Refocused school nurse role: early adopter evaluation

6. Refining the programme theory

This section brings together the findings from the two sets of participants (managers and nurses). Within realist evaluation this stage is about explaining how the programme worked or did not work, by clarifying where there were agreements and disagreements between the designers (managers) and the nurses involved in delivering the programme in practice. The section is organised into four key areas arising from the findings, but disentangled using context, mechanism and outcome configurations of realist evaluation to provide further illumination to the findings.

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

Both school nurses and managers felt that the introduction of the nine priority areas was a positive change as it provides focus in the form of specific referral pathways. Undoubtedly, the mental health and wellbeing pathway was considered the most frequently used pathway. However, a number of nurses felt they were less equipped to deal appropriately with the many referrals on this pathway. The concerns voiced by the school nurses with regards to the content of the priority areas was not as strongly mirrored by the manager's responses. Specifically, a number of school nurses highlighted the lack of a number of pathways, including physical health. They stated that this should be reconsidered, as they felt that as school nurses, their primary role should be to treat and monitor health issues. In relation to this, some school nurses felt that some of the pathways such as youth justice and homeless were more related to social work than school nursing. In practice, many of them have not received referrals on these pathways.

An area of considerable contention amongst the school nurses was the absence of a sexual health pathway. The majority of nurses felt that sexual health was adequately covered by other agencies and that sexual health referrals can be placed within other priority areas if required. However some strongly felt that sexual health should be a stand-alone priority area. This disagreement was less apparent amongst managers, who apart from one, generally accepted that sexual health was the remit of other agencies and that it fits into existing pathways.

Table 14: Refined CMO for component 1: Programme implementation and the nine priority areas (pathways)

Context	Mechanism	Outcome
The nine pathways	Provision of defined referral pathways	Improved identification of needs and perceived improvement of outcomes for children
Referrals system	Referral system empowers school nurses to withstand pressures from educational staff and other agencies who avoid the referral system	Provided a system of working with the children who are most in need of the service. Inappropriate referrals rejected or passed on
Highly-referred pathways	Mental health and wellbeing is the most highly-referred pathway	Some nurses perceived that they are less equipped to deal with some mental health referrals, but know they can refer more complex cases to CAMHS
Gaps in pathways	Perceived omission of physical and sexual health pathways	Cases often added to mental health and wellbeing pathway but perceptions that some high risk children excluded from benefitting from the service

Component 2: Role clarity and standardisation

School nurses and managers were in agreement that the school nurse role has been positively enhanced and formalised by the introduction of the refocused SN programme. Whilst both school nurses and managers could not definitively say the programme had improved outcomes for children and families, they did concur that such benefits would become apparent in the future due to the more focused nature of the school nurse role.

Both school nurses and managers were optimistic about the benefits of the referral system. School nurses further explained that this is making other agencies (such as education) take more consideration when referring a child.

Whilst there was agreement that links with certain agencies continued to be strong, there was an understanding that the priority areas have broadened relationships with additional agencies.

However, members of the wider school health team felt alienated and excluded from the programme. Whilst most were pre-occupied with immunisations others were unclear of their specific role within the pathways.

Table 15 Refined CMO for component 2: Role clarity and standardisation

Context	Mechanism	Outcome
Role clarity and standardised practice	No obvious change in relationships with certain agencies like social work, but increased awareness of additional agencies e.g. youth justice which they can refer to	SN profile raised and interagency working enhanced. Both important to early identification and improving outcomes for children.
Clarity of role through referral system	Operated through formalised referral system	Empowered midwives and validated role amongst other agencies
Perceived lack of clarity regarding the role of wider school health team	Lower bands felt alienated and excluded, with some still pre-occupied with immunisations	Confusion and uncertainties over role of lower bands within the pathways

Component 3: Engagement and accessibility

Both managers and nurses admitted that school nurses' accessibility in schools has reduced. However, further examination of the nurses' data illustrated that this was not entirely negative because the focus introduced by the pathways was vital in terms of strengthening trusting relationships with the limited number of families that access the service.

On the other hand, it appeared that children who may find it difficult to access the service through the pupil support teachers may not benefit from the service. In this regard, other ways of making the service accessible to this group of children should be explored. The concept of text message service seems interesting, although this may have its own limitations. Further evidence of how this would work should be explored, whilst looking into other novel ways of making the service more accessible to the wider school population.

Engagement of school nurses with other agencies has been enhanced due to the diverse pathways. Engaging more with other agencies ensures that other agencies are clearer of the school nurses role and the contribution they make to children and young people's assessment and support processes. It is likely that this can promote increase in early identification, referral or provision of appropriate interventions.

Table 16: Refined CMO for component 3: Engagement and accessibility

Context	Mechanism	Outcome
Engagement and accessibility to school children	Limited number of children seen and assessment by school nurses	Trusted relationships strengthened with the few children who use the service
Engagement and accessibility to other agencies	Validation of SN contribution to children's assessment and support to other agencies	Improved engagement with other agencies inherent to early identification of risk
Accessibility of school nurses through pupil support teachers	Perception that some children may be hesitant at accessing service through pupil support teachers	Perceived low engagement from less confident and more sensitive children

Component 4: Training and support

Nurse managers and nurses unequivocally established that extensive training, often involving multiagency partners, was provided as part of the refocused SN programme. The training facilitated assessment of risk and undoubtedly improved school nurses knowledge of children and young people's development, especially those linked to specific elements of the nine priority areas. The training also broadened nurses' knowledge of community assets and local services.

However, what was striking was how nurses perceived the training they received. It appeared that the training did not build nurses' skills and confidence to deliver all the priority areas in an efficient manner. It was apparent that nurses would require further skill-based training on both the more and least frequently used pathways for quite contrasting reasons. Regarding the least frequently used pathways such as youth justice and homeless, continued training would be required because the knowledge acquired was rarely practiced. Further training is also needed on the more frequently used pathways, for example mental health and wellbeing, because a more in-depth knowledge and advanced skills would be required to identify and support the spectrum of issues that are often presented through this pathway.

Table 17 Refined CMO for component 4: Training and support

Context	Mechanism	Outcome
School nurses extensively trained	Equipped nurses and facilitated risk assessment	Improved early identification of risk but less confident with intervention delivery
Multi-agency training	Awareness of community assets and local services	Increased access and engagement with wider services and greater support for children
Training and support	Low engagement with certain pathways e.g. youth justice and homeless	Reduced skills and confidence to engage with these pathways
Training and support	High and consistent engagement with mental health and wellbeing pathway	More advanced skills required to analyse and appropriately support the spectrum of cases presented on this pathway

Status of cases at end of the early adoption period

As of May 2016 Perth and Kinross had closed/discharged 50 (47%) of its cases and Dumfries and Galloway 79 (26%). The difference may have been caused by D&G nurse sometimes keeping cases open but on reduced intervention. Many of the children had been referred on elsewhere, particularly in the case of P&K. This may indicate a need for further training in order to build confidence in their own skills in the workforce.

Table 18: Percent children with certain Outcomes of Intervention for Closed Cases

	P&K % Outcomes	D&G % Outcomes
Child Development Team	31
Elsewhere in NHS	2	4
Patient Declined (or DNAs)	13	1
CAMHS	24	8
GP	7
YPHT	4
Central due to Immunisation	7
Incontinence	2	1
Intervention Completed	11	68
Left school		8
Foster Care		3
Educational Psychology		1
Physiotherapy		1
Social Work		1
Other		3

By the end of the early adoption period around two thirds of cases were open in D&G and a third in P&K. However this does not take into account the complexity of cases in the respective areas, nor whether the term 'open' meant the same in both areas (in discussion it became apparent that some School Nurses were keeping cases open so that they could keep a watching brief over certain children but this did not necessarily entail a high level of intervention), nor the length of time a child had been seen by a School Nurse.

Table 19: Status of cases at end of programme

	P&K % (N=107)	D&G % (N=299)
Open/Active	30 (32)	68 (202)
Closed	47 (50)	26 (79)
Declined by School Nurse	21 (22)	2 (5)
Unknown/Other	2 (3)	4 (13)