Refocused school nurse role: early adopter evaluation

5. Testing out the programme theory

This section uses the nurses' data to examine how the initial programme theories outlined in section three unfolded in practice.

Component 1: Programme implementation and the nine priority areas (pathways)

The perception of the programme varied between Dumfries and Galloway and Perth and Kinross. This was mainly due to the continued immunisations, which took place throughout the programme in Perth and Kinross.

"You've got a team of school nurses here, who are hugely experienced, good at their job, and we all felt that we just weren't giving it enough time, and enough, you know, effort. Because we just couldn't, because, since October, we've basically been immunising, from October to June" ( PK3, Band 6).

In Dumfries and Galloway, where more time was dedicated to the new way of working, nurses perceived the programme to be a step in the right direction in terms of giving the school nurse role a clear focus in the form of the nine priority areas.

"I think my practice has totally changed since we have done the pilot, you know, we are doing things completely different, we are focused, we are streamlined, I think we are a stronger workforce than what we were before because we are focused mainly on these nine pathways, instead of taking up a lot of things that perhaps before wasn't really our remit but we felt people are passing it on" (D1 Band 6).

Across both sites, the programme was perceived as a way of raising the profile of school nursing through the addition of clear pathways of work and a formal referral system.

"I think one of the most positive things that have come out of this is the referral system. I would love that to stay in place in the robust form it's in" ( PK12, Band 6).

Specifically, a number of nurses stated that the referral system encourages teachers to think more carefully about sending a child to the school nurse, as they are now required to use the referral form to justify their reasons for doing so. The referral system also allows the school nurses to assess each individual case before accepting it, which then allows them to pass specific cases on to other agencies who are more appropriate for dealing with a specific issue.

"I think the referral process is really good, because it gives the education staff a clearer focus on the children that we should be working with, rather than just a wee word in the corridor as you pass, which is what happened previously. I think the referral process is really good for education and for us as well, because we can have a much more, almost like a streamlined caseload that, you know, we're working with children that really need to be worked with" ( PK4, Band 6).

There were few suggestions that the pathways were quite many and longwinded, making them a little bit cumbersome to use in practice. Interestingly, the band sixes with SPQ particularly highlighted this.

"To me it's too big, there are too many priority areas, you know, it needs to be more defined, maybe more structured. It's a bit wordy as well, there is quite lot in it, there's quite a lot in it, you know" (D5, Band 6).

Although there were some concerns about the size of the pathways, a number of the nurses commented on the lack of an explicit pathway for physical health.

"We've got mental and emotional health but we don't have, sort of, ill health, physical ill health, and there are some children that we might do a small piece of work with that isn't being captured" ( PK4, Band 6).

Interestingly, findings from the consultation with children and young people within the early adopter sites suggested that children were also keen to get information and support on physical health issues (Woodhouse et al., 2016).

This meant they often found themselves placing referrals for conditions such as obesity and bed-wetting within other pathways - mostly mental health and wellbeing.

"I squeeze children that are quite overweight and obviously need that managed and you can say it will affect their self-esteem and their confidence so you can fit it under the mental health and wellbeing pathway but actually you're not recognising the problem" ( PK7, Band 6).

An area, which divided opinion amongst nurses regardless of their band or practitioner qualification status, was the apparent omission of sexual health as an explicit priority area. Some nurses believed sexual health should be a stand-alone priority area, while others contested that it is sufficiently covered by other agencies and that there are ways of working sexual health referrals into the existing nine priority areas.

"Do you know, most of them I'm not seeing and I just think it's crazy that sexual health isn't one on its own" (D9, Band 6).

"I think…there's no sexual health pathway, but as far as I was led to believe the feeling was that there shouldn't be a specific pathway for sexual health because sexual health feeds in to every single one of them" (D2, Band 5).

Nurses at both sites stated that the pathway that presents in referrals most frequently was mental health and wellbeing. This was also confirmed by the consultation with children and young people (Woodhouse et al., 2016). School nurses felt that the mental health and well-being pathway was sometimes used as a 'catch all' for occasions when there did not seem to be an appropriate pathway. They also speculated that mental health is becoming a bigger issue in children and schools see this as a key part of the school nurse's role.

This is congruent with the records, which showed that the majority of children were referred in to the service for mental health and well-being issues. As can be seen 68% of those from both P&K D&G were referred in to the service because of concerns around a child's mental health and well-being. There was quite limited representation on the other pathways, except those children who were Looked After in D&G. It should be noted, however, that a high proportion of children in P&K had not been referred into the service on any particular pathway:

Dumfries and Galloway also reported on the pathways children were assigned to after meeting with the School Nurse, when School Nurses might change the pathway following more in-depth assessment. In this case some 50.5% of children were not given a pathway presumably because the referral had been declined or the children had received one episode of care before being discharged.

Table 10: Percent of Children on Pathways at Referral and after SN intervention

	Perth and Kinross	Dumfries and Galloway
		Before SN intervention	After SN intervention
Mental Health and Well-Being	68	68	37
Substance Misuse	0	0.3
Child Protection	0	4	3.3
Domestic Abuse	3	2	2
Looked After Children	0	12	8.4
Homelessness	5	1	0
Youth Justice	3	0	0.3
Young Carers	5	0.3	2.7
Transitions	0	4	2.7
Unknown/Discharged	32	9	50.5

Please note: children could be on more than one pathway, hence the percentages add up to more than 100%

Nurses recognised that mental health and wellbeing was an important pathway, however a number of nurses, including those with SPQ felt they are inadequately trained to deal with low to moderate mental health issues. While it was generally accepted that more mental health training is needed, nurses were also aware that they could refer more severe cases on to child and adolescent mental health services ( CAMHS).

"For those of us who are not mental health trained we noticed a real gap in our training there and we sort of passed that on to relevant people, but more and more the children that were coming to see us and that were asking for our help were falling into that pathway and that was an area where we all felt we lacked somewhat" ( PK16, Band 6).

It appeared that across both sites school nurses rarely engaged with youth justice and homeless pathways. This may be because those early adopter sites experienced lower levels of child/young person homelessness and involvement in the youth justice system than is prevalent nationally. Some nurses also mentioned that youth justice was not something they considered to be within the remit of a school nurse and is more related to social work, and therefore should not probably be one of the pathways.

"I think, what we're trying to do, we're trying to turn school nurses into social workers. And a lot of the priority areas that we have, the majority of them are socially based. So, of course, you've got things like LAC, and child protection, of course that should be our priority area. But, you know, I'm not quite sure if we should be going down the lines of things like youth justice, and homelessness. And all these, there are other agencies that are equipped for that" ( PK3, Band 6).

Homelessness appeared to be a difficult area to focus on according to the nurses, regardless of their SPQ status. Firstly, nurses stated that it is likely a context-specific pathway and would be more presentable in urban areas than in rural. Secondly, it was stated that the definition of homeless often caused unnecessary referrals as children would be referred when moving house or after their parents separated, as opposed to being truly homeless.

In terms of referrals that were declined by the School Nurse team there was some variation between the two areas. School Nurses in Perth and Kinross declined nearly 20% of the referrals to them, 65% were accepted and data is missing on the remaining 16%. In Dumfries and Galloway only 5% of referrals were declined. However, there were many cases where the School Nurse had only seen the child once suggesting that the School Nurse was in some cases declining the referrals after making their own assessment.

Table 11: Reasons for Declining Referral (numbers)

	Perth and Kinross (N)	Dumfries and Galloway (N)
Already being seen by another professional (health or other)	9	2
Parent refused	1	1
Referral did not fit criteria	1	2
School Nurse felt another service was more appropriate	6
Child did not attend	2
Inadequate information was given	1
Child did not want support	1

Box 5. Summary - Implementation strategies and the nine priority areas

Nine priority areas provide clear framework to school nurses, which ensures that only relevant cases are referred to school nurses

Perceptions that gaps exist in the pathways, with the omission of sexual health keenly debated

Mental health and wellbeing viewed as the most frequently used pathway, but there were indications this was also being used to accommodate areas not covered by the priority areas

Nurses struggling to deal with mental health and wellbeing pathway because of gap in training

Component 2: Role clarity and standardisation

It appeared that within both early adopter sites, interagency support and working has always been good between agencies they traditionally work with such as social work, sexual health and education. They emphasised that this has always been the case, and that this has not been made better or worse by the introduction of the programme.

"I think, to be honest, we've always had a good working relationship with education, social work" ( PK16, Band 6).

Some nurses added that recent changes brought in as part of GIRFEC also contributed to the good practice observed between agencies.

However, other nurses indicated that the programme has made them more aware of the other agencies they had not previously engaged with, for example youth justice.

"You'd maybe become aware of others such as youth justice. You maybe would be thinking, that's something I could link in with them, so it's made you aware of different (agencies)" (D3, Band 6).

The introduction of a referral system was generally perceived to be a positive change, with school nurses in both sites stating that it formalised procedures, which in turn helped to clarify the role of the school nurse amongst other agencies.

"In the past people in a community, other professionals were never quite sure what we've done and it's always been a, you know, yes, we've been needed and appreciated but I think we've been appreciated more, especially now we have got the referral form, it can show that, you know, we've got proof that we are getting referred and why they are getting referred and I think our profile has been greatly raised with the pilot" (D1, Band 6).

Despite school nurses' perception that the refocused role has raised their profile amongst other professionals, findings from the consultation with children and young people suggest, however, that young people have limited knowledge of their school nurse and often mixed up their role with their social worker (Woodhouse et al., 2016).

The Band fives mentioned that the uncertainties surrounding the expectations of their role have been challenging for them. They felt there were inconsistencies across different areas regarding their role.

"And that's important because that's a new role, a Band 5, so if they decide that role will continue that's a really good role, a really meaningful role, but I have to be clear about what it is. Is it in primary? Is it in secondary? You have to be really clear on what everybody's role is" (D8, Band 5).

In terms of standardisation of practice, immunisation has been the most conspicuous and prevalent challenge in Perth and Kinross. Whilst they have stopped a number of previous duties, immunisations were very time consuming, and this has prevented lower bands from fully engaging with the programme.

"We've dropped a lot, we don't do health promotion and things like that anymore, but it's been taken up, the time that we gained by not doing that has been taken up with immunisations…I've not been given the opportunity to take on any of this (pilot)" ( PK10, Band 3).

Interestingly, within Perth and Kinross nurses in the lower bands expressed concerns regarding their role within the priority areas once immunisations cease.

Box 6. Summary - Role clarity and standardisation

• Role clearly defined to all relevant agencies, with referral system further formalising duties of the role
• Uncertainties of the role of wider school health team challenging for them, with some mostly pre-occupied with immunisations

Component 3: Engagement and accessibility

Many of the nurses believed that although they are not widely accessible to the wider school population, the focus that the programme brought helped to strengthen trusting relationships with the limited children and families who access the service.

"I would say that it definitely strengthens relationships with children and families because we've got more focus on what we are doing" (D1, Band 6).

Other nurses explained that because they now work with a limited group of children and families over a period of time, which often involve home visits, they are therefore able to engage more with them and this helps to build trusting relationships. Children and young people also felt that it was important to build trusting relationships prior to discussing sensitive issues with school nurses (Woodhouse et al., 2016).

Nurses asserted that accessing the school nurse service through the pupil support teachers was probably a barrier for some children.

"Well, when they had the drop-in they didn't have to speak to anybody. They could have just dropped in confidentially. Now it's not a confidential service because you'd have to go to pupil support and what happens is they may go to pupil support and say I'd quite like to see the school nurse when she's in and pupil support may say, oh, what's wrong, can I help at all and in the right way but that's not...that means that you're taking something away from that service because it's not then as accessible as a confidential service" (D8, Band 5).

In this regard, all nurses particularly within Dumfries and Galloway were optimistic that text message service might help to overcome this challenge.

In terms of engagement with other agencies, it was clear that within Dumfries and Galloway the programme has significantly facilitated this. On the other hand, it appeared that immunisation has hindered this to a certain extent within Perth and Kinross.

"What I have struggled a little bit with is some of the meetings. There's certain areas, like we've all got areas that we've been told to support. Now, for me to know everything that's going on in that area, I need to attend certain strategic meetings, right. They have not been happening (because of immunisation)" ( PK15, Band 6).

It was suggested by managers that the refocused SN role would increase home visits or referrals. However, as can be seen from the table below, the school was the main source of referral, particularly in P&K but Social Work, other health services and other agencies also referred. Most of the initial contact was made in school although the place of initial contact was often not recorded and so it is not possible to state definitively if, for instance, home visits were increasing (see table).

Table 12: Percent of Children referred to School Nurse Service by referrer

	Perth and Kinross	Dumfries and Galloway
Health Services incl GPs, HVs and A&E, CAMHS	7	6
School	92	68
Parent	1	3
Self referral	1	1
Other eg LAC, Child Plan Meeting, SACRO	0	4
Social Work	0	11
Missing	0	8

Table 13: Percent of children by Place of Assessment/Contact

	Perth and Kinross	Dumfries and Galloway
Telephone Call	12	0.3
Home	6	7
School	32	71
Unknown	50	21
Pending	1

Box 7. Summary - Engagement and accessibility

Although accessibility has reduced, stronger trusting relationships are formed with those who use the service

Accessibility of school nurses through the pupil support teacher viewed as significant barrier

Using text message service or other ways to overcome this barrier presumably needed

Component 4: Training and support

It was consistently clear that all nurses in both early adopter sites, especially the higher bands, received extensive training on the priority areas, including those delivered by agencies like CAMHS. It appeared that training equipped nurses and facilitated early identification of risk.

"…and with the training we're able to maybe identify the kind of early indicators of risk within maybe if it's risk-taking behaviours or if it's potential issues at home, we're better" (D3, Band 6).

Some nurses believed that the mandatory nature of the training was helpful compared to previous optional training.

"We've had an increase in training, more than we've ever had. It's been mandatory, almost, everybody's had to do it, which was good, because a lot of it was optional before" (D6, Band 6).

Although most nurses, regardless of their SPQ status, found the training useful, a few thought it was quite theoretical and did not equip them with sufficient tools or skills to actually deliver relevant interventions. Nurses were especially keen to be up-skilled in intervention techniques around child and adolescent mental health and well-being and the various pathways. For instance, one school nurse with SPQ revealed below that whilst it is straightforward to assess risks and assign a pathway, they often lack the skills to provide appropriate support.

"You've got the skills on maybe assessing anxiety or assessing self-harm, but what can we use to try and do a bit of work with that person? We don't have the resources to actually implement the work there. We've got the knowledge of what maybe the risk factors and things are but we've got nothing to make any interventions with" (D3, Band 6).

Some nurses suggested that continued training especially on priority areas they sparsely engage with would be useful. In particular, youth justice and homeless pathways were mentioned. Similarly, others were of the view that further training and support was required within the mental health and wellbeing pathway, which appeared to be the most heavily used pathway in both early adopter sites. Nurses explained that whilst severe mental health cases are easy to refer on, they struggle to cope with low-level mental health issues, as explained by a Band 6 nurse with SPQ in this quote.

"I think it is when the young people or children's come to us, and it's a mental health issue they've got, I feel confident enough to know if I need to move it on quickly. Because I can recognise that, you know, if they are in a stage where I have to move it onto my mental health colleagues quickly I know that. But it's with the ones who are just a wee bit, you know, sort of a wee bit of anxiety, a wee bit of they are feeling a bit low mood. It's just to have more support on, you know, where we are taking them" ( PK12, Band 6).

Further analysis showed that there was a need for further training on mental health and wellbeing. Interestingly, training needs appeared to differ disproportionately across the early adopter sites. More nurses in Perth and Kinross than Dumfries and Galloway felt there was a training gap. It was also mentioned that the mental health services in Perth and Kinross have a long waiting time and this seemed to have necessitated the perceived training need.

It was apparent that both early adopter sites had issues with how training would affect their existing staff capacity. There were concerns that the training opportunity offered to staff to acquire an SPQ put further pressure on the capacity of the existing workforce. One nurse explained:

"They're talking about training the ones we already have, because we don't have the public health nurse qualification, so…which fills us with alarm, because as well as losing our Band 5s, we'll be two Band 6s who are already in post will be going away to do training. So it's going to leave us down, sort of, three Band 5s and two Band 6s" (D4, Band 6).

It appears that there was no noticeable difference in terms of how SN with or without SPQ felt equipped to deliver the pathways. Any difference was possibly masked by the extensive, and often mandatory training given to all SN on each of the priority areas.

Box 8. Summary - training and support

• training seen as essential but did not necessarily equip school nurses with sufficient skills to support and deliver interventions
• training required in less and most frequently used pathways for different reasons
• additional training needed on the most frequently used pathways ( e.g. mental health and wellbeing) in order to support the different spectrum of cases usually presented
• ongoing training needed for less frequently used pathways (youth justice and homeless) because nurses may lose confidence to use this pathways per time
• taking staff away to pursue SPQ likely to have detrimental effects on existing staff capacity