Starting to measure up: a tool for SNs

18 September 2020

Erica Lloyd on how measuring outcomes can improve school nurses’ effectiveness.

Assessing outcomes in healthcare is becoming both a UK and a global policy priority (Department of Health (DH), 2010a). In 2011, the NHS Outcomes Framework policy began developing indicators to monitor the health outcomes of adults and children in England. This data now provides important information on the impact of services, guiding not just clinicians around their practice, but also commissioners on the future delivery of services.

The 2015 transfer of commissioning for public health children’s services to local authorities now requires a demonstration of the outcomes and impact of school nurse (SN) work (Public Health England (PHE), 2016).  

During the Covid-19 pandemic, SNs have been reactive to changes and adapted their practice swiftly. With a depth of experience of working remotely with children and young people through texts, virtual drop-ins and platforms such as ChatHealth, SNs showed skill and good preparation to deliver support virtually. As commissioners look to the future, reviewing how services are delivered, SNs need to demonstrate how effective their interventions have been. Alongside the fall in the number of SNs from 3012 to 2056 between March 2010 and 2020 (NHS Digital, 2020), there has never been a greater need to demonstrate the effectiveness of their interventions.

Despite evidence suggesting that SN interventions result in a variety of positive outcomes, there remains a lack of formal and robust evaluation of activities (Turner and Mackay, 2015). In a survey of SNs by the Royal College of Nursing (RCN, 2016) a range of mechanisms was used to measure performance, none of which SNs felt were effective.  

When attempting to demonstrate any measurable impact, there is an over-reliance on descriptive feedback as opposed to formal evaluation activities (Turner and Mackay, 2015).

Measuring outcomes is linked to improving quality of care and is an important element of decision-making

Monitoring outcomes

SN teams’ structure and service delivery varies widely across England, and this lack of consistency makes evaluation of the service nationally exceedingly difficult. Forward (2012) suggests that SNs undertake a range of interventions so wide that it is almost impossible to find an outcome tool that can measure their effectiveness. However, a tool that measures a change following an intervention on an individual level would be a powerful way to demonstrate the impact of the SN service.

Routine outcome monitoring (ROM) is now used widely by child and adolescent mental health service teams across the UK (Waldron et al, 2018). ROM was introduced to the NHS in 2009, driven by the need to measure the impact of health interventions from the patient’s point of view (DH, 2010b). This is increasingly required by commissioners, and an integral part of clinical governance and service planning. ROM can be used to measure a variety of aspects of individual mental health and wellbeing, and may take the form of questionnaires or symptom trackers (Child Outcomes Research Consortium, 2018).

SNs are well placed to address children and young people’s mental health issues: they are trusted, highly valued and appreciated (Forward, 2012). In numerous policy documents, SNs are identified as having an important public health leadership role, leading and coordinating delivery of the Healthy Child Programme and working with young people and school staff to promote health and wellbeing in the school setting, particularly in emotional and mental health (DH and PHE, 2014; DH, 2012). Anecdotally, emotional and mental health issues now make up a major part of the SN caseload.

Despite SNs being identified as well placed to address children and young people’s mental health, and concerns about the capacity of the existing workforce, the government’s recent push to improve mental health – Transforming children and young people’s mental health provision (Department of Health and Social Care and Department for Education, 2018) – fails to identify a role for SNs. This is hard to comprehend when they are frequently cited as bridging the gap between education and health, and the paper proposes school- and health-based interventions, creating a pathway between education and health.

The King’s Fund (2018) highlighted that PHE’s own research recommending support to prevent mental health problems includes investment in school nursing and health visiting, and early intervention through access to evidence-based support for children, young people and their families.

Measuring methods- Pros and cons  


  • Collect information quickly
  • Allow people time to think
  • Response rate may be low
  • Social desirability bias  

Individual interviews

  • In-depth information and detail provided
  • No problems with literacy
  • Time-consuming to carry out and analyse
  • Interviewer must avoid bias  

Focus groups

  • Gather a range of views quickly
  • Provide quotations
  • Not suitable for sensitive topics
  • Dominant group members may bias results  

Diaries and logs

  • Reflect behaviour and context precisely
  • Greater reliability over number of days
  • Under-reporting
  • Can be a burden to participants  

Case studies

  • Detailed accounts
  • Information from wide number of sources
  • Need to be triangulated with other sources of evidence
  • Can be superficial and anecdotal  


  • Gives direct evidence of outcomes rather than reported account
  • Can help understanding of programme delivery
  • Observer bias
  • Observation may influence behaviour of participants

PHE, 2017

Reluctant to measure?

Perhaps the lack of evidence for the effectiveness of interventions has been a contributory factor, both to falling SN numbers and to the failure to identify SNs as a viable option for improving the mental health of children and young people. Commissioning guidance, with performance and outcome measures, has been available for school nursing as part of the Healthy Child Programme since 2016 (RCN, 2017). Achievement of physical and mental health outcomes should be used by school health teams to evidence their crucial role in the government’s initiative to improving children and young people’s mental health. SNs’ reluctance to use outcome measures are linked to lack of time, reduced staffing and a lack of consistency in approach (Forward, 2012).

The SN toolkit for evaluation of behaviour change interventions (PHE, 2017) aims to support SNs in raising the standard of evaluations and is the first set of guidelines developed specifically for SNs (see Measuring methods, above). This framework, using ROM to measure individual interventions and then collating and disseminating the results, would be an excellent way for SNs to demonstrate the effectiveness of their interventions.

Measuring outcomes is linked to improving quality of care and is an important element of decision-making when planning services. SNs need to act quickly and hone their skills in using outcome measuring tools. This will enable them to provide evidence of the positive impact of their interventions, and their vital contribution to the improvement of children and young people’s health in the future.  

Erica Lloyd is senior lecturer in postgraduate healthcare and SN pathway lead on the SCPHN course at the University of Derby.

Image credit | iStock


Child Outcomes Research Consortium. (2018) Recommendations for using outcome measures. See: https://www.corc.uk.net/media/1487/corc-approach-v3.pdf (accessed 17 July 2020).

Department of Health. (2012) Getting it right for children, young people and families. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216464/dh_133352.pdf (accessed 17 July 2020).

Department of Health. (2010a) Essence of care. See: gov.uk/government/publications/essence-of-care-2010 (accessed 17 July 2020).

Department of Health. (2010b) Equality and excellence: liberating the NHS. See: gov.uk/government/publications/liberating-the-nhs-white-paper (accessed 17 July 2020). 

Department of Health and Public Health England. (2014) Maximising the school nursing team contribution to the public health of school aged children. guidance to support the commissioning of public health provision for school aged children 5-19. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/303769/Service_specifications.pdf (accessed 17 July 2020).

Department of Health and Social Care, Department for Education. (2017) Transforming children and young people’s mental health provision: a green paper. See: gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper (accessed 17 July 2020).

Forward C. (2012) Measuring the effectiveness of school nursing interventions: a review of outcome tools. British Journal of School Nursing 7(10): 490-500.

The King’s Fund. (2018) Transforming children and young people’s mental health provision – our response. See: kingsfund.org.uk/blog/2018/03/transforming-children-young-people-mental-health-provision (accessed 20 July 2020).

NHS Digital. (2020) NHS workforce statistics – March 2020. See: digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/march-2020 (accessed 17 July 2020).

Public Health England. (2017) School nurse toolkit: evaluation of behaviour change interventions. See: gov.uk/government/publications/evaluation-of-behaviour-change-interventions-school-nurse-toolkit (accessed 17 July 2020).

Royal College of Nursing. (2016) RCN school nurse survey 2016. See: https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/forums/children-and-young-people/staying-healthy-forum/rcn-survey-of-school-nurses-2016.pdf (accessed 17 July 2020).

Royal College of Nursing. (2017) The best start: the future of children’s health. RCN: London.

Turner G, Mackay S. (2015) The impact of school nurse interventions in England: behaviour change and mental health. British Journal of School Nursing 10(10): 494-506.

Waldron SM, Loades ME, Rodgers L. (2018) Routine outcome monitoring in CAMHS: how can we enable implementation in practice? Child and Adolescent Mental Health 23(4): 328-33.


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