Refocused school nurse role: early adopter evaluation

Executive summary

The school nurse ( SN) role is a significant part of the school health service, which is a universally accessible service provided to children and young people, aged 5-19 years and their families. However, the SN roles, models and skill mix have varied greatly across Scotland. These have encompassed roles and interventions focused in schools, as well as those with a wider public health and community function. The publication of CEL 13 (2013) ^[1] aimed to redefine the SN role to focus on delivering consistent and more efficient services across Scotland in order to deliver safe, effective and person-centred care based on the principles of Getting It Right for Every Child ( GIRFEC) national practice model. The SN role has been designed to have greater emphasis on home visiting and addressing wider policy and public health priorities. Based on available evidence, policy direction and priorities, the role focuses on nine priority areas:

• Mental health and well-being
• Substance misuse
• Child protection
• Domestic abuse
• Looked After Children
• Homeless children and families
• Children known to or at risk of involvement in the Youth Justice System
• Young Carers
• Transition points

Since September 2015, two early adopter NHS boards, Dumfries and Galloway ( D&G) and Tayside (Perth and Kinross ( P&K), have been testing this role, including the role of the wider school health team and associated redesign requirements.

The aim of the evaluation was to assess how the refocused school nursing role worked in both D&G and P&K, in order to provide learning and guidance to support SN training and any further roll out and evaluation of the service.

A realist framework informed this evaluation, combining both qualitative and quantitative data analysis. Realist evaluation uses a theory-driven approach to evaluate healthcare or social programmes. Interviews were held with staff from the SN teams and managers, both on an individual basis and in groups. The information gathered was analysed in accordance with realist evaluation methodology. Secondary data from the first 6 months of the pilot was also collected and analysed in order to capture patterns of referral both in and out of the school nursing service and the pathways being used for children.

The evaluation identified the following key findings:

What worked well?

1. The nine priority areas have undoubtedly made the school nurse role more focused and standardised. It has added value to the service by providing clear priority areas and pathways to school nurses.

2. The referral system formalises practice and ensures that school nurses receive mainly relevant referrals.

3. The role is now clearer to the nurses themselves and to all relevant agencies, including education.

4. Other agencies are increasingly aware of the contribution school nurses make to children's assessment and support process.

5. The priority areas have extended working relationships with agencies ( e.g. youth justice) that school nurses did not previously engage with.

6. Extensive and mandatory training appears helpful for delivering the pathways.

What did not work so well and may require further consideration?

1. The nine selected priority areas generated divided opinions amongst both managers and nurses, especially in terms of what qualifies to be included or excluded. However it was recognised that children and young people could move between priority areas and could also be on several pathways at once.

2. The mental health and wellbeing pathway was the most frequently used pathway. Whereas nurses referred complex mental health cases to CAMHS, they felt less equipped to deal with low to moderate cases. As there are no nationally agreed guidelines on the assessment and treatment of mental health issues in young people, it is difficult to know what kind of training would be most appropriate for School Nurses.

3. Some members of the wider school health team felt alienated and excluded from the refocussing of the SN role. Whilst the development of the priority areas and pathways gave increased clarity and structure to the School Nurse role the role of the wider School Health team still needs further clarification.

4. Accessing the service through pupil support teachers was considered as a barrier in some cases.

5. Although school nurses perceived that they are now in a position to build stronger trusting relationships with the limited number of children who access their services, it was generally recognised that they are now less accessible to the wider school population.

6. Targeted skill-based training would be required to equip nurses on some specific pathways e.g. mental health and wellbeing.

Recommendations for school nurse training and further implementation

Priority areas and Pathways

1. There needs to be a greater clarity around the pathways. It may be beneficial to amend some, e.g. the substance misuse pathway could be widened to include all risk taking behaviour.

2. Health Boards should be encouraged to adopt the nine priority areas but develop their own pathways as referral mechanisms and resources differ locally.

3. Additional training on the mental health and wellbeing pathway is required. It might be useful to involve CAMHS in any such training.

Training

4. Nurses would benefit from training approaches that seek to build practical skills within the parameters of the priority areas. This would ensure that aside from identifying risks, nurses would also be equipped with skills to deliver interventions or support where necessary.

5. When training school nurses, the rationale for the selected nine priority areas may need to be clarified and the reasons for omitting some of the obvious ones from the framework, for instance sexual health (if it is to be omitted) need to be clearly articulated. This would promote consistency across the workforce regarding the rationale for the selected priority areas.

6. Whilst it is encouraging to see staff taking up opportunities for full time training backfilling their posts is necessary. This will be particularly pertinent over the next 5 years or so whilst most staff are receiving training.

Referral

7. The current referral procedure through the pupil support teachers may exclude some groups of children who may find it uncomfortable to approach such teachers with their issues. Exploration of other means of accessing school nurses ( e.g. text message service) without going through pupil support teachers would be useful.

8. Clarification is needed around whether the School Nurses use referrals or Requests for Assistance and the role of the Health Plan Indicator ( HPI).

Wider School Health Team

1. The role of the Band fives should be consistent and clear career development/progression opportunities could be incorporated within the role.

2. Clearly articulating the specific role within the priority areas of members of the wider school health team would be useful.

3. A dedicated immunisation team is required if school nurses are to focus on the priority areas.

Recording and Record Keeping

1. Data needs to be consistently gathered using an agreed format. This data should be analysed nationally and fed back to school nurse teams for management purposes as well as being used to show the patterns of usage across Scotland.

2. The evaluation of the pilot was unable to measure any kind of impact. It is recommended that if the refocused school nurse role is rolled out nationally that some sort of outcome/impact study is undertaken.