An RCN Toolkit for School Nurses - Supporting your practice to deliver services for children and young people in educational settings - Royal ...
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An RCN Toolkit for
School Nurses
Supporting your practice to deliver services for
children and young people in educational settings
CLINICAL PROFESSIONAL RESOURCEAN RCN TOOLKIT FOR SCHOOL NURSES
Acknowledgements
Revision led by: Lauren Harding, Specialist Community Public Health Nurse
and Doctoral Research Student, Faculty of Health and Life
Carol Williams, Independent Children’s Nursing and Sciences, Oxford Institute of Nursing, Midwifery and Allied
Healthcare Consultant Health Research
Sarah Jennings, School Nurse Practice Teacher, Children’s
Steering group: Community Services, Central Manchester University
Liz Allan, Designated Nurse, Children in Care, Truro and Lead Hospitals NHS Foundation Trust
for Looked After Children Community, RCN Children and Susan A Jones MBE, Lead Nurse School Health Nursing
Young People Staying Healthy Forum and Looked After Children Nursing Services, Abertawe Bro
Pauline Carson, Lecturer, Belfast, Northern Ireland and RCN Morgannwg University Health Board
Children and Young People Staying Healthy Forum Jo Leek, School Nurse, Suffolk
Corina Christos, School Nurse Team Leader for Lambeth, Fiona Mackay, School Nurse, Abberley Hall School,
Guy’s and St Thomas’ NHS Foundation Trust and Lead for Worcestershire
School Nurses Community, RCN Children and Young People
Julia Parsons, School Nurse, Leicester Grammar School
Staying Healthy Forum
Nichola Rickard, Lead Nurse for Looked After Children,
Leila Francis, Designated Nurse Safeguarding Children, Mid
Wembley Centre for Health and Care
Essex Clinical Commissioning Group and RCN Children and
Sharon White, Professional Officer, SAPHNA (School and
Young People Staying Healthy Forum
Public Health Nurses Association)
Dwynwen Spargo, Senior Lecturer, Faculty of Life Sciences
and Education, University of South Wales and RCN Children
and Young People Staying Healthy Forum
National contributions from:
Rachel Cackett, Policy Adviser, RCN Scotland
Gemma Trainor, CAMHS Nurse and Lead for CYP Mental
Health Community, RCN Children and Young People Staying Helen Donovan, Professional Lead for Public Health Nursing,
Healthy Forum RCN
Suzanne Watts, Chair, RCN Children and Young People Ellen Hudson, Associate Director, Professional Practice, RCN
Staying Healthy Forum, and Lead for Health Visiting and Scotland
Safeguarding Children and Young People Communities Dr John Knape, Head of Communications, Policy and
Marketing, RCN Northern Ireland
Virtual reference group: Rosanna Raison, Policy and Public Affairs Officer, RCN Wales
Lucy Bennett, School Nurse, Tring Park School for the Fiona Smith, Professional Lead for Children and Young
Performing Arts, Tring, Hertfordshire People’s Nursing, RCN
Colette Datt, Nurse Consultant, The Whittington Hospital Karen Stansfield, Head of Department, Education and
NHS Trust Quality, Institute of Health Visiting
Julia Fairey, School Nurse, Tring Park School for the
Performing Arts, Tring, Hertfordshire
This publication is due for review in January 2022. To provide feedback on its contents or on your
experience of using the publication, please email publications.feedback@rcn.org.uk
Publication publication. Please contact publicationsfeedback@rcn.org.uk
This is an RCN practice guidance. Practice guidance are clearly stating which publication you are commenting on.
evidence-based consensus documents, used to guide decisions RCN Legal Disclaimer
about appropriate care of an individual, family or population in a
specific context. This publication contains information, advice and guidance to
help members of the RCN. It is intended for use within the UK
Description but readers are advised that practices may vary in each country
The RCN recognises the importance and value of school nurses and outside the UK.
working in all educational settings. This toolkit will support The information in this booklet has been compiled from
school nurses in developing their roles in practice, management professional sources, but its accuracy is not guaranteed. Whilst
and leadership to improve health outcomes for children and every effort has been made to ensure the RCN provides accurate
young people in the school environment. It is aimed at school and expert information and guidance, it is impossible to predict all
nurses and commissioners of school nursing services to provide the circumstances in which it may be used. Accordingly, the RCN
guidance on the scope of the school nursing role. It is relevant shall not be liable to any person or entity with respect to any loss
across mainstream, independent and boarding schools, or damage caused or alleged to be caused directly or indirectly by
providing links to the evidence underpinning the benefits of what is contained in or left out of this website information and
school nursing provision. guidance.
Publication date: January 2019 Review date: January 2022 Published by the Royal College of Nursing, 20 Cavendish Square,
London, W1G 0RN
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The authors would value any feedback you have about this
2ROYAL COLLEGE OF NURSING
Contents
1: School nursing in the UK 4
2: The role of the school nurse 10
3: Key public health domains for specialist community public health and school nurses 15
4: Leadership and management 28
References 33
Useful websites 38
Appendices: 40
1 – School health profile 40
2 – Example of a school nursing assessment outline and assessment sheet 45
3 – Example referral to another service 48
4 – Example referral to school nursing service 49
5 – Assessment framework 51
6 – Setting up a drop-in service 52
7 – Example of a training tool 54
8 – Specimen contract 55
9 – Specimen job description 57
10 – Specimen job advert 60
3AN RCN TOOLKIT FOR SCHOOL NURSES
1: School nursing in the UK
Introduction The background of school
Government health policy across all four nursing
countries of the UK is focused on wellbeing and Whilst public health interventions (such as
prevention of illness, empowerment of people, vaccination) had been introduced in 1853 and
professionals and communities and the creation school meals in 1906, the role of the school nurse
of new models of care to meet population was not widely introduced until around 1907,
health needs. Child health policy in the UK is with the introduction of an Act of Parliament
underpinned by the United Nations Convention to allow the medical inspection of children in
on the Rights of the Child (UN, 1989). National school. This aimed to treat disease and provide
policies identify health promotion and prevention preventive care (Kelsey, 2002). School nurses
of ill health as important to the future health of were employed to work alongside the medical
children, with a need to improve public health officers of health, providing health care in
provision and a focus on preventive health care schools and reducing the need to send children
and partnership working (Scottish Government, to the local hospital or GP. This initiative focused
2012; Welsh Government, 2013; Department on, ‘physical improvement, and …. the mental
of Health, 2013a; 2015; DHSSPS, 2014; NHS and moral improvement’ of the health of future
England, 2014a). Despite this commitment, there generations (Kelsey, 2002, p9). Initially, a
are significant inequalities in the provision of, range of organisations employed school nurses,
and access to, child health care in the UK. but employment gradually moved into local
There is wide spread recognition that poor health authorities, where they became involved in a
contributes to underachievement in education wide range of public health activity, including
and reduction in career prospects (PHE 2014), enforcement such as exclusions during outbreaks
but the number of children who are overweight of infectious disease. It was not until 1974
or who have low self-esteem and mental health that school nurses were employed within
problems is increasing. The NSPCC reported NHS community services. The early school
a 14% increase in the number of children nursing role was focused on both physical and
hospitalised for self-harm in the last three psychological health, but the role has developed
years (NSPCC, 2016). Access to diagnostic and significantly to a more autonomous role, leading
treatment services, with appropriately trained public health initiatives for school-age children
and skilled professionals is variable (BMA, and working in partnerships in schools and the
2013). The school nurse provides a key role in the community with a variety of professionals.
reduction of child health inequalities through the Early school nurses did not have any formally
provision of health education and information, recognised education (Kelsey A, 2002).
targeted interventions and signposting to other Preparation of nurses to work within schools has
services for school-aged children (RCN, 2016a). evolved with the role, with early certification and
This RCN toolkit provides school nurses later, the introduction of the specialist recordable
with information, examples of good practice, qualification. However, in 2004, the Nursing and
templates and useful websites to support and Midwifery Council (NMC) approved standards
develop professional practice. It considers the for registration in specialist community public
varying policy and practice which apply in health nursing (SCPHNs), applicable across the
the four countries of the UK and the range of UK (NMC, 2004).
educational settings in which school nurses work. www.nmc.org.uk/standards/additional-
The guidance does not separate information standards/standards-of-proficiency-for-
for independent schools, academies and faith specialist-community-public-health-nurses
schools, as the role of the school nurse is based
on a needs assessment for specific children The number of SCPHNs registered as school
within a school/group of schools, rather than the nurses on the NMC register in 2012 was 3,033
type of school or educational setting. (RCN, 2013a). The number of school nurses has
fallen by 15% in England since 2010 and was
cited at RCN Congress in 2016 as 1,208 school
nurses across the UK, supporting approximately
4ROYAL COLLEGE OF NURSING
nine and a half million children and young having direct contact with every individual in
people, with an average of 12 minutes’ school that community. The SCPHN qualification is
nurse time per year per child (RCN, 2016a). registerable with the NMC. Information on this
This is an average figure, with some schools can be found at:
having well-resourced school nursing teams
and others having a limited service, depending www.nmc.org.uk/registration/staying-on-
on the service commissioned. The RCN School the-register/scphn-registration
Nurse Survey 2016 (RCN, 2016b) showed that
School nurses are responsible for coordinating a
a wide range of staff are employed in school
team to deliver public health services for school-
nursing teams in addition to registered nurses.
aged children throughout the year. The team
These staff include: nursery nurses, health care
may be made up of different grades of staff and
support workers and first aiders who often have
professionals, with varied skills and knowledge.
no specialist training in the health and wellbeing
It is important that the skill mix is appropriate to
of children and young people. The Royal College
meet the needs of the local school age population
of Nursing has raised concerns regarding the
and that team members have clearly defined
inequalities across the UK in accessing school
roles and responsibilities, with robust job
nursing services, many with limited capacity to
descriptions to support these roles.
promote resilience and wellbeing of children and
young people (RCN, 2016c). In the independent sector, the work of the
school nurse can vary greatly depending on
The variable resources in health boards in
the directive from the governing body and the
Scotland and Wales, and the move to local
resources available. Independent school nurses
authority commissioning in England is leading
need to ensure they use evidence-based guidance
to fragmentation of school nursing services.
from government health policy and professional
The RCN School Nurse Survey (RCN 2016b)
organisations to promote the health and
suggests that there is an increasing use of health
emotional wellbeing of the children in their care.
care support workers rather than registered
Further information regarding school nursing as
nurses with a short-term focus on specific
a career can be found at:
aspects of health. The number of education
places commissioned for school nursing has www.healthcareers.nhs.uk/explore-roles/
fallen (HEE, 2016) at a time when problems with public-health/school-nurse
mental health and self-harm are increasing,
and children’s wards across the UK are dealing UK policies
with high numbers of children and young people
needing emotional and psychological support The four nations of the UK have different policies
(Fisher, 2016). An increased political and policy relating to school health provision, but the school
focus on health promotion, with a life course nurse delivers the Healthy Child Programme
approach from birth to adulthood, could improve (HCP): 5–19 years old in England and the
health and reduce health inequalities for children equivalents in Scotland, Northern Ireland and
and young people (Marmot, 2010; BMA, 2013; Wales:
RCN, 2016c).
www.gov.uk/government/publications/
healthy-child-programme-5-to-19-years-old
The principles of school
nursing www.gov.uk/government/publications/
healthy-child-programme-rapid-review-to-
School nurses or specialist community public update-evidence
health nurses (SCPHNs) are qualified nurses or
gov.wales/topics/health/publications/health/
midwives with specialist graduate level education
reports/healthy-child
in community health and the health needs of
school-aged children and young people. The role www.isdscotland.org/Health-Topics/Child-
has distinct characteristics which include the health
responsibility to work with both individuals and
a population, which may mean providing services www.health-ni.gov.uk/publications/healthy-
on behalf of a community or population without child-healthy-future
5AN RCN TOOLKIT FOR SCHOOL NURSES
Core principles Perspectives across
To deliver the public health programme the UK
effectively, there are some core principles that
school nursing work incorporates. Government health policy across the UK
expresses the commitment to improving the life
• Work with education colleagues and the chances of all children by supporting families
wider multi-agency team across health and to keep children safe and healthy. The policy
social care to influence service planners and underpinning this varies within each of the four
commissioners and the public health agenda countries, but is based on similar principles,
for 5–19 year olds. promoting health and emotional wellbeing.
The RCN survey (RCN, 2016b) reported the
• Identify the health needs of individuals and positive experiences of school nurses, especially
communities, use appropriate assessment from those who have seen significant service
tools, and develop programmes to address changes. These experiences included a greater
these needs in collaboration with other focus on public health, better interdisciplinary
agencies. working and greater investment. In England,
where commissioning school nursing has moved
• Undertake service design and workforce
into local authorities, there has been a more
planning which is underpinned by assessed
mixed response. Nurses are concerned about a
need.
focus on targets rather than the needs of local
• Promote the health, wellbeing and protection children, with little time available for addressing
of all children and young people of school age emotional health and wellbeing issues. In
(up to 19 years old) in any setting, including addition, some school nurses in England are
independent schools, academies and colleges. providing services commissioned by the local
authority, clinical commissioning groups (CCGs)
• Plan work based on local need, current and/or NHS England, which means that they can
guidance and national health priorities. be reporting to more than one body.
• Work with partners to influence public
England
health policy at a strategic and local level.
In England, significant changes have been made
• Use effective communication methods to
to the commissioning of child health services
facilitate information sharing and to provide
following the introduction of the Health and
targeted interventions.
Social Care Act 2012. The focus of government
• Ensure safe and effective practice within the policy is on improving children’s start in life
school health team, provide and seek clinical and prevention of ill health (DH/PHE, 2014a),
supervision, management, teaching and with the centralisation of public health functions
mentoring. within local government. The result is child
health commissioning from a variety of bodies:
• Maintain and enhance personal professional NHS England, CCGs and local authorities. The
development in accordance with guidance move of health visiting and school nursing to
from regulatory and professional bodies. local authorities took place between 2013 and
2015. This aligned children’s public health
• Use research and audit to deliver an alongside social care and education, with the
evidence-based service with clear outcomes, intention of removing duplication of work and
with evaluation as an integral part of the improving multi-agency working (PHE, 2016a)
process. to deliver the Healthy Child Programme and
The RCN developed a UK wide position identify services based on local need.
statement in The RCN’s UK Position on School The Department of Health emphasises the
Nursing (RCN, 2012). importance of the school nurse in leading public
health initiatives for children and young people
between 5 and 19 years of age (DH, 2012a),
6ROYAL COLLEGE OF NURSING
working closely with health visitors to provide Commissioning guidance published by Public
transition and a consistent pathway of care for Health England provides information for
children between 0 and 19 years (PHE, 2015), commissioners across the lifespan, between 0
encouraging positive health and education to 19 years. This focuses on high impact areas,
outcomes. The model for school nursing services providing guidance relating to the outcome
includes provision at four levels of working measures and associated literature for each
(4–5–6 model) (see Figure 1 on page 10), of these particular areas: www.gov.uk/
reflecting the role of the school nurse and government/publications/healthy-child-
the needs of the children with safeguarding programme-0-to-19-health-visitor-and-
considerations at all four levels. school-nurse-commissioning
• Community: reflects the wider role of www.gov.uk/government/publications/
the school nurse in leading public health commissioning-of-public-health-services-for-
within schools and contributing in the children
wider assessment to identify relevant health
needs, ensure services are provided in places Northern Ireland
accessible to children throughout the year
and undertake wider health promotion and In Northern Ireland’s integrated health and
protection activities through engagement social care system, services for children and
and collaboration. This requires leadership young people are currently commissioned by
skills and knowledge of the broader national the Health and Social Care Board and the Public
policy relating to children, which underpins Health Agency, and delivered by five health
education and social care. and social care trusts. The Northern Ireland
Executive’s ten-year strategy and action plan for
• Universal services: the school nurse will children and young people (2006–2016) set out
lead, co-ordinate and provide services to a few high-level outcomes, the first of these is
deliver the Healthy Child Programme in an that all children and young people are healthy.
area in conjunction with other professionals Despite some progress in recent years, challenges
in schools and health. This may involve drop- remain and it is estimated that 23% of children
in clinics or signposting to other services in Northern Ireland still live in poverty (RCPCH,
with the aim of preventing serious health 2015).
problems.
In Healthy Futures 2010-2015: The Contribution
• Universal plus: school nurses are the key to of Health Visitors and School Nurses in
provision of early help for those children who Northern Ireland (DHSSPS, 2010a), the focus
require additional services for additional was on promoting physical, social and emotional
health needs, emotional and mental health wellbeing for children and young people to
problems and sexual health. create healthy adults. Continuity of service
provision across the age range of 0 – 19 year olds
• Universal partnership plus: the school was emphasised through team leadership and
nurse will be involved in the provision of working within a multi-agency team covering
additional services to vulnerable children health and social care. Targeted interventions
and families with specific problems aimed at safeguarding, universal services
requiring co-ordinated input from a range to address issues such as immunisation and
of professionals, including children with substance misuse, and emotional wellbeing
complex health needs and disabilities, and and mental health providing Tier 1 and Tier
those involved in risk-taking behaviours and 2 services. Prevention, early intervention and
with mental health problems. mental health promotion was a core theme of
An overview of the six early years and school this guidance. Guidance around commissioning
aged years high impact areas is available at: included the requirement for clarity of service
www.gov.uk/government/uploads/system/ specification and outcome measures.
uploads/attachment_data/file/565213/High_
impact_areas_overview.pdf
7AN RCN TOOLKIT FOR SCHOOL NURSES
In the Northern Ireland Executive’s Programme Wales
for Government for 2016 – 2021 (Northern Ireland
Executive, 2016), the Government aims to give In 2009, the Welsh Assembly Government
children and young people in Northern Ireland published its Framework for a School Nursing
the best start in life, by improving the quality of Service in Wales, and, since this, the number
early childhood development services through of full time equivalent school nurses employed
increased capacity in the workforce. The RCN in Wales has risen from 41 in 2009, to 70 in
is lobbying for an increase in school nurses (and 2015. One of the aims of the framework was
health visitors) as a key part of this workforce. to overcome any inequality of access to school
nursing services for children and young people in
Scotland Wales and to ensure provision of a school nurse
for every secondary school.
Priorities for health and wellbeing for children
and young people in Scotland are based on This aim was achieved by May 2011, with each
Getting it right for every child (GIRFEC) (NHS of the 223 secondary schools in Wales having
Scotland, 2010), which has been updated following an appointed school nurse who is usually based
the publication of the Children and Young People outside of school premises and can be contacted
(Scotland) Act 2014. This has introduced the for advice and support. It is intended that the
need to review the role of the school nurse to school nurse supports children and young people
focus on identified priority areas and vulnerable in school through the promotion of positive health
children, avoiding duplication of work with other education and the provision of information, as
professionals and to support the implementation well as targeted involvement as necessary.
of the Chief Executive Letter 13 (2013).
In 2016, the Welsh Government and NHS Wales
To this end the Chief Nursing Officer for Scotland published the health visiting and school health
commissioned a review of school nursing which nursing component of the Healthy Child Wales
began in 2015 and is ongoing, but which has Programme (HCWP) for children of 0–7 years
involved revising the current framework for (Welsh Government, 2016b). This provides an
school nursing (NHS Scotland, 2003) to provide all-Wales universal schedule of health visiting
a focus on nine pathways relating to health needs and school nursing contacts for every child, with
of children and young people. In addition to the enhanced and intensive interventions delivered
health needs of children, the review includes the to those families and children with increased
educational needs of school nurses and teams to levels of need.
enable them to provide care, taking a pathway,
The Chief Nursing Officer commissioned RCN
targeted approach.
Wales to run a three-day political leadership
In addition, the public health strategy for child course for school nurses. The overall aim of this
health recognises the importance of the social course was to develop the ability of school nurses
and environmental influences on health (Scottish to influence health policy in Wales. Participants
Government, 2011) and underpins the pathways gained an understanding of the political system
identified as priorities for school nurses. in Wales and its impact on health policy, as
well as an understanding of the opportunities
In December 2016, the approach to school available to shape health care policy in Wales,
nursing was being tested in two early adopter both individually and as a collective group.
board sites in Scotland. School nurse education
will be tailored to the nine priority areas and Information about public health priorities across
the new refreshed role which will have a greater the UK can be found at the following websites
focus on working with families and undertaking and in Table 1 on page 11.
home visits. This planned education preparation
of nurses will be at postgraduate/Master’s level
and three higher education institutions have
been identified to provide the programme as
well as looking at flexible CPD modules once an
agreement is reached on the next steps.
8ROYAL COLLEGE OF NURSING
England
www.gov.uk/government/organisations/
department-of-health
www.youngpeopleshealth.org.uk/key-data-
on-adolescence
Scotland
www.healthscotland.scot
Wales
www.wales.nhs.uk/sitesplus/888/home
Northern Ireland
www.publichealth.hscni.net
9AN RCN TOOLKIT FOR SCHOOL NURSES
2: The role of the school nurse
The fundamental role of the school nurse community public health nursing qualification,
is to ‘co-ordinate and deliver public health but will be registered children’s or adult nurses
interventions’ to improve children and young and/or midwives, with additional modules
people’s health and wellbeing (DH, 2012b; DH relating to the role. This section explores the
and PHE, 2014a p6). School nurses provide an scope of the school nursing role and looks at how
interface between children, young people and it is changing to reflect local needs.
their families, communities and schools. They
have the skills to support holistic assessment of School nursing service models across the UK
health and wellbeing through health promotion, may differ in structure, but the focus is very
ill health prevention and early intervention similar, specifying levels of service provision,
strategies to address individual and population screening or health reviews and areas of practice
health needs. They often work alone or are or ‘high impact areas’. Public Health England has
responsible for the work of a team, undertaking developed the 4–5–6 model for school nursing
similar roles to clinical nurse specialists in acute (PHE, 2016b), based on four levels of service, five
settings. Many nurses do not have the specialist health reviews for school-aged children and six
high impact areas (Figure 1).
Figure 1: 4–5–6 Model for school nursing in England (adapted from PHE, 2016b)
4 5 6
Level of the school Health reviews High impact areas
nursing service
• Community • 4–5 year health needs • Building resilience and
• Universal assessment supporting emotional
• 10–11 year health needs wellbeing
• Universal plus
assessment • Keeping safe, managing risk
• Universal partnership plus
• 12–13 year health needs and reducing harm
assessment • Improving lifestyles
• School levers-post 16 • Maximising learning and
• Transition to adult services achievement
• Supporting additional health
and wellbeing needs
• Seamless transition and
preparing for adulthood
The model in Northern Ireland is also based School nurses lead on the delivery of the Healthy
on four levels of service, with reviews and Child Programme (DH, 2009; DHSSPS, 2010a;
screening at specific points during school life Welsh Government, 2016b) or equivalent,
(DHSSPS, 2010b). Scotland is working towards working in partnership with other agencies
nine key pathways and the Welsh framework and as part of a wider multidisciplinary team
identifies five key areas of delivery, with a focus to support the health and wellbeing of
on local needs provided through team nursing. school-aged children. School nursing is a
These local or population needs fall into six service that understands the dynamic process
broad areas, outlined above, requiring clinical of interaction between the child, the family, the
skills, multi-agency working and leadership. child in school (including alternative education
This entails school nurses undertaking a providers) and the child in the community. The
range of skilled activities and communication composition of the school nursing team will be
at individual, group and community level, dependent on key health priorities within the
including: health promotion, advice, signposting local area and the skill mix required to deliver
to other services, active treatment/procedures, these (NHS Scotland, 2003).
education, support, protection, safeguarding and
service co-ordination.
10ROYAL COLLEGE OF NURSING
Delivering on public health priorities
Whilst there are differences in public health policy between the four countries of the UK, the focus of
the school nurse role is similar and is illustrated in Table 1.
Table 1: National priorities for children and young people’s health
England (0–19) Northern Ireland Scotland (5–18) Wales
(0–19)
Emotional health and Health and wellbeing Emotional health and Emotional health and
wellbeing (including physical, wellbeing wellbeing
emotional and
developmental issues)
Alcohol and drugs Drugs and alcohol Substance misuse Parental substance misuse
Safeguarding and Safeguarding Safeguarding/child Safeguarding
promoting children and protection
young people’s welfare
including child sexual
exploitation
Domestic abuse
Looked after children Looked after children
Homelessness
Youth justice and mental Mental health, including Youth justice Mental health
health parental mental health
Supporting young carers Young carers
Readiness/transitions Transitions Transition to school and
adult life
Immunisation Immunisation Immunisation Immunisation
Accidents Health and safety, Accident prevention
accident prevention
Smoking cessation Smoking cessation Smoking, substance
misuse and alcohol abuse
Obesity, nutrition and Weight, healthy eating Healthy weight (Child
physical activity (National and increased exercise Measurement Programme
Child Measurement Lifestyle, nutrition and
Programme) exercise)
Sexual health and teenage Sexual health and Sexual health and teenage
pregnancy relationships pregnancy
Oral health Dental caries, age 5
Long-term and complex Children with additional
health needs needs, including complex
needs
These priorities form a major part of a school www.health-ni.gov.uk/publications/healthy-
nurse’s role. The priorities will vary from area to child-healthy-future
area and be dependent on local, inter-agency and
community profiling, of which the school health www.gov.scot/
profile is an integral part. Further information Publications/2005/04/15161325/13288
on this can be found at:
gov.wales/topics/health/publications/health/
www.gov.uk/government/publications/ reports/healthy-child
commissioning-of-public-health-services-for-
children
11AN RCN TOOLKIT FOR SCHOOL NURSES
National public health guidance relating to
children can be found at:
Developing a school
health needs assessment
www.nice.org.uk/search?q=child+
public+health An assessment of the health and wellbeing needs
of children and young people is an important
www.sign.ac.uk/our-guidelines.html starting point for a school nurse or nursing team
to plan services to improve health, wellbeing
https://fingertips.phe.org.uk/profile/public- and performance in school. The school nursing
health-outcomes-frameworkelines.html team will need to develop or identify a data
collection tool to collate the information required
School health profiles by providers and commissioners. The example in
Appendix 1 can be used to develop this tool and
Development of a whole school health profile could include the following information.
in partnership with other professional is part
of a school nurse’s role. School nurses provide • A description of the school’s local area.
a profile of the local area and community,
• Local deprivation indices and numbers of
identifying any local health risks and
free school meals.
environmental factors such as areas of poor
housing or high unemployment, which may affect • The ethnic profile of the school population.
the health and wellbeing of young people. School
nurses identify the health needs of the children • Does the school meet healthy food
and young people within their school caseload to standards? If not, why not? See: www.
enable provision of an holistic service to whole gov.uk/school-meals-healthy-eating-
communities, families and individuals. An action standards
plan is developed and monitored to ensure the • What types of food and drink are provided/
service provided meets the assessed needs or is on sale at the school?
modified to meet identified needs.
• What are the current health needs of pupils
The resulting school health profile should (for example, are there children with diabetes
include information regarding the current and or asthma)?
future health and social care needs of the local
under 19-year-old population and provide a • Do the teachers or school support staff need
comprehensive overview of services provided any health training?
locally for children and young people. It must be • Does the school provide before or after-
used to contribute to the wider assessment of the school activities (for example, breakfast club,
needs of children and young people in a specific cookery class, dance)? Could the school nurse
community. School nurses can use it to influence get involved in these?
the Joint Strategic Needs Assessment (JSNA 1)
(DH, 2013b) or children and young people’s plan • Are there accident black spots near the
for an area. school?
An example of a school health profile and action • Do playground facilities provide for a range
plan template can be found in Appendix 1. This of needs (for example, shade, quiet areas,
is an example only and can be adapted for use, seats, zoned areas for different activities)?
depending on the needs of the local school and • Does the school have policies covering
community. delivery of PHSE education and promoting
health and wellbeing (for example, on
medicines, drugs, smoking, food and
bullying)?
1 JSNAs are assessments of current and future health and social care needs of the local community which are met by the local
authority, CCGs, or the NHS Commissioning Board. They are produced by health and wellbeing boards (HWBs) and are unique to
each local area. HWBs consider wider factors that impact on their communities’ health and wellbeing, and local assets that can help
to improve outcomes and reduce inequalities. There is no set template or format and no mandatory data set to be included (DH,
2013a). These have been replaced by the children and young people’s plan in many areas.
12ROYAL COLLEGE OF NURSING
• What do children and young people say about • National Assembly for Wales (2001) Healthy
their own and school health? Schools Assessment Tools: practical ideas
for use with pupils
• Are schools collecting data used to inform
health needs (for example absences, • Public Health England (2016c) Measuring
attainment data, special and complex health and monitoring children and young people’s
needs, safeguarding, children in the care of mental wellbeing: A toolkit for schools and
the local authority) colleges
• Are there other agencies providing public • Lancaster K (2007) Health needs assessment:
health services for children, either in school an holistic approach, British Journal of
or in the community? Is there any other data School Nursing 2(1), 6–9.
available to inform what the health needs are
(for example, sexually transmitted infection These resources provide access to additional
rates, teenage pregnancy rates, immunisation sources of information relating to the health of
uptake rates)? children and young people. The resulting school
health profile should include information about
Information regarding demographic data and the future health and social care needs of the
health outcomes in a specific geographical area local under 19-year-old population (or under 25s,
can be found on the following websites: where relevant) and provide a comprehensive
overview of services provided locally for children
fingertips.phe.org.uk/profile/health-profiles and young people.
www.chimat.org.uk/profiles
www.scotpho.org.uk/comparative-health/
Using school health
profiles/online-profiles-tool profiles to ensure effective
www.isdscotland.org/Health-Topics/
use of resources and
Child-Health/Publications/data-tables. monitor service delivery
asp?id=1566#1566 Where the school nursing team covers a group
www.wales.nhs.uk/sitesplus/922/home of schools or liaises with other nurses in schools
within a health board or local government area,
www.wales.nhs.uk/sitesplus/888/home use of the same tool will allow benchmarking
and comparison between schools. Combining
www.publichealth.hscni.net/news/ resources to provide services could enable
statistical-profile-childrens-health-northern- services to be targeted in areas of highest
ireland-2014-15 need and ensure improved use of resources
(Box 1: Case study 1 on page 14). The assessment
A range of information can be used to assist
can be used to influence service planning and
with the development of a school health needs
commissioning, and the wider needs assessment
assessment, including online tools and national
(such as the local children and young people’s
toolkits:
plan or the joint strategic needs assessment or
• Public Health England (2014) Preparing equivalent).
a needs assessment: Guidance for school
nursing students
• www.healthyschools.london.gov.uk/
about/how-healthy-my-school
• www.gov.uk/government/publications/
personal-social-health-and-economic-
education-pshe/personal-social-health-
and-economic-pshe-education
13AN RCN TOOLKIT FOR SCHOOL NURSES
Box 1: Case study 1 Working with other
agencies
The deputy head of health visiting and school
nursing, Southern Health and Social Care School nurses work with professionals in a
Trust in NI won a service transformational variety of settings both within and outside the
leadership award for refocusing the school school. These professionals will come from
nursing service within the trust. She a range of other services including youth,
reviewed the service, recognising that community, primary care and mental health
specialist community public health school services. Where joint working occurs, it is
nurses were not able to use their specialist important that individual roles are clear to avoid
skills due to small numbers of staff being duplication of services and miscommunication
over-committed and providing a limited with children, young people and families.
service, focused on immunisation and Effective working may require roles to change
level one core work. She consulted service based on the individual needs of children and
managers and school nurses regarding young people to ensure the most appropriate
service improvements, achieved by person provides the service required.
establishing a school immunisation team
and reconfiguring the remaining service to Joint working arrangements can have benefits
allow school nurses to focus on the full public for school nurses and other providers through
health and safeguarding remit of their role. shared knowledge and skills, which gives
Clear lines of reporting, communication and opportunities to develop knowledge and skills
evaluation were established. School nurses in practice. Benefits for school nurses and wider
now provide targeted support to school-aged services include:
children, particularly those on the child • working in environments outside school
protection register and looked-after children. with young people who may not seek out the
school nurse in school
Developing an action plan • developing skills in communicating with
young people about sensitive issues such as
Once completed, the school health profile can be self-harm, crime, gang culture, relationships
used to agree an action plan for the nursing team and substance misuse
and the wider team involved in school health.
This action plan should include measurable • working alongside youth services develops
outcomes. The wider team will be made up of a outreach and community working skills,
head teacher and other staff employed to provide while increasing access to young people and
services, such as counsellors, community teams opportunities to provide health promotion
and visiting doctors in independent and special activities
needs schools. It is important to ensure that the • improving referral pathways with greater
action plan can be resourced from the existing collaboration between services, and the
school nursing team and other commissioned provision of health services, such as sexual
services. Where this is not possible, the team health advice and contraception, in settings
manager and service planners or commissioners where this is not normally found
must be informed. All action plans should be
reviewed at locally agreed intervals to monitor More effective use of resources, understanding
outcomes and make modifications where of individual roles and improved access for
required (also see Commissioning, Section 4). young people with clear pathways for referral
is likely to improve children and young people’s
access to health services and provision of early
intervention strategies.
14ROYAL COLLEGE OF NURSING
3: K
ey public health domains for
specialist community public
health and school nurses
Changes in education for school nurses with
the introduction of the specialist community Box 2: Case study 2
public health nurse role (NMC, 2004) has
influenced the direction and focus of school Evelina E-SNAP (Electronic School Nurse
nursing. Coupled with the move of public health Access Point) is an electronic single point of
services to local authorities in England and a entry referral system, set up by the school
greater commitment to improving public health nursing team at Evelina London. A duty
across the UK, there has been greater clarity system has been implemented with two
regarding the focus of school nursing with the nurses on duty at a locality base within the
aim of improving child health outcomes (PHE borough, Monday to Friday 9am to 5pm.
& DH, 2015). Table 1 on page 11 illustrates that Referrals are sent to a centralised email
school nursing priorities are similar across the account which is triaged daily by a duty
UK. National policies focusing on child health nurse. The team can also be accessed via
from birth, through the pre-school years and a centralised telephone number. Accident
into school, provide a continuum of provision by and emergency reports are all received and
health visitors and school nurses (DHSSPSNI, triaged via the single point of entry. The
2010a; Scottish Government, 2011; PHE, 2015; text messaging service, ‘CHAThealth’ is also
Welsh Government, 2016b). For school nurses, managed by the triage nurses. The nurses
priorities fall largely into six broad domains or from the five locality teams rotate with each
areas, although these overlap (see Section 2) nurse averaging one duty/month. All urgent
and will be determined by the needs assessed referrals are followed up on the day of receipt
in individual school profiles. These domains are by the triage nurses. Support staff assist the
used to structure the sections below, reviewing nurses three times a week, uploading all
the role of the school nurse in relation to specific routine referrals to the electronic records
health and wellbeing needs. system for follow up by the relevant locality
team.
Referrals and assessment The single point of entry has improved the
of individual needs accessibility to the school nursing service
at Evelina, raising the profile of the service
There is one area of practice common to all six among schools and service users. The
domains, and included in all health reviews: process of managing referrals is now quick
assessment of the individual child is key to and efficient, increasing patient facing time.
decision making in terms of assisting the child, Accurate recording of referrals has increased
either through direct support or referral to and the system has resulted in a clear audit
another service or professional. While school trail.
nurses may identify children in need of services,
or students raise issues during a drop-in session,
referrals can be received from teachers, parents, Referrals may arrive with some information
students and other professionals. A single relating to the individual’s problem, but a full
point of referral can ensure that referrals are assessment should be undertaken to determine
managed effectively and children are followed up whether there are additional issues impacting
appropriately (see Box 2). on the individual’s problems, which also need
to be addressed to improve health. The school
nurse must be skilled at communicating with
children and young people to undertake effective
assessment (RCN 2003; Children’s Workforce
Development Council, 2010). Initial assessments
should be undertaken by a school nurse, who may
then delegate ongoing support or interventions to
15AN RCN TOOLKIT FOR SCHOOL NURSES
another member of the team or make a referral It is important to use a range of communication
to another service or professional. Examples of methods when advertising services and
assessment and referral forms can be found in communicating with students, including the
Appendices 2 to 5, with guidance on setting up use of digital communication. For example,
a drop-in service in Appendix 6. information about access to drop-in sessions
(covering issues such as: emotional wellbeing and
Further guidance on communicating with young mental health, substance misuse, contraception,
people can be found at: weight management and exercise) can be
provided on the front page of student portals
www.gmc-uk.org/guidance/ethical_
and as posters or flyers in school entry packs.
guidance/children_guidance_14_21_
Students can also be signposted to useful
communication.asp
websites such as:
www.minded.org.uk
www.healthforteens.co.uk
www.disabilitymatters.org.uk
www.nhs.uk/LiveWell/TeenBoys/Pages/
Teenboyshome.aspx
Delegating to team
members www.nhs.uk/LiveWell/TeenGirls/Pages/
teengirlshome.aspx
Where support or interventions are delegated,
it is important that the member of the team Engaging with children,
concerned has the required knowledge and skills
to work independently where required (RCN,
young people and their
2013a; NMC, 2015). Where staff need to develop families
knowledge and skills in working with children,
organisations such as MindEd and Young Minds It is important for school nurses to be able to
can be used to support learning as they have engage with children and young people of all
a range of resources and learning modules for ages, to enable them to meet the demands of
professionals working with children and young school, help develop independence and assist
people (see Section 4, Education). Additional transition to adult life. This involves supporting
resources can be found at: children and young people from a variety of
backgrounds, cultures and religions. Where
www.e-lfh.org.uk/programmes there are children whose first language is not
English, the school nurse may have to help
www.e-lfh.org.uk/programmes/healthy- a child and family to access health services,
child-programme including registering with a GP. Refugee children
may not have a family member to support them,
These can be used to supplement locally provided
requiring school nurses to work with social care,
education and training sessions.
education and other health professionals to help
them integrate into school life. Peer mentors and
Advertising school health health champions can also provide support with
services integration and with a range of health problems.
It is important for school nurses to provide Engaging with parents and carers is important,
information about access to services for children especially for children with long-term health
and families as they start each school, as well as problems, young people caring for an adult, those
to professionals who may need to refer children with mental health problems, and children who
to them. The Department of Health provides are home schooled. The school nurse can provide
resources for school nurses to use to help inform information about access to services for the child
students about their role and services: and for the family where additional support is
required. Where children and young people are
www.gov.uk/government/publications/ unable to take responsibility for their own health,
students-starting-secondary-school-urged- it will be important to engage with the parents
to-get-to-know-their-school-nurse to encourage positive health behaviour and
maximise school attendance and achievement.
16ROYAL COLLEGE OF NURSING
The following websites provide information and Mental health
guidance on additional support:
There are high levels of mental health problems
www.nhs.uk/NHSEngland/ in children and young people, with increasing
AboutNHSservices/doctors/Pages/NHSGPs. levels of attention deficit hyperactivity disorders
aspx (ADHD) and autistic spectrum disorders (ASD),
as well as self-harm, anxiety and depression
www.mandbf.org/wp-content/ (BMA, 2013; DH and NHSE, 2015). Adult mental
uploads/2011/02/Peer_Mentoring_in_ health problems often start in childhood, with
Schools.pdf a quarter of all diagnosable mental health
www.gov.uk/government/news/first-ever- disorders being established by 14 years of age and
mental-health-champion-for-schools- one in ten children under 16 years of age having
unveiled a diagnosable mental health problem (PHE,
2016c and d). Early intervention in emotional
www.gov.uk/government/publications/ and psychological problems may reduce the
quality-criteria-for-young-people-friendly- severity of illness and reduce the requirement for
health-services psychiatric intervention. This requires all staff
working with children to understand the issues
www.nhs.uk/Livewell/Yourchildatschool/ facing young children and how these issues
Pages/Yourchildatschoolhome.aspx impact on emotional and mental health. School
nurses should work closely with the special
Domain 1: Resilience and educational needs coordinators (SENCO) to
ensure partnership working in service provision.
emotional wellbeing
School nurses have the skills required to
The National Children’s Bureau (NCB)
provide Tier 1 (Welsh Government, 2016a) and
suggests that a focus on wellbeing can improve
Tier 2 interventions (DH and PHE, 2014a).
engagement, reduce school exclusions and
Understanding the risk factors associated with
improve attainment in schools, especially where
the development of mental health problems can
there are good relationships between staff and
help early identification of children at risk of
pupils (NCB, 2016a; 2016b). The Children’s
developing problems. Provision of information,
Society (2016) emphasises the importance of
and support for children and parents about
listening to children’s views on wellbeing to
emotional wellbeing and positive relationships
understand issues impacting on their lives
within families and friendship groups, is
(subjective wellbeing). School nurses are ideally
important. Identification of risk factors such as
placed to listen to, and support, children and
poor parental mental health and poor family
young people to improve their wellbeing by
relationships, bullying and peer pressure, can
building resilience through the development
help promote positive behaviours through work
of positive coping mechanisms and supportive
with individual families and student groups
relationships. They have knowledge of local
(RCN, 2014a).
health inequalities and can identify those young
people requiring additional support to improve School nurses will refer young people for
achievement (PHE, 2016d). additional support within specialist services,
such as the local counselling or CAMHS service,
There is a range of toolkits available to help
where specialist skills are required. To signpost
schools and colleges understand wellbeing and
children and families to the appropriate local
how to promote it (RCN, 2014a; NCB, 2016a; PHE,
service, the school nurse must be familiar with
2016c). The toolkit published by Public Health
local provision, including this in school health
England and the Anna Freud Centre (PHE, 2016c)
profiles. Specialist counselling services may be
was developed with young people to enable them
provided or commissioned, such as local child
to explore and discuss a range of issues and also
bereavement services or young carers groups,
provides examples of how it can be best used.
and knowledge of local referral pathways is
Using these sort of toolkits can help identify issues
essential. The Department of Health/Public
impacting young people’s lives locally.
Health England pathway for promoting
emotional wellbeing and positive mental health
17AN RCN TOOLKIT FOR SCHOOL NURSES
provides examples of intervention at the four
levels of school nursing service (community,
Domain 2: Keeping safe,
universal, universal plus and universal managing risk and
partnership plus) (DH and PHE, 2014b). It reducing harm
includes case studies and emphasises the need
for local solutions based on the principles found Safeguarding in schools
in the Department of Health’s publication
Compassion in practice (2012b). This provides School nurses, along with anyone who works
evidence of the complexity of the role of the with children and young people, are responsible
school nurse in relation to promoting positive for safeguarding children and should report
mental health. concerns using local guidance (RCN, 2014b; HM
Government, 2015). A significant proportion of
Further information about promoting emotional school nursing workload relates to safeguarding,
wellbeing and mental health can be found at: including report writing and attendance at child
protection meetings (RCN, 2016b), requiring
www.rcn.org.uk/professional-development/
school nurses to have good working knowledge
publications/pub-003311
of local guidance (Children’s Commissioner,
www.minded.org.uk 2016a). In England, every local authority area
has its own local safeguarding children’s board
www.youngminds.org.uk/training_services (LSCB) or joint children and adult safeguarding
board with policies and procedures guiding
www.ncb.org.uk/resources-publications safeguarding practice across all professions and
www.inourhands.com/contact organisations. The NSPCC provides information
relating to safeguarding policy across the UK.
www.annafreud.org/media/4612/mwb- Safeguarding training is mandatory, with
toolki-final-draft-4.pdf professional and local guidance on frequency
and level of training and supervision required
www.sign.ac.uk/our-guidelines.html by staff and professional groups (RCPCH, 2014).
Nurses working in schools will have links into
Further information regarding emotional
the LSCB or equivalent across the UK and should
wellbeing and mental health policy across the UK
have contact details for the local named nurse for
can be found at:
safeguarding children, but may also report to the
www.gov.uk/government/publications/ designated lead for safeguarding within the school
improving-mental-health-services-for-young- (DfE, 2016). It is important that reporting and
people escalation mechanisms are clear and that school
staff understand the professional requirements
www.nice.org.uk of nurses, especially where health services do not
employ them. This will include provision of access
www.england.nhs.uk/mentalhealth/cyp to safeguarding supervision. Further country
www.niccy.org specific and national guidance on child protection
and safeguarding can be found at:
www.gov.wales/topics/health/nhswales/ www.nspcc.org.uk/preventing-abuse/child-
mental-health-services/policy/child-mental protection-system
www.gov.scot/Topics/Health/Services/ www.gov.uk/government/uploads/system/
Mental-Health/Strategy/Child-Adolescent- uploads/attachment_data/file/550511/
Services Keeping_children_safe_in_education.pdf
www.gov.scot/Topics/People/Young-People/ www.rcn.org.uk/professional-development/
gettingitright/wellbeing publications/pub-004542
www.safeguardingni.org
www.gov.scot/Publications/2014/05/3052
www.gov.wales/topics/health/socialcare/
safeguarding
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