During the pandemic, many school nurses brilliantly flexed their service to ensure they continued to support students. What practices have continued and how is the service looking now? Journalist Anna Scott reports.
It’s well known that multiple lockdowns had an impact on the mental health and wellbeing of children and young people. A number of longitudinal studies have highlighted the negative impact of the pandemic. For example, one study found that 44% of 11- to 12-year-olds reported an increase in the symptoms of depression, and 26% said they had greater post-traumatic stress disorder symptoms since the start of the pandemic (Wright et al, 2021).
School nursing practices also changed during this time. The pandemic restrictions combined with school nurses’ remit to deliver ‘new models of care to meet population health needs’. This meant creative and innovative practices were adopted by school nurses (Bekaert et al, 2022).
But what hasn’t been clear until now is the effectiveness of such practices – for instance, online platforms for non-school premises to deliver health promotion and education, or formal health or safeguarding assessments that are part of school nurses’ remit (Bekaert et al, 2022).
In December 2022, a scoping review of school nurse services during the pandemic was published that gives a clearer idea of how school nursing practices have changed (Cook et al, 2022). A corresponding survey, also published at the end of last year, gathered the views of a wide range of school nurses working across the UK in primary, secondary, mainstream and independent schools in a variety of ways (Sammut et al, 2022).
Furthermore, a learning report based on both the scoping review and survey, Learning from school nursing practices and new ways of working in the Covid-19 pandemic (Bekaert et al, 2022) reviewed evidence examining innovative school nurse practice with children, young people and partner agencies. All three pieces of work have helped build a better picture of what has changed and what has stayed the same, as well as overall challenges. In this article, the authors talk about that picture, while other voices from school nursing and teaching also share their experience.
The global scoping review highlights the range of responses of school nurses to Covid-19 restrictions. During lockdown, school nursing services in countries in the ‘global north’, including the UK, continued to offer casework to children, young people and families, but used online and digital platforms for consultations and appointments (Cook et al, 2022).
The expanded school health offering due to Covid-19 included infection prevention and control with children, young people and families – including training others to use PPE – and dealing with negative responses from teachers and parents (Cook et al, 2022). School nurses were involved in team planning for school reopening, infection data collection and being on-call to the multidisciplinary teams and schools due to rapidly changing guidelines, among many other responsibilities (Cook et al, 2022).
Despite the impact on their workloads, school nurses were also innovative in setting up systems to better manage Covid-19-related workloads and processes. This included developing a text support service, an online symptom-tracking system and a triage flowchart (Cook et al, 2022).
Nevertheless, school nurses surveyed across the UK reported a number of negative impacts, including an increased workload and decreased contact with children (Sammut et al, 2022 – see Stats and facts: the evolving picture, overleaf). This resulted in an increasingly reactive approach to school nursing and greater safeguarding, and virtual contacts were not satisfactory for all types of assessment (Cook et al, 2022).
On the whole, school nurses swiftly adapted their practices across the UK, and there were some benefits for multidisciplinary working, the learning report found (Bekaert et al, 2022). However, there were greater challenges in accessing, supporting and representing young children. And the changing nature of school nurses’ work reduced the opportunity for preventative work, meaning more complex issues were identified later on (Cook et al, 2022).
It was also a challenge returning to face-to-face care after lockdowns, says Anne-Marie Gallogly, complex safeguarding nurse (within the Aspire Team, part of Stockport’s school nursing service). Schools were reluctant to allow ‘visitors’ in, and there was pressure on schools to ‘catch up’, which sometimes presented as a reluctance to allow time for subjects such as personal, health, social and economic education.
‘However, the relationships and visible presence already established with colleagues in education meant that school nurses were viewed as part of the solution rather than the problem,’ says Anne-Marie.
The landscape of school nursing changed ‘dramatically’, according to Dr Sarah Bekaert, senior lecturer in child health, Oxford Brookes University, and study lead of the learning report (Bekaert et al, 2022). ‘School nursing teams flexed the service, drawing on a wide range of resources to best meet the needs of children, young people and their families, work closely with the wider professional network, and support colleagues.
‘This has introduced or accelerated a range of modes and methods to facilitate school nursing practice that may be of use going forward post-pandemic,’ she adds. So, the adaptations to practice made in response to the reduction in in-person contact led to creative ways of maintaining contact with children and young people. ‘Walk and talks’ (meeting a young person in an open space for therapeutic support) and home visiting jointly with social workers are two modes of practice that can facilitate care.
The most dramatic change has been the increase in the use of remote and virtual means of contact such as text (for example, healthcare messaging service ChatHealth) and video consultation. ‘The increased use of teleconferencing was mirrored in multidisciplinary working,’ Sarah adds. ‘This in turn raised the visibility of the school nurse with professional partners and put school nursing on the map.’
Now there is increased accessibility to the school nurse for children, young people and families through a range of remote means, Sarah explains. There is also increased presence at multidisciplinary team meetings because they are online and easier to attend. This results in improved communication with the multidisciplinary team as a result of new and improved channels for contact. ‘There is a better understanding of the school nurse role among the wider professional network – for instance, social workers or teaching staff.’
However, while the use of remote and virtual modes enabled continued contact with children, young people and parents, school nurses were very clear that carrying out formal assessments and interventions remotely was not comparable in quality to face-to-face contact.
‘School nurses also have raised concerns about confidentiality and safeguarding when unable to assess the family dynamic or environment beyond what is visible on a screen, as well as “tech-poverty” being an issue for some families leading to inequality of access,’ Sarah adds.
The use of technology and remote meetings can increase workload, with little consideration of staff wellbeing and mean lots of back-to-back meetings, according to Anne-Marie. ‘Less face-to-face with colleagues means less informal supervision, and some staff feel isolated when they are home-based. It means less face-to-face contact with social care colleagues too.’
The most dramatic change to school nursing has been the increase in the use of remote and virtual means of contact such as text and video consulation
Redeployment has also proven to be a challenge. ‘It fractured teams, with redeployed staff required to work in services that required a different skill-set, and those remaining carrying an increased workload through compromised numbers and escalating need and referrals,’ Sarah says. ‘School nurses, both on the ground and managerial, spoke of a range of supervision that had been put in place, as well as restorative work to respond to the trauma experienced by all staff.’
Impact on children and young people
Embracing creative modes for service delivery has led to school nursing being delivered in a more flexible way, which has benefits for children, young people and parents’ needs, according to Dr Georgia Cook, associate lecturer in the Department of Psychology, Health and Professional Development at Oxford Brookes University, study lead of the scoping review School nursing: new ways of working with children and young people during the Covid-19 pandemic: a scoping review (Cook et al, 2022) and co-author of the linked research.
‘The range of tools to assist in service delivery enabled close and regular contact with children, young people and parents,’ she says. ‘These resources or means of contact facilitated a timely and effective response to increased demand.’
But there are some areas where young people and children are missing out. During the pandemic, the immediate infection control and disease management demands on school nursing services compromised the ability to carry out routine health promotion and education activity beyond that related to Covid-19.
‘Delay in identifying concerns as a consequence of not seeing children and young people on a day-to-day basis, and compromised communication between service users and the school nurse, led to the emergence of more complex cases further down the line,’ Georgia says.
‘School nurses are also seeing the consequences of reduced socialisation and contact with support services during the lockdown periods, citing significant behavioural challenges, mental health concerns and a lack of relationship and sexual health knowledge in children and young people,’ she adds.
Tikki Harrold, a school health nurse and community practice teacher at Oxford Health NHS Foundation Trust, says she is seeing more disordered eating and anxiety and low mood. ‘Some children seem to be struggling more than before to manage educational expectations, as if their psychosocial development was stunted,’ she adds.
Also a co-author on the three pieces of linked research, Tikki says that the proliferation of some influencers during lockdown, when children were spending more time online, has impacted the views of young groups of boys in particular. She adds that some children ‘seem to swing to more extreme behaviours and reactions more quickly’.
Unite lead professional officer (health) Gavin Fergie says: ‘The findings highlight the complexity of health needs that today’s school nursing practitioners face on a daily basis.
‘Numerous reports highlight the damage the pandemic has had on school-age children, and without appropriate strategies this damage is only becoming more entrenched.
‘Yet sadly, school nursing practice and school nurses are still seemingly misunderstood by policy-makers. Unite-CPHVA has lobbied continually, alongside other organisations, for adequate funding to restore the required numbers of suitably qualified school nurses, not just for one financial year but on a recurring and fully funded basis.
‘Unite-CPHVA hopes that policy-makers will redress the historic underfunding with a new package in the hope that at long last we can start to support the discipline of school nursing in the way young people and hard-pressed practitioners deserve.’
Impact on the profession
Things haven’t gone back to normal for school nurses, according to Kevin McArevey, principal of Holy Cross Boys’ Primary School in Ardoyne, Belfast, and a speaker at the 2022 Unite-CPHVA Annual Professional Conference. Prior to the pandemic, his school leadership team of the principal, the vice-principal, the special educational needs coordinator, social workers, the board of governors for child protection and the school nurse would meet termly to ensure individual children were getting the help they needed – that ‘no child gets left behind’ – and the nurse was ‘a vital part of the team’.
But when the pandemic hit, that stopped, and communications were weakened between school nurses and parents in particular. Now face-to-face meetings have resumed and communications are vastly improved. But, Kevin adds: ‘A lot of the work that we did pre-pandemic is being undermined by the high workloads of school nurses who are now working across numerous schools.’ Kevin is thankful for the good relationship the school has with their school nurse Angela Evans.
Many of the issues that the school nurse at Kevin’s school is dealing with are highly complex – difficulties that are the result of transgenerational trauma of the Northern Ireland Troubles, including addiction, gambling and domestic violence – alongside helping children with care plans for conditions such as attention deficit hyperactivity disorder or allergies. But while there are challenges children face specific to where they live, many of the issues are similar across the UK, the research found, which means the challenges that school nurses face are similar too.
Nationally, it appears that services such as sexual health and mental health can be hard to reach, according to Tikki. ‘Many of our schools have access to mental health teams in schools, but often schools do not identify the need until it is too great to meet the referral criteria,’ she adds.
‘it is vital that professional bodies mobilise to ensure that the vital public health role of the school nurse continues to be recognised’
‘CAMHS [child and adolescent mental health services] waiting times are long as they struggle to respond to the huge increase in demand. Walk-in sexual health clinic access for young people [in Oxfordshire] is extremely limited – currently after school in one venue once a week. Otherwise, young people have to have telephone triage and then travel to one of a handful of countywide clinics to collect any supplies. Fortunately, some aspects of sexual health care are available in school from us.’
New dynamics and demands
‘The current challenge is how to ensure informal and formal supervision is available to staff in order to maintain morale and facilitate staff retention,’ says Dana Sammut, research associate at the University of Birmingham, survey lead of School nurse perspectives of working with children and young people in the United Kingdom during the Covid-19 pandemic: an online survey study (Sammut et al, 2022) and co-author of the linked research. A further challenge is to maintain the highly visible profile that school nursing has had in the professional landscape since the pandemic, she explains.
‘School nurses voiced that they were noticing a return to pre-pandemic modes of interprofessional practice as we emerge from restrictions, and felt that they were being told to “get back in their box”. It is vital that professional bodies mobilise to ensure that the vital public health role of the school nurse continues to be recognised,’ she adds.
The researchers believe funding and clear policy guidance on school health service commissioning is key to providing a specialist public health workforce that can fulfil the remit of the Healthy Child Programme across the UK, in the context of the additional demands from the pandemic legacy.
‘Many health-related services or programmes are commissioned into schools, such as mental health workers or navigator services,’ Dana says. ‘These services often duplicate the work of the school nurse. There should be clear policy guidance for schools and commissioners regarding the school nurse remit. If health-related services are brought in in addition to the school health service, the school nurse, as named health professional for the school, should be involved in the commissioning discussions, and oversee the service once in place.’
The researchers of the recent linked-up work have deliberately avoided making recommendations for what nurses should do now, given their increased workload both during and as a consequence of the pandemic ‘because they have already gone above and beyond in their role,’ Dana says. The researchers’ next steps, however, are to produce an evidence-based accessible practitioner-facing toolkit from the focus groups and interviews with school nurses across the UK.
‘This resource can be used by school nurses to inform their work, as well as lobby for the use of specific technology or modes of practice with managers and commissioners,’ Dana adds.
Stockport NHS Foundation Trust’s school nursing service
Stockport NHS Foundation Trust’s school nursing service returned to face-to-face work in schools back in September 2020, with weekly drop-ins in all mainstream high schools in the Greater Manchester town and borough. In June 2021, the service launched ChatHealth, a confidential text messaging service, which has offered a different way of contacting the service.
‘We saw a peak in contacts after the Covid-19 immunisation sessions in schools, with a lot of young people contacting us about their mental health,’ says Anne-Marie Gallogly, complex safeguarding nurse within the Aspire Team, part of Stockport’s school nursing service. ‘Parent drop-ins have returned, and attendance and demand have increased since Covid-19.’
A growing workload and lack of capacity
But the rise in safeguarding concerns for young people that increases the demand for school nursing input into safeguarding processes means it’s not possible for the service to offer twice-weekly drop-ins. ‘There has been a significant increase in the number of referrals from school for young people with mental health concerns,’ says Anne-Marie.
‘The increase in safeguarding concerns has led to a significant increase in invitations to attend strategy meetings. The preparation before and actions after the meeting has an impact on the capacity of the service,’ Anne-Marie adds.
In addition, school nurses are now holding cases that would previously have been held by social care due to lack of capacity in social care, and cases that would previously have been stepped up to mental health services due to lack of capacity in CAMHS. ‘We have an increasing number of referrals for children and young people needing continence support, especially around constipation.’
She concludes: ‘In an ideal world, an increase in funding would allow us to have a more robust offer in terms of health promotion – such as sessions in schools promoting dental health, and puberty lessons.’
It is fair to say the service is still helping young people on balance. As Kevin says: ‘We have a great relationship with our school nurse and she provides support and improvement to mental health and wellbeing and advice on children’s long-term health conditions. She has always been at the end of the phone, including for parents. There’s a tripartite link between parents, the school and the trust, and things must be communicated in order to garner success.’
He concludes: ‘I certainly do not believe nurses get paid for the job that they deliver. There’s always more that can be done for nurses.’
Bekaert S, Cook G, Sammut D et al. (2022) Learning from school nursing practice and new ways of working in the Covid-19 pandemic. See: https://doi.org/10.24384/1EK2-RN30 (accessed 3 March 2023).
Cook G, Appleton JV, Bekaert S et al. (2022) School nursing: new ways of working with children and young people during the Covid-19 pandemic: a scoping review. Journal of Advanced Nursing 79: 471- 501.
Sammut D, Cook G, Taylor J et al. (2022) School nurse perspectives of working with children and young people in the United Kingdom during the Covid-19 pandemic: an online survey study. International Journal of Environmental Research and Public Health 20(1): 481.
Wright N, Hill J, Sharp H et al. (2021) Interplay between long-term vulnerability and new risk: young adolescent and maternal mental health immediately before and during the Covid-19 pandemic. JCPP Advances 1(1): e12008.
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