More than one in five children in the UK is overweight; binge drinking and drug taking are on the increase; and we have the highest rates of teenage pregnancy and sexually transmitted diseases in western Europe. It seems at times that the nation is sitting on a public health time bomb: the school nurse can be a key figure in defusing it. As the only health professional to whom children can refer themselves, she or he is in a unique position.
As well as providing support and advice for pupils with physical or emotional problems, nurses form an important link between schools and outside agencies and can take a lead in developing health education programmes. Their numbers have declined over the past 20 years but there are now plans to reverse the trend as well as expand the role. In the 2004 White Paper "Choosing Health", the Government announced a target of a minimum of one full-time, qualified nurse for each secondary school and its cluster of feeder primaries. And advice on how schools can work with nurses to help pupils develop healthier lifestyles is due to be published by the DfES later this year.
WHAT DO SCHOOL NURSES DO?
The role of the modern school nurse is far removed from the nit nurse stereotype of the past. Dealing with head lice outbreaks, organising vaccinations and carrying out basic health screenings are only a small part of the job nowadays. Many nurses are highly qualified, often with an area of specialism, and are increasingly taking on responsibilities that used to be the preserve of doctors. Those working in schools are likely to hold a degree in community nursing, or a further qualification such as the school nurse certificate. They may also have diplomas in areas such as family planning, asthma or diabetic nursing, and some may provide this specialist service in schools across the health authority.
General school nurses will run drop-in advice sessions for pupils and provide ongoing support for those with specific health problems or disabilities, as well as monitoring pupils' hospital admissions and attendances at casualty, and following them up if necessary. They also support pupils with emotional or mental health problems, and run parenting programmes for families of children with behavioural difficulties. They have a key role in child protection which involves liaising with social services and attending case conferences for children at risk. In addition to all this, many are increasingly involved in working with schools to develop their health education initiatives and have a role in planning and delivering PSHE programmes.
Given such a wide remit, it's no surprise that many school nurses feel they have too much on their plates. In a survey carried out last year by the Royal College of Nursing (RCN), 60 per cent said that they were finding it difficult to meet the expectations of schools, despite the fact that they often worked more than their contracted hours. There are currently about 3,000 school nurses working in the UK, with most employed by local primary care trusts. He or she will currently cover around eight schools - one secondary and its feeder primaries - and have an average caseload of 2,400 pupils.
About two-thirds work part-time with many on term-time only contracts, but are often expected to look after the same number of schools as their full-time colleagues. With part-time working taken into account, this equates to only one full-time nurse for every 14 schools, and the RCN estimates that the number of practitioners will need to double if government targets are to be met. Also, as Fiona Smith, children and young people's nursing adviser at the RCN, points out, caseloads and workloads are not necessarily the same thing and pupils in deprived areas may be more vulnerable and require more intervention. "The target of one nurse for a secondary school and cluster of primaries should be seen as the bare minimum. The Government should ensure that money is available to fund additional posts if an effective service is to be provided." The RCN has expressed concerns that primary care trusts are diverting money that should be spent on school nursing towards funding gaps in other areas. It wants cash to be ring-fenced specifically for the service.
A RECRUITMENT CRISIS?
In keeping with the general nursing population, around one in five school nurses is nearing retirement age, which means recruitment will need to be stepped up if provision is to be increased. Part-time and term-time only working have made the specialisation attractive to women with families; according to the RCN survey, men account for only 1 per cent of school nurses (see case study). Given that boys generally tend to be less open to health advice than girls, the lack of male nurses as role models concerns the Royal College. The same applies to the dearth of school nurses from ethnic minority groups: the survey showed that 97 per cent are white.
According to Fiona Smith, it's vital that the service better reflects the diversity of pupils and the specialism needs to be more heavily promoted through opportunities for trainee and newly qualified nurses to undertake placements in schools.
AN EVOLVING SERVICE
Some health authorities are already expanding school nursing services to include telephone helplines and drop-in sessions outside school time. As Heather Hough, one of three nursing practice managers with the South Downs Health Trust's school nursing service in Brighton, East Sussex, says, the health and welfare needs of pupils don't disappear when the bell goes or when school breaks up for the holidays. "Families with difficulties often find that having the children at home all day means it's even harder to cope. This is when the support of the school nurse can be crucial," she says. The three practice managers in Brighton work all year round and Ms Hough acknowledges there will be an increasing need for continuous contracts as the service develops.
Investment in Brighton means that staffing is almost up to the Government's recommended level and school nurses in the area are now taking on more prominent roles. Facilities previously run by doctors, such as the enuresis clinic that helps children with bedwetting and continence problems, are now led by school nurses, which has significantly reduced waiting times.
"School nursing used to be a small and relatively low profile service but now it's changing faster than at any time in the past. It's challenging but very exciting too," says Ms Hough.
Some health authorities feel the role has expanded so much that the term "school nurse" is becoming outdated. North West Wales Health Authority is considering changing the title to "young people's health nurse" to reflect the fact that the service is available to anyone up to the age of 18, regardless of whether they attend school, as well as to home educated children. The authority has also enhanced the role of the nurse by using healthcare assistants.
According to the RCN survey, many school nurses feel their expertise is wasted on tasks such as height and weight checks and vaccination programme administration as it leaves little time for specialised health promotion and child protection work. In North West Wales, nursing assistants have taken over tasks such as routine screening and going into schools to provide training on dealing with head lice outbreaks.
Health promotion is an increasingly important part of the school nurse's role and one the Government wants to develop. A pilot for school nurses delivering PSHE is now in its final phase, as is a similar scheme for teachers (see resources). Nia Pritchard, a school nurse with the North West Wales service, says regular involvement in the classroom raises a nurse's profile within the school. She teaches a range of health topics, but is most in demand to cover sex education, contraception and sexually transmitted diseases. "Many teachers don't feel confident in talking to children about these - and I actually prefer not to have the teacher present as pupils are more likely to clam up and be reluctant to ask questions."
She often asks for larger classes to be split to avoid management problems but never teaches boys and girls separately. "It's important that they overcome their embarrassment and learn to talk about these issues openly in the company of the opposite sex," she says. She also feels it's vital that PSHE co-ordinators and school nurses find time to plan programmes together, and always ensures that she is involved in a series of lessons with the same class. "That way you access all the pupils and build up a rapport with them, which means they're more likely to feel comfortable approaching you when they need individual advice." Most nurses work from offices in local clinics but Ms Pritchard has recently moved her base into a secondary school. "I'm more visible now, which has resulted in more pupils coming in for a chat."
School nurses are likely to be approached by pupils on issues that they feel unable to talk about with their parents or other adults. They are bound by the Nursing and Midwifery Council's code of professional conduct and are not allowed to disclose information to parents without the pupil's permission. The only situation in which they are required to break confidentiality is if the young person is considered to be in danger of harm or abuse. In the case of contraceptive advice and treatment for pupils under 16, school nurses follow the Fraser guidelines which allow them to provide contraceptive advice without parental permission if the young person is deemed capable of understanding the information, is adamant they do not want parents to know, and is considered likely to engage in sexual activity whether or not they receive contraceptive advice. These guidelines also apply to information about abortion. Most nurses, however, will usually try to persuade pupils to involve their parents if they feel it is necessary.
Where issues such as contraception and abortion are discussed in the classroom, the nurse will be guided by school policies which may be shaped by their general ethos, as in the case of faith schools.
Nurses in the independent sector?
As they are usually employed by individual schools rather than by the local health authority, caseloads are much smaller in the private sector; the average reported in the RCN survey is just under 700 pupils. However, they are often expected to minister to staff as well as pupils, may be required to attend sporting fixtures to deal with injuries and, in boarding schools, will be responsible for running the sick bay. Like their state school counterparts, many are now involved in developing health education initiatives.
Pay and conditions have tended to lag behind but the RCN now reports that more schools are employing well qualified nurses on salary levels similar to the state sector. However, many independent school nurses have told the RCN that they feel isolated in their work as they lack easy access to the NHS support network. The college recommends that they have the chance to undertake further training and forge links with other health professionals.