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Leading the school nursing revolution

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School nursing is a prime example of how nurses'? roles in the community are changing.
We looks at how recent policies have opened up one nurse?s career pathway

School nursing is a prime example of how nurses'? roles in the community are changing.
We looks at how recent policies have opened up one nurse?s career pathway

Community nursing is changing fast. But perhaps no part of it has changed as dramatically as the role of the school nurse.

In 1992, the year that school nursing manager Gail Smith embarked on her career, the school nurse was known mostly for wielding a nit comb and assisting in school medicals.

But in recent years, school nurses have been handed a central role in the government's plans for public health and children, as outlined in the green paper Every Child Matters (2003) and the white paper Choosing Health: Making Healthy Choices Easier (2004).

Not only has this transformed the image of the school nurse in the eyes of students, parents and teachers, it has now created a challenging new career option for nurses.

The recommendations of the inquiry into the death of Victoria Climbié included the need for improved multi-agency working in the area of child protection. As an H-grade school nursing manager, Ms Smith is a multi-agency lead, working with other initiatives such as Sure Start - a government programme focused on ensuring every child has the best start to life.

Caseloads vary around the UK. Where Ms Smith works in York, a school nurse working 10 hours a week will have 1,000 children on her books.

There was almost no career development when Ms Smith started, but now nurses can progress to team manager and school nursing manager, or become a specialist in child protection, sexual health or enuresis (bedwetting).

'From being hardly seen and not being understood, now suddenly everyone wants a bit of us,' she explains.

But there are problems with this evolving role.

School nurses work under different grades around the country, and this can cause difficulties in terms of training and progression. 'You have nurses on E grades doing the same as G grades elsewhere in the country - that may change with Agenda for Change,' says Ms Smith.

But an advantage of the role is that it attracts nurses from a wide range of backgrounds.

Ms Smith has experience in orthopaedics, coronary care, medical wards and paediatric surgery. She was initially attracted to school nursing because the role allowed her to work term times only.

'The downside of that is we are not paid for school holidays,' she admits. 'It's generally been a job where you are not the major breadwinner.'

However, this has not deterred her. 'It's a wonderful career - of all the different areas I have worked in I haven't felt as passionately as I have about school nursing.'

Today, the school medicals have gone and the vision and hearing tests, weighing and measuring, are performed by technicians.

When five year olds start primary school, their parents are offered an appointment with the school nurse. 'We ask if they have any concerns about bedwetting, speech, clumsiness. Weight is very important because of obesity and type 2 diabetes. Very often we identify problems they haven't identified before.

'We can talk about diet, lifestyle, offer help and advice. It seems to be really appreciated by parents but it has to be done diplomatically - we have to be careful not to be too prescriptive.'

Teachers also refer children if a possible health condition is impacting on their education, for instance undiagnosed dyslexia.

In secondary schools, there are other issues. 'Sometimes we see 11 or 12 year olds who may have bullying issues. There's been a massive increase in youngsters who self-harm.

'If a child thinks they're anorexic, we'd assess them, weigh them and discuss diet. It may get to the point where we have to involve parents.'

School nurses regularly address school assemblies to inform students of their service. They also teach classes about sex and relationships, drugs or healthy eating - always with a teacher present. 'We have got one foot in health and one foot in education.'

For children with special needs - increasingly integrated into mainstream education - school nurses advise teachers on issues such as severe asthma, or training dinner ladies to cope with an anaphylactic reaction.

But at the heart of their work is a confidential weekly drop-in service where teenagers can discuss any problems they are having with health, family, relationship or mental health matters. Many school nurses are now also dispensing contraception, following recommendations in the government?s Social Exclusion Unit (SEU) report in 1999.

Unlike teachers, who are in loco parentis, school nurses can respect a child's wish for confidentiality, unless she or he is perceived to be at risk of harm.

'Staying safe' is one of the key outcomes in the government's new children's policy - especially around child protection. Whenever a child attends A&E the school nurse is informed, to ensure that cases like Victoria Climbié's do not go unmissed. 'We have to learn from these high-profile cases - it's a massive part of our work.'

A recent chief nursing officer's review concluded that 1,500 additional school nurses are needed to guarantee a pledge of one school nurse to every secondary school, plus its feeder primaries. However, Ms Smith notes that little new funding has come in to help fulfil this ambition - an issue currently being highlighted by union bodies, such as the RCN school nurses forum.

Up to 40 nurses used to apply for each school nursing job advertised in York, but recently, with improvements in career development, more vacancies are arising.

'It's still a very much sought-after job,' Ms Smith says.

Further information

The green paper Every Child Matters and follow-up reports can be found at

The white paper Choosing Health: Making Healthy Choices Easier can be found at

This could be for you if: You enjoy working with young people and enjoy health promotion
you need to be good at: Communicating, working autonomously, decision-making and multi-agency working
you need to have: Experience of working with children and in the community
you don't need: A school nursing degree - this is currently only required in certain roles, although this may change under Agenda for Change
Similar jobs you could consider Health visiting, which also involves working with pre-school children and their parents.

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