School Nurse Well-Being as a Workplace-Embedded Outcome: A Collective Qualitative Case Study

Design

This study used a qualitative collective case study design to examine how workplace conditions shape school nurses’ psychological well-being across diverse institutional contexts. Case study methodology is well suited to investigating complex phenomena within real-world settings and bounded systems (Creswell & Poth, 2018). For this study, each participant is a case and represents a bounded system and unit of analysis. Because school nurses work in highly heterogeneous environments—varying by school type, student acuity, staffing structures, and geographic region—a collective case approach enabled systematic comparison across cases while preserving contextual depth. Examining multiple bounded cases supports both within-case and cross-case analysis, strengthening analytic rigor and theoretical insight (Schoepf & Klimow, 2022; Stake, 1995). This design therefore allowed identification of convergent and divergent workplace patterns influencing well-being.

Ethical Considerations

All study procedures were approved by the George Washington University Institutional Review Board (IRB #NCR245586) and conducted in accordance with ethical standards (Capili & Anastasi, 2024). Verbal informed consent was obtained from each participant over Zoom before data collection. Confidentiality was ensured by de-identifying participants and their personal information before data were analyzed and synthesized. To protect the anonymity of participants, names and identifying information were replaced with aliases and participant identification numbers, and composite profiles were created (Creswell & Poth, 2018).

Population and Setting

The target population was school nurses who met the following eligibility criteria: as a licensed registered nurse, work full-time as an elementary, middle, or high school nurse in a public school, have at least 1 year of experience as a school nurse, speak English, have access to the Zoom meeting platform, and be able to provide informed consent. Using personal and professional networks, the primary researcher contacted school nurses by email and/or phone using an IRB-approved recruitment script. The study setting was virtual—all data collection was acquired using a web-based questionnaire (REDCap), a web-based meeting platform (Zoom), and a web-based journaling format (REDCap). Participants represented a nationally diverse sample of school nurses working in U.S. public elementary, middle, and high schools across the Northeast, South, Midwest, and West, reflecting substantial regional variation in school nurse staffing and coverage documented in the National School Nurse Workforce Study 2.0 (Willgerodt et al., 2024).

Sampling Procedure and Sample Size

Purposeful sampling was employed to ensure inclusion of participants across different school settings and geographic contexts, consistent with qualitative best practices for capturing variation in experiences (Creswell & Poth, 2018). Study participants identified additional eligible school nurses as a snowball sampling method to support ongoing recruitment and data collection. Prior qualitative case studies using interviews and journaling have demonstrated that analytic depth is typically achieved with 14–19 cases (Foong et al., 2022; Mastroianni & Storberg-Walker, 2014). Consistent with this guidance, recruitment for this study continued until data saturation was reached—defined as the point at which no new analytic insights emerged (Aguboshim, 2021; Glaser & Strauss, 1967)—resulting in a final sample of 26 cases.

Measures and Data Collection

The NSM guided data collection across a multistage exploration of school nurses’ perceptions of workplace factors and their psychological well-being using semi-structured interviews (to explore intra-personal factors), journaling (to explore inter-personal factors), and analysis of workplace documents (to explore extra-personal factors) (Neuman, 1989). All study measures were pre-tested with a small focus group of school nurses (Howard, 2019). Focus group pretest data were used only for instrument refinement and were not included in the analysis. Results of workplace document analysis are not reported in this paper.

Data Analysis

Data analysis included exploration of participant data to identify links to the NSM constructs of intra-personal, inter-personal, and extra-personal factors. Data analysis was completed in three separate phases. First, data from the sociodemographic questionnaire were analyzed for descriptive statistics and frequency distribution. Second, data from the interviews and journaling were analyzed together using the constant comparative method. Third, data from the job descriptions were analyzed using content analysis. Fourth, two coders—the primary researcher and a trained qualitative analyst—independently coded the data using thematic analysis to identify patterns and relationships among and between codes, with discrepancies resolved through discussion.

Thematic analysis was conducted following Braun and Clarke's (2006) approach, involving iterative coding, pattern identification, and theme development across cases. A theory-informed coding framework grounded in the NSM guided analysis of interview and journal data. A codebook, developed from prior literature and iterative review, was applied independently by the primary researcher and a trained qualitative analyst. Intercoder reliability was assessed in NVivo using Cohen's kappa, with discrepancies resolved through consensus meetings to ensure analytic rigor (Lombard et al., 2002). Coding was iterative and reflexive, allowing for the refinement and addition of codes as analyses progressed. Using constant comparative and thematic analysis, coded data were organized into patterns and synthesized into themes that addressed the study's research questions.

Sociodemographic Questionnaire Results

Participants represented 13 states, including Colorado, Connecticut, Illinois, Kentucky, Maryland, Michigan, Minnesota, New Jersey, North Carolina, South Carolina, Texas, Wyoming, and the District of Columbia. Among the respondents, all 26 identified as female and non-Hispanic or Latino, and most identified as White. The sample also reflected a relatively younger cohort, with the majority aged 44 years or younger. Further demographic and workplace characteristics are summarized in Table 1.

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Table 1.

Participant Demographics and Workplace Characteristics.

Variable	Category	Frequency	Percentage (%)
Geographic location	Midwest	10	38.50
	South	9	34.60
	Northeast	4	15.40
	West	3	11.50
Gender	Female	26	100
	Male	0	0
Ethnicity	Non-Hispanic or Latino	26	100
	Hispanic or Latino	0	0
Race	White	24	92.31
	Asian	1	3.80
	Black or African American	1	3.80
Age of participants (years)	25–34	3	11.5
	35–44	12	46.2
	45–54	8	30.8
	55–64	2	7.7
	65 or older	1	3.8
Highest degree achieved	Associate's degree (ADN)	1	3.85
	Bachelor's degree (BSN)	16	61.54
	Master's degree (MSN)	9	34.61
Years as a school nurse	1–2	2	7.69
	2–5	9	34.62
	6–10	8	30.77
	11–15	5	19.23
	16–20	1	3.85
	>20	1	3.85
Number of studentsresponsible for	<250	1	3.80
	250–500	7	26.90
	501–1,000	8	30.80
	1,001–2,000	6	23.10
	2,001–3,000	2	7.70
	3,001–4,000	0	0
	>4,000	2	7.70
Number of schoolsresponsible for	1	16	61.54
	2	4	15.38
	3	2	7.69
	4	1	3.85
	6 or more	3	11.54
Reporting structure	School district	22	84.62
	Department of Health	3	11.54
	Hospital organization	1	3.85
Salary	≥$80,000	11	42.30
	$60,000–$79,999	8	30.80
	$40,000–$59,999	5	19.20
	≤$39,999	2	7.70

Most participants were bachelor's-prepared, and school nursing experience ranged from 1 year to over 20 years, with the majority reporting between 2 and 10 years of experience (65.38%, n = 17). Participants served student populations of varying sizes, most commonly between 250 and 1,000 students (57.69%, n = 15), and the majority were responsible for one school (61.54%, n = 16). Most participants reported the school district as their supervisory structure, and many identified other school nurses as key sources of professional support (88.46%, n = 23). In addition, most participants reported to the school district (84.62%, n = 22). Salaries varied across participants, with the largest proportion reporting annual earnings of $80,000 or more (Table 1).

Interviews and Journal Entry Results

The findings generated from coders’ analysis of interview transcripts and journal entries highlighted five emergent themes: team membership, professional recognition, flexibility, role clarity, and because of the kids. Table 2 provides exemplar quotes illustrating both positive and negative impacts on school nurses’ psychological well-being. Some themes emerged based on frequency (team membership, professional recognition, and role clarity), while others emerged based on the emotion connected to the participants’ perspectives (flexibility and because of the kids). According to Nowell et al. (2017), themes can also emerge based on content that captures something important in relation to the overall research question.

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Table 2.

Themes and Subthemes on School Nurses’ Feelings of Well-Being.

Themes	Subthemes	Example Quotes
Team membership	Support	“We have each other's back [and] incredible support from administration and the team” (Participant 14).
		“I do not always feel that the leadership team is in touch with the needs/concerns of all the school nurses” (Participant 2).
	Feeling valued	“Many times, I do not feel valued as a team member in the school setting. My concerns are not valued. These types of stressors affect so many body systems, including the immune system and my mental health” (Participant 23).
	Decisionmaking	“There are often changes in policies and procedures that directly affect the school nurses, but we do not have a voice in decision-making process” (Participant 2).
	Professionalappreciation	“I find myself frustrated like, I joke, and I’ll say, I’m the redheaded stepchild, you know of the school, ‘cause I would, I don’t fit in in any specific spot” (Participant 10).
		“You just have to keep in mind, you know, I’m in an education setting, not a medical setting” (Participant 26).
	Relationships	“Nurse relationships can impede psychological well-being if they bring a negative attitude to the group or have an unwillingness to change” (Participant 1).
Professional recognition	Salary/compensation	“The pay is not great. It is not equitable” (Participant 13).
		“We have taken a big cut in pay to be in the school” (Participant 11).
	Feeling valued	“People's relationship with the role of the school nurse like it makes a huge difference. You know their perception of the role” (Participant 10).
	Professionalappreciation	“The acuity level of our students is significantly increasing and they cannot possibly understand what it takes to run a health office safely” (Participant 14).
	Support	“The challenges when working with staff that are not in the healthcare field can complicate the workplace even more” (Participant 24).
Flexibility	Work-lifebalance	“I don’t miss holidays. I don’t have to work weekends, so I feel like my well-being is good cause I’m not having to miss out on things that are important to me, and make me feel good” (Participant 24).
	School nurseschedule	“The schedule is fantastic” (Participant 11).
Role clarity	Responsibility	“In the context of education, it's just not always clear what my role is” (Participant 5).
	Reportingstructure	“The two building nurses report to me, and I report to, for whatever reason, the middle school principal” (Participant 25).
	Uncertainty	“I feel like sometimes I’m thrown things that aren’t for me. They don’t know what to do and they throw it to me anyways” (Participant 8).
	Nurse:Student	“I am the sole nurse for 21 buildings and 12,000 students” (Participant 18).
	Professionalappreciation	“No one really knows what's going on with the nurses themselves. It was like daunting, because I think they thought that I was a sub” (Participant 3).
Because of the kids	Relationships	“So I really love being able to build those relationships with families and the students” (Participant 5).
	Nurse acuity	“During the school day I had 11 g-tube feeds” (Participant 5).

Psychological Well-Being as a Workplace-Embedded Construct

Participants did not describe psychological well-being using formal mental health terminology. Instead, they described it through their lived experience of work—feeling valued or dismissed, supported or isolated, confident or uncertain in their role. This pattern suggests that school nurses experience well-being less as an internal emotional state and more as a reflection of how their organizations treat them (West et al., 2018). When nurses described being listened to, included in decision-making, and supported in managing complex student needs, they associated these conditions with positive workplace experiences. Conversely, when they felt excluded, undervalued, or left to manage clinical responsibilities without adequate support, they described frustration, uncertainty, and diminished well-being.

Jakobsson and Moberg (2025) found that Swedish school nurses felt capable of and motivated to engage in student health-promoting activities in a “positive work environment” (p. 11). This positive work environment was described as one in which there was structure, clear expectations, and interprofessional collaboration. In contrast, these same school nurses reported workload constraints and poor dynamics with their colleagues limited their motivation for and capacity to provide student health promotion.

This workplace-anchored understanding of nurse well-being aligns with the findings of Bond et al. (2025), who argue that well-being is not merely an individual responsibility but a systemic outcome shaped by organizational conditions. Nurses cannot sustain their well-being in environments that undermine professional values or expose them to persistent stress. This study extends that evidence by showing that the school nurse setting introduces distinct workplace challenges that further erode well-being. The findings highlight a structural dimension to school nurse well-being, emphasizing the critical role of organizational environments in enabling or constricting safe and effective practice.

Team Membership as a Structural Determinant of Well-Being

Team membership was one of the most powerful influences on well-being that emerged from this study. Participants described feeling psychologically well when they were included in meetings, consulted for clinical decisions, and treated as legitimate members of the school community. Inclusion signaled respect and professional legitimacy, whereas exclusion communicated that their expertise and presence were dispensable. Importantly, these dynamics were not trivial or interpersonal in a narrow sense; they determined whether nurses had access to information, authority, and institutional protection when managing medically complex students.

These findings refine prior research on collegial relationships in school nursing. While Maughan and Adams (2011) highlighted the importance of interactions that support school nurses’ integration and perceived value within the school team, the present study suggests that inclusion in institutional processes and decision-making further shapes nurses’ well-being beyond interpersonal relations alone. Nurses who lacked a voice in policy changes, care plans, or scheduling decisions experienced significantly greater distress, even when interpersonal relationships were cordial. Similarly, Aljabery et al. (2024) found that system-level constraints contributed to nurses’ emotional and psychological suffering even when interpersonal dynamics were not overtly conflictual.

Professional Recognition as Institutional Valuation

Professional recognition was not simply about being thanked; it reflected whether nurses’ clinical expertise was acknowledged and integrated into school operations. Participants who felt recognized reported greater confidence, psychological safety, and satisfaction. Those who felt invisible or treated as an afterthought described diminished morale and emotional fatigue. Recognition was deeply intertwined with salary, reporting structures, and administrators’ understanding of nursing practice.

These findings align with White et al.'s (2024) call for improved communication and respect for school nurses, but they also show that recognition operates structurally. Nurses interpreted low pay, unclear authority, and limited consultation as evidence that their role was undervalued. This suggests that professional recognition in school nursing is not merely cultural; it is embedded in organizational hierarchies and resource allocation decisions.

Flexibility as a Buffer, Not a Cure

Flexibility—especially predictable schedules and realizing a work-life balance—was one of the strongest promotive factors for well-being. Nurses repeatedly cited weekends, holidays, and summers off as essential to recovery and sustainability. These findings echo Sohail et al.'s (2023) emphasis on work-life balance as protective. However, this study also shows that flexibility alone cannot compensate for inadequate staffing, unclear roles, or lack of recognition. Flexibility buffered stress but did not eliminate it.

Role Clarity and Institutional Vulnerability

Role ambiguity emerged as one of the most destabilizing stressors. Participants frequently described reporting to administrators without healthcare training, managing conflicting expectations, and being left to make high-risk clinical decisions without clear guidance. This placed nurses in ethically and professionally precarious positions, increasing anxiety and emotional strain. Smith and Firmin's (2009) identification of role ambiguity as a source of occupational stress is strongly supported here, but the present study adds a critical institutional dimension: ambiguity was often produced by educational systems that do not structurally integrate nursing expertise into leadership and policy.

Junco et al. (2024) highlighted the absence of standardized protocols and good clinical practice guidelines as obstacles to their effectiveness. In examining the state of school nursing in Spain, they found that in the absence of acknowledgment, appreciation, and regulations at the national level school, nurses are limited in their ability to contribute to the health of Spanish students.

“Because of the kids”: Student relationships as a source of professional meaning

Despite organizational challenges, nearly all participants described their relationships with students as the primary reason they remained in school nursing. Students provided emotional affirmation, purpose, and a sense of contribution. However, this meaning coexisted with rising medical acuity and increasing workload. Nurses described caring for students with complex conditions that would previously have precluded school attendance, yet they continued to find the work rewarding. This may demonstrate that meaningful relationships can sustain engagement even when structural conditions are difficult, supporting Gavin and Pleu'’s (2024) findings on student engagement and job satisfaction.

Integrating the NSM

The findings strongly support the NSM (Neuman, 1989), particularly its emphasis on inter-personal and extra-personal stressors. While intra-personal coping was present, the dominant influences on well-being were relational and institutional. Team membership, recognition, role clarity, and flexibility represent extra-personal structures that either protected or eroded psychological stability. Relationships with students, colleagues, and administrators functioned as interpersonal forces that could buffer or intensify stress. This suggests that interventions must target organizational systems, not only individual resilience.