Standard 3

Relationship between Theory, Research and Practice

By design, the school nurse preparation program provides a variety of opportunities for candidates to reflect, analyze, and implement the relationships between theory and evidence based practice related to school nursing.

By design, the School Nurse Credential Program provides a variety of opportunities for candidates to reflect, analyze, and implement the relationships between theory and evidence based practice related to school nursing.  In coursework, school-based observations and supervised fieldwork, candidates examine nursing, education, other theories and research, and their relationship to (a) student health and wellness; (b) school and community health; and (c) student achievement.

Criterion 1: In coursework, school-based observations and supervised fieldwork, candidates examine education, other theories and research.

Prior to entering the credential program, candidates are required to take a course in nursing research, as well as a statistics course, so they understand the importance of research in nursing practice. The core school nursing courses are designed so candidates gain an understanding of the importance of evidence based practice in school nursing.  In NURS 184, Week 2, candidates may respond to a question to discuss the impact school nursing has on school performance based on research findings to validate school nurse interventions in the educational setting.  Candidates demonstrate that evidence-based practice means the conscientious, explicit and judicious use of current best evidence in making decisions about the care for clients, and that school nurses must make an effort to keep abreast of evidence based practice through reading current research articles specifically related to school nursing practice. Within the program, candidates have online access to research articles in the National Association of School Nursing Journal of School Nursing and the American School Health Association Journal of School Health.

Weekly questions in NURS 184 and NURS 185 (seminars) require candidates to read current research articles in order to respond with evidenced-based criteria. Candidates develop an awareness that school nurses cannot rely on intuition, unsystematic observations, pathophysiologic rationale, in providing appropriate care, but must use research and evidence to guide clinical decision making. Thus, evidence-based practice combines the current research-based evidence with clinical expertise and client preferences to make a decision about approaching the care for a specific child or adolescent. This is further exemplified in NURS 186 in a case study assignment in which candidates address these three concepts in order to meet the healthcare needs of the child.

In addition, journal questions in practicum courses candidates select research articles specifically related to client care in their clinical practice to Candidates apply how current research findings to specific situations. The importance of research is also emphasized in NURS 185, School Nurse Seminar, Week 13 The questions relate to applying research in school nursing, role of the school nurse in research projects, as well as grant writing and steps to publishing articles and research findings.
In N 185 candidates may complete a research paper describing adolescent mental health issues in which they are required to review current research related to the subject matter. Online discussion with regard to evidence based practice also takes place among candidates in practicum courses.

Candidates in the post-baccalaureate program do not complete a research project; however, they complete surveys to determine staff and student interest in programs and health education offerings. Candidates apply theory and clinical knowledge as a basis for decision-making in school nursing practice. The candidate applies theoretical concepts from nursing, the behavioral, social, and public health sciences. The program includes, but is not limited to, the specific theories and clinical knowledge domains delineated below. Students acquire knowledge about theoretical concepts and contemporary issues through nursing courses and coursework in other departments. The credential program is designed to provide students opportunities to apply theories and investigate contemporary concerns throughout the core school nurse courses (NURS 184, NURS 185, NURS 186, NURS 187) and accompanying coursework. In the core courses, this may be done through written assignments, responses to weekly research questions, online discussions with peers, participation in small group activities, in accomplishing competencies and skills in practicum experiences as observed by a candidate’s school nurse preceptor and evidenced through clinical journaling (see Syllabi). Theories introduced in didactics are applied in clinical experiences (see Matrix and Course Content Analysis). Elementary school age issues, with relative theories and knowledge domain, are studied in NURS184, Introduction to School Nursing, and carried out in NURS 186, School Nurse Practicum I. Issues specific to adolescent health concerns (growth and development, attitudes, mental health, and learning theories, group process,) are addressed in Nursing 185, School Nurse Seminar, and carried out by candidates in their secondary practicum experience in NURS 187, School Nurse Practicum II.

Specific Theories Used by Candidates in the Program

Nursing Theories:
Theory of Care - Neuman’s Systems Model/Theory (stress/coping). Margaret Neuman (1979) Theory of Development in Nursing and Health as Expanded Consciousness. Neuman’s Systems Model is the theoretical foundation of the Nursing Department curricular plan, and adapts very well to school nursing practice. Candidates in the program learn to apply it in helping clients identify and reduce stressors and strengthen lines of defense in coping with internal and external stressors that impact a client’s ability to function effectively, thus impacting a child’s ability to learn or a family’s ability to cope with the pressures of life. It was the theorist’s belief that nursing theories should focus on the life process, aspects of the life process related to health, and actions facilitating health. This theory focuses on health as expanding consciousness, and on the relationships among the concepts of consciousness, movement, space, and time.

Self-Care – Dorothea Orem. (1971, 1980, 1985, 1991). Nursing: Concepts of Practice. “According to Orem, nursing is one of a family of health care services. The unique focus in nursing is the potential or actual self-care deficits of patients that can be addressed through nursing systems. When self-care deficits are addressed, self-care requisites are met, meaning that actions that persons need to take on their own behalf in the interest of supporting live processes, maintaining structural and functional integrity, and promoting development and well-being are accomplished. This theory relates to the school nurse’s goal in helping clients become independent through taking responsibility for their own health related matters to the degree that it is possible.

Adaptation Model – Sister Callista Roy. (1970). Adaptation: A conceptual framework for nursing. The concept of adaptation is a core component of the adaptation model, and it is closely linked with the concept of health. The person, as an adaptive system, is in constant interaction with a changing environment. This person-environment interaction is known as adaptation, and it is reflective of the person’s health. Adaptive responses promote integrity relative to the goals of the human system – survival, growth, reproduction, and mastery – thereby promoting health. A goal in school nursing is to assist the client, in this case school age children and adolescents, to adapt to changes that must take place in order for the client to reach optimal ability to learn.

Transcultual Nursing Model – M. Leininger. (1978, 1992). Transcultural Nursing:
Concepts, theories, and practice. (New York: Wiley). Health and care behaviors tend to vary transculturally and take on different meanings in different context. Therefore, culturally congruent nursing care cannot be determined through superficial knowledge and limited contact with a cultural group. Leininger contends that nursing care must be based on transcultural knowledge discovered by examining social structure, worldview, cultural values, language, and environmental contexts…. According to Leininger, nursing care actions and decisions that recognize and respect cultural care values of people will result in congruency and will prevent cultural imposition, cultural care negligence, and cultural care conflicts. This is a very important model in school nursing practice, as the school nurse student must be able to work effectively with children, adolescents, and families from various ethnic and culturally different backgrounds other than their own.

Community Nursing Practice Model – (Parker & Barry, 1999) is a conceptual framework that guides practice, program development, and research. The model, developed from essential values, is a dynamic and creative flow of concentric circles depicting the complexity and interconnection of relationships and services directed toward the well-being of individuals and communities. The model provides a framework for school nursing practice grounded in the core values of respect and caring. It guides practice by focusing on promoting the well-being of individuals and communities while reaching out to and through the circles to build and strengthen relationships and connections in the broader context. Instrumental values, values that bring the core values of life, have been adopted from the World Health Organization (1978). These are access, essentiality, empowerment, community participation, and intersectoral collaboration, interrelated themes of person, nursing, community and environment contribute to this model.  

Major theories of development:
Piaget, Cognitive (1952); Erikson, Psychosocial (1963); Kohlberg, Moral Development (1971) - These theorists theorize that growth and development generally proceeds in an ordered sequence based on discernible developmental stages. Further, that growth and development are regarded as an epigenetic process, where each new stage is built on previous stages that depend on successful resolution of critical development tasks at each stage. Precise labeling of those stages depends on the theorist and developmental area.

Family Theoretical Concepts:
Family Systems Theory (Kerr & Brown) views the family as a whole system that continually interacts with its members and the environment. A change for one member results in change in another.  Forces outside the family, such as the school system can influence the family system. Family Stress Theory is useful in examining family stressors and strengths as well as resources in adaptation and restoring family stability (Boss, 2002). Family Development Theory is also a useful approach in studying family patterns, the dynamic nature of the family, and how change occurs in the family.

Hierarchy of Needs:
Maslow’s Hierarchy of Needs (1954). Students may use this to prioritize client problems. According to Maslow’s hierarchy, man’s most basic needs, which must be satisfied first, are physiological needs for food, water, sex, clothing, and shelter. At the next step in the hierarchy are safety needs, which include both physical and economic security. The third rung in the hierarchy includes belonging needs, such a membership in a family and other groups, maintaining friendships, and feeling accepted by others. Above that level is man’s need for respect, which includes self-esteem, status and prestige, and recognition for one’s achievements. At the top of the pyramidal is man’s need for achieving his fullest potential, which is called self-actualization. According to Malow’s theory, man cannot achieve his potential until all his lower level needs (physiological, safety, belonging, and respect) are satisfied because his energy, both physical and psychic, is tied up with lower levels attending to more urgent needs. Theoretically, then, unless the client can be assisted in meeting lower level needs, he may never be able to achieve higher-level wellness and self-actualization. This is important for school nurses to understand in attempting to assist children, adolescents, and their families solve problems which may be directly or indirectly contributing to their ability to function and health and well-being.

Learning Theory Relevant to the School Nurse as Health Educator
Constructivist learning theory (Danielson 1996), the constructionist approach to learning emphasizes that learning takes place when the learner is able to make sense of the concepts for themselves when combined with emotional maturity and motivation of the learner. Learning takes place when the learner is able to construct the meaning of the experience in the real world, i.e., moving from simple to complex, concrete to abstract, and directional to comprehensive. Developmental variations, individual learning styles, and environmental factors all need to be considered when helping a learner see the world from a new perspective. The constructionist approach challenges the teacher to recognize that the learner needs to make sense of the experience themselves. They have to examine the meaning and its applicability and make a decision as to how this can be used to change their behavior. School nurses can use Danielson’s framework when implementing the role of educator. The clarity and simplicity of the framework makes it transferable to any teaching situation and it is supported by premises of major learning theories.

Management (Role Theory for the School Nurses) Theoretical Concepts:
Scanlan’s definition of management (1974) “The coordination and integration of all sources (both human and technical) to accomplish specific results” is referred to here. Students are encouraged to view themselves as managers of school health programs and leaders. Those managerial functions are: Planning, organizing, directing, heading, and controlling. Steven’s (1978) view leadership as one of the functions essential for effective management. Leadership refers to one’s ability to influence others to follow or to take directions. For a manager to be successful, strong leadership must be exercised. (Wold,1981, pp.399-435).

Ethical Decision Making Theories:
Mila A. Aroskar (2001) Exploring ethical challenges in school health. Legal Issues in School Health Services, 81-93, states “The effectiveness of school nurse practice can be enhanced when the nurse is aware of the potential for ethical dilemmas. When the School Nurse stops to consider how the ethical principles of beneficence, autonomy, justice, and non-malfeasance, the risk of paternalism, and the professional code of ethics are operative in a family intervention. The development of a positive nurse-family relationship is supported.”  Through a NURS 184 assignment (week 14), students gain insight into different ethical theories, i.e., Virtue or Character Theory, Principle-based theories (duty-based and consequence-based), the Theory of Care, and the Communitarian (community-based) Theory, that can be applied to their school nursing practice.

Other theories which for useful in school nursing and in completing assignments:
Communication Theories – The following website provides candidates with a rich resource of information for understanding of communication theories and theoretical fieldwork in this area. School nurses must be able to communicate effectively. Here students can find specific communication theories of value to them for school nursing practice.   http://www.tcw.utwente.nl/theorieenoverzicht/

Health Promotion Theories – Theories of health-related behaviors, the process of changing behaviors and community and environment factors that influence behavior. Candidates in the program learn to understand the fundamentals of health promotion and the important role the school nurse plays in promoting a healthy life style for children, families, school staff, and community. This is demonstrated in practicum courses.
http://www.nci.nih.gov/cancerinformation/theory-at-a-glance/page1

Use of Theory in Courses

Stress and Coping COUN 174/200, N184, N185, N186, N187
Self-Care N184, N185, N186, N187
Adaptation N184, N186, N187
Community Nursing Practice Model  N184, N186, N187
Transcultural Theory N184, N186, N187
Ethical Decision Making N184, N186, N187
Growth & Development   N136, N184, N185, N186, N187
Family    COUN174/200, N184, N186, N185, N187
Hierarchy of Needs  N184, N185, N186, N187
Management N184, N186, N187
School Nurse Role    N184, N185, N186, N187
Communication COUN174/200, N185, N187
Counseling COUN174/200, N186, N187
Crisis Intervention COUN174/200, N185, N187
Health Promotion N1184, N185, N186, N187
Learning/Motivational N137, N184, N185, N186, N187
Adolescent Theories N185, N187
Ethical Theoretical Concepts N184, N186, N185, N187

Criterion 2: Candidates examine education, other theories and research, and their relationship to student health and wellness.

Candidates incorporate theories relevant to school nurse goals of seeking optimal health and wellness for clients through health care interventions, health teaching and health promotion. Examples of these are: Neuman’s Systems Model, which the candidate can use to strengthening lines of defense against internal and external stressors; Orem’s Self-Care, that emphasizes independence and responsibility on the part of the client in taking responsibility for self-care; Roy’s Adaptation Model, that seeks to move the client to adapt to internal and external changes in their lives; and Leininger’s Transcultural Theory, which sheds light on caring with those of other cultural backgrounds. Candidates also learn that it is necessary for them to have insight into developmental theories and learner readiness; family theoretical concepts, and Maslow’s Hierarchy of Needs, which must be met before other problems can be resolved.

Candidates recognize that school nurse must reflect on proven research, as well as established theory and planned outcomes identification in order to expect measurable outcomes in school nursing practice resulting from specific nursing interventions. Candidates develop care plans based on research related to the health problem and use the Nursing Process in assessing and identifying outcomes. In caring for clients, candidates validate not only what was done and how well it was done, but also to examine the impact of the nurse’s skills and knowledge with measurable outcomes. Outcome measurements provide objective evaluative evidence related to the healthcare process. The measurement of outcomes is essential in demonstrating the effectiveness of nursing care delivery (Hill, 1999).

In planning health lessons and health promotion, candidates measure learning outcomes as a result of their efforts. They consider their target audience with regard to age, learning capability and ethnic differences. Candidates research teaching methods, classroom management, and learning theories, appropriateness of subject matter, as well as identify age appropriate learner readiness (spelled out in CDE (2003) Health Framework for California Public Schools: Kindergarten through Grade Twelve), CDE (2008) Health Education Content Standards, and relevant sections of the CA Education Code, before selecting subject matter and developing a teaching plan and outline. In planning to meet the health care needs of school age children, or discuss health related issues with a child’s family, candidates are expected to keep Leininger’s Cross-Cultural Theory in mind and to familiar themselves with research relevant to any ethnic and cultural differences that may impede their ability to effectively meet the needs of the client. Candidates develop relevant healthcare plans based on client needs, current research, and use the Nursing Process in assessing and identifying outcomes.

Candidates examine education, other theories and research, and their relationship to student health and wellness.

Supportive Documentation:
Criterion I Matrix relevant to theories – Sec. 2, p. 30
N184 and N185 Weekly Questions Booklets, Sec. 3, p. 136 and 261
N186, N187 syllabi, Sec. 3, p. 199 and 328

Examples of Student Assignments relevant to criterion:
N184, weekly questions relevant to health education, week 10
N185, Research Paper on adolescent mental health issues
N186, Health Teaching Plan and Classroom Teach
N187, Health Education Curriculum Proposal and Teach
Aggregate Teaching/Small Group Activity

See also:
N184, N185, N186, N187 binders of samples of student work on site.
N184, N185, N186, N187, completed assignments stored in Blackboard courses.

Criterion 3: Candidates examine education, other theories and research, and their relationship to school and community health.

In NURS 184, Introduction to School Nursing, the importance of viewing school nursing practice from a global perspective is stressed. Candidates gains insight into the fact that in order to meet the needs of school age children, adolescents, and families the school nurse must reach well beyond the school building and develop meaningful relationships within the community (See NURS, Week 8, i.e., Community Nursing Practice model, use of a School Health Index, cultural competent care, helping students and families cope with stress). Candidates study the Community Nursing Practice model which is an excellent guide that helps the candidate understand school community and beyond. The model is a conceptual framework that guides practice, program development, and research (Parker & Barry, 1999). The model, developed from essential values, is a dynamic and creative flow of concentric circles around a core, the substance of the core being unique lived experiences of staff and faculty with those receiving care. These services provided to students, school staff, and families from the community, as a direct result of efforts and involvement on the part of the school nurse, occur in frequently overlapping categories of care as:  design and coordinate care; primary prevention and health education; secondary prevention (health screening and early intervention); tertiary prevention; and nurturing wholeness, which includes respecting self-care practices, honoring lay and indigenous care, inviting participation; and providing culturally competent care.

In NURS 186, School Nurse Practicum I, and NURS 187, School Nurse Practicum II, candidates practice the various aspects of the concentric circles within the Community Nursing Practice Model. The first circle includes persons and groups in each school and community who share concern for the well-being of persons served at the center (students, staff. families, and relevant others). Candidates understand that the school nurse is the health professional that the school community looks to for leadership in working to bring about optimal levels of wellness for students and staff through assessment, health promotion and health education, evaluation of relevant safety issues and control of communicable disease.  The second circle includes structured and organized groups whose members also share concern for the education and well-being of the persons served at the center but within a wider range or jurisdiction - such as a district or county (policy making groups, i.e., the school district and county health department. Candidates in the program recognize that school district policy must be understood and adhered to as it relates to school nursing practice, i.e., health education guidelines, excusing students from school during school hours, exclusion policies, etc. The candidate also recognizes the importance of community agencies and the need to develop insight into the various services available to children, adolescents, and families. To this end, candidates are required to spend a specific number of hours each semester in the community becoming acquainted with these agencies and services. Candidates acquaint themselves with other groups with an interest in the well-being of clients such as parent groups and other interest groups. Candidates in NURS 184, Introduction to School Nursing, have an assignment in which they are required to attend a school board meeting and to write a paper related to the experience and the role of the school board as it relates to the education and well-being of school age children. Candidates research the role of SARB (Students Attendance Review Board) and to attend a SARB board meeting to gain insight into the role of school district and community in keeping kids in school. The third circle includes state, regional, national, and international organization members from whom consultation or funds are sought – building relationships and community with members and collaborating about scholarship, policy, outcomes, practice, research, educational needs of school nurses. Early in the program, candidates are given information on the value of their professional organizations at the state, national, and international level, that contribute so significantly to professional school nursing practice, i.e. professional standards of practice, position statements, journal articles and published research that validates best nursing practice, educational offerings, and networking opportunities that benefits their school nursing practice. Candidates incorporate state and federal legal guidelines that guide school nursing practice in applicable assignments. In NURS 185, School Nurse Seminar, Week 13, candidates time specifically involved in gaining insight into the benefits of research and its importance in validating school nursing practice. They discover about funding sources and grant writing activities. In NURS 187, School Nurse Practicum II, candidates participate in research projects, i.e., surveys, data gathering, and other activities.

Candidates examine education, other theories and research, and their relationship to school and community health.

Supportive Documentation:
Criterion I Matrix relevant to theories – Sec. 2, p. 30
N184 and N185 Weekly Questions Booklets, Sec. 3, p. 136 and 261
N186, N187 syllabi, Sec. 3, p. 199 and 328

Examples of Student Assignments relevant to criterion:
N184,  School Board Meeting and write up
N185,  Respond to a question related to benefits of research
N186,  Attend a SARB meeting and discuss in journal question
N187, Encouraged to participate in research projects – data gathering, surveys, etc.

See also:
N184, N185, N186, N187 binders of samples of student work at site.
N184, N185, N186, N187, completed assignments stored in Blackboard courses.

Criterion 4: Candidates examine education, other theories and research and their relationship to student achievement.

Candidates demonstrate the responsibility the school nurse has is to assist school age students in achieving an optimal level of wellness in order to be ready and able to learn. Theories previously discussed support the school nurse in assisting students achieve academic success. Candidates understand that the school nurse can contribute to learner engagement, both through care provided in the health office and content taught in the classroom. They also demonstrate that the school nurse has a responsibility to identify barriers to student learning, i.e., basic survival needs, threats to safety, and health problems that interfere with learning, and to help these clients resolve those issues. Through awareness of current studies related to student achievement issues in public schools, such as the one by the California Department of Education special task force on factors that affect student achievement (2002) Learning, Teaching, Leading, articles related to issues in education, and research articles relevant to their own school nursing practice and practicum experience, candidates are able to in turn apply this insight and research in to their school nursing practice in order to achieve favorable outcomes in health promotion, health education and their client care, so that school age students can reach a level of optimal learning ability.

In practicum courses, NURS 186 and NURS 187, before candidates teach a health lesson in a classroom or participate in a program related to health promotion, they examine theories relevant to student achievement, i.e., Danielson’s Constructivist learning theory (1996); developmental theories such as those of Piaget, Erikson, and Kohlberg; as well as relevant teaching strategies and the California Department of Education (2003) Health Framework for Public Schools in California: Kindergarten through Twelfth Grade for age appropriate subject matter and learner readiness. Candidates must also describe other theories that relate either directly or indirectly to student achievement such as those described previously, i.e., Neuman Systems Model as it relates to strengthening lines of resistance at the primary intervention level, through health teaching and health promotion to prevent damage to health and well-being; secondary level, through identifying and resolving health related barriers to learning; and tertiary level, through helping clients with disabilities and chronic health conditions to gain and maintain optimal levels of wellness in order to learn; health promotion theories, and nursing models and theories that directly or indirectly relate to a client’s ability to learn.

Candidates examine education, other theories and research and their relationship to student achievement.

Supportive Documentation:
Criterion I Matrix relevant to theories – Sec. 2, p. 30
N184 and N185 Weekly Questions Booklets, Sec. 3, p. 136 and 261
N186, N187 syllabi, Sec. 3, p. 199 and 328

Examples of Student Assignments relevant to criterion:
N184, Wkly questions related to theories and learning strategies specific to children
N185,  Wkly questions related to theories, research, strategies related to adolescents
N186, Lesson development and classroom teach
N187, Facilitation small group activity or development of relevant curriculum

See also:
N184, N185, N186, N187 binders of samples of student work at site.
N184, N185, N186, N187, completed assignments stored in Blackboard courses.

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