VOL: 96, ISSUE: 48, PAGE NO: 38
Elaine Halligan, BSc, RGN, OHND, CertEd, is occupational health adviser, Bournemouth and Poole CollegeImagine you have two months to give 160,000 16 and 17-year-olds a life-saving vaccine. This is the problem college nurses faced in the autumn of 1999 (Department of Health, 1999a), despite the fact that the young people:
Imagine you have two months to give 160,000 16 and 17-year-olds a life-saving vaccine. This is the problem college nurses faced in the autumn of 1999 (Department of Health, 1999a), despite the fact that the young people:
- Were not all in the same place at the same time;
- Had no money to get to the clinics;
- Were likely to forget their appointment or turn up when there was a queue of 200;
- Had 18-year-old friends who wanted to know why their lives couldn't be saved too.
In addition, there was a shortage of vaccine and the college nurses had no help in identifying, locating or contacting the young people and no funding. So how did they do it?
The arrangements for the campaign were complex. Sufficient conjugate vaccine was not available in time so all first-year university students were urged to have the existing polysaccharide vaccine. Students were individually notified through the University and Colleges Admissions Service (UCAS) and GPs were funded to provide it (DoH, 1999b; 1999c).
Those aged under 18 who were at school were to be notified through the Schools Health Service and given the new vaccine.
It appeared that further education students had fallen through the net: neither the UCAS system nor the Schools Health Service involved them, so they were not included. The College Nurse's Forum (CNF) and the Association of Colleges contacted the DoH urgently to find out how they intended to communicate and fund the programme in the further education sector. Arrangements were subsequently made via local immunisation coordinators.
Further education and college nurses
One-quarter of all 16 and 17-year-olds continue their studies in Britain's 444 further education colleges. Admissions to these colleges increased by 79% between 1991 and 1997, making them the largest education sector in the UK (Office for National Statistics, 1999). Fewer than 100 colleges employ nurses, other than as teaching staff. College nurses are hired directly by each college and work as independent practitioners, often managing a complex and unique position that involves a mix of student health and welfare, occupational health and health promotion.
Nurses' response to the programme
Anecdotal evidence gathered from college nurses suggested that the programme was a 'nightmare' to administrate. A survey of college nurses was carried out to:
- Find out how the campaign had been planned, implemented and evaluated in further education;
- Identify the strengths and weaknesses of the campaign and examples of best practice;
- Identify ways in which groups could work together in future campaigns.
A structured postal questionnaire was sent to 95 CNF members and 52% were returned. This represented 50 colleges of further education in 47 health authorities in England and Wales.
Most college nurses (62%) heard about the campaign between September and October 1999, mainly from the media, colleagues and, eventually, local immunisation coordinators or school nurses. Some of the difficulties they experienced were common to all and related to communication and liaison. Nurses found it difficult to contact all the different groups involved, and obtaining information from them that did not conflict was equally difficult.
There was also a general feeling that the DoH timescale - to have the entire client group vaccinated by December - was unrealistic. In further education the academic year begins halfway through September, which left little time to plan and implement the campaign.
The amount of time allocated for planning by local community health services varied enormously between colleges. Most nurses held planning meetings with community health services for four to eight hours, although 17% held no planning meetings at all. It did not help that the campaign was held during the busiest time of the college year and that enrolment databases are not usually completed until November at the earliest.
Understanding different roles
The community health services failed to understand the unique ways in which colleges work. Unlike school pupils, college students do not attend at the same time and in the same place: there is a wide variety of attendance patterns, such as flexible part time, day/block release and full time. This made it impossible to know the best times for sessions or how many vaccines to order.
About 60% of college nurses experienced difficulties in coordinating vaccination sessions. Many felt that some community staff saw this as a lack of organisation and cooperation, but session times were often dictated by restrictions on community staff and did not relate to student timetables.
Administration of the campaign
Despite the support of the colleges' senior management, 59% of nurses reported that they had been left to coordinate the campaign and only 14% worked as part of a team. They reported feeling 'very alone' and 'overwhelmed by the scale of the task'. The number of students (up to 3,500 in some colleges) and their location (several campuses, with some on work placements) posed administrative challenges.
Most nurses easily obtained an adequate supply of campaign leaflets and consent forms before the start of the programme. However, there were problems that related to these materials being supplied in batches of 500 only. Some colleges had to reorder several times, which sometimes delayed the campaign for up to five weeks.
Materials were not supplied in large print or braille and were difficult to obtain in any language other than English.
The number of vaccination sessions provided by health authorities varied from one of one hour's duration to 60 hours made up of 15 four-hour sessions. An appointment-only system was most common (Fig.1), but a combination of appointments and drop-ins proved to be the most successful method.
Students could not be relied on to keep their appointment times and academic staff could not be relied on to remind them.
Age of recipients
Initially, 16 and 17-year-olds were targeted, but during the campaign the DoH changed the age range to include 18-year-olds. Until then, college nurses had difficulties explaining to those aged over 17 why they could not have the vaccination when many sat in the same classroom or shared the same social lives and accommodation as their younger friends. Consequently, those aged over 17 were often vaccinated.
Under-16s were also vaccinated. Many in this age group go to college for reasons such as non-attendance at school. Because these students were at risk of not being identified by their school's health service they were vaccinated during the first phase of the programme in the college. In all, the ages of those who received a vaccination varied between 14 and 25.
Shortfall on targets
As a result of difficulties in administrating the programme and getting students to attend, many colleges did not achieve their local targets of up to 90% vaccinations. Most achieved between 50% and 60%, and about 48,000 students were vaccinated by the 50 colleges that took part in the survey.
Although this entailed an enormous amount of organisation and work by all the agencies involved, only one-third of the targeted age group in further education were vaccinated.
Evaluation of campaign results
Because the campaign was so complex and it was the first time that colleges of further education had been involved in mass vaccination, it might be assumed that an evaluation would have been carried out by the local health authority in conjunction with the college nurses.
Most nurses (84%) said there was no evaluation. Where one was carried out, the nurses said it was almost entirely an internal process involving the gathering of figures, meetings with line managers, and formative feedback.
The cost, generously borne by the further education sector, was difficult to quantify and figures of up to £3,000 were mentioned. This included costs related to time, postage, printing and accommodation. A total of 88% of colleges were not offered any funding by their local health authorities.
'The role of the college nurse is essential in bringing health care and health promotion issues to a large number of young adults. This was demonstrated to the students in practical terms during the campaign. It also stretched my managerial and organisational skills, and in doing so taught me a lot about myself.'
This quote is typical of the response from college nurses, 90% of whom reported that the campaign contributed to their professional practice.
Nurses' communication and motivational skills were improved by forging links and liaising with community health services, particularly school nurses, the DoH, health promotion and meningitis awareness agencies, college colleagues, students and parents.
Although they were relieved when the campaign was over, many nurses said they had enjoyed the experience and found working as a team with health professionals satisfying. Nurses who work in further education often feel isolated and appreciated the chance to communicate with other health professionals.
Increased confidence among nurses
The college nurses were pleased with the way they had organised this extensive health campaign and said they were looking forward to using their skills in future initiatives.
The DoH and many community health staff, however, had not been aware of their existence and those that had had no idea what their role entailed. The campaign emphasised the expertise and professionalism of college nurses, highlighting the need for colleges to employ a nurse. Their clinical knowledge was also enhanced, as they had to extend it and keep up to date with the latest information on meningitis, immunisation, anaphylaxis and resuscitation.
The campaign was most successful in colleges that had developed close working partnerships between community health services and college nurses. Success appeared to depend on:
- Frequent contact and liaison;
- An appreciation of the unique environment and challenges within it;
- An understanding of different professional roles.
As a result of the experiences described in the survey it has been suggested that the DoH should include further education colleges from the start of future initiatives.
For example, college nurses could play a valuable role in providing advice on the timing of campaigns and the types of materials to use. Funding should be arranged to enable them to get administrative support. The partnerships formed during this campaign should be continued and developed, with frequent contact between the organising groups.