Paper 4 - The school nursing role in integrated community nursing teams
This series of brief papers on the Transforming Roles programme aims to update stakeholders on the professions’ contribution to the wider transformational change agenda in health and social care in Scotland. The fourth paper defines the refocused school nursing role in NHSScotland.
The Chief Nursing Officer ( CNO) is committed to maximising the contribution of the nursing, midwifery and health professions ( NMaHP) workforce and pushing the traditional boundaries of professional roles. The Transforming Roles programme aims to provide strategic oversight, direction and governance to:
- develop and transform NMaHP roles to meet the current and future needs of Scotland’s health and care system
- ensure nationally consistent, sustainable and progressive roles, education and career pathways.
Phase 1 of Transforming Roles focused on nursing roles.
Integrated community nursing teams
Shifting the balance of care from hospital to community and primary care settings at, or near people’s homes aims to improve population health, increase quality and safety, and secure best value from health and social care services.
Delivering on these aims requires a different approach that enables community nursing staff to develop new and innovative ways of working to provide safe, effective, person-centred care and clinical interventions tailored to need. Health visitors, family nurses, general practice nurses, community children’s nurses, school nurses and their wider teams, working as integrated community nursing teams, would provide a seamless interface and reduce any boundaries between their practice and place of care.
Integrated community nursing teams will play a key role in prevention, early intervention, reducing inequalities, and planning, providing, managing, monitoring and reviewing care, building on current roles and best practice to meet the requirements of people with more complex health and care needs in a range of community settings.
Role of wider school health and wellbeing teams
This paper outlines the school nurse contribution within wider health and educational wellbeing teams in schools. Wider teams may include education staff, allied health professionals, community children’s nurses, staff nurses, clinical support workers and health improvement staff, all of whom play a vital role in schools. This will enhance the perception of schools as an important portal for universal access to health services for children.
The school nursing contribution will be critical within this wider team context, working across health and education to support early identification and intervention, and promote health, wellbeing and attainment for the most vulnerable children and families and those at risk of significant harm. With this very much in mind, the school nursing role in Scotland has been reviewed and refocused to outline school nurses’ contribution within a wider interagency setting.
Developing a school nursing role for the future
A national steering group was commissioned by the CNO/Scottish Executive Nurse Directors ( CNO/ SEND) group to work during 2015–2016 on developing, testing and evaluating a refocused nursing role for school-aged children and their families.
It is well known that prevention, early identification and intervention throughout the early years of life are crucial to people’s future experience of health and wellbeing. It is also recognised that continuing preventative approaches and holistic assessment of children after they reach the age of five, particularly focusing on vulnerable children and families and those who have experienced, or are at risk of, adverse childhood experiences ( ACEs),  are equally vital.
The roles of health visitors and school nurses, with their wider teams, have been refocused to reflect this evidence. The aim is to ensure a preventative foundation throughout the early years by providing critical support and interventions to children under five and their families, complemented by a stepped-skill approach to universal and targeted services for all children of school age.
The roles focus on public health priority areas and are embedded in integrated multiagency working. Public health approaches to children and families include utilising strength-based models, reducing inequalities by increasing access to appropriate interventions, responding to the needs of vulnerable and hard-to-reach groups, increasing levels of literacy and numeracy, raising attainment and improving health and wellbeing outcomes. The model developed provides a robust platform of service provision and an integrated approach to services across the 0–19 age range, underpinned by interdisciplinary and multiagency working.
A rapid review of evidence to identify effective interventions provided by school nurses was carried out by the Chief Scientist Office Nursing, Midwifery & Allied Health Professions Research Unit at Stirling University to support the review.
Future vision for school nursing in Scotland
Increasing the capacity and competency of school nurses to maximise their contribution as part of multiagency/multidisciplinary teams to supporting health and wellbeing and raising attainment of the school-age population will contribute significantly to:
- preventing ACEs
- reducing the effects of inequalities
- ensuring a focused and targeted approach to promoting health and wellbeing for children and young people.
School nurses will work alongside health visitors, community children’s nurses, general practice nurses and others in specialist roles (such as looked-after children’s nurses) to create seamless interfaces between roles and within their wider teams, ensuring all work together at locality level as a team and at times of transition (for example, when children move from pre-school settings to primary school). Complementary elements of service provision will include delivering immunisation, screening (height and weight) and body mass index measurements, and providing health zones/drop-in clinics and brief interventions. Considerable potential exists to enhance the remit of interagency teams to undertake greater public health activity and/or work in response to local needs.
Refocused school nursing roles will be cluster/locality-focused and aligned and integrated with general practice and partner agencies, potentially across the 5–19 years age range, moving away from a ‘one nurse per school or learning community’ model. The National Vaccination Transformation Programme is supporting NHS boards and health and social care partnerships to identify and implement local models of delivery for national immunisation programmes, which should facilitate school nurses’ ability to fully embrace implementation of the refocused role.
Key features of the refocused school nursing role
The refocused school nursing role envisages a continuing focus on prevention, early intervention and support for the most vulnerable children over five years, following on from the role and focus of health visiting. In addition to focusing on children and families allocated an ‘additional’ health plan indicator ( HPI) at the four-year review using the GIRFEC National Practice Model assessment framework, the role will concentrate primarily on ten priority pathway areas  under the overall headings of vulnerable children and families, mental health and wellbeing and risk-taking behaviour:
- emotional health and wellbeing
- substance misuse
- child protection
- domestic abuse
- looked-after children
- youth justice
- young carers
- sexual health.
Improved liaison, information-sharing and targeted interventions in these areas could achieve significantly better outcomes for children and young people.
The refocused school nurse role incorporates health assessments of all looked-after children at home or in kinship care, enabling greater access to assessment and routine screening for the most vulnerable children and young people, who are most likely to experience the poorest outcomes. Where appropriate, this will enable looked-after and accommodated children’s nurses to focus on vulnerable children and young people in residential care, and provide supervision and guidance to core services.
Partnership-working, particularly with parents/carers, the wider family, general practitioners and other health professionals, the education, criminal justice and social work sectors, and voluntary organisations, will be central to the refocused role.
The refocused role was tested in two early adopter sites, NHS Dumfries & Galloway and NHS Tayside (Perth and Kinross), from November 2015 to November 2016.
An evaluation was carried out after the first six months by the Scottish Collaboration for Public Health Research and Policy ( SCPHRP)  and a consultation exercise with school-aged children and young people was commissioned and undertaken by Children in Scotland. 
The aim of the evaluation was to assess how the refocused role worked in the early adopter sites and to provide learning and guidance to support national training and implementation. While the findings’ limitations were recognised, they supported the refreshed role for nursing in schools, highlighting the important part nursing can play in early identification and intervention and in achieving positive outcomes for children and young people, particularly in areas such as mental health and wellbeing.
The main findings are shown in Box 1.
Box 1. Main findings from evaluation of the refocused role in two early adopter sites
- There was clarity of role and referral processes, enabling positive and appropriate partnership-working and effective referral mechanisms.
- The referral pathway most utilised in both sites was emotional health and wellbeing, where over 400 referrals took place over six to nine months.
- The mental health pathway provided an overarching focus for the school nursing service, with the remaining nine pathways clearly impacting on children and young people’s emotional health and wellbeing. The ten existing pathways were therefore reconfigured to sit under an overarching heading of ‘Vulnerable Children and Families’, indicating the two main sources of referral and intervention (mental health and wellbeing, and risk-taking behaviour).
- The importance of frequent and detailed holistic assessment was emphasised.
- Complex assessment of all vulnerable children and families, in particular for looked-after children, was also found to be very important.
- The refocused role provided clarity on school nurses’ roles in child protection.
- Having a separate dedicated immunisation team to deliver immunisation programmes positively impacted on the ability of school nurses to implement the refocused role and deliver improved outcomes.
- The benefits of home visiting and the importance of offering services at home, in schools and within communities was reinforced.
- Referrals to child and adolescent mental health ( CAMH) services reduced, with possible reductions in CAMH service waiting times in future being anticipated.
- The timing of, and threshold for, referrals into CAMH services improved.
- A potential role for the third sector in reducing referrals to medical, CAMH and health services was identified.
- Future benefits in educational attendance, attainment and achievement in school are anticipated.
- School nurses’ work with parents/carers and wider families increased.
- The refocused role supported early identification, early referral and prevention of deterioration and escalation of issues, ultimately affecting middle-to long-term health outcomes.
Educational preparation for school nurses
Work has been undertaken to refocus school nursing education pathways, preparation, clinical placements and continuing professional development activity to ensure provision responds to future service and population requirements. This has included a move to a regional model of delivery with three education providers – the University of the West of Scotland, Robert Gordon University and Queen Margaret University.
Discussions on future workforce numbers and requirements have begun, based on learning from the early adopter sites and reflecting the range of key multiagency stakeholders engaged and working with the school-aged population.
The CNO, Children and Families, Education, and Population Health directorates of the Scottish Government will work together and with NHS boards/integrated joint boards to develop an implementation plan for the school nursing/school health workforce. This will aim to scope additional detail on the interagency/multidisciplinary roles and requirements required to support health and wellbeing within the school context.
Further work to clarify the nature of a core school nurse caseload, focusing on meeting the needs of looked-after children, addressing behavioural, speech and language issues, identifying priority areas and ensuring that school-aged children and young people are reassessed at key transition points, is ongoing. Where developmental or behavioural issues have been identified pre-school, these will be further assessed and monitored by school nurses and wider interagency teams.