Date of Award


Degree Name

PhD Nursing

Dissertation Committee

Patricia A. Roth, EdD, RN, Chair; Mary Jo Clark, PhD, RN; Susan L. Instone, DNSc, RN


Grounded theory, medically fragile, nursing, public schools, school nurses, students


In 1999, the Supreme Court ruled that school districts were financially responsible to provide related services including nursing services, to medically fragile students. This decision applied to children attending public schools who have complex health problems and are tracheostomy dependent. The purpose of this grounded theory study was to explore role perceptions of eighteen school nurses caring for these children in classrooms. Six dimensions emerged from the data: Promoting Family/Nurse Connections, Adapting the Environment, Claiming Authority, “Standing Out There”, Striking a Balance and Experiencing Success. Promoting Family/Nurse Connections emerged as the central perspective, essential to implementing a plan of care. Solicited parental knowledge about individual student preferences and care routines helped contribute to a successful transition between the home and classroom. Adapting the Environment described the context in which the work of these nurses took place. Classroom challenges of limited physical space, lack of privacy, and inadequate specialized equipment were frequently encountered. School nurses faced the complexities of providing highly sophisticated nursing care to students with differing language capabilities, ethnicity, or health values. Implementing plans of care required continuing communication with numerous health care providers and multiple insurance payers. Claiming Authority described the in-depth clinical knowledge and technical expertise school nurses needed to manage students requiring respiratory support, artificial feedings, and urinary catheterizations in classroom settings. Nurses frequently functioned in collaboration with teachers, therapists, and members of the educational support team. “Standing Out There,” described conditions of both fear and autonomy. Fear was heightened by a sense of being the only nurse, and having limited emergency equipment on site or assistance from trained medical personnel. Positive outcomes resulting from independent nursing decisions reinforced a sense of autonomy. Striking a Balance described the professional nursing judgment involved in conducting physical assessments, determining health priorities and balancing these with each student's educational program. Experiencing success was a consequence of respecting students' intrinsic values of perseverance and determination, facilitating successful student transitions, and effectively integrating facets of the nursing role. Further research questions regarding medically fragile children in classrooms were generated, and areas of ethical conflict and health policy reform were identified.

Document Type

Dissertation: Open Access



Included in

Nursing Commons