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School nurses' contribution to young people's future health

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VOL: 101, ISSUE: 47, PAGE NO: 19

Sara Christian, BSc, RGN, is research associate, Nursing Research Unit, King's College, London

Fiona Ross, PhD, BSc, RGN, DN, is director, Nursing Research Unit, King's College, London;Fiona Brooks, PhD, BSc, is reader in primary health care, Centre for Research in Primary and Community Care;Vari Drennan, PhD, MSc, RGN, RHV, is senior lecturer in primary care nursing, Royal Free and University College, London

Children and young people have the right to be healthy, safe and secure at school. It is critical to identify how best this can be achieved in the context of the widely documented challenges threatening their long-term health in the UK today. This paper is the result of discussion at an expert seminar organised by the assistant chief nursing officer, and aims to integrate policy and research by bringing together key experts. Views expressed are those only of the authors.

Children and young people have the right to be healthy, safe and secure at school. It is critical to identify how best this can be achieved in the context of the widely documented challenges threatening their long-term health in the UK today. This paper is the result of discussion at an expert seminar organised by the assistant chief nursing officer, and aims to integrate policy and research by bringing together key experts. Views expressed are those only of the authors.

Children and adolescents exhibit high levels of risky behaviours such as drug-taking, smoking, sedentary lifestyles and being overweight, and as many as one in five adolescents in the UK experience serious psychological problems (British Medical Association, 2003). In an international context, young people in the UK are not only near the top of the league tables for the majority of high-risk behaviours but also feel less supported by their peers and school system than those in other western countries (World Health Organization, 2004).

Research has highlighted both the needs of young people in the school environment and key areas for intervention (Box 1, p20). School nurses, as the key health representatives in schools, could justifiably be seen to have a pivotal role in promoting the future health of the young people with whom they work.

School nurses' role
School nursing has evolved over the past 100 years from a service embedded in a medical model to one with a greater emphasis on public health and health promotion. Despite this, the chief nursing officer for England's review (DoH, 2004) found that the size of the school nursing workforce was a 'significant barrier to the effectiveness of the service'.

If the potential of school nurses to improve the health of the nation's children is to be realised, a strategic rethink in relation to both the numbers and roles of school nurses is required. HM Treasury has made a commitment to provide substantial additional funding and a review is under way to address ways of developing school nursing. Current policy drivers represent a real opportunity for health service managers to think innovatively about this unique role and make strategic changes to the way in which it is understood, developed and organised.

A systematic literature search on recruitment and retention among school nurses found no information on this workforce in the UK and only a small amount from the US (Drennan et al, 2005). The information on community nurses in general indicated an older, female, part-time workforce. The workforce census from 2003 provided incomplete data and there is little evidence on why practitioners choose to become school nurses although it appears to be a sought-after job (Kenny, 2005), presumably because of its term-time only commitment.

We do know that school nurses see themselves as being in an adverse role, experience problems with their status and location and feel sidelined in policy decisions (Kenny, 2005). We also know their role encompasses a huge range of activities.

The issue needing to be addressed by managers is how priorities for school nursing might be developed. Several systematic reviews of 'gold-standard' evidence to identify, map and evaluate nurse-led interventions in schools have concluded that there was little evidence for the effectiveness of school nursing interventions. This was primarily because the interventions were rarely described in detail (Bunn et al, 2005).

The lack of a developed evidence base makes it difficult to direct nurses' energies to where they could be most effective. However, qualitative evidence indicates that school nurses are valued by young people and families as neutral and credible health promotion experts. However, as visitors in the school they lack the direct authority to bring about change and face constant negotiation on access and the nature and remit of their role.

Possible strategies
Many roles traditionally undertaken by school nurses could be carried out by other professionals such as welfare officers or health educationalists or by multidisciplinary teams. It is therefore important to identify which contributions are unique to nurses and what their clear contribution would be to a mixed team. These include:

- Their capacity to link physical health and emotional well-being in a holistic approach;

- Their status as trusted professionals who offer confidentiality;

- Their local knowledge of the health system;

- Their ability to provide a unique and vital bridging role between services and to make direct referrals;

- Their position as 'outside' the education system, which is valued by young people.

In the future, school nurses need to be valued for these unique attributes and promoted as brokers for other services, coordinating with and referring to other agencies. They should have a higher profile as public health experts, advocates and confidential advisers on all health issues in schools and be seen as leaders of the holistic approach to public health.

A better understanding of the effectiveness of the school nurse's role could be achieved through large-scale, randomised studies to evaluate particular interventions with longer follow-up and sufficient detail to allow for replication. Further evidence could be taken from well-designed qualitative studies of young people's experience of the health journey through school. In addition to understanding the effectiveness of interventions, thought needs to be given to how these services are offered. It is also necessary to identify and evaluate possible strategies to develop such services. For example:

- Could general medical service-type contracts be useful where schools are offered core, additional and enhanced services?

- Might a menu of interventions be useful from which head teachers could select according to local needs and the priorities and ages of children?

The organisation of the role needs to be refined, particularly in terms of who makes decisions about what is required, who owns the service and the implications of different ownership and nurses' authority to bring about change. Detailed, accurate information on this workforce is also essential to understand its needs as well as recruitment and retention issues. Questions to be addressed include:

- Does school nursing need to be a year-round rather than term-time-only commitment?

- Should the workforce reflect the gender balance in schools by attracting more male recruits?

There has been some debate over where services to young people are best situated. A greater role for GPs has been suggested but research has indicated that young people want services in schools and local communities in addition to primary care (Brooks et al, 2004). Alternative models need to be assessed for the future, including the possibility of community health specialists for children and young people or possibly mixed professional teams with a clear nursing contribution which are attached to schools.

Conclusion
It is clear that school nurses require a new strategic vision to give them the authority and capacity to bring about change. This is likely to involve a clearer leadership role through direct influence on governing bodies. In order to implement this influential role funding is needed to recruit enough practitioners and to begin the huge task of introducing them to and preparing them for this role.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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