Mapping Of Professional Qualification Routes and Continuous Professional Learning Opportunities relating to Psychological Trauma, in the Children and Families Workforce

4. School Nurses and Health Visitors

Fig.1 A diagram describing Health Visiting and School Nursing pathways (note: a pdf of this image is available separately on request if a larger font size is needed)

Introduction

4.1 Health Visitors and School Nurses have the most formalised and straightforward learning pathway of the five areas of work explored in this research. This is due to a few factors:

4.2 Scottish Government have clearly outlined the remit for these areas of work in “Specialist School Nursing: priority areas and pathways” (Scottish Government, 2018) and “Universal Health Visiting Pathway in Scotland: pre-birth to pre-school” (Scottish Government, 2015).

4.3 There are narrow academic qualification requirements for both of these areas of work — individuals must achieve a bachelor’s degree in Nursing or Midwifery, and then a Specialist Community Public Health Nurse (SCPHN) Masters (NMC, 2022a).

4.4 The oversight and regulation of both the education pathways and the register of practising nurses is overseen by the Nursing and Midwifery Council (NMC), who set out clear requirements for Health Visiting and School Nursing.

4.5 Health Visitors and School Nurses predominantly work for the NHS within local health boards meaning that organisational structure, funding, and career development are similar for Health Visitors and School Nurses across Scotland.

4.6 This section of the report will provide an overview of how each of the following four steps in the journey work and to what level trauma informed practice is being covered.

Nursing and Midwifery Council Specifications

4.7 The Nursing and Midwifery Council (NMC) set out specifications for ‘pre and post-registration’ nursing standards. Their pre-registration standards outline the requirements to become a registered Nurse, and a registered Midwife — pre-registration level education (e.g., undergraduate-level Nursing and Midwifery degrees) must align with these standards. Their post-registration standards outline the requirements to become a Specialist Community Public Health Nurse (SCPHN), which includes Health Visitors and School Nurses — SCPHN education programmes must be approved in line with the new standards by 2024.

Table 1: Standards Summary

Standard

Future nurse: Standards of proficiency for registered nurses (NMC, 2018)

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

None

Summary of trauma-components included

There is no mention of the term 'trauma' or immediate related terms, however, the material emphasises that registered nurses must understand how to develop and deliver 'person-centred' care plans. It also states that registered nurses must be able to identify signs of, and support patients who suffer from, mental and emotional distress or vulnerability, as well as signs of vulnerability in themselves or their colleagues.

Standard

Standards of proficiency for midwives (NMC, 2019)

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Partial coverage of Level 1: Trauma Informed

Summary of trauma-components included

These standards place clear importance on the psychological factors surrounding childbirth, however, they do not align precisely with the Knowledge and Skills Framework's definition of trauma informed practice. Most mentions of the term trauma refer specifically to physical trauma associated with childbirth, however analogous terms are used such as 'abuse,' 'distress,' and 'vulnerable,' with a clear requirement for midwives to recognise certain forms of traumatic experience such as abuse, and exploitation. There is a requirement to understand the additional care needs of those that have experienced psychological complications, and respond to unsafe psychological situations, however this description does not fully extend to the principles, practice, and benefits of trauma informed care.

Standard

Standards of proficiency for specialist community public health nurses (NMC, 2022b) – Core Competencies

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

None

Summary of trauma-components included

The post-registration standards include requirements for more in-depth understanding of trauma; however they still do not meet the Knowledge and Skills Framework’s definition of ‘trauma informed’

The material is bullet pointed so it does not go into any subject at depth or in a way that is meant to be a teaching or training resource. As part of this, the material refers to relevant themes around trauma and understanding the impact on children and families. It also references identifying and responding to abuse and neglect, evaluating the effects of trauma on child development, minimising the risk of ACEs and references 'trauma informed approaches' in assessment, support and monitoring or referrals. In terms of effects of trauma on the worker, the material also references using specialist professional knowledge to identify people who are at risk of abuse in or outside of the workplace and having an occupational health team who is responsive to trauma.

Standard

Standards of proficiency for specialist community public health nurses (NMC, 2022) – Health Visitors

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Partial coverage of Level 1: Trauma Informed

Summary of trauma-components included

These specifications have limited mention of trauma, and do not mention the term 'trauma informed'. However, they partially cover elements of Level 1, for instance by stating that Health Visitors much initiate person-centred interventions to minimise risks of abuse, domestic violence, and child maltreatment, yet not explicitly stating they must use trauma informed principles. There are requirements for Health Visitors to understand and respond to certain, but not all, forms of trauma.

Seeing trauma included explicitly in the 2022 version of these standards is positive, as this was not the case in previous versions of these standards.

Standard

Standards of proficiency for specialist community public health nurses (NMC, 2022) – School Nurses

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Partial coverage of Level 1: Trauma Informed

Summary of trauma-components included

These specifications explicitly mention the requirement for School Nurses to use trauma informed approaches, and in several instances cover the requirement to understand trauma. However, there is no material covering the impact of trauma on the self, and it only partially covers the impact of trauma and adversity on access to support, and on trauma informed relationships and recovery.

Seeing trauma included explicitly in the 2022 version of these standards is positive, as this was not the case in previous versions of these standards.

Degree Level

4.8 Midwifery and Nursing Degrees are the two points of entry that allow you to progress and specialise as a Health Visitor and School Nurse. Nursing degrees remain the most common route for those that become School Nurses, although it also is possible for those who study Midwifery at an Undergraduate level to become a School Nurse. Health Visitors may come through Nursing or Midwifery Undergraduate degrees. All Midwifery and Nursing degrees across the UK must align to the NMC’s standards.

4.9 There are four pathways within nursing available in Scotland: (1) Adult Nursing; (2) Children’s Nursing; (3) Learning Disabilities Nursing; and (4) Mental Health Nursing. These are taught across numerous institutions.

4.10 Glasgow Caledonian University, Edinburgh Napier University and the Open University offer all four types of Nursing Undergraduate Degrees. These institutions tend to have a core set of modules that all Nursing students take and a series of modules relating to their specialism. For example, at Glasgow Caledonian University, all Nursing bachelor's degree-level students take the same modules in their first year, then in their second and third year they have four common modules and two modules specific to their specialism.

4.11 Robert Gordon University and Dundee University are the only other institutions who deliver Children’s Nursing. Otherwise, there are nine institutions delivering Mental Health Nursing and 11 institutions delivering Adult Nursing.

4.12 Midwifery Undergraduate Degrees are offered at Edinburgh Napier University, Robert Gordon University, and the University of the West of Scotland.

Analysis against the Knowledge and Skills Framework for Psychological Trauma (NES, 2017)

4.13 Predominantly, when analysing course materials against the Knowledge and Skills Framework, Nursing Undergraduate Degrees are including material around trauma informed practice — to a Level 1: Trauma Informed or Level 2: Trauma Skilled practice with exception of The Open University which provided no evidence of education around trauma. However, this is not the case with Midwifery Undergraduate Degrees, in which available course materials focused on physical trauma, not psychological trauma.

4.14 In Table 2 below, we have analysed each education programme based on available public information, such as module descriptions and learning objectives, to identify what trauma informed components are included. In some instances, module descriptions and learning objectives do not include any mention of trauma, or trauma informed material.

Table 2: Degree Level Qualifications Summary

Qualification

BSc Nursing (Adult), Dundee University

Material Source

Information shared through correspondence with relevant individuals

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No evidence of trauma informed practice

Summary of trauma-components included

Materials predominantly cover physical trauma as opposed to psychological trauma except for third year when “post critical illness psychological trauma” is covered.

Qualification

BSc Nursing (Children), Dundee University

Material Source

Information shared through correspondence with relevant individuals

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Partial coverage of Level 1: Trauma Informed

Summary of trauma-components included

Materials only partially touch on elements of Level 1: Trauma Informed Practice through materials covering ACEs and trauma, and children and young people mental health.

Qualification

BSc Nursing (Mental Health), Dundee University

Material Source

Information shared through correspondence with relevant individuals

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 2: Trauma Skilled

Summary of trauma-components included

Materials meet Level 2: Trauma Skilled Practice and the materials from NES provide a golden thread running throughout the course.

Qualification

BSc / BSc (Hons) Nursing (Adult, Children, Learning Disabilities and Mental Health), Glasgow Caledonian University

Material Source

Information shared through correspondence with relevant individuals

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 1: Trauma Informed

Summary of trauma-components included

The syllabus explicitly covers learning Trauma Informed practice. Within Mental Health this is expanded further through learning outcomes such as "Explain the implications of early life trauma and its impact across the lifespan"

Qualification

BSc Adult Nursing (Robert Gordon University, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 1: Trauma Informed

Summary of trauma-components included

Adult Nursing at RGU covers trauma informed practice as indicative content in two of their course modules.

Qualification

BSc Mental Health Nursing (Robert Gordon University, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 1: Trauma Informed

Summary of trauma-components included

Mental Health Nursing at RGU covers trauma informed practice as part of their learning outcomes in two of their modules as well as across two parts of their indicative course content.

Qualification

BSc Children and Young People's Nursing (Robert Gordon University, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 1: Trauma Informed

Summary of trauma-components included

Children and Young People’s Nursing at RGU covers trauma informed practice as indicative content in three of their course modules.

Qualification

BSc Children and Young People and Mental Health Nursing (Robert Gordon University, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 2: Trauma Skilled

Summary of trauma-components included

Children and Young People and Mental Health Nursing covers trauma informed practice as part of their learning outcomes in two modules, trauma skilled approaches as part of their learning outcomes in one of their modules as well as across two parts of their indicative course content.

Qualification

BSc Adult and Mental Health Nursing (Robert Gordon University, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 2: Trauma Skilled

Summary of trauma-components included

Adult and Mental Health Nursing covers trauma informed practice as part of their learning outcomes in two modules, trauma skilled approaches as part of their learning outcomes in one of their modules as well as across two parts of their indicative course content.

Qualification

BSc Adult and Children and Young People Nursing (Robert Gordon University, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 1: Trauma Informed

Summary of trauma-components included

Adult and Children and Young People Nursing covers trauma informed practice across two parts of their indicative course content.

Qualification

BSc Nursing – Adult (University of Stirling, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 1: Trauma Informed

Summary of trauma-components included

Level 1: Trauma Informed practice is covered within a module.

Qualification

BSc Nursing - Mental Health (University of Stirling, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 2: Trauma Skilled

Summary of trauma-components included

This course teaches to a Trauma Skilled level of practice and dedicates a full module to the materials.

Qualification

BSc Nursing - Adult, Children and Young People, Learning Disabilities and Mental Health (The Open University, 2022)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma-components included

No evidence was found of trauma informed practice being included in the curriculum.

Qualification

BSc Mental Health Nursing (Abertay University, 2022)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma-components included

Trauma informed practice was not explicitly mentioned in the available course content. However, the impact of childhood experiences is mentioned within two modules.

Qualification

BSc Midwifery (Robert Gordon University, 2022b)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma-components included

No evidence of trauma or trauma informed practice being taught. However, modules cover topics such as: Sensitive individualised care; Mental health; Domestic abuse; and Child protection.

Qualification

BSc Midwifery (University of the West of Scotland, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma-components included

No evidence of trauma informed practice material that aligns with the Knowledge and Skills Framework. Whilst trauma and learning materials such as 'Transformative nursing in the NICU: trauma informed and age-appropriate care' are present in the materials, in this context trauma refers to physical traumas.

SCPHN Specialisation

4.15 Once someone has registered as a Nurse, they can further specialise through a Specialist Community Public Health Nursing (SCPHN) programme at postgraduate maters level. All SCPHN programmes must also align with the NMC’s standards and go through the NMC’s approval process.

4.16 It’s important to note here that the post-registration standards were updated in 2022, and that the current SCPHN programmes were validated against the previous 2004 standards and will be working towards implementation of the 2022 standards. The new standards come into effect from the 1st of September 2022. Post-registration students on existing programmes can complete the programme they started, however all SCPHN programmes must be approved in line with new standards by 1 September 2024 — no students will be able to commence a programme approved against the 2004 SCPHN standards after 31 August 2024 (Institute of Health Visiting, 2022).

4.17 In Scotland, School Nursing SCPHN programmes are offered by three institutions: Robert Gordon University, Queen Margaret University and University of the West of Scotland.

4.18 Health Visiting SCPHN programmes are offered by five institutions: Robert Gordon University, Queen Margaret University, University of the West of Scotland, University of Stirling, and Glasgow Caledonian University.

Analysis against the Knowledge and Skills Framework for Psychological Trauma (NES, 2017)

4.19 While the NMC’s post-registration standards for Health Visitors and School Nurses have partial coverage of Level 1: Trauma Informed, available documentation of relevant SCPHN shared a mixed picture of how trauma informed practice embeds across the different universities’ course modules. Conversations and interviews would suggest that work is underway in many institutions to include materials on trauma informed practice.

4.20 In Table 3 below, each education programme has been analysed based on available public information, such as module descriptions and learning objectives, to identify what trauma informed components are included.

Table 3: SCPHN Level Qualifications Summary

Qualification

Health Visiting, Glasgow Caledonian University

Material Source

Information shared through correspondence with relevant individuals

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Level 1: Trauma Informed

Summary of trauma components included

Students complete the NTTP Level 1: Trauma Informed online training in a module on Vulnerability, Safeguarding and ACEs

Qualification

Person-Centred Practice (Health Visiting) (Queen Margaret University, 2022a)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma components included

There is no explicit mention of trauma or trauma informed practice across the materials, however, the course module descriptions outline adjacent topics such as Adverse Childhood Experiences and the application of childhood development theories to explain, aid assessment and analyse stages of development and milestones.

Qualification

Person-Centred Practice (School Nursing) (Queen Margaret University, 2022b)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma components included

There is no explicit mention of trauma or trauma informed practice across the materials, however, the course module descriptions outline adjacent topics such as Adverse Childhood Experiences and the application of childhood development theories to explain, aid assessment and analyse stages of development and milestones.

Qualification

Advancing Practice, Health Visiting and School Nursing (Robert Gordon University, 2022c)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

Partial coverage of Level 1: Trauma Informed

Summary of trauma components included

These materials cover some elements of Level 1: Trauma Informed, such as Transgenerational trauma, Adverse Childhood Experiences, Vulnerable Groups and Managing conflict and complexity.

Qualification

MSc Early Years Practice Health Visiting (University of Stirling, 2022b)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma components included

The materials do not explicitly suggest coverage of Knowledge and Skills Framework materials or equivalent education; however, module overviews do include exploring the latest research on children's experiences of abuse and neglect, and Getting It right for Every Child (GIRFEC) (policy to ensure children and young people can receive the right help, at the right time, from the right people) although it is worth noting that GIRFEC currently is not trauma informed.

Qualification

SCPHN Health Visiting (University of the West of Scotland, 2022b)

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma components included

Trauma is not explicitly mentioned in module descriptions, although the ‘Safeguard Children, Enable Families’ module covers adjacent topics, such as the complexity of safeguarding and protecting children and families.

Qualification

SCPHN School Nursing, University of the West of Scotland

Material Source

Publicly available course modules analysed

Which levels of the Knowledge and Skills Framework for Psychological Trauma (NES, 2017) does this satisfy?

No explicit evidence of trauma informed practice available.

Summary of trauma components included

No explicit mention of trauma in the available module descriptions, however, modules include ‘GIRFEC and child-centred public health’ and 'Enhancing Wellbeing in Children & Young People'.

Employer Continued Professional Learning

4.21 Continued Professional Learning (CPL) is monitored by the NMC, which requires evidence of 35 hours of CPL every 3 years in order to remain registered. Of the stipulated 35 hours, 20 hours must be participatory learning which might involve attending a seminar, workshop, or group discussion — anything which involves interaction with one or more other professionals (NMC, 2021). The NMC does not stipulate what training a professional should be doing.

4.22 Health Visitors and School Nurses are predominantly employed by the NHS and therefore have a similar framework in which their CPL takes place. There are certain mandatory trainings that all Health Visitors and School Nurses take such as: Public Protection, Child Protection, and the Neglect Toolkit. Local health boards have access to TURAS, an online portal which has a number of free-to-access learning materials. The Health Visitors and School Nurses we spoke to reported that they did have access to the Knowledge and Skills Framework Level 1 and 2 through their internal portal, and one mentioned that it was mandatory for them to complete within their Health Board.

4.23 The remaining CPL is dependent on individuals to manage with the support of their Team Leader. It is part of a Team Leader’s responsibility to discuss professional development opportunities with individuals and teams of School Nurses or Health Visitors. This means that Continued Professional Development and Learning is, to a certain extent, dependent on individual and team learning needs and interests, CPL provision and awareness of CPL available. As a result, if individual Health Visitors and School Nurses or their Team Leaders acknowledge the importance of trauma and trauma informed practice, they are much more likely to ensure they are trained in Level 1: Trauma Informed Practice or Level 2: Trauma Skilled Practice.

4.24 Argyll and Bute HSCP produced a one-off programme of trauma training for their staff as part of the NTTP Local Authority Delivery Trials. The programme educated staff between Levels 1 and 3, depending on the proximity of their role to people with experience of trauma. They are now trying to work out how to keep the momentum going and the learning continuous.

4.25 Certain Health Visitors we spoke to had chosen to learn more about trauma informed approaches and provided examples of other training they have had access to. This ranged from local resources such as conferences to online resources available across the UK. It was noted that some of these trainings had been paid for out of their own pocket but attended on work time.

Frontline Workers’ Experiences

4.26 All of the Health Visitors and School Nurses we spoke to had an understanding of trauma and trauma informed practice, although they had all gained this knowledge in different ways; some had conducted their own learning, some had completed levels of the Knowledge and Skills Framework, and others had learned about trauma informed practice in their bachelor’s or master’s education.

4.27 Whilst one participant reported that the Knowledge and Skills Framework Level 1 and 2 was mandatory in their workplace (NHS Fife), most respondents reported that it was not compulsory for them to have in-depth training on trauma, and that learning about approaches to trauma is typically dependent on personal interest. Many also noted that it can be difficult to receive funding for training outwith what is mandatory or readily available. One Health Visitor suggested that this could be addressed by delivering trauma informed training as ‘informal teaching such as during safeguarding or clinical supervision.’

4.28 University of the West of Scotland (UWS) came up as an example of an institute that was currently delivering materials covering trauma. Two frontline workers we spoke to reported receiving workplace team training delivered by UWS, and one trainee Health Visitor reported learning about trauma through modules within their course.

4.29 One trainee School Nurse spoke about the importance of the workplace reinforcing the education they are receiving at university to ensure what is being taught remains part of their practice:

"School Nursing specifically is a service in the midst of really significant transformation with 10 developing pathways and lots of training being offered/attended and it can be too much without the opportunity to take the time to consolidate it before you're getting more training. So, for me, it would be about considering the frequency and intensity of training and where to fit it in to all the training being promoted." —Trainee School Nurse, South Lanarkshire