Nursing the whole person
It is hardly a surprise when a professional working in schools expresses delight at plans to improve the ratio of adults to children in her field. What does take the breath away is the numbers she has in mind.
"The Scottish Executive is aiming for a target of 1:1,700," says Janice MacLeod, a school nurse employed by Lothian University Hospitals NHS Trust. "That is brilliant. If we are going to support New Community Schools, Healthy Respect and all those other initiatives, we need the nurses on the ground."
The current national ratio of nurses to schoolchildren is 1:2,154 but in many places the true figure is much worse. Scotland's 350 full-time equivalent school nurses are spread very thinly and unevenly. So, the launch of A Scottish Framework for Nursing in Schools, the Scottish Executive report in which the target is published, has been welcomed by Ms MacLeod and her colleagues for the consistency of practice and the detailed improvements it should bring.
The image of school nurses has been a problem for a long time, as Health Minister Malcolm Chisholm recognised when he and Education Minister Cathy Jamieson launched the framework last month. He described it as the tool that will "deliver a revolution in school nursing, putting behind us forever the old image of the nit nurse".
Ms MacLeod, who is the Scottish representative on the nurses' professional body, the Community Practitioners' and Health Visitors' Association, is acutely aware of the problem. "The traditional view of the school nurse was that you just stood up and said 'You can't do this' and 'You can't do that'
and you were a bit frosty and all you did was look for head lice. We have moved on in leaps and bounds from that. This new framework should lay Nitty Nora to rest forever."
Part-time contracts, inadequate accommodation and resources, low staffing levels and lack of time to set up and run groups that can make a real difference to children's health and well-being are just some of the worrying consequences that flowed from the unflattering and inaccurate image of the school nurse.
There was widespread consultation before the document was written, says Ms MacLeod, which appears to have paid off. "It's about making school nurses feel more valued," she says.
"It's about having a base to work from. In some places they don't even have a desk, but work from their car. It's about having a computer to let us communicate and share information through the Internet or even just write a letter. It's about access to telephones: some schools won't let nurses use theirs.
"School nursing is very much a needs-driven service, so we could be out doing sex education with a group at one school, then get a call from another to see a young person urgently. How can we do that without access to a telephone? Some nurses use their own mobile phones - I do - but it means you're supporting the service when it should be supporting you."
The framework is more than a set of pious hopes and aspirations, say the nurses. It is a detailed working document containing a review of the current provision of school nursing around the country, together with a set of standards that from now on have to be met by everyone working within the service.
School nurses will now be involved in promoting healthy lifestyles and healthy schools, especially with regard to mental and sexual health, substance misuse, nutrition and physical activity. They will work with vulnerable children and those with chronic and complex health needs and support teachers and parents with the administration of medicines.
Two-thirds of the standards deal with strategic and management issues, ensuring that nurses are provided with clear leadership, career structures and continuing professional development, that core school nursing is no longer disrupted by mass immunisation programmes and that routine screening and surveillance, which can occupy inordinate amounts of nurses' time, focuses on those areas where sound evidence exists of their value and effectiveness.
"No doubt there will still be some problems," says Ms MacLeod. "But the framework was launched jointly by Malcolm Chisholm and Cathy Jamieson, and colleagues like the director of education were there at the launch and heard the same things we did. So it is very much a shared commitment between health and education.
"Nurses on the ground are going to do everything we can to make it happen.
We will also be doing everything in our power to influence what happens at a strategic level, because the framework makes the health boards and senior management accountable, as well as the nurses.
"I've been in school nursing for 12 years, having previously been a sister in acute hospital wards. I came into the service because by the time I saw heart attack victims it was too late. I wanted to work with young people and convince them of the benefits of prevention. I had this vision of where school nurses ought to be.
"If you ask most nurses why they do the job they will say it's because they want to make a difference. I want to make a difference. I think this new framework is wonderful."