environment are: factual knowledge about their clinical
practice; conceptual knowledge about practice alignment; procedural knowledge to educate
others; and reflective metacognitive capabilities.
Interviews show that first, factual knowledge of current practices heightened school
nurses’ confidence in being able to provide the best clinical care to students, an implicit way of
conveying their value. Second, school nurses were conceptually aware of their role alignment to
the mission of the educational environment, revealing itself in school nurses not only caring for
students in the school, but coordinating care for them outside the school. Third, school nurses
showed a competence of procedural clinical knowledge through their willingness and passion to
capably educate the individuals in the educational environment. However, the school nurses have
not adequately conveyed their essential value in meeting the educational mission, as evidenced
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by the organization's lack of constant support. Fourth, and finally, school nurses engaged in
metacognitive processes continually thinking about health care practice improvement and
engaging in meaningful sharing of health information for student wellness. The results of the
interviews showed that there are no validated gaps in any knowledge influences.
Results and Findings: Motivation Results
Just as someone needs to know how to do something, it is equally as vital that they are
motivated to do it – that is, they want to do it and that they will do it (Rueda, 2011). For school
nurses to convey their value in contributing to the educational mission, the assumed motivational
influences for this study are two-fold. The first motivational influence is self-determination, with
indicators of self-determination being attaching importance to role competence, autonomy, and
belonging. The second motivational influence is self-efficacy, with the indicator for self-efficacy
being the positive expectation of task success. Table 8 is the summary of the findings for both
assumed motivational influences. The table shows that the findings from the interviews show
that there was no gap validated for the self-determination indicators but that there was a partial
gap validated for self-efficacy.

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Table 8
Summary of Assumed Motivation Influences
Assumed Motivation Need
Gap Validated
Yes / No
Self Determination Theory –
K-12 school nurses need to believe that by creating awareness of their value
in the education setting, they are empowered to achieve role competency,
practice autonomy within the school, and be integral to the school community.
Not Validated
Self-Efficacy –
K-12 school nurses need to believe that the school administration appreciates
and values the significance of their role and practice in the education setting.
Partially
Validated

Self-Determination Theory - K-12 school nurses need to believe that by creating awareness of
their value in the education setting, they are empowered to achieve role competency, practice
autonomy within the school, and be integral to the school community. This gap is not
validated.
Self-determination is the ability to influence task outcomes. This theory encapsulates
three indicators that motivate school nurses to believe that they can convey their value in the K-
12 educational environment. Fourteen out of 14 school nurses interviewed positively described
two of the self-determination needs indicators underpinning their motivation for their practice.
First, they expressed having assured competence in their role and, second, having autonomy in
their practice. The third needs indicator, belonging, received mixed responses from the school
nurses in that they did not always have a sense of unwavering belonging in the educational
setting.
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Role Competence. Fourteen of 14 school nurses confidently spoke about mastery in their
role as healthcare providers in the educational environment. The interviews revealed that the
school nurse must have role mastery, first, with clinical information to provide adequate
healthcare to students. Second, the school nurse must also successfully coordinate the care they
cannot provide themselves, and third, communicate with others about the students' healthcare
needs.
Clinical Information for Student Care. The first critical role competence identified by
school nurses was to have the most current clinical information to perform practice so that they
know they can influence students' quality health outcomes. Being responsible for all health care
concerns in the educational environment, school nurses said they face a myriad of healthcare
situations that require them to have the factual clinical knowledge to address the student's issues.
Nurse Smiley explained the plethora of clinical situations that school nurses need to feel
competence in handling when she said,
[School nursing] is much more than giving out Band-Aids. There’re all these emotional
things that you have to figure out. So, if somebody is coming in for a stomach-ache you
can't just say, well, five minutes rest, away you go. You have to figure it out … some are
getting bullied, some have a terrible home life, some … they just don't want to be in
school. There's a lot of behavioral things you have to figure out.”
As this statement indicates, school nurses explained that they have practical knowledge
and must be prepared to find the underlying cause of a student’s issue. School nurses described
the heightened symptom vigilance necessary during COVID-19 to keep everyone in the school
community safe. Nurse Carter noted,
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We kept the protocol very, very tight in each of our schools that if the child presents with
something that could potentially be a COVID symptom. Abdominal pain is a sign of
COVID. I had a child come in saying his stomach hurt. I asked him six or seven different
ways. Are you sure it’s stomach-ache? Are you hungry? Did you eat breakfast? Do you
feel hunger pangs? No, no, no. My stomach hurts. And then I have to dismiss a kid.”
Physical assessment during COVID was described as critical by the school nurse as they
spoke of the consequences often inconveniencing families as a sick child meant that parents had
to also stay home from work. Nurse Carter went on to say, “some parents are either thankful for
you, or they are like, oh my gosh, not again, how am I ever going to get to work myself? So, you
know, it’s hard.” Nurse Hansen concurred with the importance of knowing that the clinical
symptoms are COVID-related when she noted, “parents initially … their knee jerk reaction is to
be mad at me because I'm the one telling them your kid can't come to school for 20 days, because
they must isolate, which is a tough pill to swallow.” These examples show the implications of
remaining current in correctly assessing a student’s health condition and how it impacts the
school community and families. The importance of constantly staying up to date with health
assessment and health delivery changes was a competency factor for school nurses to be sure
they can successfully practice and influence students’ health and well-being. Their desire to use
state-of-the-art practice conveys to the educational community the school nurses’ commitment to
ensuring that students are healthy and able to participate fully in the educational experience.
Care Coordination. A second important characteristic of role competence identified by
the school nurses was connecting students with appropriate community clinical care. School
nurses expressly remarked how they acted as advocates for students to receive the health care
they needed. Being an advocate is especially important with students from low-resource families
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who may not have a provider. Nurse Ender described that school nurses, as front-line health
providers:
See the students often if they don't have a provider, you know we might be the first one
… the first healthcare person that realizes that this family needs help … and we put them
in touch with either Husky insurance or the local clinics that you know … do sliding
scales and you don't have to be a citizen.
Ensuring that students are healthy and remain that way was described by the school
nurses who spoke about getting students access to basic immunizations. Nurse Mallory noted, “if
they’re lacking any immunizations or a recent physical … I would stop and make sure that they
have access to what they need.” Over time school nurses said they developed a knowledge base
of community resources that may not be obvious to families. Nurse Ender admitted,
I like helping the kids and families … helping put them in touch with the resources that
are available that not everybody is aware of … when I was first a new school nurse, it
was more about figuring out how to manage the flow of the little kids coming into the
nurse’s office after recess. But it’s evolved into, you know, much more meaningful …
more than first aid.
School nurses described the importance of their role to help students and families
maximize community resources. Ensuring that students access appropriate care at just the right
time ensures that students are as healthy as possible, and conveys the value of having a
healthcare professional in the educational environment dedicated to making these connections.
Communicate Expertise. The third role competence identified by school nurses as vital
was to communicate their expertise, borne in the motivational belief that sharing their knowledge
about health and accessing health benefits students and families. Sharing health knowledge was
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especially important during COVID-19 when school nurses became the nucleus for education
and information about quarantining, contact tracing, COVID testing, and vaccination. Nurse
Ender encapsulated the importance of her role, commenting that school nurses in her district
“make sure that [COVID-19] guidance is followed … talk to people who have questions … you
know, just educate our community about what we are doing and why.” Similarly, school nurses
described being at the forefront of pushing out information to parents about COVID-19 signs and
symptoms. Nurse Janssen said, “I’ve used email this year a lot as a useful tool to bring people
together and relay the clinical knowledge they’ll need to know … you know how to quarantine
and what isolation looks like.” School nurses also pointed out how they educate families who do
not have access to healthcare providers about getting access to a mandated physical or other
primary care services. Nurse Fernandez said she helps uninsured and non-English speaking
families by having them “sign up with the school-based health clinic … by sending the form
home for the parents to fill out, and they consent to what services they want the child to receive
at the school-based health clinic.”
All school nurses explained how their inclusion in “504” meetings is critical to learn
about the student’s medical needs and develop health care plans that outline how a student’s
chronic condition affects their learning and how educators can ensure maximum learning. Nurse
Fernandez described why it is essential for the school nurse to attend a 504 meeting when she
said, “a student has a new diagnosis that's interfering with their schoolwork. I can give input and
suggestions for accommodations that would help the student at school.” Being prepared for
possible health issues of medically complex students in the school, Nurse Carter explained how
determined she was to let the education team know she was integral for the health and well-being
of the student. She recalled a student who had a “liver transplant and open-heart surgery, and she
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is on numerous immunosuppressive drugs. So we had to implement a whole plan for her …
every teacher did have to know she has a biliary drain. And God forbid that gets dislodged. Boy.
So you better call me right away.” This example epitomizes the school nurses’ descriptions of
value-add by integrating and aligning their clinical knowledge with their learning needs, guiding
the education team from a health needs perspective.
Through communicating their clinical knowledge, school nurses trust that they can
influence the health care outcomes to ensure that students can participate fully in the educational
setting. Using communication to share health information conveys the value of the role and
expertise of the school nurse in the educational setting.
Autonomy. As typically the only healthcare professional school in the school, nurses
described their autonomy, explaining they felt empowered to make decisions to take ownership
of student’s healthcare. They indicated feeling confident attending to their work to bring the best
health care they could provide for students and the school setting. This independence is a
motivational force for nurses, as Nurse Bond explained, autonomy for him as a professional is a
driving force. He said that because he has autonomy, he can “triage and make decisions about
next steps for those students [which] … happens to be important … I think a lot of over the
shoulder stuff wouldn’t be enjoyable for me.” School nurses explained how clinical autonomy
was necessary in the education setting as it allowed them to make important, timely decisions. As
Nurse Hansen proclaimed, “I just kind of make my work my own, which is necessary because
it’s a lot of game time decisions.” Being empowered was described by the nurses as making
decisions about the student’s health needs to adequately care for them, emphasizing the value
they brought to the educational environment.
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Autonomy was described as essential for the school nurses during COVID-19 as their
role as the health care expert became central in the educational environment. Nurse Smiley
explained how her community trusted her to make decisions:
I think I'm valued … because they … they need me. And this year is even better because
of COVID because they're terrified of it. So I'm like the COVID police. You have this,
you've got to go get a test. I think they depend on me. They depend, that when they send
someone down to me they won't come back to them until you know they are either
cleared, or they go home.
School nurses also described how they have the autonomy to set up a positive health
climate within the school through education and policy development. During COVID-19 school
nurses described how they took charge to develop protocols within their school such as
instituting policies for safely moving students and staff around the school to maintain social
distance. Nurse Janssen described how he used his knowledge about safe physical environments
during COVID-19 to
Meet with each of the teachers and went into their classrooms and actually, you know,
assessed the physical environment … seeing traffic flows and what is safe … I've had
some success teaching people what a safe environment looks like and some routines that
they can take. Now we're just trying to keep people on them.
Having autonomy was described by school nurses when they spoke about using reflection
to consider proactively thinking about wellness opportunities that would make a difference to
their community. Nurse Aarons said that she does “a lot of educational boards and I don't ask if I
can do it, I just do it and they love it.” The examples school nurses gave described the practice
autonomy they were empowered to show that they add value to their community. School nurses
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described that having autonomy enabled them to self-regulate their practice to influence the care
decisions for students - essential as the only health care provider in the building. An autonomous
practice allows school nurses to convey value by bringing their unique health expertise to care
for students in the educational setting.
Belonging. Feeling like they belonged revealed dichotomous responses from school
nurses. All school nurses described a sense of belonging assigned to the value of their healthcare
role. However, four out of 14 nurses specifically identified that they felt discounted and lacked a
sense of belonging apropos their significance compared to others in the educational setting.
When the school nurses spoke about bringing their healthcare expertise to the educational
setting, 14 out of 14 school nurses said they felt connected and belonged. This was exemplified
when the nurses named no less than 30 other individuals in the school setting with whom they
interacted with processes to enhance the students' wellbeing. Significant collaborations where
they identified a strong sense of belonging were in partnerships with teams, including (to name a
few) the principal, guidance counselors, social workers, and the school psychologist. Discussions
centered on caring for students and sometimes families who were struggling and needed extra
support. Nurse Garcia described weekly meetings where “we meet together about kids that we
think are in danger … [to] think about what might impact the child's ability to be their best at
school.” During COVID-19 school nurses became the nucleus for education and information
about quarantining, contact tracing, COVID testing, and vaccination. Nurse Bond described the
reliance on him when he said:
I feel like the role of the nurse during the time of COVID in the school has elevated a bit.
There's a lot of questions that come my way … administration, principals,
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superintendents, and teachers have said, you know, I really don't want [COVID-19] to
affect their learning.
The school nurses also felt a sense of belonging when they worked with ancillary staff to
ensure the student’s needs are met. Nurse Garcia commented that she has a student with a
vitamin deficiency who is a super picky eater “so we were brainstorming with the kitchen help
… about a few things that he does like and how we can get them to him, and then, you know,
give that information to mom.” School nurses mentioned that working with ancillary staff
allowed them to convey their value to all school staff. The number of opportunities like this that
school nurses mentioned revealed how valuable these collaborations are to bring the health care
lens to help students overcome any barriers to success in school.
Nurses reported that the sense of belonging within the community is not limited to
collaborating with staff within the school building. Three school nurses specifically mentioned
that direct contact with families fills them with a sense of belonging to the entire community.
Nurse Swain explained that families do not hesitate to include her in unexpected ways when she
said, “people bring in their babies and say, ‘do they need to go to the doc?’ I know I’m not in
charge, I’m not their pediatrician, but I’ve had them do that.” These connectedness moments in
the educational environment bring a sense of purpose to school nurses, motivating them as they
bring added value to the community.
School nurses also believed they were connected and belonged due to advocacy by others
on their behalf. Nurse Swain shared about her principal, “I feel that in a lot of ways she’s got my
back ... she’s really there and wants me to be a part of the conversation as the health provider in
the school.” Nurses explained that they felt significant support from both their principal and their
nurse supervisor when they needed to have their opinions and their judgments respected.
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Despite the overall sense of belonging and being connected to the educational
community, there were times that school nurses felt that their value and significance was
overlooked. Four of the school nurses reported on occasion feeling that disproportionate weight
was placed on the importance of teachers as professionals over themselves as professionals. This
disparity was remarked upon by Nurse Carter when she said that as a school nurse she should be
“at the same level with the teachers, but I’m not ... teachers are certified, and I am not certified, I
am licensed.” This sentiment of disparity in the role differentiation in the educational setting
caused these school nurses to not feel valued. In a similar comment about the nurse’s disparity
compared to teachers, Nurse Smith noted,
I wish we had more in-service time like the teachers ... they get to meet with each other,
you know, once a week [during school hours] … they get relief time from the classroom
to do that ... we get to fit things in between kids or, you know, depending how busy your
day is ... we work through lunch.
Even though school nurses mentioned these issues of being treated differently, they were
quick to accept that it is just the way things are. They excused the disparity saying, “we’re
hourly employees” or “the teachers have a contract.” Nonetheless, their comments elicited a
tone of unfairness in being treated differently than teachers, even though both are professionals
within the educational environment. However, when probed about these issues, school nurses
said that even though this was the case, they were not discouraged from participating and
advocating for themselves in the school environment. While belonging drew some comments
about feeling excluded, it was a source of frustration for school nurses rather than a demotivator.
Furthermore, school nurses explained that they would continue to advocate for themselves and
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their role because, in the end, they believe unquestionably in the value that they bring to
students.
School nurses verified that they could influence the care of students in the educational
environment, an essential factor of self-determination theory. With health as the lens, they
perceive they have role competence, autonomy, and a sense of belonging when their health
expertise can influence their school's health, well-being, and safety. As professionals and equals
who are part of the team that ensures students are at maximum capacity to learn and succeed, the
school nurses described frustration with not belonging as equal professionals in the educational
environment.
Self-Efficacy - K-12 school nurses need to believe that the school administration appreciates
and values the significance of their role and practice in the education setting. This gap is
partially validated.
Having self-efficacy means having a positive expectation for task success by having
enough knowledge and time to complete the task. During the interviews, three themes emerged
identifying the school nurses’ self-efficacy in the K-12 educational environment. Two themes
recognized significant self-efficacy, and one theme was found as having the potential to lessen
the school nurse's ability to be completely self-efficacious. The two themes that 14 of 14 school
nurses indicated feeling self-efficacy were: having the right skills to meet the emergent need at
hand and receiving positive feedback from others. The third, sometimes having unmanageable
workloads, was identified by six of the 14 school nurses as impacting the school nurse's self-
efficacy.

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Having the Right Skills. The first theme that emerged was the school nurse’s optimistic
expectation of task success due to having the required skills. School nurses described having the
skills to effectively approach many areas of their work, including, as already described,
coordinating care for students outside of their scope, developing health assessment plans for
students, and sharing timely health information to others in the education community. Not yet
discussed are the school nurses’ descriptions about their aptitude for implementing an accurate
health assessment of students coming to their health office. They described this as a necessity
because they typically worked in isolation from other nurses to confirm opinions and bounce
ideas off. As Nurse Carter noted, “I really like that, this is truly the first nursing job I've had
where I really depend on my nursing assessments. Because I am the only person, besides my
colleague in the building, who has any knowledge of this. I make darn good assessments.” The
school nurses also expressed the skills of self-assessment as a valued personal accomplishment
because it meant a successful quality health encounter with the student. Nurse Winfrey stated
that nursing assessment allows her to bond with her students, giving her a great sense of
satisfaction. She remarked, “I like connecting with them and making them feel heard, and that
they are important, and listening to them, and just treating them like people instead of you know,
get them out of here … get back to class. I like the detective work. I like to figure out why
they’re down here.” These examples of successful student encounters were central to what was
revealed by school nurses as a huge motivational impetus for their work.
The nurses described how the health assessment process, occurring at the beginning of
their encounter with every student, was intermingled with a deep concern for getting to the root
of the student's concern. Nevertheless, although self-assured, school nurses described being
particularly self-reflective of their practice. Self-reflection, another tenet of self-efficacy, was
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pointed out by the school nurses as a consideration that they can improve over time. Nurse
Hansen disclosed about her health assessment that
You know, you hope you make good decisions, and you hope you make the right
decisions. It can be kind of nerve-wracking, and there have been plenty of times where I
probably made the wrong call and sent the kid home too quickly, or maybe I should have
sent them home right away, and then didn't.
Either through being self-reflective or feeling self-assured, the school nurses described
having the skills to do their work, which led to feelings of confidence to use their health
expertise to make independent clinical decisions. As often the only health care provider in the
school, this is essential. School nurses’ assurance of knowing how to complete a task conveys
their value in the educational setting
Receiving Positive Feedback. The second theme that emerged was the school nurses’
belief in their self-efficacy through receiving feedback from others. Six of the 14 school nurses
interviewed explicitly mentioned positive feedback as a motivation factor for their work efforts.
They described that the feedback comes from administrators, teachers, and parents. Nurse Carter
said that after assessing and referring a student to see a physician she “usually get[s] a thank you
call from the mom or the parents saying, you know, thank you, I’m so glad that you referred me
and, you know, it’s very rewarding, very rewarding.” The feedback that their caring was
meaningful to the community indicated self-efficacy to the school nurses and motivated them.
Nurse Fernandez remarked that she spent some time in a school that did not usually have a
school nurse, and where, as a result, the health care issues would fall to the principal adding to an
already busy workload. Nurse Fernandez said that at the end of the day the principal, “stopped by
my office and [said], hey listen, thank you for subbing today … you've been great with the kids
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… I've seen what you've done.” School nurses indicated that they appreciated all positive
feedback as an indicator of success in task completion, giving them confidence in their work.
Nurse Bond, one of the few male school nurses who works with 5
th
and 6
th
graders going through
puberty reported that while people at first may be skeptical and hesitant about “how it will play
out” he has found that “after building a bit of a relationship, then they will come clean and go …
hey, I wasn’t really sure how I’d feel about, you know, a male in this role, but it’s working out
really well.” While all nurses reported feeling self-assured in their ability to successfully
practice, acceptance such as this by the community builds self-assurance. Self-assurance
positively leads to task success, and task success conveys value of the practice of school nurses
in the educational environment.
Workload Expectation. The third theme that emerged as a potential demotivator for
school nurses was the stress surrounding the volume of health encounters they had and the
expectations to manage the workload alone and without support from within their school. School
nurses were concerned that having heavy workloads affected both student and nursing outcomes.
Six of the 14 school nurses expressly mentioned not having enough time to do everything they
needed. Four nurses mentioned that having an extra pair of hands to help in the nurse’s office
would be helpful. Nurse Ender mentioned the number of hours taken away from patient care that
are spent inputting data especially at the beginning of the year when she said,
There are so many tasks that could be done by someone else … having another person
that could be delegated to … and I know it’s all about money. [For instance] I'd like to
see more time built into the beginning of the year for planning so that, you know, usually
the beginning of the year is a real kind of crunch, where you're getting all the new kids
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records in and the medications. I'd like a little more time to be able to look at those
student records and meet with teachers before the kids are there. That would be nice.
The school nurses indicated being frustrated by the school administration not providing
extra help to assist with or ensuring the nurse could put aside time for essential record-keeping.
Importantly, they explained that the essential task of record-keeping, something that can be
accomplished by administrative support, took time away from the school nurse to give the care
she thought necessary. Nurse Hansen said that there are days when she cannot achieve all she
needs to, stating, “even though I am fortunate enough to have a health paraprofessional to take
care of little boo boos and stuff … as far as time and manpower … sometimes I wish we had a
second nurse.” Two nurses mentioned that before they became a school nurse, they imagined that
they would have time to be more proactive with health teaching with students and within their
school. Once they started and realized that they were alone dealing with the volume of health
issues that came into the nurse’s office and they “were staying late every day to get things
wrapped up.” Nurse Janssen said that
There were times last year where I might have, on a really busy day, 70 visits, you know
from a school that might have 280 [students] in it on a day, and that’s just the visits I log
… but those kind of days didn’t even leave you time to chart until the end of the day.
This expectation to manage the volume of work was an outward frustration for the school
nurses, with their school administration, who were not inclined to do anything about their
workload levels. The “settling for” that things are as they are was indicated by the school nurses’
interviews as the rationalization that “things will never change.” The school nurses described
their sense of release from their frustrations of managing their workload alone by relying on
connections they had with their fellow school nurses in the district. Fourteen of 14 school nurses
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reported that, on an as-needed basis, they were in constant contact with colleagues in the school
district, posing any questions they felt needed an answer. So, while most do work in isolation of
direct contact with other nurse professionals, they never felt truly alone.
This workload expectation infers a partial self-efficacy gap for school nurses, mainly
because they felt that the educational administration undervalued the importance of adequate
nursing staff. School nurses believed inadequate staffing levels impacted their ability to care for
the students in their school adequately. The lack of importance to the organization for adequate
health care staffing devalues school nurses as partners in the educational mission of ensuring
students’ educational success. Denial by the organization for recognizing the need for more
nursing staff and knowing that it would not change was a source of frustration for school nurses.
School nurses verified that they mostly have a positive expectation of task success, an
essential factor for self-efficacy. They believe that they have the right skills and see evidence of
this through positive feedback from others; both indicators adequately convey their value.
However, they reported a lack of self-efficacy for student care due to inadequate staffing,
resulting in high workload volumes. School nurses were concerned that a high workload can
result in unsafe care, which does not allow them to convey their value in the educational setting.
Summary of Motivation Results
The two theories used in this study as indicators for school nurses' motivation were self-
determination theory and self-efficacy theory. Regarding self-determination theory, school
nurses described the motivational drivers of role competency and role autonomy as positive
motivators for the health care role they bring to the educational community. A diminished sense
of belonging was revealed when the school nurses spoke to the perceived discounting of their
position compared to teachers. This perception of not belonging was described as a frustration
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rather than a demotivator. Instead of feeling demoralized, the school nurses revealed many
examples of inclusion as health professionals in many critical situations that impact student
health. Regarding self-efficacy, school nurses described role self-efficacy by feeling confident in
having the appropriate skills and by way of reinforcement from positive feedback. However, as
often the sole healthcare provider in the building, they opined a lack of functional self-efficacy
because of the often-immovable workload expectations that the organization seemed disinclined
to do anything about.
Results and Findings: Organizational Results
An organization's culture influences how people within the organization can reach both
personal goals and help the organization achieve its mission. This study focused on two assumed
cultural model influences and two assumed cultural setting influences. Table 9 is the summary of
the findings for the assumed organizational influences revealing one a gap partially validated,
and three gaps not validated.

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Table 9
Summary of Assumed Organization Influences
Assumed Organizational Need
Gap Validated
Yes / No
Cultural Model Influence 1 –
K-12 school administration needs to foster an environment where school
nurses have a sense of belonging that respects their professional capacity to
contribute to the educational mission’s success.
Partially
Validated
Cultural Model Influence 2 –
K-12 school administration needs to foster an environment where school
nurses are fully empowered to convey their value to others.
Not Validated
Cultural Setting Influence 1 –
K-12 school administration needs to provide school nurses with access to the
support of other healthcare professionals.
Not Validated
Cultural Setting Influence 2 –
K-12 school administration needs to provide adequate professional
development opportunities for school nurses.
Partially
Validated

Cultural Model Influence 1 - K-12 school administration needs to foster an environment
where school nurses have a sense of belonging that respects their professional capacity to
contribute to the educational mission’s success. This gap is partially validated.
Organizational efficiency is enhanced when the appropriate grouping of staff, including
specialists, is in place to enact the mission. When a person in the organization has a unique
specialization, the feeling of belonging is heightened when they are given the recognition that
values the uniqueness their role brings to the organization. When queried about how their school
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administration fosters a sense of belonging, two themes emerged that were contradictory. First,
14 of 14 school nurses felt they belonged due to enjoying professional autonomy and practicing
without unnecessary oversight. Second, 14 of 14 school nurses believed they did not belong
because financial compensation for salary and professional development did not respect their
professional expertise.
School Nurse Autonomy. From the organizational standpoint, the role of a health care
expert in a school is unique and nevertheless complementary, and fourteen out of the 14 school
nurses reported appreciating that school administration did not impose unnecessary oversight.
Nurse Winfrey said that she feels very much like she can independently go about her work when
she said, “I have a lot of autonomy because I'm the only one in the school that's health care. But I
think I feel like one of the team members. I think people are appreciative and respectful of the
position.” They indicated feeling confident in using their health expertise and making
independent clinical decisions, confirming a sense of belonging in their school. Nurse Janssen
articulated how his sense of autonomy gave him a sense of apartness from the education burdens,
but without feeling excluded. He explained, “there is a piece of me and my practice and I want
my health room to be a little bit insulated from some of the stuff that happens in the school …
we’re on our little island … it feels less stressful sometimes.”
Role autonomy meant that they chose to initiate interactions used to show their value as
healthcare providers were integral to the running of the school. One nurse said she is on morning
door duty to see students as they come into school, vigilantly undertaking nursing assessment so
she could follow up if someone looked unwell. Similarly, Nurse Bond says he “walks around the
school … interact[ing] with students … in a proactive way … developing relationships before
that relationship becomes important.”
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Communication with teachers about the nurse role was identified as a high priority with
school nurses. Nurse Fernandez, working in a new school during COVID-19, wanted the
teachers to know that she was there to ensure the best for each student. She said that she “visited
classrooms just to introduce [her]self and to let them know they can always call me because our
main priority is the children - we're on the same team. I don't like anybody feeling that healthcare
is divided from the teachers we're all here for the same purpose.” The sentiment of being able to
independently come to a decision yet communicate the solution was also described by Nurse
Taylor. She said that when she “feels something needs to be addressed [she] will address it [and]
will always discuss it with the principal first.” Even though their focus is healthcare in the
education setting, school nurses perceive their role is embraced by others as integral, bringing
visible value to the school community. The school nurses described work autonomy by the
administration not micromanaging, which provided them with a sense of belonging as
professionals in their school.
School Nurse Compensation. Conversely, 14 of the 14 school nurses said that if the
school nurse wage is a marker for value, they feel very undervalued in the K-12 education
environment. Nurse Winfrey explained, “the pay for school nursing is pretty minimal … I think
people would feel more valued if they were paid more. That sort of an ongoing issue.”
Conceding that wages are “an ongoing issue” was described by other nurses as an “unresolvable
issue,” tying it to being a health professional in the business of education. Nurse Carter said, “I
am not remunerated for my role, I can understand that, partly because I am in an educational
system, so the emphasis is not on the support staff, which is what I am considered to be part of
… that’s what it is I guess.” Others said they didn’t even ask for wage adjustment because they
already know the answer “that there is no budget.”
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Three of the 14 school nurses identified that they were paid hourly, which meant there are
compromises to student health care if the school is not prepared to pay for the nurse’s time
outside of regular hours. Nurse Carter explained that the principal did not invite her to an
important “out of hours” student success meeting. She said,
I would say, why didn't you call me you know even if it started before school? And I
think part of that is that now I'm an hourly employee. So many extra hours I have to be
paid … oh, my goodness. I understand he has to think about his budget numbers, he’s got
other things to think about. But on the other hand, if you’re going to pay me for a half-
hour, it’s not a ton of money. Right? So, quality of care would be there.
Nurse Carter’s presumption of budget restriction indicated that the administration did not
align the school nurse as an essential contributor in helping meet the student’s educational needs.
Not being considered a significant contributor is tantamount to leaving the school nurses as not
fully belonging in the educational setting. Not being considered a valuable and essential
contributor is also evidenced by inadequate compensation. School nurses verified that inadequate
compensation indicates that the organization does not value their professional role and practice
as critical in meeting the educational mission.
Cultural Model Influence 2 - K-12 school administration needs to foster an environment
where school nurses are fully empowered to convey their value to others. This gap is not
validated.
As often the only health professional in the building, the school nurses interviewed
believed that by and large, their administration was aware of how their specialist role
complemented the educators and other support personnel in meeting the K-12 education mission.
Fourteen out of 14 school nurses described that the administration supported them in conveying
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their health leadership role to ensure optimal student health. Three themes emerged as central to
the school nurses feeling empowered by the administration to convey their value. First, they
develop a relationship with the school administration; second, they build trust and credibility
within the school community; and third, they contribute to team-based settings and, when
necessary, advocate for inclusion.
Relationship Building with School Administration. To facilitate inclusion in the
educational setting, Nurse Swain expressed the importance of creating bonds with administrators
who can help pave the way. She claimed that “developing a good working relationship with …
administrators in your building [ensures] they appreciate what you come to the table with
because they, like many people, have no idea really what school nurses do.” These relationships
were vital for school nurses as they spoke of aligning their expertise and scope of practice with
the school’s needs and the student population. Knowing that the school principal has oversight of
the big-picture needs of the school population, Nurse Fernandez spoke about how she daily
checks in with her principal, aligning her work with the school administrator’s needs. She
explained,
You know I'm always touching base with [the principal] on a daily basis. When I first
walked in the door, they’re the first person I see … hey do you have anything to report on
your end? What’s going on? What are the goals for today? Would you like to see anything
happen, you know, on the medical end? … because at the end of the day, you know, when
I'm in their building they are my boss. That's their building, you know what I mean. So
we're in constant communication throughout the day.
School nurses mentioned their principal values them and is crucial for ensuring that they
are included as part of the school team, often “having a direct line to them.” Nurse Garcia said
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that during COVID, there had been occasions when she was self-isolating at home and her
principal “feels frantic to not have a nurse in school.” She explained this was because in her
absence her workload fell to the principal. With the impact of COVID-19 all school nurses
explained that they “are definitely part of the COVID conversation” by being involved in health
and safety meetings and collaborating on everything from closing down classrooms when there
is a potential case, to contact tracing, working on protocols. Nurse Hansen explained that she
“worked a lot with administration in the summer getting ready for school … and getting
procedures and protocols in place … like we talk all the time.” School nurses seizing
opportunities to form trusted relationships with administrators created quality interprofessional
interactions that support the entire school's performance. In an environment where the
relationship with administrators advances inclusion for decision-making, the school nurses can
convey their health leadership role as valuable in the educational environment.
Build School Community Trust and Credibility. As the school nurses revealed,
communicating value is especially important because often others around them "have no idea
what they do." School nurses said that they felt that to convey their value, they took every
opportunity to build trust and credibility for their role with teachers, school staff, and parents
alike. Nurse Hansen spoke about keeping the lines of communication open with parents to
educate them about the healthcare decision-making process and to help them feel comfortable
with her as their child’s school nurse. As she explained, “I want them to be able to come to me
with issues [so] I call them a lot … just to let them know what’s going on … and try to give my
thought process behind things so that people see where I am coming from … why I think this is
important.” Nurse Bond says he engages teachers in his assessment and care process by sharing
his thoughts. He described that he tells them,
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Here's what I saw, here's the sort of critical thinking of the logic train that I'm traveling to
get to this conclusion. And that's why I feel good about them being in class … in fact I
think they right now would benefit from being distracted.
Nurse Fernandez described that she has built trust in her community where her judgement
is never questioned. She explained,
God forbid, if there's like a school emergency where I have to call 911 … it's like okay,
let's go work it. We just give the principal a heads up, I'll call and right away all the
supports are put into place. They'll close the hallway down. They'll have someone meet
me in my office, it’s a very smooth process.
The school nurses' explanations about their leadership role in addressing the student's
health needs showed how they align with the educational mission. Organizational support that
encourages the school nurses to build trust and credibility in their community allows them to
convey their value as an essential partner in the education of students.
Value Through Collaborations. School nurses highlighted how administration support
through inclusion in team-based settings gave them opportunities to convey unique expertise to
ensure students’ health and wellbeing as engaged students. Fourteen of the 14 school nurses
reported that they are welcomed as collaborators in the educational environment. The school
nurses reported that there are many ways they collaborate, including team meetings, leading
student wellbeing committees, and in health education in the classroom, bringing their trusted
health expertise enhances the conversation. With the impact of COVID-19 very much top of
mind during the interviews, all school nurses explained that they “are definitely part of the
COVID conversation” by being involved in health and safety meetings and collaborating on
everything from closing down classrooms when there is a potential case, to contact tracing,
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working on protocols. Nurse Hansen remarked about the level of inclusion when she noted, “and
this year is just insane. We are collaborating with everyone this year because they look to us as
the person who knows the most about the pandemic, or who’s gathering the most information
within the school about COVID.” As the school’s healthcare provider, nurses described being
pivotal to working with COVID-related working groups focused on keeping everyone safe and
healthy.
School nurses stated that their health expertise meant that administrators welcomed them
to lead committees such as the medical emergency response team, and student success teams. As
well, school nurses mentioned being included in team meetings “for students who have a
complex health issue.” One of the outcomes that school nurses are responsible for on these
occasions is to develop a nursing care plan that is shared with the team about the nursing care the
student will receive in school. Nurse Mallory detailed how she was able to think about what was
needed to create a health care plan that works specifically for the student.
And so, I'm at the meeting and I kind of, you know, I always request the medical
documentation. But then, from that I can give input on suggestions for accommodations
that would help them at school. Or with our special ed kids, when they have their PPT
meetings, the same thing - I can give input on suggestions on other ways things can be
done. Individualized health plans. I do make individualized health care plans for students.
Most of them are emergency plans, but I do make plans for kids.
As this account shows, being in attendance is necessary so school nurses can discover
more about the student’s health issues to share their expertise in caring for the student while in
school. Despite most school nurses reporting attending these meetings, one nurse explained how
she may be asked to one meeting and left out on other occasions. Nurse Carter reported that
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when the principal did not include her in a meeting, potential difficulty may have been added for
caring for the student.
Honestly, I think the principal doesn't think it's important enough. Because there have
been some meetings that I should have been involved in, even for legal matters. … [He
would say], don't worry about it, I could tell you what they said. And then I'll say, well,
did they tell you what sort of medications this kid’s on after being released from a
psychiatric hospital? And of course he draws a blank. And he goes … no. So I should
have been there, because then that would have shown the parent that they have the full
support of the school … right, [also] so quality of care would be there.
During the interviews, school nurses rarely pointed out this faux pas on behalf of the
administration. They offered many more accounts of administrators welcoming school nurses to
attend meetings and how collaborative contributions strengthen their ability to be seen as health
experts contributing expertise as an essential factor in successfully educating students.
Cultural Setting Influence 1 - K-12 school administration needs to provide school nurses with
access to the support of other healthcare professionals. This gap is not validated.
School nurses reported that their administration supported their connecting with other
healthcare professionals, which was essential as they often work in isolation. The themes that
emerged as necessary networks for school nurses were, first, school nurse peer interactions and,
second, connections with allied health professionals. School nurses described how these
collaborations strengthened their ability to convey their value in the educational setting. Fourteen
out of 14 school nurses reported using peer-to-peer interactions with other school nurses and
their nursing supervisor to gain information for their practice. Similarly, 14 out of 14 nurses
reported seeking out other allied health professions to create strategies for student well-being.
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These allied health connections are frequently with the social worker, the school psychologist,
and the guidance counselor.
Access to Other School Nurses. School nurses value their role autonomy, especially as it
allows for immediate decision-making. Nonetheless, 14 out of 14 school nurses said they value
and appreciate the opportunity to make frequent contact with other school nurses to “chat
amongst each other” and “bounce things off each other.” Describing the pleasure in having her
colleagues on-hand, Nurse Garcia said,
One of my favorite things about this job is that I actually like being the only nurse in my
school environment … but we all like to interact with each other and you know, bounce
stuff off each other ... but we’re also not getting in each other’s way.
School nurses reported that these opportunities increase their effectiveness, so they make
connections as frequently as they need and report receiving timely feedback. School nurses said
they “thrived” on the reciprocal collaborative arrangement for nursing knowledge within their
school district.
The reassurance of having a nurse colleague close at hand gave themselves leeway with
knowing that they could lean on others for information that they do not have. These
opportunities to collaborate with student care were appreciated by both the novice and more
experienced nurses. As a new school nurse, Nurse Bond explained that he had a student with
what was described to him to be seizure-like activity and
Having not seen it myself, I wasn’t sure what to do … the next steps. So, I called the
other school nurse, shared what was going on, and got her advice and her input. You
know, sharing those trickier moments where I’m not totally sure what the next step
should be. She’s a great resource that way.
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As described in detail earlier, the school nurses feel confident with having knowledge for
their practice, but they welcomed their peers as resources to help with the need for a tremendous
breadth of information.
An important nurse colleague in each district is the nurse supervisor, the district’s school
health nurse leader. Ten of the 14 school nurses reported being in frequent contact with the nurse
supervisor to either brief them about events happening, get advice, or simply reflect on a course
of action. The opportunity to connect was described by Nurse Swain with a sense of gratitude
toward the availability of her nurse supervisor, “[my colleagues and I] are really lucky that we
her as a contact that we can reach out to and say, what do you think about this situation … and
she will call or email back pretty quickly.” The nurses also felt like their supervisor was not “just
their boss,” but a colleague who reciprocated by asking for their knowledge input. Nurse Hansen
described her nurse supervisor as:
Very approachable … she calls all the school nurses once a day, just to check in,
especially this year. I feel like she respects our own individual knowledge and
experiences because she’ll come to us and be like, so I have this seventh grader who this
is what’s going on with them, what do you think we should do?
The nurse supervisor was described by Nurse Mallory, a relatively new nurse, as being a
great mentor noted, “my nursing supervisor we've had for the past five years, she is big on data.
It's something that helped me when I first started to get me very organized.” As the school nurses
typically work in isolation, they described being able to depend on trusted available colleagues to
increase their effectiveness by sharing knowledge. They also reported a sense of comfort in
knowing that they were not alone in their practice. The interviews showed an overwhelming
number of reports about positive knowledge sharing and the sense of professional support the
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school nurses had within their school district. These peer-to-peer interactions strengthen the
school nurse’s ability to convey their value in the educational setting.
Access to Allied Health Professionals. Also, importantly the school nurses recounted
the indispensability of the allied health professionals within the school, such as the social worker,
the school psychologist, and the guidance counselor. These professionals increased the
effectiveness of the school nurse in different ways than their nurse peers by providing care within
the school or for community services coordination. Describing themselves as the central point of
contact for student wellbeing, if there is an issue outside of what the school nurse can solve, they
describe quickly reaching out to the appropriate allied health professional. These collaborations
included mental health needs such as counselling, or social welfare needs such as access to food
or shelter. Nurse Ender explained that
Oftentimes if I think that there may be some counselling needs, I reach out to guidance or
the social worker and the school psychologist … if a student’s coming to see me quite
often, and I think that there’s something they may need help with … I can ask them … do
you want to speak to Mrs. So-and-so … to try to coordinate our efforts.
School nurses also described how this is a reciprocal arrangement with the allied health
staff. Nurse Fernandez described how she worked with the school’s social worker by reaching
out to a student’s family to determine what may be happening in the home environment that had
altered a once “A/B” student to no longer be achieving these grades. She explained, “she comes
to me, she’s like, can you … touch base with the mom to see what’s going on … and I’ll reach
out to [the family] and we work together that way.” Access to the opportunity to share
professional expertise in the school building was described as a valuable commodity for school
nurses to successfully care for the complete health and well-being of the students. As with their
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school nurse peers, they “have each other cell phone numbers,” reaching out as often as
necessary.
While these collaborations are optimal, one school nurse specifically mentioned being
excluded from an important opportunity to coordinate care with other health professionals in the
school. Nurse Carter explained her frustration when the school nurses in her district were
deliberately excluded from a district wide clinical team monthly meeting.
[We] used to be part of, which still bothers me, the clinical team [which consisted of] all
of the guidance counselors, social workers, and psychologists within the district and they
would have a once-a-month meeting, and we would be invited to it. But then I
complained … and the nurses were removed from the clinical meetings and are no longer
invited. And I feel like, I'm clinical, I dismiss kids - I need to know what's going on.
This mention of such exclusions was rare among the school nurses interviewed. It does however
corroborate the earlier mention of Nurse Carter being excluded from a student success meeting.
Both examples describe how the opportunity to share knowledge between professionals was a
source of frustration to the school nurses. They believed that this lost opportunity effectively
decreases the school nurses’ ability to care for the student in such a way that ensures the students’
successful academic achievement.
Numerous organizational benefits result from administrators supporting knowledge
sharing through professional interactions, especially when the school nurses described accessing
the skills and resources of allied health professionals. Through this collaborative work, the
school nurse’s ability to convey their value in the educational setting is strengthened.

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Cultural Setting Influence 2 - K-12 school administration needs to provide adequate
professional development opportunities for school nurses. This gap is partially validated.
To maintain nursing licensure, the State of Connecticut requires at least 10 hours of
professional development every two years (State of Connecticut, 2019d). When asked about
access to professional development opportunities, school nurses replied with 14 different
answers, all of which seem to be district specific. The responses ranged from, "I don't think that
there's a great emphasis on the importance of continuing education for school nurses" (Nurse
Swain), to "my supervisor organizes weekly meetings" (Nurse Mallory). Despite the variability,
two themes emerged. First, as with salary compensation mentioned earlier, school nurses
identified limited professional development funding. Second, are the school nurses’ perceptions
about the adequacy of the time allocated to professional development opportunities.
Professional Development Funding. In addition to salaries, school nurses' district
budgets extend to professional development activities which are necessary to stay current in their
practice. While 11 of the 14 school nurses reported having enough funding to attend professional
development, the contradiction is that they felt the necessity to be cautious about how they spent
funding. Nurse Winfrey indicated an access to professional development paradox when she said
that while her school district is very education-focused, “if we wanted to, there are funds that set
aside in our budget for professional development,” but the contradiction arises when she
announced, “But, none of us go very often.” Similarly, other school nurse’s posited that
administration supports their professional development but that they know there is limited
funding. Evidence of this was revealed by nurses commenting they “don’t go very often” and
“never push the envelope.” Nurse Ender explained that although she does attend a lot of "good
free professional development," however when she requested funding for a seminar she said,
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"There wasn't funding. But I understand the situation these times that way.” Caution with
funding shows that school nurses are acutely aware of the limits on the educational funding put
aside for professional development. As Nurse Garcia said, “I’ve never pushed the envelope with
extensive travel or anything but attend anything within the state.” School nurses' caution in using
professional development funds is a sign of the organization's devaluing their need to attend
training as an expert to stay current.
Only three of the 14 school nurses revealed how much funding they get for professional
development. One school nurse admitted receiving between $150 and $200 annually, stating that
this is not enough money. Two nurses remarked that they felt that professional development was
so important that they are willing to pay out of pocket for any shortfall that was not paid for by
their employer. One school nurse said there were no professional development funds put aside
for her. School nurses also revealed that professional development funding was not always
assured. Nurse Fernandez, who usually received funding toward professional development, said
she was planning to attend an in-state training opportunity that lasted for several days but did not
end up going because "money got tight and it was a three-day thing. So, I would have to get
childcare for my daughter." When probed, she revealed that "money got tight" because her
employer was not going to pay for the professional development, meaning that she would not
only have to pay the registration and accommodation but the childcare costs as well. Out-of-
pocket spending is an indicator of school administration’s devaluing the importance of school
nurses’ adequate financial support to stay current with practice and potentially maintain required
continuing education credits.
Time Allocated. There were varying responses to whether administrators gave nurses
time out of their school day to attend professional development, only two of the 14 school nurses
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explicitly identifying that they wished more. Eleven of the 14 school nurses implied that they
would be paid for the time that they were attending learning opportunities. Three of the school
nurses said that their administrator allowed them time for professional development, but only
within their allotted work hours. One school nurse whose school district pays nurses hourly said
that nurses in her district were less likely to do professional development outside of the hours
they are scheduled to be in school. Nurse Swain’s comment reflects this, using the disparity that
teachers get professional development days when students are not in school. She said about
school nurses, “there's no enthusiasm to use those days for professional development because
[nurses] want to get paid for that, and because we’re hourly … employees, they (the school
district) don't want to pay for it.” Conversely, Nurse Ender expressed that in her district,
“generally on the days that the teachers have … there's a half-day scheduled almost every month
where staff stays for the full day and the students go home early. And we usually have our classes
during that time.” Furthermore, in corroboration of results presented earlier about professional
development funding, two school nurses compared the time allotted for professional
development to teachers. Nurse Smith commented that for her district, “we wish we had more
professional development like the teachers ... they get relief time from the classroom … we don’t
get any time.” On the other hand, Nurse Garcia remarked that in her district, “we have as many
professional development days as the teachers.” These reports from the nurses revealed that the
school administration did not always recognize the value to the organization in exchange for the
investment of time allocated for professional growth. Healthcare practices evolve, and for school
nurses to adequately convey their value, they must have adequate time to attend professional
development to remain current.

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Summary of Organizational Influence Results
Organizational culture can influence how well people who work within it can achieve
individual goals supporting its mission. This results section addressed how the administrators in
the K-12 educational setting environment influenced the school nurse's performance goal of
conveying their value as integral to furthering the educational mission. The results focused on
two assumed cultural model influences and two assumed cultural setting influences.
The first cultural model influence was the sense of belonging that ensues when the school
nurse's professional capacity is respected. Here a dichotomy emerged with school nurses feeling
valued due to the autonomy that was afforded them. On the other hand, they felt undervalued
due to being under-compensated. The second cultural model influence was the sense of
belonging that ensues when school nurses are empowered to convey their value. School nurses
described that they were empowered to convey their value through building solid relationships
with K-12 school administration.
The first cultural setting influence was that the administration provides school nurses
access to other professionals. School nurses described having regular and convenient access to
both peers and allied health professionals, enhancing their ability to convey how their role
enhances the educational mission. The second cultural setting influence was that the
administration provides adequate professional development for school nurses. School nurses
described that professional development funding was an issue. The interviews also revealed that
most school nurses were satisfied with the time allotted. However, some felt that as professionals
who are part of the team whose role is to ensure students are healthy and ready to learn, they are
not given the same opportunities as the educators.
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The interviews revealed partial gaps in the first cultural model influence (a sense of
belonging) and the second cultural setting influence (adequate professional development
opportunities). There was no gap validated for the second cultural model influence (an
empowering environment) and the first cultural setting influence (access to other professionals).
Summary of Knowledge, Motivation, and Organizational influence (KMO) results.
The school nurse interviews were summarized to determine the gaps in the assumed
knowledge, motivation, and organizational influences identified as necessary for school nurses to
successfully convey their value as integral for meeting the educational mission. The results of
this study show that there are no validated gaps in any of the four knowledge types: factual,
conceptual, procedural, nor metacognitive. The results for the two motivational influences show
no gaps in the self-determination theory indicators, but there is a partial gap in school nurse’s
self-efficacy. The results of the four organizational influences show two partial gaps: in the first
cultural model influence, and in the second cultural setting influence. However, there are no gaps
validated for the second cultural model influence, nor the first cultural setting influence. Table 10
provides a summary of the results for all knowledge, motivation, and organizational influences.

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Table 10
Summary of Assumed Influences and Validation Status
Assumed Organizational Need
Gap
Validated
Y / N
Knowledge
Factual –
School nurses need to know about nursing procedures, regulations, and legislation that affect the students in
their care, and update their practice as any of these evolve.
Not
Validated
Conceptual –
School nurses need to know and understand the alignment between their nursing practice and the
educational mission in order to help students lead productive and successful lives.
Not
Validated
Procedural –
School nurses need to ensure that school administrators understand why their role and practice is essential
bringing value to the K-12 educational setting.
Partially
Validated
Metacognitive –
School nurses need to know what factors in the educational setting influence their clinical practice and to
work with others to ensure that their healthcare role continues as a strength for the education community.
Not
Validated
Motivation
Self Determination Theory –
K-12 school nurses need to believe that by creating awareness of their value in the education setting, they
are empowered to achieve role competency, practice autonomy within the school, and be integral to the
school community.
Not
Validated
Self-Efficacy –
K-12 school nurses need to believe that the school administration appreciates and values the significance of
their role and practice in the education setting.
Partially
Validated
Organization
Cultural Model Influence 1 –
K-12 school administration needs to foster an environment where school nurses have a sense of belonging
that respects their professional capacity to contribute to the educational mission’s success.
Partially
Validated
Cultural Model Influence 2 –
K-12 school administration needs to foster an environment where school nurses are fully empowered to
convey their value to others.
Not
Validated
O - Cultural Setting Influence 1 –
K-12 school administration needs to provide school nurses with access to the support of other healthcare
professionals.
Not
Validated
O - Cultural Setting Influence 2 –
K-12 school administration needs to provide adequate professional development opportunities for school
nurses.
Partially
Validated

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Of all assumed KMO influences, there were four influences that were “partially
validated.” A “partially validated” influence denotes that a need emerged within that influence.
Table 11 identifies the four specific validated gaps from each influence and the four validated
needs.

Table 11
Summary of “Gap Validated” from Assumed Influences
Gap Validated in Assumed Organizational Need Validated Need:
Knowledge
K - Procedural –
School nurses need to ensure that school
administrators understand why their role and
practice is essential bringing value to the K-12
educational setting.
School nurses use advocacy skills to convey to
the educational administration why their role is
indispensable.
Motivation
M - Self-Efficacy –
K-12 school nurses need to believe that the school
administration appreciates and values the
significance of their role and practice in the
education setting.
K-12 school nurses need to believe they can
advocate for change in workload levels.
Organization
O - Cultural Model Influence 1 –
K-12 school administration needs to foster a sense
of belonging where school nurses can explicitly
convey why their professional contributions as
essential to the educational mission’s success.
K-12 school administration needs to allow school
nurses an advocacy platform that values their
professional capacity.
O - Cultural Setting Influence 2 –
K-12 school administration needs to provide
adequate professional development opportunities
for school nurses.
K-12 school administration needs to value school
nurse’s professional development to gain skills.
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Chapter Five will present the recommendations to address the observed “partial gaps” in
knowledge, motivation, and organizational influences detailed in this chapter. Chapter Five
discussion and recommendations will enable the principals in Connecticut K-12 school districts,
by June 2023, to achieve the goal of implementing best practices that provide school nurses with
a culture of support empowering them to perform at their full scope of practice ensuring students
are healthy and ready to learn.

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Chapter Five: Recommendations and Discussion
Chapter Four presented knowledge, motivation, and organizational (KMO) findings for the
first two research questions:
1. How does working in the educational environment impact the school nurse’s ability
to convey the value of their contribution to the education mission?
2. What are the knowledge, motivation, and organizational influences that facilitate or
impede the school nurses’ ability to convey to individuals in the educational
environment the value of their role and how it furthers the educational mission?
Based on those findings, Chapter Five will answer the third question guiding this study:
3. What are the knowledge, motivation, and organizational resource recommendations
for Connecticut K-12 school nurses to be able to convey to individuals in the
educational environment the value of their role and how it furthers the educational
mission?
Chapter Five will deliver concrete recommendations for each validated gap based on
research-based principles. Following the suggested recommendations, an implementation and
evaluation strategy is introduced. Finally, the chapter ends with the study’s limitations and
delimitations, and recommendations for future research. The chapter will end with concluding
reflections.
Findings and Results
Analysis of the interview findings either validated or did not validate the school nurse’s
ability to convey their value in the educational environment. The theme central to the findings
show that the school nurses in this study perceive that they strongly possess many of the
identified knowledge, motivation, and organizational influences on which this study is based.
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Knowledge Strengths
School nurses must have competency in knowledge of nursing care and critical thinking
that forms the foundation of the nursing process (National Association of School Nurses, 2017).
School nurses were adequately prepared with the knowledge to meet the health needs of the
students in their educational setting. They have the clinical knowledge to physically assess
students' acute needs and care for students with chronic needs, which is consistent with other
studies identifying the variety of work that the school nurse must know to accomplish students'
clinical care (Davis et al., 2019; Knauer et al., 2015; Morse et al., 2020). Consistent with other
studies (Anderson et al., 2018; Davis et al., 2019; Morse et al., 2020), they had an excellent grasp
of their scope of practice.
In alignment with the research, school nurses described seeking knowledge they did not
have from other school nurses and allied professionals (Estabrooks et al., 2005; Jameson et al.,
2018; Sortedahl, 2012). They also used these peer-to-peer interactions for the metacognitive
process of reflection in seeking better practice (Salter & Kothari, 2016). Contrary to this, there is
research that describes school nurses feeling a sense of isolation, sometimes which has been
described as “frightening,” because the school nurse works alone (Burch & Stoeckel, 2021;
Libbus et al., 2003; Morrison-Sandberg et al., 2011). School nurses in this study did not report a
sense of isolation. Instead, they explained the constant contact they have with nurses in other
schools, appreciating the collegiality of both these nurses and allied professionals in their school.
The more novice school nurses in this study found confidence over time through gaining
experience and being able to have these peer-to-peer interactions (Smith & Firmin, 2009).
Motivational Strengths
When employees are motivated, there is a measurable positive sequela to the organization
because motivation propagates energy and persistence to accomplish the work at hand (Clark &
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Estes, 2008). In describing their work, school nurses revealed having role competence,
autonomy, and belonging, all indicators of self-determination, giving them an immense sense of
job satisfaction and feeling valued. Job satisfaction as a result of competence, autonomy, and
belonging, is a common theme throughout the nursing profession (Broussard, 2007; Chang et al.,
2010; Kennedy et al., 2015; Porter-O'Grady & Clavelle, 2020). School nurses identified
satisfaction in successfully coordinating community care for students, especially those whose
families may not have access to healthcare providers (Libbus et al., 2003; Smith & Firmin,
2009). Another important source of satisfaction for school nurses was the role allowing them the
ability to gain work-life balance by moving from the hospital clinical setting into the school
setting. The satisfaction of not working nights and weekends confirms previous research where
the school nurse work schedule is viewed as a major advantage for working in this setting (Smith
& Firmin, 2009).
Organizational Strengths
Including the right people in the organization, in this case, school nurses, to meet the
mission is imperative for school success (Collins, 2001). Consistent with the research (Daughtry
& Engelke, 2018; Leroy et al., 2017; Rodriguez et al., 2013), school nurses said that because
they could tend to students’ health needs, they could get the students back to class quickly.
Connecticut school nurse state-wide survey data also confirms the value of school nurse
presence, showing that nurses returned students to class within half an hour more than 75% of
the time (Connecticut State Department of Education, 2018). Research shows that employees
who can exercise professional autonomy are more likely to experience job engagement and
advance the organization’s goals (Jameson & Bowen, 2020; Kennedy et al., 2015; Maslach &
Leiter, 2016). School nurses felt valued for their professional expertise because they practiced
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autonomously with limited oversight. They described having opportunities to strategically
communicate their value in pursuit of good health for students. They did this one-on-one with
educators and others in the community or through participation in group settings conveying
health information of value to all. Cultural mores that allow school nurses to communicate
expertise are beneficial to helping the organization achieve its goals (Best et al., 2021; Jameson,
2018; Maslach & Leiter, 2016).
Knowledge, Motivation, and Organizational Needs
While there are many strengths that emerged as existing for school nurses to convey their
value in the K-12 educational environment, the study identified several opportunities for school
nurses to ensure the organization appreciates and values their role and practice. One knowledge
need and one motivational need align with organizational structure deficits and two
organizational needs that are barriers to school nurses being fully able to convey their value. The
identified needs are not surprising given that the focus of K-12 schooling is not health but
delivering education to students for them to successfully graduate to go on and lead productive
lives. What is surprising is that the research evidence shows that health and learning are
interdependent (Asada et al., 2020; Centers for Disease Control and Prevention, 2020c; Council
on School Health, 2016). In support of this fact, and well known to school nurses, learning is
easier for healthy students. So the placement of school nurses in the K-12 educational sector is in
complete alignment with the educational mission to ensure that students succeed in school
(Allison et al., 2019; Basch, 2011; National Association of School Nurses, 2017). The
recommendations to bridge the gaps focus on developing strategies to remove the structural
barriers that hinder the educational sector’s ability to fully embrace the school nurse role as an
equal partner in the education of students.
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Recommendations for Practice
The recommendations below address the validated gaps that emerged from the findings.
There are four validated gaps and three recommendations outlined. There is one knowledge
influence recommendation corresponding to the procedural knowledge gap. There is one
motivational influence recommendation that corresponds to the self-efficacy gap. The two
validated organizational influences are combined into one recommendation because the source of
the issue is the same, revealing itself in two different ways within the school nurse’s
organization.
Knowledge Influence Recommendations
This study evaluated four knowledge influences: factual, conceptual, procedural, and
metacognitive. One need emerged, so one recommendation is addressed. The identified need is
that the organization has not fully aligned the value of school nurses as indispensable for meeting
the educational mission. Table 12 presents the validated procedural knowledge influence and
recommendations that school nurses need to address to reach their organizational goal.

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Table 12
Summary of Knowledge Needs and Recommendations
Validated Procedural
Knowledge Need
Specific Gap Principle
Context-Specific
Recommendation
K-12 school nurses
need to ensure that
school administrators
understand why their
role and practice is
essential bringing
value to the K-12
educational setting.
School nurses need to
convey to school
administrators why
their expertise is
indispensable so they
can connect the
nurse’s value to the
educational mission.
Goal achievement is
enhanced when
education is provided
to gain knowledge
and skills for novel
situations (Clark &
Estes, 2008)

The automated
knowledge of experts
makes it difficult for
them to explain what
they know to others.
Organizational goals
are achieved when
experts are explicit
with sharing what
people should know.
(Rueda, 2011)

School nurses and
school nurse
supervisors need to
develop advocacy
skills to help
administrators align
why their expertise is
indispensable for
meeting the
educational mission.
(Nikpour &
Hassmiller, 2017)

Procedural Knowledge Recommendation: Advocacy Skill Development for School Nurses and
School Nurse Supervisors
“Advocacy is a major competency for leading change in policy development and
implementation” (Aronowitz et al., 2021). The recommendation to the organization is to enhance
school nurse leadership skills by developing advocacy strategies that enable them to improve
school administration’s understanding of how their role is indispensable in meeting the mission
of K-12 education. The development of advocacy skills will meet this knowledge need and be
deployed to meet the motivational and organizational needs. Confidence in advocacy empowers
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school nurses to create and propose organizational structural change policies that ensure safe
conditions for student healthcare.
School nurses, by nature, are change agents. Consistent with the literature (Anderson et
al., 2018; Minnesota Department of Health, 2020), school nurses in this study described using
advocacy to create change for student wellness, pursuing opportunities to ensure students receive
appropriate and adequate healthcare. However, nurses are trained to advocate for patients but not
to advocate for themselves, their colleagues, or the nursing profession (Johnson, 2021). The
culture of nurses is that at the systemic level, the concerns of nurses are largely ignored. Should
nurses want to change the status quo, they battle the challenge of speaking up with the risk of
losing their job (Johnson, 2021). Nurses in this study recognized this when they explained that
even if they wanted something to be different, it was unlikely to happen. The acceptance of the
status quo was revealed when study participants explained that although they believed they were
showing value, this work did not secure the perception of others in the educational setting that
they are indispensable in their educational settings. Although they believed they were recognized
and valued, their implicit actions do not translate unequivocally to their role being seen as
mission-critical by others in the educational environment.
To be seen as a driving force that is indispensable for education to meet its mission,
school nurses need to become expert self-advocates who can explicitly state why their role and
position is essential to meeting the educational mission. The intuitive nature of the school nurse’s
expertise makes it harder for them to recognize that others may not make the connection between
their role value and how it is integral in the educational setting (Rueda, 2011). Therefore, it is
critical to empower them with advocacy skills that explicitly connect their role to students'
academic outcomes. Findings within school nursing research show that time and again, school
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nurses called to be actively engaged in advocacy in support of their importance as contributors to
child and adolescent health (Baltag et al., 2016; Bayik Temel et al., 2017; Blackborow et al.,
2018; Maughan & Adams, 2011; Nikpour & Hassmiller, 2017), as a good investment in public
funds (Baltag et al., 2016; Maughan, 2018), and to garner appropriate scope of practice
recognition (Aroke, 2014; Burch & Stoeckel, 2021).
Advocacy might seem complicated, as interviews revealed that school nurses are apt to
“accept their lot” as “support staff.” These feelings align with evidence that nurses operate
through marginalized (hooks, 1984) and internalized oppressed group behavior that has evolved
in healthcare where they are subordinate to the physician (Johnson, 2021; Roberts, 1983; Roberts
et al., 2009). However, even in feeling marginalized, school nurses spoke about knowing “why”
their value aligns strongly with the confluence of health, education, and academic achievement
(Centers for Disease Control and Prevention, 2020c). Communication by school nurses to help
others with how their role aligns with their organization is essential for triggering organizational
change (Lewis, 2019). Advocacy, through communication, is the vehicle for change to gain
support within the educational community (Johnson, 2021; National Academies of Sciences,
2021). Rather than focusing on the “what” and the “how” of school nursing, focusing on “why”
the school nurse is essential “has a deeper, more emotional and ultimately more influential
value” (Sinek et al., 2017, p. 15). Building capacity for advocacy is essential for school nurses to
meet the need to convey their professional role as indispensable in the educational environment.
Motivation Influence Recommendations
Two motivational influences were evaluated in this study: self-determination theory and
self-efficacy. One need emerged as a gap, so one recommendation will be addressed. The
identified need is that high workload expectations can diminish the school nurse’s self-efficacy
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for ensuring safe care for students. Table 13 presents the validated motivational influence and
recommendations that school nurses need to address to reach their organizational goal.

Table 13
Summary of Motivational Needs and Recommendations
Validated
Motivational Need
Specific Gap Principle
Context-Specific
Recommendation
K-12 school nurses
need to believe that
the school
administration
appreciates and
values the
significance of their
role and practice in
the education setting
(self-efficacy).

High workload
expectations diminish
self-efficacy to
provide adequate
care.
Goal achievement is
enhanced when
individuals believe in
their ability to
perform specific tasks
(Clark & Estes, 2008)

Self-efficacy leads to
setting high goals and
strategically planning
ways to achieve them
to attend to all tasks
(Zimmerman et al.,
2017)
School nurses and
school nurse
supervisors should
advocate for
workload conditions
that promote greater
job satisfaction, and
decrease burnout in
order to ensure
adequate, safe student
health care (Jameson
& Bowen, 2020; Liu
et al., 2018).

Self-Efficacy Recommendation: School nurses and school nurse supervisors need to believe
they can advocate for change in workload levels.
Consistent with school nurse workforce studies (Davis et al., 2019), study participants
believed they are sometimes unable to adequately achieve the goal of providing safe healthcare
for students because they lack both time and staff who can complete supportive administrative
tasks. The recommendation is to empower the school nurses to believe that they can advocate for
workforce change to ensure safe conditions for student healthcare (Dolatowski et al., 2015;
Endsley, 2017; Jameson et al., 2020). Advocating for workforce levels is vital for school nurses
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to think they can affect because unsafe staffing impacts patient outcomes, nursing care, and
nursing staff (Combe et al., 2015; Jameson & Bowen, 2020; National Association of School
Nurses, 2015a).
School nurses can facilitate workforce advocacy in several ways. For example, one way
is to improve school nurses data-driven decision-making abilities enabling them to capture their
workload levels accurately in order to strategically educate the school administration about the
resources needed for safe student care (Brown et al., 2020). Effective workforce advocacy
requires consistent data collection about the myriad of issues the school nurses handle (Brown et
al., 2020; Institute of Medicine, 2011). For instance, at the beginning of the school year, families
supply health records and information about their child to the school nurse. This large amount of
paperwork and information needs to be expeditiously processed to recognize what has an
immediate impact on student healthcare. Safe student care means they must quickly process the
known health information to share with the education team. If school nurses captured data about
this effort, it becomes evidence of their practice to advocate for additional staff during this
period. School nurses in the study found their rigorous and routine data collection was invaluable
as they used it to make change within their school.
Relationships are also a powerful tool for self-advocacy and school nurses conveyed
positive results from the relationships they built within the school. Effective advocacy comes by
building on these relationships through consistent communication with the administration
through regular data-sharing efforts. The school nurse can also demonstrate their expertise by
showing the administration first-hand what the nurse’s workflow looks like and sharing stories of
how their work aligns with the educational mission. They can also leverage their unique health
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knowledge sharing with administrators what is important for them to know (Brown et al., 2020;
Cornelius & Gustafson, 2021).
Organizational Influences Recommendations
This study evaluated four organizational influences. Of these, one cultural model and one
cultural setting influence were validated as gaps. The two validated organizational influences are
combined into one recommendation since the cultural model gap affects the cultural setting gap.
That is, potentially, there will be no solution in the cultural setting without resolving the cultural
model challenge. Table 14 presents the validated organizational influences and the one
recommendation that needs to be addressed to reach its goal.

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Table 14
Summary of Organizational Needs and Recommendations
Validated
Organization Need
Specific Gap Principle
Context-Specific
Recommendation
Cultural Model:

K-12 school
administration needs
to foster an
environment where
school nurses have a
sense of belonging
that respects their
professional capacity
to contribute to the
educational mission’s
success (valued).
K-12 school
administration
undervalues school
nurse’s professional
expertise through
wage under-
compensation.
The organization’s
most important asset
is its people.
Investing in them
increases motivation,
commitment, and
skills which in turn
enrich the
organization.
(Bolman & Deal,
2017; Wheelen,
2019)

Students, schools,
and communities,
benefit from the cost
effectiveness of
having a full-time
school nurse in a
school (Davis et al.,
2019; Wang et al.,
2014; Yoder, 2020)

School administrators
need to allow school
nurses and school
nurse supervisors an
advocacy platform to
convey their value as
the precursor to
structural changes
(Kennedy et al.,
2015).

O - Cultural Setting
Influence 2 –
K-12 school
administration needs
to provide adequate
professional
development
opportunities for
school nurses.
K-12 school
administration
undervalues school
nurse’s professional
development through
inadequate financial
support for
professional
development.
Investing in people
through education
advancing their skills
is a powerful
advantage for the
organization (Bolman
& Deal, 2017;
Wheelen, 2019)

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Organizational Recommendation: Empower School Nurses with an Advocacy Platform to
Convey Their Value as Indispensable to the Education Mission
At the root of this organizational recommendation is the identified need of study
participants. School nurses believe that if they were truly valued then, the organization would
better align their compensation with the value of the work they do for their school community.
Undercompensating is consistent with numerous school nursing studies (Campbell, 2018;
Connecticut State Department of Education, 2020c; Jameson, 2018). Research also shows that
school nurses are a cost-effective hire to both the school and the community (Baisch et al., 2011;
Wang et al., 2014). There is also evidence to show that the social benefit of having a school
nurse available is critical to provide equitable access to healthcare and reduce health disparities
(Baisch et al., 2011; Fleming, 2011; National Academies of Sciences, 2021; Rodriguez et al.,
2013).
Juxtaposing this evidence is the agreement by study participants that even though they
feel under-compensated, they love their work and continue to come to school every day to help
their students. So ultimately, there is no driving force for administrators in the K-12 education
sector to believe there is a need to make any changes to funding for school health services,
primarily as it competes with the multiple accountabilities assigned to limited education budgets
(Burke, 2005; Huang et al., 2020). There is a growing awareness that health is not separate but
integral to the community (Centers for Disease Control and Prevention, 2020c; National
Academies of Sciences, 2021). This viewpoint calls for interdisciplinary and intersectoral
practitioner models as the way to realize healthy communities. School administrations need to
embrace these initiatives, in this case, the intersectoral health-and-education partnership, and
158

recognize the close alignment of the school nurse with helping them meet their educational
goals.
With health so closely aligned with the student’s ability to learn, the recommendation to
the organization is to provide an advocacy platform that allows school nurses to explicitly
convey the value of their role as indispensable in meeting the mission of K-12 education. As
stakeholders in the organization, school nurses’ unique knowledge, abilities, energy, and effort
are all assets that advance the organization’s mission (Bolman & Deal, 2017; Lin et al., 2019;
Wheelen, 2019). An advocacy platform empowers school nurses to conceive and promote
organizational structures that align both health and educational missions. Principals can use
inclusive leadership and a diversity mindset to leverage the diverse perspectives that school
nurses being to the educational environment (van Knippenberg & van Ginkel, 2021). An
advocacy platform gives the school nurses a voice to share what is affecting them negatively and
to offer to the educational community perspectives about what is needed to make the
organization thrive (Tapia, n.d.). As described by the participants in this study, school nurses
play a critical role in advancing health equity. Empowered with an advocacy platform, the school
nurses exhibit the power, legitimacy, and urgency (Mitchell et al., 1997) of their role as
indispensable to the organization and, as a result, provide to students equitable healthcare.
According to Mitchell et al. (1997), stakeholders possessing all three characteristics become
definitive stakeholders in the community and, in turn, assert compelling reasons for the focus of
attention and resources by organizational leaders. The organization’s willingness to provide an
advocacy platform gives the school nurses a sense of belonging, heightening their ability to
convey their value as essential to the educational mission, ensuring that students can achieve
academically (Kennedy et al., 2015).
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Integrated Knowledge, Motivation, and Organizational Recommendations
Interviews with the school nurses indicate that individually and collectively, they bring
value to each of the hundreds of students in their care and collectively to millions of students
throughout K-12 education. School nurses explained how they provide students with equitable
access to healthcare and wellness education with benefits to the students, the families, the school,
and the community.
The data collected in this study revealed that school nurses demonstrate value through
being directly engaged in student care, ensuring that students are healthy and able to learn.
However, school nurses also report that administrators do not always see their role’s significance
as essential in coordinating student’s wellbeing relative to their ability to learn. This infers that
school nurses need to explicitly take a leadership advocacy role to help administrators connect
the value of their position to the educational mission. Advocacy also becomes a theme to address
the school nursing workforce issues that exist as barriers to work self-efficacy. By adopting a
data-driven mindset, school nurses are equipped with evidence to advocate to administration
about the nature and volume of their work. When the organization encourages school nurses to
take an advocacy platform, they are fully empowered to convey their value as indispensable to
the educational mission. School nurses work where children go to school, giving all children free
access to a healthcare provider. Although the nurse's value to their students speaks for itself,
underpinning this advocacy platform is the school nurses' lens as a healthcare provider who is
well-placed to advance health equity. When all of the needs identified in this study are taken care
of, school nurses are well-positioned to fully convey their value taking ownership and
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responsibility as advocates to leverage opportunities for change to mitigate the deep-seated and
societal challenges of health inequities.
Implementation and Evaluation: Fully Empowering School Nurses to Convey Value
The recommendation of this study supports the need for school nurses to further their
advocacy efforts to convey to educational administrators and policymakers how indispensable
school nurses are in the school community. In accord with the release of the Future of Nursing
2020-2030 report (National Academies of Sciences, 2021), there is a window of opportunity
(Kingdon, 1995) for school nurses to initiate change as the nation emerges from the COVID-19
pandemic.
The Future of Nursing 2020-2030 report recommendations center on achieving health
equity through building and strengthening nursing capacity and expertise (National Academies
of Sciences, 2021). As the school nurses in this study revealed, their nursing expertise as front-
line care professionals ensures students have immediate access to a health provider who can
coordinate care, provide wellness education. In consensus with the findings of this study, the
Future of Nursing report states that the funding for school and public health nurses is “woefully”
inadequate (National Academies of Sciences, 2021). This study’s proposed implementation does
not address this more significant policy-based issue. Instead, it focused on the preliminary steps
for tackling such a considerable and vital undertaking. This study’s recommendation strengthens
the school nurses’ expertise by building their advocacy capacity and empowering them to speak
to the critical nature of their position in the education sector.
Proposed Implementation Strategies
Agenda setting to address the need for building advocacy capacity requires collaboration
by school nurses, the primary stakeholder in this study, with the study’s identified secondary
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stakeholders. The secondary stakeholders have the responsibility to facilitate addressing the
needs. Table 1 identified each stakeholder’s performance goal. Table 16 provides proposed
activities addressing the needs identified in this study and align with these stakeholder goals.
One additional stakeholder is included in the implementation plan, the Association of School
Nurses of Connecticut (ASNC). The ASNC is the state-wide school nursing association that
traditionally plans events and training for Connecticut school nurses. Using their role, the goal
for this stakeholder group replicates the goal for the Connecticut Department of Education.
Proposed Evaluation Plan
The assigned stakeholders will implement the proposed action steps. The Connecticut
State Department of Education and the Association of Connecticut School Nurses will execute at
the state-wide level or at the school district level if school nurses request. The school nurse and
school nurse supervisors will implement the action steps at the district level or regionally when
consensus building is necessary. According to the stakeholder’s timelines and their capacity, they
will implement the action steps. As the implementation is contingent on the community
engagement via stakeholder involvement, which is yet to be determined, the specific evaluation
will depend on the plan's structure. For them to evaluate their implementation, broad approaches
to a formative and process evaluation (Agency for Toxic Substances and Disease Registry, 2015)
include deliberate reflection and assessment to determine one or more of the following nine
evaluative questions:
1. Is there successful recruiting and retention of intended participants?
2. Is the process to create partnerships sufficient to engage essential stakeholders?
3. Is there active maintenance to ensure sustainability of the inclusion of all
stakeholders?
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4. Are stakeholders well positioned to ultimately help the agenda succeed?
5. Are training programs and materials meeting the standards to achieve the intended
outcomes?
6. Are projected timelines being maintained?
7. Is there sufficient coordination with ongoing programs and activities?
8. Is process and outcomes communication sufficient to maintain momentum?
9. What else can be done, and who else can be involved?
Consistent reflection on these questions allows for course correction to agenda implementation
(formative evaluation) or to shed light on the implementation processes (process evaluation).
Table 15 includes a selection from one or more of the above approaches to evaluation. These are
suggestions for each actions step. Stakeholders may find it helpful to reflect on evaluation
questions not assigned to the action step. Of note is Question 9 which continually poses the
question of what else can be done.

163

Table 15
Proposed Implementation and Evaluation Plan
Need addressed Action Step Evaluation Time
Frame
Secondary Stakeholder: Connecticut Department of Education (CDE) & School Nurse Advisory Board (CDE-AB):
Goal: … will provide K-12 school nurses with the tools required to enable nurses to be empowered to share information about their
role and practice so they can convey their value to individuals in the local educational environment.
Self and professional
advocacy (Knowledge
– Procedural)
• Assess current advocacy skill set to determine learning need 1, 8 January
2022
• Source existing advocacy education opportunities 2, 4, 5, 7
• Reconcile current data collection to determine purpose and end use. Make
recommendations for
enhancements and reporting considering advocacy.
4, 6, 7, 8
• Create learning opportunities: advocacy; data management and reporting 1, 3, 5, 7
• Convene communities of interest to build advocacy capacity 1, 3, 7, 8, 9
• Champion school nurses’ efforts to share knowledge explicitly identifying
value
2, 3, 4, 7, 9
Secondary Stakeholder: Association of School Nurses of Connecticut
Goal: … will provide K-12 school nurses with the tools required to enable nurses to be empowered to share information about their
role and practice so they can convey their value to individuals in the local educational environment.
Self and professional
advocacy (Knowledge
– Procedural)
• Convene local consensus discussions: grass roots alignment to foster shared
understanding of issues to focus advocacy efforts
1, 3, 7, 9 January
2022
• Convene communities of interest to build advocacy capacity 1, 3, 7, 8, 9
• Work with CDE & CDE-AB to deliver learning opportunities for data
management and reporting
2, 4, 7, 9
Secondary Stakeholder: School Nurse Supervisors
Goal: … will mentor, provide tools, along with clear, current, and challenging goals that enable school nurses to have a sense of
mastery for their full scope of practice so they can convey their value to individuals in the local educational environment.
(Organization -
Cultural Setting &
Cultural Model)
• Champion school nurses training attendance 1, 3, 5, 7, 9 June
2022
• Champion school nurse’s involvement in district-wide, statewide, and national
efforts to create change
2, 3, 7, 8, 9
• Advance the cause for advocacy with school administration 2, 3, 4, 8, 9
• Using advocacy agenda, further develop relationships with district
administrators
2, 3, 8, 9
Primary Stakeholder: School Nurses & Secondary Stakeholder: School Nurse Supervisors
Goal: … will convey to individuals in the educational environment the value of the nurses’ role and how it furthers the educational
mission in order for the community to appreciate and advocate for each school to have a full-time nurse onsite daily.
Self and professional
advocacy (Knowledge
– Procedural)

• Attend advocacy training opportunities 1, 5, 7, 8 December
2022
• Attend consensus discussions and join communities of interest 1, 3, 7, 8
• Using advocacy agenda, further develop relationships with district
administrators
2, 3, 8, 9
Advocacy self-
efficacy (Motivation –
Self-efficacy)
• Attend data management training opportunities 1, 5, 7, 8 December
2022
• Strategically implement data management practices 2, 3, 4, 7, 9
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Need addressed Action Step Evaluation Time
Frame
Secondary Stakeholders: School Principals & School Administration
Goal: … will implement best practices to provide school nurses with a culture of support that empowers them to perform at their full
scope of practice ensuring students are healthy and ready to learn.
Advocacy Platform
(Organization -
Cultural Setting &
Cultural Model)
• Create opportunities for school nurses to share knowledge explicitly
identifying value
2, 3, 4, 8, 9 June
2023
• Observe the work of other school nurses
• Champion school nurses as critical to the education mission 3, 4, 7, 8, 9

Limitations and Delimitations
Limitations and delimitations, or weaknesses, are a part of every study. Limitations are
influences in the study that are not in the researcher’s control (Creswell & Creswell, 2018;
Merriam & Tisdall, 2016). Delimitations are the choices made by the researcher during the
process of designing the study and reporting the results (Creswell & Creswell, 2018). Both are
important to acknowledge as they show that the researcher has considered the limitations. As a
result of this transparency, they strengthen the credibility of the study. Knowing all limitations is
not possible; however, several may apply to this study.
One limitation is in terms of the sample, and participation in the study was voluntary. As
much care as possible was taken to choose various school nurses representing different
populations across Connecticut. As participants self-selected to be in the study, they may not
fully represent all Connecticut school nurses. Because of this study design, the results reflect
those interviewed but not necessarily generalizable to the entire school nurse population. A
second limitation is that while every effort was taken to conduct the interviews consistently,
participants may not have been forthcoming with their answers. The researcher was responsible
for interpreting participant responses, so a third limitation is that there is unintended elucidation
when developing and summarizing resulting themes.
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There are also several clear delimitations in this study due to the decisions made by the
researcher. The first is that there may have been methodological errors that impacted the
research. Even with the guidance of experts, this is the first study by this researcher, so the study
may not be as fully explored as possible. The Clark and Estes (2008) gap analysis choice as the
conceptual framework may have been insufficient to fully understand how the school nurses can
convey their value in the educational environment. The second delimitation is that although
every attempt was made to ensure the interview protocols collected the expected data, the
questions may not have been the best to answer the research questions and get to the causes of
the issue. The interview questions were developed based on the KMO influences, with the school
nurse's input during the pilot interviews. The final delimitation is the worldview and positionality
that the researcher brings to the study (England, 1994). The researcher is not a school nurse as an
outsider to this profession may not fully represent the school nurse perspective or may have
inadvertently misrepresented findings and recommendations.
Recommendations for Future Research
The goal of this study was to focus on school nurses in Connecticut and how they
perceive their ability to convey their value. The body of research on the nurse's ability to convey
their value could be enhanced if there were observations of nurses' interactions with others
during their work. In addition, a study of the documentation school nurses keeps might also
inform researchers of the types of data they collect to determine if there currently exists evidence
for nurses to convey their value. It would also be valuable to repeat this research with school
nurses in other states to understand this issue across various populations. Future research might
include using a holistic approach to learn more about how different stakeholders perceive school
nurses. For instance, it would be valuable to explore the stakeholder's perceptions of the school
166

nurse during COVID-19 and their perceptions of the school nurse's role in terms of health equity
in underserved communities.
Conclusion
The purpose of this study was to identify the knowledge, motivation, and organizational
influences affecting school nurse’s ability to convey their value fully. The researcher conducted
semi-structured interviews with 14 Connecticut school nurses. Interview findings identified one
motivational gap and two organizational gaps. Based on existing literature, recommendations are
proposed to address these needs. An implementation plan to engage the school nurse community
was presented, along with a recommended timeline.
Central to this population and reinforced by this study is that school nurses are
responsible for the health of future generations. This duty and responsibility are one that society
cannot ignore as their work, also evidenced by the school nurses in this study, directly influences
the social determinants of health that affect students and their families. Therefore, the
recommendations in this study include empowering school nurses with advocacy skills so that
they can explicitly connect the value of their role as integral to the educational mission. Another
recommendation is to improve nurses' data-decision making to gather evidence to advocate for
the organization to increase the numbers and distribution of school nurses to safely meet
students' healthcare needs. The final recommendation is for the school administration to value
the professional role of the school nurses as a member of the organization. The recommendation
to the school administration is to empower school nurses with an advocacy platform so they can
convey how indispensable they are to the educational mission.
As noted by Bolman and Deal, “changing old patterns and mindsets is difficult” (Bolman
& Deal, 2017, p. 39). Sustainable change requires a transformative approach that empowers the
167

stakeholders to form a shared vision of the future and gives them a voice to advancing an agenda
for change that improves their lives (Chinn, 2013; Creswell & Creswell, 2018; Mertens, 2009).
Emboldened by the health care inequities revealed by the COVID-19 pandemic, school nurses
are in the perfect position to seize this moment and build the agenda for professional change.

168

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209

Appendix A: Interview Protocol
Greeting
• Hello, introduction
o How are you?
o How are you and your family managing during the pandemic?
o Is this still a good time for us to have this conversation?
• Thank you for
o your time
o taking the time to complete the diary
• Situate myself again …
o through the outreach I have done with school nurses I have a deep passion for the
work school nurses do.
o on a personal level when children were in school … the school nurse really made
a difference

• Participation in this study is completely voluntary. If you decide not to participate there
will not be any negative consequences. Please be aware that if you decide to participate,
you may stop participating at any time. As well, when asked, you may decide not to
answer any specific question.

• The purpose of this interview is to talk with you about your role, and about how others in
the educational environment value your role and your practice in ensuring students are
healthy and ready to learn.
• Your participation in this study will last approximately one hour.

Confidentiality
• Now that I have described the purpose of the interview, I am hoping that you continue to
agree to being interviewed, and if you do, let me emphasize that
o This conversation is private and confidential
o I also need to confirm with you if it is okay to record this when we begin the
interview questions?
o If we can record, I will send you a transcript of the conversation to be sure that
you agree to using any or all of the information that we discuss
o If you choose not to have parts included, I can delete that from the transcript,
making it ineligible as data for the study

o I need your consent to record. And when I start the recording, zoom will
announce that the conversation is being recorded, and there is an option for you
to select in agreement.

Introduction
• 20 questions over the next 50 minutes
210

• As I ask these questions use examples if you think it might help to illustrate the answer
• Open-ended response; I might interrupt to probe or re-direct
• I’ll be typing notes as you speak (just in case of technical issues)
• Here we go!
o “I’m turning on the recording now”

Interview Questions Potential Probes
Question Type
(Patton)
Opening discussion
1. Opening question: Please tell me how
long you have been a school nurse and the
age range of the students that you are
responsible for. Who do you report to?

Background
/demographic
2. Introductory question: Cast your mind
back … what was it about school nursing
that attracted you to it?

Background
3. Transition question: How is the school
nurse in the position to ensure students
have access to health care?

• Please share any experiences when
you felt that you really made a
difference.
• … were unable to make a
difference.
• Can you share an experience when
you felt like you were unable to
make a difference?
• tell me more
Opinion
3a. What role does the school nurse have
in ensuring health equity for students?
•
Opinion
4. Transition question: Thinking from the
lens of your role … what does your
educational community look like?
• Who is included in your
community?
• Principals? Teachers? Parents? etc?
Knowledge
211

Interview Questions Potential Probes
Question Type
(Patton)
5. Transition question: How do you
interact with people in your community?

• Besides students, who in your
community do you interact with
the most?
• Why do you interact with this
group the most?
• If I followed you through a typical
day, what would I see you doing?
Experience/
behavior
KMO Discussion about school nursing practice
6. Key question: How do you feel you are
perceived in the education environment?

• Do you feel like you are part of
your school community?
• How essential do you feel in your
school community?

Opinion /Feeling
7. Key question: How are you able to
convey your abilities as a school nurse to
your community?

• Do you feel that the environment is
inclusive of all ideas?
• … inclusive of your role?
• Tell me about a time when others
sought you out for help? … did not
and should have.
Experience/
behavior
8. Key question: Think back over these
past few months with COVID affecting
your role. Using this time frame as an
example, are you able to share your
abilities as a contributor to the
conversations?

• How were you involved in any
arrangements about COVID in the
school?
• Who is making the decisions
around the health of students in
your school during COVID?
• How did you get information on
COVID to support the student’s
health needs?
• tell me more
Experience/
behavior
9. Key question: Other than during
COVID, are you able to convey your
abilities as a contributor to the
conversations?
• can you give me examples?
Experience/
behavior
212

Interview Questions Potential Probes
Question Type
(Patton)
10. Key question: What can be done at a
faculty, principal, leadership level to make
you feel a part of the school community?

Opinion
11. Key question: How do you convey
your value to the school community in
which you work?
• What means exist for you to
convey your value in your
community? What sorts of things
do you do to convey this value?
Can you tell me about a time when
you had the opportunity to convey
your value?
• How does that make you feel?
• What else could have happened in
this situation?
Experience/
behavior
12. Key question: Do you feel that you
have autonomy in your role? Tell me what
that looks like for you?

• For instance … think back to a
time when you wanted to make
something happen that you feel
benefited the students in the
school. Walk me through what
that was and what happened
• What more can the faculty,
principal, leadership level to make
sure you have more autonomy?
• What role did others in the school
play? … the teachers play? … the
principal? … the superintendent?
… the school board?
• What do you feel you learned
from the experience?
• What did you especially like
about the experience, if anything?
• What did you dislike, if anything?
Opinion
213

Interview Questions Potential Probes
Question Type
(Patton)
13. Key question: As the school nurse how
are you empowered in your school
community?

• What more can the faculty,
principal, leadership level to make
you more empowered in your
school?
• What are the resources that you
wish you had to help you with your
work?
• What are some examples?

Opinion
14. Key question: What opportunities do
you have to collaborate with others?
• Tell me about others in the school
who collaborate with you
• Is there something that you would
envision that would be the perfect
scenario for a collaborative
practice?
Experience/
behavior
15. Key question: Tell me about the
opportunities that you get to interact with
other healthcare professionals. Who are
these professionals? Why do you interact
with them?

Experience/
behavior
16. Key question: Tell me about how you
reflect on your practice. How much time
do you have to establish and set
strategies?
• How does that make you feel?
• What else can happen in this
situation?
Experience/
behavior
17. Key question: Think back to a time
when you wanted to make something
happen that you feel benefited the students
in the school. Walk me through what that
was and what happened.

• What role did others in the school
play? … the teachers play? … the
principal? … the superintendent?
… the school board?
• What do you feel you learned from
the experience?
• What did you especially like about
the experience, if anything?
• What did you dislike, if anything?
• tell me more
Experience/
behavior
214

Interview Questions Potential Probes
Question Type
(Patton)
18. Key Question: What are the
professional development opportunities do
you have?

• Are there any challenges to getting
professional development
opportunities?
Experience/
behavior
Final Questions
19. Ending question: What changes, if
any, do you envision would nurture your
ability to practice school nursing as you
wish to practice?

Opinion / Values
20. Ending question: If you were creating
a school that respected school nurses
giving them the support to do their jobs as
effectively as possible, what would you
establish?
• Could you tell me more about your
thinking on that?
• Can you give me an example to
clarify the point?

Opinion / Values
21. Final question: Have we missed
anything that you would like to say?
• What should I have asked you that
I haven’t asked?

Closing
This covers the things that I wanted to ask.
Thank you [person] for giving me the opportunity to talk with you candidly about your work as a
school nurse.
o Is there anything now that you think I should strike from the conversation?
o As I review the data, and get some preliminary findings, or if I need clarification
would you mind if I reached out to you again?
o Do you have any questions?

All the best as you continue to navigate this pandemic. Please let me know if I can be of
assistance.

215

Other Probes
• What do you mean by that?
• Can you help me understand what you mean by that?
• Could you tell me more about your thinking on that?
• Can you give me an example to clarify the point?
• Any other reason?
• Would you tell me what you have in mind?
• Why do you feel that way?
• Which would be closer to the way you feel?

216

Appendix B: Crosswalk Showing KMO Assumed Influence, Data Collection, and Research
Question
Assumed Influence Data
Collection
Interview Question Research Question
Need to know about
nursing procedures,
regulations, and legislation
that affect the students in
their care, and update as
practice as any of these
evolve. (K-F)
Interviews 3. Transition question: How is the school nurse in
the position to ensure students have access to health
care?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
9. Key question: Other than during COVID, are you
able to convey your abilities as a contributor to the
conversations?
13. Key question: As the school nurse how are you
empowered in your school community?
14. Key question: What opportunities do you have to
collaborate with others?
15. Key question: Tell me about the opportunities
that you get to interact with other healthcare
professionals. Who are these professionals? Why do
you interact with them?
16. Key question: Tell me about how you reflect on
your practice. How much time do you have to
establish and set strategies?

RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ2. What are the
knowledge, motivation, and
organizational influences that
facilitate or impede the
school nurses’ ability to
convey to individuals in the
educational environment the
value of their role and how it
furthers the educational
mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?

Need to know and
understand the alignment
between their nursing
practice and the
educational mission in
order to help students lead
productive and successful
lives. (K-C)
Interviews

3. Transition question: How is the school nurse in
the position to ensure students have access to health
care?
4. Transition question: Thinking from the lens of
your role … what does your educational community
look like?
6. Key question: How do you feel you are perceived
in the education environment?
RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
217

Assumed Influence Data
Collection
Interview Question Research Question
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
11. Key question: How do you convey your value to
the school community in which you work?
13. Key question: As the school nurse how are you
empowered in your school community?
17. Key question: Think back to a time when you
wanted to make something happen that you feel
benefited the students in the school. Walk me
through what that was and what happened.

recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?
Need to know how to
effectively convey to the
K-12 education community
the school nurse’s role and
the value that they bring.
(K-P)
Interviews 3. Transition question: How is the school nurse in
the position to ensure students have access to health
care?
3a. Transition question: What role does the school
nurse have in ensuring health equity for students?
5. Transition question: How do you interact with
people in your community?
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
9. Key question: Other than during COVID, are you
able to convey your abilities as a contributor to the
conversations?
11. Key question: How do you convey your value to
the school community in which you work?
16. Key question: Tell me about how you reflect on
your practice. How much time do you have to
establish and set strategies?
17. Key question: Think back to a time when you
wanted to make something happen that you feel
RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?
218

Assumed Influence Data
Collection
Interview Question Research Question
benefited the students in the school. Walk me
through what that was and what happened.
Need to know what factors
in the educational setting
influence their clinical
practice and to work with
others to ensure that their
healthcare role continues
as a strength for the
education community. (K-
M)
Interviews 4. Transition question: Thinking from the lens of
your role … what does your educational community
look like?
6. Key question: How do you feel you are perceived
in the education environment?
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
9. Key question: Other than during COVID, are you
able to convey your abilities as a contributor to the
conversations?
11. Key question: How do you convey your value to
the school community in which you work?
13. Key question: As the school nurse how are you
empowered in your school community?
15. Key question: Tell me about the opportunities
that you get to interact with other healthcare
professionals. Who are these professionals? Why do
you interact with them?
16. Key question: Tell me about how you reflect on
your practice. How much time do you have to
establish and set strategies?
17. Key question: Think back to a time when you
wanted to make something happen that you feel
benefited the students in the school. Walk me
through what that was and what happened.
18. Key Question: What are the professional
development opportunities that you can get involved
with?
19. Ending question: What changes, if any, do you
envision would nurture your ability to practice
school nursing as you wish to practice?
RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?
219

Assumed Influence Data
Collection
Interview Question Research Question
Need to believe that by
creating awareness of their
value in the education
setting, they are
empowered to achieve role
competency, practice
autonomy within the
school, and be integral to
the school community (M-
SDT)
Interviews 5. Transition question: How do you interact with
people in your community?
6. Key question: How do you feel you are perceived
in the education environment?
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
9. Key question: Other than during COVID, are you
able to convey your abilities as a contributor to the
conversations?
10. Key question: What can be done at a faculty,
principal, leadership level to make you feel more of a
part of the school community?
11. Key question: How do you convey your value to
the school community in which you work?
13. Key question: As the school nurse how are you
empowered in your school community?
14. Key question: What opportunities do you have to
collaborate with others?
16. Key question: Tell me about how you reflect on
your practice. How much time do you have to
establish and set strategies?
17. Key question: Think back to a time when you
wanted to make something happen that you feel
benefited the students in the school. Walk me
through what that was and what happened.
18. Key Question: What are the professional
development opportunities that you can get involved
with?
19. Ending question: What changes, if any, do you
envision would nurture your ability to practice
school nursing as you wish to practice?

RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ2. What are the
knowledge, motivation, and
organizational influences that
facilitate or impede the
school nurses’ ability to
convey to individuals in the
educational environment the
value of their role and how it
furthers the educational
mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?
220

Assumed Influence Data
Collection
Interview Question Research Question
Need to believe that they
are of value to the
education setting and can
effectively share the
significance of their value
to their school community.
(M-SE)
Interviews

4. Transition question: Thinking from the lens of
your role … what does your educational community
look like?
5. Transition question: How do you interact with
people in your community?
6. Key question: How do you feel you are perceived
in the education environment?
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
9. Key question: Other than during COVID, are you
able to convey your abilities as a contributor to the
conversations?
10. Key question: What can be done at a faculty,
principal, leadership level to make you feel more of a
part of the school community?
11. Key question: How do you convey your value to
the school community in which you work?
13. Key question: As the school nurse how are you
empowered in your school community?
14. Key question: What opportunities do you have to
collaborate with others?
16. Key question: Tell me about how you reflect on
your practice. How much time do you have to
establish and set strategies?
17. Key question: Think back to a time when you
wanted to make something happen that you feel
benefited the students in the school. Walk me
through what that was and what happened.

RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?

221

Assumed Influence Data
Collection
Interview Question Research Question
Administration needs to
foster an environment
where school nurses have a
sense of belonging that
respects their professional
capacity to contribute to
the educational mission’s
success. (O-CM1)
Interviews 5. Transition question: How do you interact with
people in your community?
6. Key question: How do you feel you are perceived
in the education environment?
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
9. Key question: Other than during COVID, are you
able to convey your abilities as a contributor to the
conversations?
10. Key question: What can be done at a faculty,
principal, leadership level to make you feel more of a
part of the school community?
13. Key question: As the school nurse how are you
empowered in your school community?
14. Key question: What opportunities do you have to
collaborate with others?
17. Key question: Think back to a time when you
wanted to make something happen that you feel
benefited the students in the school. Walk me
through what that was and what happened.
19. Ending question: What changes, if any, do you
envision would nurture your ability to practice school
nursing as you wish to practice?

RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ2. What are the
knowledge, motivation, and
organizational influences that
facilitate or impede the
school nurses’ ability to
convey to individuals in the
educational environment the
value of their role and how it
furthers the educational
mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?
Administration needs to
foster an environment
where school nurses are
fully empowered to convey
their value to others. (O-
CM2)
Interviews 3. Transition question: How is the school nurse in
the position to ensure students have access to health
care?
3a. Transition question: What role does the school
nurse have in ensuring health equity for students?
5. Transition question: How do you interact with
people in your community?
RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

222

Assumed Influence Data
Collection
Interview Question Research Question
6. Key question: How do you feel you are perceived
in the education environment?
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
9. Key question: Other than during COVID, are you
able to convey your abilities as a contributor to the
conversations?
10. Key question: What can be done at a faculty,
principal, leadership level to make you feel more of a
part of the school community?
11. Key question: How do you convey your value to
the school community in which you work?
13. Key question: As the school nurse how are you
empowered in your school community?
14. Key question: What opportunities do you have to
collaborate with others?
15. Key question: Tell me about the opportunities
that you get to interact with other healthcare
professionals. Who are these professionals? Why do
you interact with them?
17. Key question: Think back to a time when you
wanted to make something happen that you feel
benefited the students in the school. Walk me
through what that was and what happened.
19. Ending question: What changes, if any, do you
envision would nurture your ability to practice
school nursing as you wish to practice?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?
223

Assumed Influence Data
Collection
Interview Question Research Question
Administration needs to
provide school nurses with
access to the support of
other healthcare
professionals. (O-CS1)

Interviews 11. Key question: How do you convey your value to
the school community in which you work?
14. Key question: What opportunities do you have to
collaborate with others?
15. Key question: Tell me about the opportunities
that you get to interact with other healthcare
professionals. Who are these professionals? Why do
you interact with them?
18. Key Question: What are the professional
development opportunities that you can get involved
with?

RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ2. What are the
knowledge, motivation, and
organizational influences that
facilitate or impede the
school nurses’ ability to
convey to individuals in the
educational environment the
value of their role and how it
furthers the educational
mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?

Administration needs to
provide adequate
professional development
opportunities for school
nurses. (O-CS2)
Interviews

3. Transition question: How is the school nurse in
the position to ensure students have access to health
care?
3a. Transition question: What role does the school
nurse have in ensuring health equity for students?
7. Key question: In your community, how are you
able to convey your abilities as a school nurse to
your community?
8. Key question: Think back over these past few
months with the COVID affecting your role. Using
this time frame as an example, are you able to share
your abilities as a contributor to the conversations?
RQ1. How does working in
the educational environment
impact the school nurse’s
ability to convey the value of
their contribution to the
educational mission?

RQ2. What are the
knowledge, motivation, and
organizational influences that
facilitate or impede the
school nurses’ ability to
convey to individuals in the
educational environment the
224

Assumed Influence Data
Collection
Interview Question Research Question
11. Key question: How do you convey your value to
the school community in which you work?
14. Key question: What opportunities do you have to
collaborate with others?
15. Key question: Tell me about the opportunities
that you get to interact with other healthcare
professionals. Who are these professionals? Why do
you interact with them?
18. Key Question: What are the professional
development opportunities that you can get involved
with?

value of their role and how it
furthers the educational
mission?

RQ3. What are the
knowledge, motivation, and
organizational resource
recommendations for
Connecticut K-12 school
nurses to convey their value
in the educational
environment?

225

Appendix C: Zoom Instructions
These Zoom instructions will be included as an attachment in the email sent to participants who
will take part in the interviews.
Zoom Instructions
The interviews will be held synchronously online via the Zoom video conferencing
platform (Zoom Video Communications Inc., 2020). Zoom is a cloud-based platform that allows
for online group meetings, includes chat capabilities, and has the capacity for secure recording of
sessions. You do not need a Zoom account to access the Zoom meeting.
For security reasons, you will receive a unique Zoom ID link when the interview time has
been agreed to. The Zoom account is in my name and is provided by my employer and can be
used for research purposes. Your privacy is protected as access to any recordings is password
protected.
Participants can easily connect to the session via web browser on a computer, or an app
from an electronic device. Here are some tips for added privacy during the Zoom interview:
• To turn off your device camera:
o Use the “Stop Video” function in the bottom menu bar to turn off your
device’s camera to avoid being seen
• To change your participant screen name:
o open the “participants” list function in the bottom menu bar
o mouse over your name in the participant list
o click more → “Rename” → enter a new screen name
Zoom recording is disabled as you enter the meeting. The researcher will verbally request
that you agree to be recorded. Only once you agree will the recording be started. Zoom will then
require you to electronically consent to the recording. If you do not agree to be recorded, the
recording will not be started. For security purposes, all Zoom recordings are password protected.
More information about Zoom can be found at https://zoom.us/
This study has received approval from the University of Southern California Institutional Review
Board.
226

Appendix D: Communications
Email 1: Email to Request Participation
Subject: USC Doctoral Student: An Opportunity to take part in Research about CT School
Nursing
Welcome!
My name is Janene Batten and I am a doctoral student in the Organizational Change and
Leadership program at the University of Southern California (USC) Rossier School of
Education. By further way of introduction, although I am studying at USC, I have lived in
Connecticut for the past 25 years. As a university medical librarian in Connecticut, I have a
long-standing connection with school nurses by providing for your information needs. As a result
of this connection, I am deeply interested in your nursing practice in the educational
environment.
So here I am today with an invitation for you to participate in a study. The purpose of the
study is to evaluate Connecticut K-12 school nurse’s perceptions about how individuals in the
educational environment value your role and practice in ensuring students are healthy and ready
to learn. This study can benefit school nurses by identifying resource recommendations for
Connecticut K-12 school nurses to convey their value to the educational environment. This study
has received approval from the University of Southern California Institutional Review Board.
More information about the study is attached in the document titled Information Sheet for
Exempt Research.
Should you choose to participate, I will conduct an interview that will take us
approximately one hour. During these interviews, I will ask you about your current experiences
as a school nurse in the educational environment and what your ideal work environment looks
like. In return for participating in the interview, you will receive an advance copy of a research
report summarizing the findings.
Due to the current pandemic health precautions, the interview will be via Zoom (Zoom
Video Communications Inc., 2020), and at a time that is convenient for you when we can speak
uninterrupted.
227

I hope that you choose to join me for a conversation about your work as a school nurse. If
you would like to participate in an interview, please click the link below and follow the
instructions. The link is to a short confidential survey of 15 questions, including details about
how to get in contact with you. The questions include demographic details about you and your
place of work. This information will be used to both contact you, and to provide some
background for the study about the participants. All information in this survey is completely
confidential.
Thank you for assisting me with my doctoral research and for contributing to the science
advancing the understanding of Connecticut school nursing practice. I would be grateful if you
spent a few minutes reviewing USC’s information sheet [web link to be added] for exempt
research that describes the research’s purpose and outlines your rights as a research subject.

If you have any questions about this study, please contact me or my advisor, Dr.
Alexandra Wilcox (amwilcox@usc.edu).

Thank you for your time

Janene Batten (janeneba@usc.edu)
Doctoral Candidate, University of Southern California

This study has received approval from the University of Southern California Institutional Review
Board.

228

Email 2: Follow up Email Confirming Participation
Subject: USC Doctoral Student: Scheduling an Interview for School Nursing Research
Dear [name of participant]
Thank you for offering to participate in an interview that will focus on how individuals in
the educational environment value your role and practice in ensuring students are healthy and
ready to learn. As a reminder, this study is associated with my doctoral program at the University
of Southern California (USC) Rossier School of Education.
Attached to this email are three documents:
1. Information Sheet for Exempt Research
2. Informed Consent for Research form to participate in this research.
3. Zoom instructions
4. Instructions for keeping a diary (non-mandatory)
Scheduling the Interview
Due to the current pandemic health precautions, the 60-minute interview will be via
Zoom, and at a time that is convenient for you when we can speak uninterrupted. I would like to
arrange a time for us to meet to have a conversation about your work as a school nurse. I would
like to meet some time during the week of [January X]. Can you please let me know:
• three day-and-time windows during that week would work for you to set aside this
hour? I am also happy to meet with you on the weekends.
• if you would prefer to not record the interview
Once we confirm when we will meet, I will send you a separate email with the meeting
invitation, including the Zoom meeting link.
[Name], I am really looking forward to our conversation. Thank you again for helping
with this study to identify resource recommendations for Connecticut K-12 school nurses to
convey their value to the educational environment.
If you have any questions about this study, please contact Janene Batten (janeneba@usc.edu) or
my advisor Dr. Alexandra Wilcox (amwilcox@usc.edu).

229

Many thanks
Janene Batten
Doctoral Candidate, University of Southern California
This study has received approval from the University of Southern California Institutional Review
Board.

230

Appendix E: Participation Survey
University of Southern California
Rossier School of Education - Organizational Change and Leadership

Doctoral Study:
ACHIEVING THE EDUCATIONAL MISSION: ARE CONNECTICUT SCHOOL NURSES
VALUED

Survey for interview participants.

Hello again

Thank you for offering to participate in a study to discover Connecticut school nurse’s
perceptions about how individuals in the student health environment value the role and
practice in ensuring students are healthy and ready to learn. For more information about this
study please see this Information Sheet – Exempt Research that you received in email.
The study is associated with my doctoral program at the University of Southern California (USC)
Rossier School of Education. This study has received approval from the University of Southern
California Institutional Review Board.
This survey is anonymous. It is designed to gather basic information about the school nurses
who agreed to participate in an interview. Participation in this survey is completely voluntary.
Completion of the survey is taken as agreement to consent to participate. However, if you no
longer want to participate, please discontinue completing the survey and go to the last question
and let me know that you no longer want to participate.
If you have any questions about this study, please contact Janene Batten (janeneba@usc.edu) or
my advisor Dr. Alexandra Wilcox (amwilcox@usc.edu).
I am looking forward to hearing more about you!
Janene Batten (janeneba@usc.edu)
Doctoral Candidate, University of Southern California
This study has received approval from the University of Southern California Institutional Review
Board.
Details about your SCHOOL NURSING DEMOGRAPHICS
1. How many years have you been a school nurse?
2. What is your current position?

231

3. How many schools are you responsible for?
4. How many students attend the school/s where you work?
5. Approximately how many students with chronic conditions do you care for?
6. How many other school nurses are there …
… in your school
… in your district
7. Who is your employer? E.g. Board of Education; Board of Health;
8. What is your current employment status?
Full-time
Part-time
Per Diem
Other
9. Does your school district have a school nurse supervisor?
Yes
No
Not sure
10. Does your school district have access to a school-based health center?
Yes
No
Not sure
11. What is your past work experience prior to becoming a school nurse?
Details about your EDUCATION
12. How many years have you been a registered nurse?
13. What was your entry point into nursing? Please select one.
Diploma
Associates Degree
Bachelor’s Degree
Secondary Bachelor’s Degree
Master’s Degree
14. What is your highest level of education?
232

Diploma
Associates Degree
Bachelor’s Degree
Master’s Degree
Doctoral Degree
15. What year did you receive your highest degree?
16. Are you a national board-certified school nurse (NSCN)? Please select one.
Yes
No
Not sure
17. How many years since you obtained your NSCN certificate?
18. Do you have state-specific school nurse certification? Please select one.
Yes
For which state?
No
Not sure
19. How many years is it since you obtained your state-specific certificate?
Details about your PROFESSIONAL AFFILIATIONS
20. Are you a member of the Connecticut School Nurses Association?
Yes
No
Not sure
21. Are you a member of the National Association of School Nurses?
Yes
No
Not sure
22. What other professional organizations are you a member of?
NONE
Name of Other Organization
Not sure
233

MORE ABOUT YOU
23. What is your year of birth?
24. How would you describe yourself? Please select all that apply.
Asian
Black/African
Caucasian
Hispanic/Latinex
Native American
Pacific Islander
Prefer not to answer
Write in option

25. Is there anything else that you would like me to know about you or your school nursing
situation?
Thank you for taking the time to complete this survey. I will be reaching out via email in the
next few weeks to set up a convenient time for us to talk.
If you have any questions about this study, please contact me Janene Batten
(janeneba@usc.edu) or my advisor, Dr. Alexandra Wilcox (amwilcox@usc.edu).
Janene Batten
Doctoral Candidate, University of Southern California
This study has received approval from the University of Southern California Institutional Review
Board.

234

Appendix F: Information Sheet for Exempt Research
The information sheet for exempt research will be included as an attachment in the email
sent to participants who will take part in the interviews.

INFORMATION SHEET FOR EXEMPT RESEARCH
STUDY TITLE: Achieving the Educational Mission: Are Connecticut K-12 School Nurses
Valued?
PRINCIPAL INVESTIGATOR: Janene Batten
FACULTY ADVISOR: Alexandra Wilcox, JD, MFA, EdD
You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything that is unclear to
you.
PURPOSE
The purpose of this qualitative phenomenological study is to evaluate how Connecticut K-12
school nurses perceive their practice and role in the educational environment are valued in
furthering the education mission, ensuring students are healthy and ready to learn.
School nurses are distinct nurse specialists who work in the K-12 educational environment
and whose core focus is to promote students’ healthy behaviors to support educational
achievement (National Association of School Nurses, 2017). However, school nurses encounter
barriers to practice to their full scope. School nurses do not work in the healthcare milieu of
collaborative support of other nurses in proximity. They work in isolation and without
underlying culture and infrastructure vital to the success of nursing practice
We hope to learn how working in the educational environment affects the school nurse’s
ability to convey how the school nurse role and practice further the education mission. You are
invited as a possible participant because you are a Connecticut K-12 school nurse.

235

PARTICIPANT INVOLVEMENT
Participation in this study is completely voluntary, and you have the right at any time and
for any purpose, to withdraw from the study.
You will be interviewed as a part of this study. The time of the interview will be arranged
at a time that is convenient to you. As a participant, you have been informed about the topics that
will be discussed and have been encouraged to keep a diary of events or thoughts you have on
the topic. These diaries will remain as your notes unless you decide to pass them along to the
researcher. If you do pass them along, they will remain confidential.
Interviews will take place via the Zoom video conferencing platform and will last
approximately one hour. With permission, each interview will be audio-recorded and transcribed
verbatim later. The Zoom software automatically includes the identifying credentials of the
person that is logged in to the interview. If you do not want to be identified by the credentials in
Zoom during the interview, please ensure that you have followed the instructions explaining how
to remove your name from the software. If you choose not to do that, it will be edited at the time
of transcription.
CONFIDENTIALITY
The members of the research team, Janene Batten and Dr. Alexandra Wilcox (faculty advisor),
and the University of Southern California Institutional Review Board (IRB) may access the data.
The IRB reviews and monitors research studies to protect the rights and welfare of research
subjects.
When the results of the research are published or discussed in conferences, no identifiable
information will be used.
Every effort will be made to protect your privacy and to preserve confidentiality. All
information about your participation, as well as the content of the conversation, will be
confidential. You will have the opportunity to strike anything from the record before the end of
the interview.
The Zoom software automatically includes the identifying credentials of the person that is
logged in to the interview. Please ensure that you have followed the instructions explaining how
236

to remove your name from the software. If you choose not to do that, it will be edited at the time
of interview transcription.
Transcription software will be used to transcribe the interview recorded via Zoom. All
identifying information will be removed at that time. As necessary, editing the transcript will
ensure that participant details are removed from the transcript, but that what remains are
identifiers that distinguish who said what. You have the right to review the transcript after the
interview to determine if there is anything that you wish to edit, or do not want to be included in
the data analysis.
All data from this interview will be stored on a secure hard drive. The data will be
destroyed at the end of the study.

INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact Janene Batten (janeneba@usc.edu) or
Dr. Alexandra Wilcox [faculty advisor] (amwilcox@usc.edu).
IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at 323-442-0114 or email
irb@usc.edu.

National Association of School Nurses. (2017). School nursing: Scope and standards of practice
(3rd ed.). American Nurses Association.

Abstract (if available)

Abstract Background: Healthy students are better learners is central to the K-12 education mission to graduate students successfully. School nurses support students’ educational success by taking care of their immediate health needs, coordinating care for students’ chronic health conditions, and promoting healthy behaviors. This study uses a knowledge, motivation, and organizational gap analysis framework to evaluate how Connecticut school nurses perceive their role and practice in the educational environment are valued to further the educational mission. ❧ Methods: A qualitative phenomenological design was used. Fourteen Connecticut school nurses were interviewed via Zoom in January 2021. Data from interviews was analyzed using thematic analysis. ❧ Results: Although school nurses believe that they bring value to students by providing equitable access to healthcare and wellness education, they felt that the organization did not recognize how indispensable they are to meeting the educational mission. School nurses identified four areas of opportunity: advocacy skills that enables the organization to recognize the alignment of the school nurse expertise with the educational mission; belief in their ability to advocate to change workload levels to ensure the provision of safe healthcare; and an advocacy platform within the organization to convey their value as essential to the educational mission. ❧ Recommendations: Empower school nurses to advocate how and why their role is indispensable to the K-12 educational mission.

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Asset Metadata

Creator Batten, Janene (author)

Core Title Achieving the educational mission: are Connecticut K-12 school nurses valued?

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2021-08

Publication Date 08/03/2021

Defense Date 07/06/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag K-12 education,OAI-PMH Harvest,school nurses

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Wilcox, Alexandra (committee chair), Datta, Monique (committee member), Hinga, Briana (committee member)

Creator Email janene.k.batten@gmail.com,janeneba@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC15675127

Unique identifier UC15675127

Legacy Identifier etd-BattenJane-9979

Document Type Dissertation

Format application/pdf (imt)

Rights Batten, Janene

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu