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Prevention is better than cure

From health education to immunisation, nurses are key. Martin Whittaker reports

Our image of the school nurse is somewhat out-of-date - we still cling to the traditional idea of a matronly figure in the sick bay who helps the doctor conduct medicals and checks for nits.

Today, the job covers a much broader range of responsibilities, depending on the type of school. It often includes child protection, immunisations, health promotion, sex education and personal, social and health education (PSHE).

School nurses also provide the link between schools and a host of other professionals, such as health visitors, members of social services, special educational needs co-ordinators and those working for child and adolescent mental health services.

There has been a fall in the number of school nurses in the last 20 years, bringing chronic staff shortages and high workloads. The Royal College of Nursing estimates that there are fewer than 3,000 school nurses in the UK, each caring for an average of 2,400 pupils. On average, school nurses cover at least ten schools.

One nurse per school?

Yet these shortages became apparent just as the Government focused on the health and well-being of children and young people with the introduction of the Every Child Matters agenda and extended schools.

A taskforce has been set up to modernise and promote school nursing. The Government wants at least one full-time qualified school nurse working with each cluster of primary schools and related secondary school.

School nurses are mostly employed by primary care trusts, and, geographically, provision is patchy. Some areas have seen the role virtually disappear, only to bring it back again when the need arose.

The job has changed dramatically, says Rosalind Godson of the Community Practitioners' and Health Visitors' Association. "Before the 1990s, school nurses sorted out medicals. Many worked in a standardised way. Now there's more emphasis on preventative health than there was. And if we're going to prevent people from getting ill, it's obviously easier to catch them when they're young."

The generic term - "school nurse" - is out of date. Different local authorities use a range of different titles, such as "young person's health adviser" or "school health adviser".

To be a school nurse you have to be a qualified and experienced registered nurse - two years' practice is usually required before specialising. You can enter school nursing from any of the main nursing branches - adult, child, mental health or learning disabilities.

Although it's not essential to do so, many school nurses then take further qualifications, such as a postgraduate course in school nursing.

Nurses working in special schools are not required to have extra qualifications - but most jobs ask for qualified nurses with experience of working with children with complex needs.

"There are only adult courses," says Rosalind Godson. "You can be an adult learning disability nurse, but you can't be a child learning disability nurse."

In a bid to overcome outmoded stereotypes about the role of the school nurse, in 2005 the Royal College of Nursing commissioned a detailed survey into what the job entails, as well as numbers and workload.

While the majority of nurses work in state primary and secondary schools, a quarter cover special needs schools, and one-in-six cover pupil referral units. A third work in independent schools.

State sector overload

The survey found that the role differs depending on whether the nurse works in the state or independent sector. State-sector nurses cover an average of eight schools; those in independent schools typically provide a service in one school.

In the state sector, most time is taken up attending child protection conferences and immunisations, followed by appointments with pupils, health promotion activities and screening. Nurses at independent schools spend most of their time attending injuries, being available to pupils and running sickbays.

A third of state-school nurses said their job was not clearly defined.

Three-quarters said they would like to change the balance of their role - wanting to spend more time on health promotion, PSHE, drop-in sessions for pupils, and family support. But the main factors preventing school nurses from developing their role are lack of time and heavy caseloads - three-quarters of state school nurses report that their workload is too heavy.

The job is not well-paid, with a starting salary of pound;19,000, but the RCN's survey shows most school nurses care passionately about their work:

"Many refer to the quality of the relationship fostered with pupils and their families and being able to make a difference to the health and wellbeing of families as sources of job satisfaction."

* Joy Winks MBE is a team leader for school nurses working across a group of special schools.

"There's a core role where we work with all children - mainstream and special - around child protection, looked-after children, medical matters, making sure the links are there between education and the health service, and that the children get the care they need in school.

We're also involved in care planning for schools, and training and support for school staff in looking after young people with medical needs.

Then there's obviously the basic screening that happens to every child when they come into school. After that it's public health - linking in with the healthy schools initiative. You are part of the school life and helping with the personal and social health education, whatever the needs are in that school.

It might be a school where the children have sexual health problems, in which case the school nurse would identify that while looking at the needs with the school staff. Or it might be that the parents need a lot of support, so the nurse might run parents' groups.

The job depends on the needs of the school, because special needs vary from multiple, complex profound disabilities, to more moderate learning disabilities and children on the autistic spectrum. There's a huge range of need.

The job is changing in a lot of ways - we've been the Cinderella service for a while, but we have come more to the fore now. People are realising the value of the school nurse and what she can actually put into a school setting, helping with the health needs as well as the public health side.

We work as a team and share skills. For example, it could be that we have someone with a specialism in tracheostomy, and there's a need for that specialism in another school; then the nurse will go out and support.

The issues for special schools are similar to mainstream, but with others added. But because of the disability discrimination act we have a standard that goes across all children - that is the core. After that, we profile the school, and look at the needs of the school.

In some areas, a special school will have a nurse who pops in, just like mainstream schools do. In my area we have a team that works across the special schools. But we get mainstream people to come and help if we're doing something special and need their expertise."

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