Research evidence in the acute care nursing literature identifies the impact a positive work environment has on job satisfaction, nursing turnover, cost-reduction strategies and patient outcomes (Li et al., 2013; Lizano & Mor Barak, 2015; Portoghese, Galletta, Coppola, Finco, & Campagna, 2014). School nurses play a critical role in the provision of child health care. Yet, we have little information on levels of burnout or factors defining the school nurse work environment. The school nurse work environment is very different from acute care hospital settings. School nurses practice independently, often in isolation from other nurses. In the acute care setting, nurses typically report to another nurse administrator who understands the role and responsibilities of the nurse. In contrast, school nurses usually report to a school administrator who has limited understanding of the scope of nursing practice and professional nurse practice laws and regulations. The limited school nurse literature suggests that school nurses have consistently acknowledged they feel a lack of control or sense of powerlessness, identifying conditions such as a lack of participation in decision making processes, inadequate administrative support, poor communication, and large student to nurse workloads (Broussard, 2007; Chang, Shih, & Lin, 2010; Junious et al., 2004; Lineberry, Whitney, & Noland, 2017). When nurses work in disempowering conditions, they are more likely to be burned out and less satisfied with their jobs (Laschinger, Wong, Cummings, & Grau, 2014; Poghosyan, Nannini, & Clarke, 2013; Van Bogaert, Kowalski, Weeks, Van heusden, & Clarke, 2013; Yang & Li, 2018).
The over-arching intent of this convergent parallel mixed methods study was to explore how school nurses’ perceptions of their work environment illuminate understanding of the relationships between workplace empowerment, burnout and areas of work job satisfaction.
This study, approved by the university IRB, used a convergent parallel mixed method design. The reason for combining both quantitative and qualitative data was to better understand this research problem through a robust investigation integrating qualitative and quantitative methodological traditions. Data were collected in parallel, analyzed separately according to their specific methodologies, and then integrated with equal weighting. The MBI-HSS was used to measure the relationship between burnout and the Areas of Worklife Survey (AWS) was used to measure areas of work life satisfaction among 100 New Jersey school nurses. At the same time, empowerment was explored using semi-structured in-depth interviews with 20 New Jersey school nurses. The analysis of the interviews used an iterative process of across, between and over lines of transcripts to generate concepts and themes that emerged from interpretations of the data. Quantitative results were analyzed with descriptive statistics, correlations, regression models and analyzed for differences. Convergent analysis used qualitative software thematic cluster analysis to understand the relationships, contrast and compare findings from both data sets (Creswell, 2014; Siddiqui & Fitzgerald, 2014). This research examined responses from a larger mixed-methods study that investigated the factors associated with challenges and barriers, levels of burnout and job satisfaction in the school nurse work environment (Jameson, 2018). This research was the first known use of the MBI-HSS and AWS with school nurses found in published research and dissertations, addressing a substantial gap in the school nurse work environment literature. Data were collected in 2016 and 2017.
The major theme that emerged from the interview data was “Caged Leaders.” School nurses viewed themselves as health care leaders with no authority or formal power, working as the sole health care individual in a setting focused primarily on educational outcomes. Three areas emerged from the interview data regarding empowerment: control over the content of practice, control over the context of practice, and control over competence. A surprising finding was that school nurses rated control over practice highly in the AWS survey data; these findings were not consistent with the interview data. Twenty-eight percent of school nurses were highly burned out. Workload was the biggest predictor of burnout. All subscales combined explained 56% of the variance in burnout. Convergent analysis of workplace empowerment indicated that surveillance and student safety were most strongly affected.
The construct of control alone in the AWS may not adequately address the unique characteristics of the school nurse work environment. School nurses described disempowering workplace structures which limited areas of control over practice, lack of access to resources and limited authority or power, suggesting that school nurses will likely experience stress and frustration which could lead to burnout, reduced job satisfaction, and influence the provision of safe and quality care (Dyrbye et al., 2017; Goodwin, 2017; Manzano-García & Ayala, 2017). This study moves our understanding of school nursing workplace empowerment that control is multi-dimensional and is more than the ability to make decisions about daily clinical practice matters autonomously. School nurses require the resources and work environment structures that promote control over practice, self-efficacy practices to believe they have the ability to be empowered, and an understanding that there is power in relationships and care provision. Using this understanding indicates that these areas can support school nurses to be empowered and use that power to contribute to the health and safety of those in their care. The evidence provides a beginning point for school nurse researchers, school administrators, policy makers and school community stakeholders in understanding predictors of school nurse burnout, organizational factors that influence role enactment, links to student health outcomes and developing targeted interventions.