Position Statement on School Nursing: Potential to impact on prevention agenda and mental health outcomes
Introduction and Background
Public health is at the forefront of transforming population health for all communities and across the lifespan. The importance of building on the support in the early years and sustaining this across the life course for school-aged children and young people to improve outcomes and reduce inequalities has been recognised (1). The Chief Medical Officer articulated the crucial role of School Nurses in delivering a proportionate universalism approach, with a range of services from universal to universal plus and beyond (2). The Healthy Child Programme from 5 to 19 years old provides an evidenced based framework to support local public health delivery for children and young people and is led by school nursing services, providing place-based services and working in partnership with education and other providers (3). ‘All Our Health’, key to the NHS Five Year Forward plan, highlights the growing importance of taking action to improve health outcomes and tackle inequalities and provides examples of topic areas where School Nurses are key contributors (4).More recently Matt Hancock, Minister for Health and Social Care, has recognised the unique position of School Nurses as the professionals with the first and most frequent
interaction with children and young people and in a position to influence their lifestyle choices, and to spot when helped might be needed (5).
The Role of the School Nurse
School Nurses are registered nurses/midwives, with additional degree/post graduate training in specialist public health nursing leading to Nursing and Midwifery Council (NMC) recordable qualification as Specialist Community Public Health Nurse (SCPHN). Their aim is to improve the health and wellbeing of children and young people, supporting children and young people in making healthy lifestyle choices, enabling them to reach their full potential and enjoy life. The nature of their work requires clinical input and effective leadership.
School Nurses are;
The single biggest workforce specifically trained and skilled to deliver public health for school-aged children (5-19), trusted and valued by children and young people,
The key health professionals who provide a link between school, home and the community, uniquely positioned within community and education settings to support multi-disciplinary teams, with relationships within primary and secondary care,
Skilled in managing the relationships between child, family and school settings,
Clinically skilled in providing holistic, individualised and population health level assessment and intervention. (6)
The evidence listed above clearly demonstrates the impact on health outcomes alongside the return on investment of providing prevention and early intervention in a child’s life and sustained into adulthood. And yet, although the Chief Medical Officer emphasised the importance of maintaining and building on the progress made through the transfer of commissioning to local authorities, the trend is one of disinvestment (7). The figures are stark: -
Between 2010 and 2017 there has been a 16% decrease in the number of full time School Nurses while we have seen a rise of 450,000 of school aged pupils,
14% of the total public health funding cuts in 2016-7 fell on services aiming to improve children and young people’s health. The proposed cuts for 2019-2020 will have a further significant impact.
These cuts are coupled with a complex picture of workforce and service delivery with some local authorities wholly decommissioning school nursing services, with decreases in the commissions and uptake of SCPHN training (8).
The School Nurse is ideally placed to tackle the wider determinants of health, combining our safeguarding role and prevention/early intervention role to reduce the impact of adverse childhood experiences (ACES).The School Nurse is in a position to identify risk factors, promote health and disrupt exposure to further risk and support the children and young people and their families to recover, with a particular opportunity during times of adolescent neuro-development.
What is ‘good’ school nursing: Evidence, outcomes & potential for return on investment
Public Health England (PHE) monitors a range of health and wellbeing indicators however data systems remain in their infancy and many of the outcomes are relatively long term. However, PHE commissioning guidance outlines performance and outcomes measures for school nursing services across the six high impact areas and is an example of how improvements and outcomes can be realised:
Building resilience and emotional wellbeing
Reducing risk from harm and improving safety
Maximising learning and achievement
Supporting complex and additional health and wellbeing needs
Seamless transition and preparation to adulthood (9)
Although data systems are immature there are many narratives that do demonstrate the impact of school nursing across England. The examples of good practice and how and what School Nurses achieve are plentiful, some of these examples are evidenced below.
Young people wanted their school nurse to offer accessible, visible and confidential services (10).In response, School Nurses have offered more traditional services such as ‘drop in’s’ in schools or other settings offering advice and support on a range of health issues. This is alongside embracing innovation and extending reach using technology. For example, ChatHealth text messaging service are used by 32 areas across England and in October alone School Nurses provided over 1500 episodes of care.
Supporting children and young people in vulnerable groups. School nurse service have pathway approaches that allow those not accessing mainstream education to have the same access to support that those in school receive. These pathways are incorporated within services or might be offered as part of specialist team. For example, https://vivbennett.blog.gov.uk/2016/11/01/supporting-vulnerable-groups-by-heidi-ferrier-hixon/. Young Carers are particularly hidden group and School Nurses have lead the way in supporting these young people
An increasing number of children and young people have complex needs, long term medical needs and/or special educational needs. School nurse play a crucial part in supporting these children and young people to access education, learn and achieve. Many school nurse services provide training for schools to enable them to support pupils with medical needs. https://www.ncb.org.uk/sites/default/files/uploads/documents/Research_reports/Nursing%20in%20Schools%20-%20Final.pdf
Staying healthy is a key priority. Many School Nurses services are crucial in providing the National Child Measurement Programme (NCMP) and extend their provision through providing intervention which support healthy weight and physical activity. For example, Warwickshire School Nurses delivered interventions to improve healthy eating and physical activity https://vivbennett.blog.gov.uk/2017/08/25/breakfast-and-activity-can-children-be-encouraged-to-enjoy-both/. Dental health is another priority area. School Nurses in Hampshire targeted oral health as part of wider public health prevention within the community that they service https://vivbennett.blog.gov.uk/2015/09/29/oral-health-jane-levers/
•School Nurses are key to the delivery of positive sexual health messages and achieve this through interventions such as ‘clinic in box’ and providing high quality sexual health and education in schools Examples of good practice can be found in Bath, Oxford and Doncaster https://vivbennett.blog.gov.uk/2016/11/01/teenage-pregnancy-and-young-parents-the-key-contribution-of-school-nurses-by-alison-hadley/
The impact of the school nurse on promoting emotional health and wellbeing
Children and young people’s mental health and well-being has been recognised as a rising issue, gaining wider publicity from the public and political agenda; resulting in publications such as Future in Mind (11) and the most current Green paper, ‘Transforming Children and Young People’s Mental Health Provision’ (12).
All policies advocate tackling the wider determinants of health and wellbeing inequalities, however fail to acknowledge the significance of the school nursing team contribution within the public health setting.
It is extensively documented that School Nurses are well placed to identify and support young people who are at risk of having problems with their emotional health and well-being and offer emotional support and education (13, 6, 11).
The priority afforded to interventions targeting positive mental health and emotional health and wellbeing has led to the development of a national pathway guidance showcasing many examples of our practice
Walsall school nursing service offer targeted interventions using evidence-based CBT packaged and training wider children’s workforce to deliver interventions
The intrinsic link between emotional wellbeing and other health outcome priorities must be explored when the School Nurse impact on emotional health and well-being is considered; more notably in adolescence as the causative or consequential factors of poor mental health.
Key indicators such as healthy weight, sexual health and drug and alcohol misuse are vital triggers for school nursing teams to initiate contact with young people who may be struggling with their emotional health. Drop in sessions at high school are the main domain for School Nurses to provide advice and support and a study carried out by Kay et al (2006) (14) found that the majority of consultations carried out by the school nurse were concerning issues relating to emotional wellbeing and mental health such as low mood, anxiety, depression and self-harm. Kelly et al (2005) (15) identified that parents and teachers perceived School Nurses to be invaluable when delivering mental health interventions, partly due to the skills and attitudes they possess but also because of their ability to liaise with multi agencies.
The School Nurse can also be the neutral, supportive adult to children suffering the impact of parental mental illness helping build resilience, and contributing to emotional wellbeing.
As outlined by key government documents, which create the framework to which school nursing provision is modelled, early intervention is key and the universal service we provide to the school age population is well timed and strategic in meeting their needs (DH 2009, DH 2014).
There are key opportunities at the current time for Government to support both the physical and mental health of children and young people through well-resourced School Nursing services.
The current level of disinvestment in the provision of school nursing services as part of wider public health services for children and young people is a threat to the maintenance and ability to build on the progress made in improving health outcomes for our children and young people. In response to these concerns we ask that the expertise of School Nurses, as public health practitioners is recognised, and appropriate funding streams identified to maintain and develop this highly skilled workforce.Also to recognise the crucial role and contribution School Nurses make to high impact areas which support health and wellbeing through the Government reflecting the contribution of school nursing within current policy.
We also ask that consideration is given to reviewing mandation of core school nursing activity in conjunction with health visiting.The current inequity in the system leads to opportunity for dilution of school nursing resource in 0-19 services in order to meet currently mandated contacts.
1.Fair society, healthy lives: The Marmot Review: strategic review of health inequalities in England post-2010. (Marmot, 2010)
6.Maximising the school nursing team contribution to the public health of school-aged children - Guidance to support the commissioning of public health provision for school aged children 5-19 (DH, PHE, 2014)
7.Return on investment of public health interventions: a systematic review. Masters Journal of Epidemiology & Community Health 2017; 71(8):827-834.
12.Transforming-children-and-young-peoples-mental-health-provision-a-green-paper (DHSS 2018)
13.Day, P (2016) ‘Motivating Teen Spirit: Early metal health intervention’ British Journal of School Nursing, Vol 11 Issue 2
14.Kay, C M. Morgan, D L. Tripp, J H. Davies, C and Sykes, S (2006) ‘To what extent are school drop-in clinics meeting pupils self-identified health concerns? Health Education Journal 65 (3) pp 236-251
15.Kelly, N Greaves, C Buckland, L Rose, J (2005) ‘School nurses: well placed to address challenging behaviour’. Community Practitioner 78 (3) pp 88-92
17.Rt Honourable Matt Hancock and DHSC 2018: New technology is key to making NHS the world's best https://www.gov.uk/government/news/matt-hancock-new-technology-is-key-to-making-nhs-the-worlds-best
18.“The Adverse Childhood Experiences (ACE) Study”. cdc.gov. Atlanta. Georgia: Centers for Disease Control and Prevention.National Center for Injury Prevention and Control.Division of Violence Prevention.May 2014.Archived from the original on 27 December 2015.Read More