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A scottish framework for nursing in schools

annex A: School Nursing in Scotland - Current State of Development

Findings of an investigation

1. INTRODUCTION

As part of the development of the Scottish Framework for Nursing in Schools, an overview of current service provision was undertaken to inform the process. Information was gathered in a variety of ways, including a questionnaire sent to school nurse managers, focused discussions with groups of school nurses, meetings with key people, groups and organisations and a review of the relevant literature. The findings of this process are summarised in this annex and reflected in the framework.

A questionnaire was used to gather quantitative data on the service, identify any planned developments and seek managers views on the strengths and weaknesses of their service. Twenty-nine responses were received from across mainland Scotland, with some Health Board areas producing more than one response. The three island NHS Boards responded that they were currently reviewing the provision of nursing in schools and proposed to use the framework to inform future development.

Respondents to the questionnaire were from a variety of backgrounds and levels within their organisations, varying from team leaders and practice development nurses, through clinical managers and co-ordinators to directors of nursing, suggesting a wide variation in the organisation and management of services.

Focused discussions were arranged throughout mainland Scotland to enable school nurses and other members of staff to share their views about the service, discuss current practice, highlight their strengths and weaknesses and explore their visions and ideas about how the service may look in the future. Twenty-two groups were conducted with the number in each group between twelve and twenty. In total, 262 nurses contributed to these discussions. A standard format was used with each group and the findings compiled and reported similarly to allow comparisons and variations to be established.

This summary brings together information from both questionnaires and discussions, along with the contributions of other key informants from health and education services. It represents a combination of factual information and opinions, perceptions and ideas.

2. THE SCHOOL NURSING WORKFORCE

Managers were asked to identify the total number of staff working in the school nursing service. A total of 513 people were identified. The breakdown of clinical grades is reflected in table 1.

Because of complications in the way that Whole Time Equivalents (WTE) are calculated, particularly for those nurses working only during school terms, it was not possible from the questionnaire results to give an accurate reflection of the number of WTE staff. Figures from ISD show 312 WTE staff, however, this excludes the A and B grade staff as the occupational code used to analyse the data includes only qualified staff. Furthermore the numbers of nurses in remote and rural areas who provide a service into schools as part of a combined role will also be excluded. The overall figure is therefore very difficult to calculate, but is likely to be in the region of 350 -360 WTE, giving an overall ratio of nurses to pupils of 1:2154.

Table 1 School nursing staff by grade.

2.1 Work Patterns

Most school nurses work only during school term-time. Of nurses working in grades A to F, some 91% work term-time only, with only 47 working throughout the year. Of these, most are working with New Community Schools or special schools, very few are within the mainstream setting. In some areas, those school nurses who do work throughout the year work in district nursing or health visiting roles during school holiday periods and are unable to work with school age children and young people.

Most school nurses work part time often tying in with the school day of six hours. Hours worked ranged from as little as 12 hours per week to full time (37.5 hours) with an average of 24 hours per week. Many school nurses reported being involved in work out-with the normal school day and reported that part time, term time working limits the development of new and innovative practice.

2.2 Work Settings

The majority of school nurses work either in mainstream schools or with a combination of mainstream and some other elements.

Some 17% (88) of school nurses work in, and are often based within, special schools. Recent changes in policy promote the inclusion of children and young people with special needs into mainstream schools. This will have an impact, both on the role of these nurses and on those working with mainstream schools, requiring new approaches to teamwork and utilising specialist skills.

27 (5%) nurses work exclusively with New Community Schools, often on a secondment to support the health contribution to the pilot. 10 nurses are employed by the NHS to work with private and independent schools.

Most school nurses are based within health centres or clinics, with a small number based within schools. In one area school nurses reported having no office base, working mainly from home and cars.

School nurses provide a first point of contact between the school and NHS services, backed up by specialist services such as mental health, family planning, drug and alcohol services and specialist paediatric nurses where such services exist. Nurses in more remote and rural areas reported having limited access to specialist health workers or health promotion staff.

2.3 Qualifications

Nurses come to the school nursing service with a variety of qualifications and skills, although there is no mandatory post registration qualification to practice as a school nurse. Prior to 1992 there was a short school nursing certificate course. This was replaced in 1992 by a longer diploma level qualification and subsequently in 1997 by the degree level specialist practitioner programme.

Reliable information on the numbers of nurses with relevant school nursing qualifications proved difficult to collect as many respondents to the managers questionnaire reported not having access to such details.

However, from the information available, it seems that some 22% of nurses hold a certificate in school nursing, 6% a diploma in school nursing and 24% have a degree, although for most this was not a degree in school nursing but in a related topic. It can therefore be concluded that less than half of the school nursing workforce have the requisite school nursing qualification to underpin their practice. These figures obviously exclude the 48 school nurses who have recently completed the new public health nursing programme, which gives them both a degree and a specialist practice qualification.

In addition to basic qualifications, there was significant evidence of individual nurses having undertaken further study relevant to their field of practice. Most notable were qualifications in family planning and sexual health, reflecting the increasing numbers of school nurses who are involved in young people's drop in clinics and in teaching the subject in secondary schools.

Some respondents commented that relevant educational programmes are not always available. The part time nature of the workforce can also make releasing nurses to undertake further education difficult. This is particularly the case in more remote areas.

3. PUBLIC HEALTH NURSING

In recognition of the need to enhance skills within the workforce, and as a first step towards creating a new public health nursing role, 48 school nurses were seconded from all areas of Scotland in September 2001 to the new public health nursing programme. Most have now completed the programme and have a specialist qualification in public health nursing.

Respondents were asked how they planned to develop the role of the new public health nurses in the school environment. Common themes in the responses included:

• Providing clinical leadership to the school nursing service
• Undertaking needs assessment and targeting services to meet those needs
• Developing the service for school aged children and young people at both an individual and community level

* Creating networks and developing partnerships with other agencies

Table 2 summarises the range of responses received.

Table 2 Developing the public health nursing role in schools.

4. CORE WORK PATTERNS

School nurses and their managers were asked about the core duties undertaken in school nursing. There are differences of working practice throughout the country but the following gives a brief overview of the main areas of work identified.

4.1 Screening and surveillance

Although practice has changed significantly from nurses screening children every second year for height, weight and vision, many nurses and managers mentioned that they felt there was still too much screening and surveillance undertaken and were unsure if the evidence was there to support a continuation of this. Some school nurses estimated that 60% of their working year is taken up with screening, meaning that less time is available for more proactive work with individuals or groups. Many respondents await the publication of Health for All Children 4 in order to support changes in practice.

Whilst there is significant variation between areas, screening consistently seems to take place in Primary 1, Primary 7 and Secondary 3. Many responded that the scope of such sessions had broadened to include health interviews and relevant health education/promotion. The common content of surveillance programmes is summarised in table 3.

Table 3 Common elements of School Health Surveillance

4.2 Immunisation

Immunisation sessions are increasingly becoming fully nurse led, although there is significant variation in practice across the country. Patient Group Directions, practice guidelines and training are being developed locally to support this. Where immunisation is not nurse led, school nurses tend to organise, co-ordinate and follow up sessions and often immunise as part of the team with medical colleagues.

The main school based immunisation programmes are:

• Heaf testing and BCG - secondary two
• Diphtheria, Tetanus and Polio - secondary three

Very few school nurses reported having adequate clerical support during immunisation sessions with school nurses having to take responsibility for making appointments, issuing consent forms, retrieving and filing records. In one area, school nurses estimated that 30% of their working year was spent on immunisation programmes.

Mass campaigns such as for example the Meningitis C campaign, where immunisation was offered to all school age children have been successfully delivered through the school health service. The Meningitis C campaign in particular created significant pressure on the service. Completing extensive campaigns such as this within existing resources was felt by respondents to create real difficulties for the service, with many areas of the core service having to be suspended for the duration of the campaign.

4.3 Health Promotion

The development of New Community Schools and the Health Promoting Schools concept has created a fertile environment for health promotion activities in schools. However, respondents reported that the ability of school nurses to respond to this opportunity has been variable, dependent on both core work programmes and the skills of the staff. There was however evidence of innovative and exciting health promotion work both within the schools and in the wider community.

Topics covered commonly include:

• Puberty and growing
• Sexual health and contraception
• Smoking, alcohol and drugs
• Healthy eating and healthy lifestyle choices
• Mental health and well being
• Dental health

School nurses reported participating in health fairs, talks to parents and providing education for teachers on health related topics as well as being involved in individual and group focused work with pupils.

Respondents felt that whilst a considerable amount of health promotion is undertaken by school nurses, much more could be offered. Lack of training, poor access to resources, competing time pressures and poor understanding of the school nursing role were felt to limit the potential of health promotion opportunities.

4.4 Curricular Work

Many school nurses reported being involved in delivering health related components of the curriculum. This was felt to be an area that could be developed further. The New Community Schools ethos of improving the health and well-being of all in the school community and working towards the status of Health Promoting School was felt by some to create opportunities for inter agency teamwork to promote health and well being. Some respondents clearly felt that the role of the school nurse is not sufficiently well developed and understood to enable effective partnership working.

4.5 Nursing Care Tasks

Nurses working in special schools are actively involved in delivering nursing care. Respondents identified a broad range of areas, including:

• Checking of blood pressure and temperature
• Asthma care including use of the epi-pen
• Seizure management and care including administration of emergency medication
• Gastrostomy and naso-gastric feeding
• Catheterisation and continence care
• Administration of nebulised medication
• Personal hygiene and care
• Oxygen therapy and care

With the future integration of more children and young people with special needs into mainstream schools, the available skills and expertise will be more thinly spread so new ways of working will be required. Joint assessments and planning, partnership working and multi-agency support will be essential to ensure the best possible care and support for the child and the family.

4.6 Additional Work

School nurses have increasingly been involved in the development of new ways of working with children and young people, providing and contributing to a growing range of services that take place outside of the school day. Some of the extra activities undertaken by school nurses include:

• Sexual health clinics
• Enuresis clinics
• Multi-agency drop-in clinics
• Relaxation groups prior to and during exams
• School liaison groups
• Parents evenings/sessions
• Home visits - family support
• Bullying groups and transition groups

Both school nurses and managers agree that out of school activities are important and should be developed further, however the part time and term-time employment of many school nurses makes this difficult. Many school nurses reported having developed these important and successful services in their own time and sometimes at their own expense. Maintaining clinics and clubs over school holiday periods is often impossible and can lead to failure of the service.

5. RESOURCES, FACILITIES AND EQUIPMENT

5.1 Information Technology

Respondents to the school nurse managers questionnaire were asked if school nurses in their area had access to information technology. Less than one third of nurses were said to have access. Even then access is often shared with other colleagues.

School nurses also responded that access to I.T. was limited, training was not always easily available and computers were sometimes not maintained or in working order.

Access to IT was regarded by many as an essential tool in terms of communication, access to evidence to underpin practice and maintaining effective administrative systems.

5.2 Clerical and Administrative Support

Many school nurses reported having limited or no clerical support. Only 20% had access to clerical support, with a further 57% saying that there was limited access, usually associated with record storage and the computerised child health system. In some areas school nurses reported spending time filing, making appointments, typing or writing letters and dealing with other clerical duties. In one area the school nurses also make appointments for the dental service.

School nurses are being encouraged to expand their skills to develop their public health role, work with vulnerable children, create a nurse led service and be innovative. Clearly this will not be possible whilst their valuable clinical skills are wasted on undertaking clerical work.

5.3 Facilities and Equipment

Adequate accommodation within schools was identified as a problem by many nurses. Medical rooms, where they exist, are often now used by many services or agencies, and are not available for the school nurse. Some school nurses reported being asked to work in inappropriate and unsuitable areas.

Availability of reliable equipment was also reported as problematic, with scales for example being outdated or not maintained or calibrated. Mobile telephones were not available to many school nurses, making effective communication extremely difficult.

6. SCHOOL PROFILING, NEEDS ASSESSMENT AND REVIEWS

6.1 School profiling

Respondents were asked if a needs assessment of the school age population or school profiling had been performed in their area. Responses from questionnaires indicated that 17% of areas had done school profiling, with a further 46% reporting limited profiling.

Many managers and nurses felt that school profiling was important but commented that it was time consuming and that a suitable profiling tool did not appear to be available. Some school nurses had profiled schools using a variety of different tools but were concerned that none appeared to meet their expectations. A common profiling tool sensitive to both the rural and urban issues in Scotland may be a valuable and useful development allowing national comparisons, forward planning and evaluation.

6.2 New Community Schools

There are New Community School pilots in each of the 32 local authority areas and most have already extended the approach to other schools. By 2007 the concept will be rolled out to incorporate all Scottish schools. A key driver for the development of the framework is to ensure that the school nursing service fulfils its potential contribution within the ethos of integrated children's services. Respondents were asked how involved school nurses were within the current pilots.

In sixteen local authority areas school nurses were reported to be very involved in all aspects of New Community Schools. In some of these areas the school nurse is recognised as the key driver for health issues within the schools. Where there are joint assessment teams the school nurse is often an active part of this.

In seven local authority areas managers and nurses said that involvement did not include planning the health contribution within New Community Schools but that the nurse was involved in some of the work.

In the remaining six areas the school nurses were involved in a limited way with involvement dependent on the approach of individual schools.

6.3 Links with Local Health Care Cooperatives

Managers and school nurses were asked to describe how school nurses and LHCCs currently communicate and interface. Their responses suggest that school nursing is at different stages of alignment and integration into LHCCs and there are differing views about the value and effectiveness of relationships. Responses varied from very poor communication through to full integration, with most reporting at least some degree of communication and influence within the LHCC.

Close working with the LHCC was generally welcomed but there was concern that this needed to be properly managed and overall leadership of the school nursing service maintained.

7. STRENGTHS AND WEAKNESSES OF THE SCHOOL NURSING SERVICE

School nurses and managers were asked what they thought were the strengths and weaknesses of the service, and while some are clearly local issues and problems, some common themes were apparent.

The main concerns, which were apparent throughout the responses, were:

• Lack of leadership both locally and nationally
• Limitations of term-time and part-time contracts
• Lack of resources
• Lack of consistency in staff grading
• A need to raise the profile of the service

8. FUTURE DIRECTION OF THE SERVICE

Managers and school nurses were asked their views on how they see the future of the school nursing service. A number of respondents have plans to undertake reviews of the current service, others were awaiting the publication of the framework to help guide developments. A number of key themes emerged from the discussions. These are summarised below:

• Develop the public health nursing role in schools, utilising the expertise of newly qualified public health nurses.
• Develop team approaches utilising skill mix and developing/making best use of specialist areas of expertise e.g. child protection, sexual health.
• Undertake needs assessment and school profiling (the need for a reliable consistent approach was highlighted).
• Develop effective links with New Community Schools, improving joint planning and working with education.
• Prioritise workload to include:
• Work with vulnerable children and families
• Child and adolescent mental health
• Work with children who have special needs both in special and mainstream schools
• Develop more flexible work patterns, not restricted to term-time, in order to meet needs of children and young people.
• Review location of school nurses and consider school-based options.
• Develop effective networks to support practice development.

9. CONCLUSIONS

The information given by school nurses, managers and other key respondents gives an insight into their perceptions of the current service and its potential future development. Respondents recognised the positive and innovative practice happening in many areas but also are aware of the problems and barriers that exist. The majority of school nurses are keen to develop their role and encompass public health work, innovative practice and true partnership working. All agree that they have a vital role to play in addressing the health needs of school age children and young people.

In order to take the service forward, priorities need to be agreed and the balance between core screening and surveillance work and addressing the needs of the school community addressed.

To achieve the vision of a modern school nursing service prepared to address the health needs of today's children and young people a number of issues need to be addressed:

• Effective enabling leadership is required at all levels of the organisation
• Practice must be based on the needs of the school community and evidence of effectiveness
• Working hours need to be more flexible to better reflect the needs of the school community
• Appropriate education needs to be in place to ensure nurses are equipped to meet the needs of the school community
• Partnership working with other professionals and agencies needs to be promoted and supported
• Mechanisms need to be established to share good and innovative practice
• A shared understanding with all key partners of the contribution of the school nursing service is required.

The findings from respondents to the questionnaire and participants in the group discussions provide a clear picture of the current development of the school nursing service in Scotland. They have been used to inform discussion throughout the development of this framework and underpin the standards set out in it.

Implementing the framework will need time and commitment at all levels of NHS Scotland but the benefits should be seen in the health of future generations.

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