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The role of the school nurse in special schools for pupils with severe learning difficulties
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International Journal of Nursing Studies 40 (2003) 771–779
The role of the school nurse in special schools for pupils with severe learning difficulties Gordon Moorea, Roy McConkeyb,*, Margo Duffya a
Down Lisburn Health and Social Services Trust, Disability Resource Centre, Downpatrick, UK b School of Nursing, University of Ulster, N. Ireland, UK Received 8 April 2003; accepted 1 June 2003
Abstract The work of two paediatric nurses working full-time in special schools was monitored over a full school year. Most of their time was spent on routine tasks with small numbers of pupils who required enteral feeding and suctioning. They were also responsible for administering medications to around 1 in 6 of the pupils. Both nurses had an involvement in staff training and health promotion classes; more so in one school than the other. In two similar schools which did not have a nurse, the routine tasks were done mainly by teachers or assistants with support from visiting community nurses. Health promotion formed part of the school curriculum. The presence of the nurses in schools was valued by school staff, parents and other health and social care professionals. The implications of these findings are discussed in the context of the British Government’s aspirations for school nurses to play a key role in reducing health inequalities. r 2003 Elsevier Ltd. All rights reserved. Keywords: School Nurses; Special Schools; Learning disability/difficulties
1. Introduction Children with severe learning difficulties (intellectual disabilities) often have additional physical disabilities and particular health care needs. Many more are surviving into adulthood due to advances in medical technology. In recent years there has been an expansion of nursing provision in community settings in an attempt to meet their needs as nearly all such children now live with their natural families or substitute families up to the adult years and beyond. In the main these services have been provided by specialist learning disability nurses (Department of Health, 1998). In the United Kingdom all these children are enrolled in schools; invariably special schools for pupils with severe learning difficulties. However, the school nursing *Corresponding author. School of Nursing, University of Ulster, Newtownabbey NI BT37 0QB, UK. Tel.: +44-289036889; fax: +44-2890368202. E-mail address: [email protected] (R. McConkey).
service provided by health authorities to all UK schools appears to have limited involvement with these children and their families. School nurses fulfill many different functions but with an emphasis on disease prevention through immunisation programmes and health screening, and also on health promotion. Recently, in England and Wales there is renewed emphasis on the role which school nurses can play in tackling health inequalities and in raising educational standards (Department of Health, 2001). The Department expects ‘‘the school nurse to lead teams, including nurses and other community and education workers, to assess the health needs of children and school communities, agree individual and school health plans and deliver these through multidisciplinary partnerships’’ (p. 8). Moreover, the school nurse is seen as a key link between primary care services and schools on the one hand and between schools and parents on the other. However, there are likely to be additional issues for school nursing within special schools. A previous study in Northern Ireland (McConkey and Kelly, 2001)
0020-7489/03/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0020-7489(03)00111-1
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identified a range of different nurses involved with various types of special schools; including school nurses, community learning disability nurses, health visitors, district nurses and children’s nurses. Of the 42 special schools surveyed only six had a nurse based full-time in the school and three had a part-time nurse. In all schools, the main role of the nurses was on ‘hands-on care’ for pupils with particular medical and health needs. This included enteral feeding, administering medication, wound management, e.g. dressings to pressure sores, rectal medication and suctioning. In recent years, children who have conditions associated with poor life expectancy have been surviving into adulthood mainly due to more effective medical interventions and improved quality of care. Consequently, more chronically ill and technology-dependent children such as those with trachyostomies and gastrostemies, are entering schools, particularly schools for children with severe learning difficulties (Glendinning et al., 1999; Morris, 1999). The Education Act (1995) and the Children’s Act (1989) both emphasise the rights of all young people to education and they place a responsibility on education, health and social services to ensure that no child is excluded from schooling. Nonetheless educational staff have expressed concerns about dealing with emergency procedures such as epileptic seizures or diabetic reactions and many question their own competency in performing healthcare related procedures such as enteral feeding, or in administering medications (McCarthy et al., 1996). Thus, it is likely that the role of the school nurse in special schools will need to embrace a wider range of functions than those envisaged for nurses working in mainstream schools although similar issues may arise if these schools have enrolled pupils with special educational needs (Esparet et al., 1999). The present study was undertaken as an action-based research project in which a full-time school nurse was appointed to each of two special SLD schools covered by one Health and Social Services Trust. By monitoring the nurses’ work over a period of one school year, a fuller assessment could then be made of the particular roles they had played in the pupils’ healthcare. Moreover, the reactions of school staff, parents and other health and social services professionals could be obtained in order to assess the value they placed on the nursing inputs. Finally, information was also obtained from two ‘contrast’ schools who did not have access to a school-based nurse in order to assess how they responded to their pupils’ healthcare needs. 1.1. Ethical approval Ethical approval for the research was not sought as the decision to provide the nursing service had been taken by the relevant Health and Social Services Trust in
conjunction with the Education and Library Board which managed the two schools. All the information about individual children and their families was confidential to the two nurses; all data collected about the pupils were required for their nursing care within schools and no named data would be used in the research report. The principals and teachers of the two contrast schools were fully informed about the study and again no named data was obtained about their pupils.
2. Method 2.1. Schools A full-time school nurse was appointed to two special schools for pupils with severe learning difficulties (intellectual disabilities). The nurses were registered children’s nurses and they were appointed at Grade E. Two contrast schools were chosen in other parts of Northern Ireland who did not have a full-time nurse available to them. However, both had access to specialist community nurses who visited the schools; in one school from the learning disability team and in the other school from community paediatric nursing staff. All four schools were managed by local authorities and they were co-educational. All the children attending had a statement of special educational needs. Pupils were generally grouped broadly by age but there were specialist classes for those with profound and multiple learning difficulties and for those with marked autistic spectrum disorders. Each project school had a non-teaching principal teacher and a ratio of around 8 pupils per teacher and 4.5 pupils per assistant. Hence, the adult-to-pupil ratio was 1:2.7. In addition physiotherapists, occupational therapists and speech and language therapists were based in the school on a sessional basis. Similar ratios were found in the two contrast schools. 2.2. Pupils In the four schools pupils ranged in age from 3 to 19 years. Table 1 summarises their characteristics on a range of indicators over the course of one school year. As the table shows, epilepsy was the most common condition across all four schools although it was significantly less prevalent in one of the contrast schools. Around 1 in 6 pupils required medications to be administered in schools; this included oral and rectal medications, inhalers, insulin injections and application of creams. Dressing were required in two of the schools with clinical tests, such as urine testing and recording weights or seizures, needed for pupils in all four schools. The number of children with PEG or NG feeding was
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Table 1 The number and percentages of pupils requiring the procedures listed in the four schools Procedures
Project School A (N ¼ 121)
Project School B (N ¼ 93)
Contrast School A (N ¼ 108)
Contrast School B (N ¼ 109)
Total (N ¼ 431)
Epilepsy
47 39%
29 31%
17 16%
37 34%
130 30%
Admin. of medicines
19 16%
17 18%
17 16%
21 19%
74 17%
Dressings
8 16%
5 6%
20 19%
2 2%
35 8%
Clinical tests/obs.
3 3%
8 9%
5 5%
8 7%
24 6%
PEG feeding
4 3%
1 2%
1 1%
6 6%
12 3%
Diabetes
1 1%
1 1%
4 4%
2 2%
8 2%
Catheterisation
0 0%
2 3%
3 3%
0 0%
5 1%
NG feeding
2 2%
1 2%
0 0%
1 1%
4 1%
Tracheotomy
1 1%
0 0%
2 2%
0 0%
3 1%
Statistically significant difference po0:05:
small and varied across the schools as did the number with catheters and trachyostomies. In sum, the needs of the pupils varied across the four schools; a pattern reported for other special schools in Northern Ireland (McConkey and Kelly, 2001).
3. School nurse activity A record was kept for a full school year (10 months) of all the different activities undertaken by the school nurses. These were recorded on a computer-based database used by certain HSS Trusts in N. Ireland which records the number of contacts nurses have with each pupil but not the amount of time taken on each individual task. Table 2 summarises the main activities carried out with pupils on a regular basis. Although medications accounted for the greatest number of contacts, these usually took around 15 min to administer whereas PEG feeding and suctioning took very much longer and in Project School A especially, most of the nurse’s time was devoted to this. Indeed,
Table 2 The number and percentage of contacts the school nurse had regularly with pupils in one school year Activity
Project School A
Project School B
Administering medication PEG feeding Mouthcare NG feeds Suction Catherisation Glucometer checks
1476 605 385 356 117 0 0
716 109 0 184 111 316 109
41.8% 17.1% 10.8% 10.0% 3.3% 0.0% 0.0%
32.0% 5.0% 0.0% 8.0% 5.0% 14.0% 5.0%
there were marked differences between the workload of the nurses in the two schools as Table 2 shows. The remainder of the nurses’ time was taken up with administration (an average of 1 h 24 min per day) which included completion of daily contact sheets for each pupil who received ‘hands-on’ care such as PEG feeding as well the documenting of individual health plans for each pupil and contact with families.
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Other duties of the nurses involved responding to referrals, health promotion activities and staff training. 3.1. School exclusions In each of the two project schools, a pupil was enabled to return to school on the appointment of the school nurse having been previously excluded as neither the school medical officer or the principal teacher felt that the school could safely manage their care. One pupil had cerebral palsy, epilepsy, severe visual impairment, trachyostomy and required enteral feeding via a NG tube. The other pupil had Batten’s disease; a progressive neurological condition that resulted in apnoea episodes. In addition three other pupils attended School A more frequently as they often required oxygen therapy and suctioning to maintain airway patency. 3.2. Contrast schools In the two contrast schools many of the activities noted in Table 2 were done by either assistants, teachers or the pupil’s mother. For example, in Contrast School A medications were administered mostly by the classroom assistants whereas in Contrast School B this was undertaken by teachers and/or the classroom assistants. PEG Feeding was done in Contrast School A by an assistant and the pupil’s mother whereas in Contrast School B this was done by a teacher for one pupil and by a visiting nurse for four pupils. In Contrast School A, catheterisation for three pupils was done by assistants. In sum, many of the tasks undertaken daily by nurses in the project schools were done by school staff in the contrast schools. Only very few staff in either school reported that they had received any formal training in these procedures. The principal teachers were not aware of any children who were presently excluded from attending schools because of medical conditions.
4. Referrals During the school year a record was kept of all pupils referred to the school nurse. A total of 163 referrals was made in the ten months for Project School A (154: 94% from teachers and principals; six (4%) from parents and three (2%) from the community paediatrician). Project School B had fewer referrals overall, 80 in all. Of these 74: 92% were from teachers or the principal, three (4%) from learning disability team members, two (3%) from Hospital and one (1%) from the community paediatrician. In School A the bulk of the teacher referrals were of pupils in the special needs unit (69: 43%) whereas the comparable unit in School B made only 3 referrals (4%). However, most referrals in School B were of pupils in Middle school classes (8–12 years) (30: 38%) with comparable figures for School A of 27 referrals (17% of total). Table 3 summarises the most common reasons for referral to the nurse. The most common reasons were skin conditions, such as rashes, bee stings, pressure sores, and general malaise which included high temperatures and feeling unwell. However as Table 3 shows, the nature of the referral varied across the two schools. Other reasons for referral included application of dressings, diabetes management, eye problems and nose bleeds. The nurses were able to deal with the majority of referrals within school (84% in School A and 93% in School B). However in School A for 21 instances (12% of referrals) the pupil was sent home but this happened in only four instances (3%) in School B. Four referrals were made to GPs (one in School A and three in School B) and four pupils in School A had to be taken to Accident and Emergency because of falls and to control bleeding. 4.1. Contrast schools Information was gathered from the two contrast schools as to how they dealt with the conditions that had
Table 3 The number and percentages of pupils referred by reason for referral Reason for referral
Project School A (N ¼ 180)
Skin conditions General malaise Respiratory problems First aid—cuts Pain—abdominal, headache Infestation—head lice Epilepsy management
48 29 18 9 18 8 19
Project School B (N ¼ 129) 27% 16% 10% 5% 11% 4% 11%
30 10 10 18 8 16 5
Total (N ¼ 309) 23% 8% 8% 14% 6% 12% 4%
78 39 28 27 26 24 24
25% 13% 9% 9% 8% 8% 8%
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been referred to the nurse. Skin problems, malaise, first aid and respiratory issues were dealt mainly by assistants and teachers with children being sent home as required. In the contrast schools, four and three pupils respectively had been taken to Accident and Emergency in the past year.
5. Health promotion A variety of health promotion classes were devised and presented by the nurses in the two project schools although more health promotion work was done in School B as the nurse had more time available for this. The health promotion included: three to six sessions for six female students on ‘becoming a teenager’ that dealt with personal development, menstruation and personal hygiene. Workbooks were created and kept at home as a way of involving families in reinforcing the learning. Ten weekly sessions were held for three, 16–17 years old on weight reduction, exercise and diet. The fitness suite at the local leisure centre was used for this. ‘Well Teddy’ clinics were held for pupils aged 4–8 years to improve their compliance during school medicals and on visits to GPs and dentists. These were based around play with dolls and teddies. The principal teachers of the two schools also reported that health promotion featured in the school curriculum for nearly all classes. In one of the project schools, a teacher in a senior class had developed an extensive personal relationships programme. 5.1. Contrast schools The two principal teachers reported that health promotion was covered by class teachers as part of the curriculum for most classes, with the primary focus being on hygiene and personal care.
6. Staff training In Project School B the nurse provided short training sessions to the teachers and assistants on diabetes, epilepsy, First Aid and meningitis. The nurses in both schools trained the staff working on summer activity schemes on epilepsy management. 6.1. Contrast schools The principal teachers reported that training had been provided by health visitors or community pediatric nurses on PEG feeding and catheterisation. The Clinical Medical Officer had also provided training in one school although the topic was not specified.
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7. Evaluation of the school nursing service After one full school year of operation, an evaluation of the service as undertaken by independent researchers from the University of Ulster. Reactions to the school nursing service was obtained through telephone interviews with selected parents, and by self-completion questionnaires from school staff and other health and social service professionals in contact with the two project schools. It was not feasible to obtain the reactions of the pupils due to the severity of their disabilities. 7.1. Parental views The parents of 23 pupils with whom the school nurse had most frequent contact during the school year were selected for telephone interviews and 19 were contactable (83%). Only one reported having had no contact with the nurse; eight (42%) reported weekly contact; three (16%) monthly contact and seven (37%) occasional contact. The most frequent contact was by the nurse phoning home or the parent phoning the nurse at school (N=14 parents: 74%). In six instances, the nurse visited the family home. In all 17 parents (89%) felt that the service had been beneficial to their child. One commented: I am far happier having a nurse on site with my daughter. The nurse found a urine infection that N had, which saved her from suffering pain. The process of diagnosis and treatment is simpler now. I have much more peace of mind. One parent was unsure of the benefits of the school nurse and another felt that the nurse had not provided the family with enough information concerning the child’s health and illnesses. When asked to put in order of priority their preference for increased staffing in the school, 12 parents (63%) named nurses as their first priority over more therapists (although 3 parents (16%) named these as their first priority) and more teachers and assistants (4 parents (21%) named these as their first priority). All but one of the families had to carry out various procedures for their child at home; the median was three but these ranged from one to eight. The most common were administering rectal valium (12 families); giving medicines orally (10); use of inhalers and nebulisers (9) dressing sores and wounds (7) use of oxygen and suction (7) and NG or PEG feeding (7). Similar data has been reported by Kirk (1999). Parents were invited to say if they would be happy or unhappy with different people doing these procedures. No one was unhappy with nurses doing them but four
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parents (21%) expressed unhappiness if they were to be done by teachers, assistants or therapists. 7.2. Views of school staff A self-completion questionnaire was distributed to all teachers and assistants within the two project schools (N ¼ 82) and replies were received from 70 persons (85%). The most commonly given benefits for having a school nurse were having someone available to cope with medical procedures and emergencies (49 people mentioned this: 70%); someone to give medical advice and judgments (25 mentions: 36%); they give teachers and assistants more time to do they job they are trained/ paid for (23 mentions: 33%) and it allowed the school to take a more holistic approach toward the pupils’ needs (10 mentions: 14%). When asked to put in order of priority their preference for increased staffing in the school, 50 respondents (70%) named nurses as their first priority and a further 13 (19%) as their second priority over having more therapists, teachers or assistants in the school. The school staff were also asked to indicate how willing they would be to undertake certain procedures as listed in Table 4. Respondents could indicate for each one, whether or not they did it already and if they did not do it, whether they would willing to do it if asked or if they would be unwilling. As Table 4 shows, teachers and assistants were more unwilling to undertake tasks that involve technological interventions such as PEG feeding or catheterisation but were more willing to undertake more routine procedures such as giving medications or changing dressings. There were also marked differences between the two schools with teachers and assistants in Project School A being significantly more unwilling to undertake most procedures than those in Project School B. The reasons for the differences were not clear. This data underpins the staff’s view of the need to have a nurse based in the school.
7.3. Views of other health and social services staff Nine members of the learning disability teams involved with the two schools also completed questionnaires. This included community learning disability nurses, clinical medical officers, social workers, OTs and physiotherapists. They identified the main benefits of having a school nurse as giving a specific focus for pupils with complex needs (3 mentioned this); previously excluded pupils were able to attend school with subsequent reduction on strain on the family (2 mentions); community nurses have more time for community work (2 mentions) and support to families (2 mentions). Once again, the bulk of respondents choose nurses as their first priority for increased staffing (N ¼ 6: 66%) with two others mentioning it as a second priority. 7.4. Contrast schools The principal teachers in the two contrast schools were asked to comment as to how the needs of their pupils with complex needs could be better met in the future. Both spoke of the need for a school-based nurse. For example: We need a school nurse available who is an expert on children’s needs: someone who can advise/support teaching staff, and provide home liaison. These views were also echoed by teachers and assistants; nearly all of whom mentioned the need to have a school-based nurse. Their willingness to be involved in the procedures was not ascertained formally.
8. Discussion A number of conclusions can be drawn from this study. The work of the two nurses varied across the two special schools. In School A which had more children requiring PEG or NG feeding, most of her time was
Table 4 The number and percentage of school staff unwilling to do the procedures listed Activity
Project School A (N ¼ 39)
Project School B (N ¼ 31)
Total (N ¼ 70)
Administering medication Glucometer checks Dressings Suction/oxygen Insulin injections Epilepsy–rectal valium NG feeds PEG feeding Catherisation Tracheotomy
11 16 34 34 35 36 37 37 36 35
6 14 10 19 20 19 18 20 22 26
17 30 44 53 55 55 55 57 58 61
28% 41% 87% 87% 90% 92% 95% 95% 92% 90%
19% 45% 32% 61% 65% 61% 58% 65% 71% 84%
24% 43% 63% 76% 79% 79% 79% 81% 83% 87%
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taken up with this. This school also had a higher proportion of staff who were unwilling to do these and other procedures, and this staff also made a higher proportion of referrals to the nurse; predominantly for skin complaints and general malaise in the children. In School B the nurse became more involved in health promotion activities with pupils of varying ages. This only occurred to a very limited extent in School A due to lack of time. Thus an unsurprising conclusion is that the role of the school nurse will vary according to the individual needs of pupils and that these will vary even across special schools. Indeed it is possible that changes can occur within a special school during the course of school year. For example the workload in Project School B changed on the death of a pupil who had required enteral feeding and suction. A starting point therefore, as recent Department of Health (2001) guidance suggests, is that a School Health Plan is drawn up based on individual health assessments of each pupil in the school which could then be aggregated to inform and shape appropriate service planning. The present study suggests that particular attention must be paid to the hands-on procedures that are required to be undertaken in schools with pupils who have special needs. For those pupils with particular medical needs, it has been proposed that an individual healthcare plan is drawn up (Department for Education and Employment, 1996). Although this may be done in conjunction with the multi-disciplinary team, including doctors and therapists, the school nurse is seen as the main coordinator. However, a nurse does not necessarily need to be based full-time in the school to undertake this role although he or she will need to maintain regular contact so that changes in children’s needs can be identified quickly and presuming that services can respond flexibly. These plans should also cover the management of risks and procedures for accessing medical assistance in case of emergencies. Once individual healthcare plans are formulated, the issue is then identifying the personnel who are involved in implementing the plan especially with those children who are medically frail or who are technologically dependent. When the children are at home, it is the parents who undertake all the procedures, sometimes with little training and on-going support, unless an emergency arises. By contrast, school staff appear unwilling to do these tasks although this was more evident in one of the project school than in the other. The reasons for this were hard to determine with any certainty. However, in the two contrast schools it was often teachers and assistants who undertook the procedures carried out by the school nurses in the project schools but they did this with insufficient training and support
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from health services staff and the teachers felt that this was not necessarily their role. This would appear to imply that when nurses are made more available to special schools, they are expected to undertake the procedures instead of school staff. Indeed a case could be made for nurses undertaking these routine tasks rather than training other care staff to do them. Nurse training would enable them to detect the signs and symptoms of potential deterioration in a child’s condition that can occur rapidly in some children. Moreover, nurses can provide an immediate response to medical emergencies; they are available to give advice to parents and other school staff, and they possess skills in the early detection of health needs and to instigate health promotion interventions. Nurses also provide a professional resource to back-up primary care staff and specialist disability teams. Contrariwise, there may be dangers that a school-base nurse would become professionally isolated and easily segregated from other paediatric nursing developments with most of their time spent on routine tasks. However, this is a challenge for all nursing staff irrespective of their work setting and it is incumbent on the individual and their manager to maintain and update the nurses’ skills. An argument could be made for other staff to be trained in carrying out routine tasks albeit under the supervision of a trained nurse (Marshall and Foster, 2002). Most obviously this could be a classroom or personal assistant although to date few have had training for this role nor do they have this written into their job descriptions. Ideally some form of nationally accredited training would be required, for example within the British National Vocational Qualifications (NVQ) framework, along with some form of training updates. There are also legal issues that need to be addressed in terms of liability if injury or death results from interventions made by non-medically trained personnel (Servian et al., 1998) as well as the issue as to which authority—education or health—would fund their appointment. But even if all this were to happen, the parents, school staff and other professionals consulted in this study gave greater priority to having nurses within the special school than more teachers, assistants and therapists. In the absence of clear guidance from government, local arrangements will continue to be necessary between education and health authorities. This study suggests that this will need to be done for each individual school although a broader strategic view will also be required to address issues such as joint training of educational and health staff and exploring the options of developing new forms of accredited training on a preservice as well as inservice basis. A related issue is the type of qualification and training that will best prepare nurses for working within schools.
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Paediatric nurses appear to be best qualified to meet the needs of pupils with specialised medical needs although they may not be so well equipped to take on the wider health promotion role envisaged in recent Government guidance. This too has implications for future training courses (Tommet et al., 1993). In the present study, the nurses had limited opportunity to fulfill a broader health promoting role within the wider school population. In part this was due to a lack of time, especially in one school but no coherent policy appeared to have been developed between the nurses and teachers as to the particular health gains they aimed to produce for the pupils in the school. However, in one school teachers delivered topics within the education curriculum while the nurse provided health promotion in response to parental request and individual pupil needs. Contacts with parents appeared to centre around particular incidents that had arisen in school. An overall School Health Plan would be one way of furthering this goal and this may indeed develop once the needs of particular pupils are adequately addressed and a clear statement is made about the role and functions of the nurse within a special school. 8.1. Limitations of the study The study was limited to two special schools for pupils with learning difficulties and may have limited applicability elsewhere as pupils’ needs vary and with nurses who have different expertise or remit from their managers. The project predated the aspirations for school nursing as set out in recent Departmental guidance (2001) although this approach would provide an informative contrast with the nursing roles adopted in the two special schools in this study.
More detailed information could have been obtained from the contrast schools regarding the procedures carried out by school staff and the access they had to advice and support from nurses who were not school based. This would give a clearer indication of the feasibility of using non-nursing staff to carry out routine procedures appropriately and efficiently. 8.2. Policy implications The study has highlighted the additional roles that school nurses will have to undertake with pupils who have special needs; especially those attending special schools. It has identified Registered Sick Children Nurses as being the most suited for these additional roles. These nurses would work within a community children’s nursing services but in partnership with support staff in learning disability teams. It is questionable though whether nurses are required to undertake many of the routine tasks. However, in the absence of a proactive policy to train and support other staff to undertake such tasks then it is likely that the school nurse will be expected to do them. This may deflect nurses from taking on the wider health promoting role envisaged in recent Government Guidance. Nevertheless a common policy for the deployment of nurses across all special schools is not recommended given the variation found among the needs of pupils attending the four schools in this study. Rather local arrangements will be required between education and health authorities which may be best facilitated by having a flexible personnel resource—including nurses and specially trained nursing assistants—that can be deployed as pupil’s needs change across and within schools.
Table 5 Recommendations from the study Nursing services to pupils in schools for children with severe learning difficulties should be provided by a Registered Sick Children’s Nurse within existing Disability Service provision; School Nursing Service provision or by the Community Paediatric Nursing Team as appropriate. Depending on the profile of the pupils in the school and assessment of their needs, the service may be staffed by a full-time nurse based in the school or by an appropriately qualified and skilled healthcare worker supervised by a nurse. The service must be flexible and responsive to needs. Training should be provided for education staff to raise their awareness of the healthcare needs of pupils and to build their confidence in working alongside professional nursing staff and/or healthcare workers to provide holistically for pupils. The development and implementation of individual pupil healthcare plans and protocols should be pursued to ensure that the health needs of pupils in school are met by the most appropriate agency. Healthcare plans for individual pupils should form part of the pupil’s Education Plan and be reviewed regularly in conjunction with all professionals and the child’s parents/carers.
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Schools and health services will need to work more closely together if they are to fulfill the aspirations for reducing health inequalities and promoting a healthier school population. In Northern Ireland a joint working group from the Departments of Health and Education has been set up to provide future guidance on school nursing. They are presently considering the main recommendations to emerge from this study (see Table 5).
Acknowledgements Our thanks to the Sonee Burghri for assistance with data analysis and the school staff and parents for their willingness to provide information. We acknowledge the guidance received from the project Steering Group and the work done by Brenda Murphy and Leigh Tweedie as project nurses.
References Department for Education and Employment, 1996. Supporting Pupils with Medical Needs. HMSO, London. Department of Health, 1998. Signposts for Success in Commissioning and Providing Health Services for People with Learning Disabilities. HMSO, London.
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Department of Health, 2001. School nurse practice development resource pack. Department of Health, London. Esparet, M.C., Moss, P.J., Roberts, K.A., Kerr, L., Green, A.E., 1999. Special needs children in the public schools: perceptions of school nurses and school teachers. Issues in Comparative Pediatric Nursing 22, 167–182. Glendinning, C., Kirk, S., Guiffrida, A., Lawton, D., 1999. The community-based care of technology-dependent children in the UK: definitions, numbers and costs. Research Report, NPCRDC, University of Manchester. Kirk, S., 1999. Caring for the technology-dependent children at home. British Journal of Community Nursing 4, 390–394. Marshall, D., Foster, I., 2002. Providing healthcare inputs to children in special schools. British Journal of Nursing 11 (1), 28–35. McCarthy, A.M., Williams, J.K., Eidahl, L., 1996. Children with chronic conditions: educators’ views. Journal of Pediatric Health Care 10 (6), 272–279. McConkey, R., Kelly, M., 2001. Nursing inputs into special schools in N. Ireland. International Journal of Nursing Studies 32, 395–403. Morris, J., 1999. Hurtling Into a Void: Transition to Adulthood for Young People with Complex Health and Support Needs. Pavilion Publishing, Brighton. Servian, R., Joanes, V., Lenehan, C., An Spires, S., 1998. Towards a Healthy Future. Policy Press, Bristol. Tommet, P.A., York, J.L., Tomlinson, P.S., Leonard, B.J., 1993. Graduate nurse education: developmental disabilities and special health care needs. Issues in Comparative Pediatric Nursing 16 (4), 239–258.
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The role of the school nurse in special schools for pupils with severe learning difficulties Gordon Moorea, Roy McConkeyb,*, Margo Duffya a
Down Lisburn Health and Social Services Trust, Disability Resource Centre, Downpatrick, UK b School of Nursing, University of Ulster, N. Ireland, UK Received 8 April 2003; accepted 1 June 2003
Abstract The work of two paediatric nurses working full-time in special schools was monitored over a full school year. Most of their time was spent on routine tasks with small numbers of pupils who required enteral feeding and suctioning. They were also responsible for administering medications to around 1 in 6 of the pupils. Both nurses had an involvement in staff training and health promotion classes; more so in one school than the other. In two similar schools which did not have a nurse, the routine tasks were done mainly by teachers or assistants with support from visiting community nurses. Health promotion formed part of the school curriculum. The presence of the nurses in schools was valued by school staff, parents and other health and social care professionals. The implications of these findings are discussed in the context of the British Government’s aspirations for school nurses to play a key role in reducing health inequalities. r 2003 Elsevier Ltd. All rights reserved. Keywords: School Nurses; Special Schools; Learning disability/difficulties
1. Introduction Children with severe learning difficulties (intellectual disabilities) often have additional physical disabilities and particular health care needs. Many more are surviving into adulthood due to advances in medical technology. In recent years there has been an expansion of nursing provision in community settings in an attempt to meet their needs as nearly all such children now live with their natural families or substitute families up to the adult years and beyond. In the main these services have been provided by specialist learning disability nurses (Department of Health, 1998). In the United Kingdom all these children are enrolled in schools; invariably special schools for pupils with severe learning difficulties. However, the school nursing *Corresponding author. School of Nursing, University of Ulster, Newtownabbey NI BT37 0QB, UK. Tel.: +44-289036889; fax: +44-2890368202. E-mail address: [email protected] (R. McConkey).
service provided by health authorities to all UK schools appears to have limited involvement with these children and their families. School nurses fulfill many different functions but with an emphasis on disease prevention through immunisation programmes and health screening, and also on health promotion. Recently, in England and Wales there is renewed emphasis on the role which school nurses can play in tackling health inequalities and in raising educational standards (Department of Health, 2001). The Department expects ‘‘the school nurse to lead teams, including nurses and other community and education workers, to assess the health needs of children and school communities, agree individual and school health plans and deliver these through multidisciplinary partnerships’’ (p. 8). Moreover, the school nurse is seen as a key link between primary care services and schools on the one hand and between schools and parents on the other. However, there are likely to be additional issues for school nursing within special schools. A previous study in Northern Ireland (McConkey and Kelly, 2001)
0020-7489/03/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0020-7489(03)00111-1
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identified a range of different nurses involved with various types of special schools; including school nurses, community learning disability nurses, health visitors, district nurses and children’s nurses. Of the 42 special schools surveyed only six had a nurse based full-time in the school and three had a part-time nurse. In all schools, the main role of the nurses was on ‘hands-on care’ for pupils with particular medical and health needs. This included enteral feeding, administering medication, wound management, e.g. dressings to pressure sores, rectal medication and suctioning. In recent years, children who have conditions associated with poor life expectancy have been surviving into adulthood mainly due to more effective medical interventions and improved quality of care. Consequently, more chronically ill and technology-dependent children such as those with trachyostomies and gastrostemies, are entering schools, particularly schools for children with severe learning difficulties (Glendinning et al., 1999; Morris, 1999). The Education Act (1995) and the Children’s Act (1989) both emphasise the rights of all young people to education and they place a responsibility on education, health and social services to ensure that no child is excluded from schooling. Nonetheless educational staff have expressed concerns about dealing with emergency procedures such as epileptic seizures or diabetic reactions and many question their own competency in performing healthcare related procedures such as enteral feeding, or in administering medications (McCarthy et al., 1996). Thus, it is likely that the role of the school nurse in special schools will need to embrace a wider range of functions than those envisaged for nurses working in mainstream schools although similar issues may arise if these schools have enrolled pupils with special educational needs (Esparet et al., 1999). The present study was undertaken as an action-based research project in which a full-time school nurse was appointed to each of two special SLD schools covered by one Health and Social Services Trust. By monitoring the nurses’ work over a period of one school year, a fuller assessment could then be made of the particular roles they had played in the pupils’ healthcare. Moreover, the reactions of school staff, parents and other health and social services professionals could be obtained in order to assess the value they placed on the nursing inputs. Finally, information was also obtained from two ‘contrast’ schools who did not have access to a school-based nurse in order to assess how they responded to their pupils’ healthcare needs. 1.1. Ethical approval Ethical approval for the research was not sought as the decision to provide the nursing service had been taken by the relevant Health and Social Services Trust in
conjunction with the Education and Library Board which managed the two schools. All the information about individual children and their families was confidential to the two nurses; all data collected about the pupils were required for their nursing care within schools and no named data would be used in the research report. The principals and teachers of the two contrast schools were fully informed about the study and again no named data was obtained about their pupils.
2. Method 2.1. Schools A full-time school nurse was appointed to two special schools for pupils with severe learning difficulties (intellectual disabilities). The nurses were registered children’s nurses and they were appointed at Grade E. Two contrast schools were chosen in other parts of Northern Ireland who did not have a full-time nurse available to them. However, both had access to specialist community nurses who visited the schools; in one school from the learning disability team and in the other school from community paediatric nursing staff. All four schools were managed by local authorities and they were co-educational. All the children attending had a statement of special educational needs. Pupils were generally grouped broadly by age but there were specialist classes for those with profound and multiple learning difficulties and for those with marked autistic spectrum disorders. Each project school had a non-teaching principal teacher and a ratio of around 8 pupils per teacher and 4.5 pupils per assistant. Hence, the adult-to-pupil ratio was 1:2.7. In addition physiotherapists, occupational therapists and speech and language therapists were based in the school on a sessional basis. Similar ratios were found in the two contrast schools. 2.2. Pupils In the four schools pupils ranged in age from 3 to 19 years. Table 1 summarises their characteristics on a range of indicators over the course of one school year. As the table shows, epilepsy was the most common condition across all four schools although it was significantly less prevalent in one of the contrast schools. Around 1 in 6 pupils required medications to be administered in schools; this included oral and rectal medications, inhalers, insulin injections and application of creams. Dressing were required in two of the schools with clinical tests, such as urine testing and recording weights or seizures, needed for pupils in all four schools. The number of children with PEG or NG feeding was
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Table 1 The number and percentages of pupils requiring the procedures listed in the four schools Procedures
Project School A (N ¼ 121)
Project School B (N ¼ 93)
Contrast School A (N ¼ 108)
Contrast School B (N ¼ 109)
Total (N ¼ 431)
Epilepsy
47 39%
29 31%
17 16%
37 34%
130 30%
Admin. of medicines
19 16%
17 18%
17 16%
21 19%
74 17%
Dressings
8 16%
5 6%
20 19%
2 2%
35 8%
Clinical tests/obs.
3 3%
8 9%
5 5%
8 7%
24 6%
PEG feeding
4 3%
1 2%
1 1%
6 6%
12 3%
Diabetes
1 1%
1 1%
4 4%
2 2%
8 2%
Catheterisation
0 0%
2 3%
3 3%
0 0%
5 1%
NG feeding
2 2%
1 2%
0 0%
1 1%
4 1%
Tracheotomy
1 1%
0 0%
2 2%
0 0%
3 1%
Statistically significant difference po0:05:
small and varied across the schools as did the number with catheters and trachyostomies. In sum, the needs of the pupils varied across the four schools; a pattern reported for other special schools in Northern Ireland (McConkey and Kelly, 2001).
3. School nurse activity A record was kept for a full school year (10 months) of all the different activities undertaken by the school nurses. These were recorded on a computer-based database used by certain HSS Trusts in N. Ireland which records the number of contacts nurses have with each pupil but not the amount of time taken on each individual task. Table 2 summarises the main activities carried out with pupils on a regular basis. Although medications accounted for the greatest number of contacts, these usually took around 15 min to administer whereas PEG feeding and suctioning took very much longer and in Project School A especially, most of the nurse’s time was devoted to this. Indeed,
Table 2 The number and percentage of contacts the school nurse had regularly with pupils in one school year Activity
Project School A
Project School B
Administering medication PEG feeding Mouthcare NG feeds Suction Catherisation Glucometer checks
1476 605 385 356 117 0 0
716 109 0 184 111 316 109
41.8% 17.1% 10.8% 10.0% 3.3% 0.0% 0.0%
32.0% 5.0% 0.0% 8.0% 5.0% 14.0% 5.0%
there were marked differences between the workload of the nurses in the two schools as Table 2 shows. The remainder of the nurses’ time was taken up with administration (an average of 1 h 24 min per day) which included completion of daily contact sheets for each pupil who received ‘hands-on’ care such as PEG feeding as well the documenting of individual health plans for each pupil and contact with families.
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Other duties of the nurses involved responding to referrals, health promotion activities and staff training. 3.1. School exclusions In each of the two project schools, a pupil was enabled to return to school on the appointment of the school nurse having been previously excluded as neither the school medical officer or the principal teacher felt that the school could safely manage their care. One pupil had cerebral palsy, epilepsy, severe visual impairment, trachyostomy and required enteral feeding via a NG tube. The other pupil had Batten’s disease; a progressive neurological condition that resulted in apnoea episodes. In addition three other pupils attended School A more frequently as they often required oxygen therapy and suctioning to maintain airway patency. 3.2. Contrast schools In the two contrast schools many of the activities noted in Table 2 were done by either assistants, teachers or the pupil’s mother. For example, in Contrast School A medications were administered mostly by the classroom assistants whereas in Contrast School B this was undertaken by teachers and/or the classroom assistants. PEG Feeding was done in Contrast School A by an assistant and the pupil’s mother whereas in Contrast School B this was done by a teacher for one pupil and by a visiting nurse for four pupils. In Contrast School A, catheterisation for three pupils was done by assistants. In sum, many of the tasks undertaken daily by nurses in the project schools were done by school staff in the contrast schools. Only very few staff in either school reported that they had received any formal training in these procedures. The principal teachers were not aware of any children who were presently excluded from attending schools because of medical conditions.
4. Referrals During the school year a record was kept of all pupils referred to the school nurse. A total of 163 referrals was made in the ten months for Project School A (154: 94% from teachers and principals; six (4%) from parents and three (2%) from the community paediatrician). Project School B had fewer referrals overall, 80 in all. Of these 74: 92% were from teachers or the principal, three (4%) from learning disability team members, two (3%) from Hospital and one (1%) from the community paediatrician. In School A the bulk of the teacher referrals were of pupils in the special needs unit (69: 43%) whereas the comparable unit in School B made only 3 referrals (4%). However, most referrals in School B were of pupils in Middle school classes (8–12 years) (30: 38%) with comparable figures for School A of 27 referrals (17% of total). Table 3 summarises the most common reasons for referral to the nurse. The most common reasons were skin conditions, such as rashes, bee stings, pressure sores, and general malaise which included high temperatures and feeling unwell. However as Table 3 shows, the nature of the referral varied across the two schools. Other reasons for referral included application of dressings, diabetes management, eye problems and nose bleeds. The nurses were able to deal with the majority of referrals within school (84% in School A and 93% in School B). However in School A for 21 instances (12% of referrals) the pupil was sent home but this happened in only four instances (3%) in School B. Four referrals were made to GPs (one in School A and three in School B) and four pupils in School A had to be taken to Accident and Emergency because of falls and to control bleeding. 4.1. Contrast schools Information was gathered from the two contrast schools as to how they dealt with the conditions that had
Table 3 The number and percentages of pupils referred by reason for referral Reason for referral
Project School A (N ¼ 180)
Skin conditions General malaise Respiratory problems First aid—cuts Pain—abdominal, headache Infestation—head lice Epilepsy management
48 29 18 9 18 8 19
Project School B (N ¼ 129) 27% 16% 10% 5% 11% 4% 11%
30 10 10 18 8 16 5
Total (N ¼ 309) 23% 8% 8% 14% 6% 12% 4%
78 39 28 27 26 24 24
25% 13% 9% 9% 8% 8% 8%
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been referred to the nurse. Skin problems, malaise, first aid and respiratory issues were dealt mainly by assistants and teachers with children being sent home as required. In the contrast schools, four and three pupils respectively had been taken to Accident and Emergency in the past year.
5. Health promotion A variety of health promotion classes were devised and presented by the nurses in the two project schools although more health promotion work was done in School B as the nurse had more time available for this. The health promotion included: three to six sessions for six female students on ‘becoming a teenager’ that dealt with personal development, menstruation and personal hygiene. Workbooks were created and kept at home as a way of involving families in reinforcing the learning. Ten weekly sessions were held for three, 16–17 years old on weight reduction, exercise and diet. The fitness suite at the local leisure centre was used for this. ‘Well Teddy’ clinics were held for pupils aged 4–8 years to improve their compliance during school medicals and on visits to GPs and dentists. These were based around play with dolls and teddies. The principal teachers of the two schools also reported that health promotion featured in the school curriculum for nearly all classes. In one of the project schools, a teacher in a senior class had developed an extensive personal relationships programme. 5.1. Contrast schools The two principal teachers reported that health promotion was covered by class teachers as part of the curriculum for most classes, with the primary focus being on hygiene and personal care.
6. Staff training In Project School B the nurse provided short training sessions to the teachers and assistants on diabetes, epilepsy, First Aid and meningitis. The nurses in both schools trained the staff working on summer activity schemes on epilepsy management. 6.1. Contrast schools The principal teachers reported that training had been provided by health visitors or community pediatric nurses on PEG feeding and catheterisation. The Clinical Medical Officer had also provided training in one school although the topic was not specified.
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7. Evaluation of the school nursing service After one full school year of operation, an evaluation of the service as undertaken by independent researchers from the University of Ulster. Reactions to the school nursing service was obtained through telephone interviews with selected parents, and by self-completion questionnaires from school staff and other health and social service professionals in contact with the two project schools. It was not feasible to obtain the reactions of the pupils due to the severity of their disabilities. 7.1. Parental views The parents of 23 pupils with whom the school nurse had most frequent contact during the school year were selected for telephone interviews and 19 were contactable (83%). Only one reported having had no contact with the nurse; eight (42%) reported weekly contact; three (16%) monthly contact and seven (37%) occasional contact. The most frequent contact was by the nurse phoning home or the parent phoning the nurse at school (N=14 parents: 74%). In six instances, the nurse visited the family home. In all 17 parents (89%) felt that the service had been beneficial to their child. One commented: I am far happier having a nurse on site with my daughter. The nurse found a urine infection that N had, which saved her from suffering pain. The process of diagnosis and treatment is simpler now. I have much more peace of mind. One parent was unsure of the benefits of the school nurse and another felt that the nurse had not provided the family with enough information concerning the child’s health and illnesses. When asked to put in order of priority their preference for increased staffing in the school, 12 parents (63%) named nurses as their first priority over more therapists (although 3 parents (16%) named these as their first priority) and more teachers and assistants (4 parents (21%) named these as their first priority). All but one of the families had to carry out various procedures for their child at home; the median was three but these ranged from one to eight. The most common were administering rectal valium (12 families); giving medicines orally (10); use of inhalers and nebulisers (9) dressing sores and wounds (7) use of oxygen and suction (7) and NG or PEG feeding (7). Similar data has been reported by Kirk (1999). Parents were invited to say if they would be happy or unhappy with different people doing these procedures. No one was unhappy with nurses doing them but four
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parents (21%) expressed unhappiness if they were to be done by teachers, assistants or therapists. 7.2. Views of school staff A self-completion questionnaire was distributed to all teachers and assistants within the two project schools (N ¼ 82) and replies were received from 70 persons (85%). The most commonly given benefits for having a school nurse were having someone available to cope with medical procedures and emergencies (49 people mentioned this: 70%); someone to give medical advice and judgments (25 mentions: 36%); they give teachers and assistants more time to do they job they are trained/ paid for (23 mentions: 33%) and it allowed the school to take a more holistic approach toward the pupils’ needs (10 mentions: 14%). When asked to put in order of priority their preference for increased staffing in the school, 50 respondents (70%) named nurses as their first priority and a further 13 (19%) as their second priority over having more therapists, teachers or assistants in the school. The school staff were also asked to indicate how willing they would be to undertake certain procedures as listed in Table 4. Respondents could indicate for each one, whether or not they did it already and if they did not do it, whether they would willing to do it if asked or if they would be unwilling. As Table 4 shows, teachers and assistants were more unwilling to undertake tasks that involve technological interventions such as PEG feeding or catheterisation but were more willing to undertake more routine procedures such as giving medications or changing dressings. There were also marked differences between the two schools with teachers and assistants in Project School A being significantly more unwilling to undertake most procedures than those in Project School B. The reasons for the differences were not clear. This data underpins the staff’s view of the need to have a nurse based in the school.
7.3. Views of other health and social services staff Nine members of the learning disability teams involved with the two schools also completed questionnaires. This included community learning disability nurses, clinical medical officers, social workers, OTs and physiotherapists. They identified the main benefits of having a school nurse as giving a specific focus for pupils with complex needs (3 mentioned this); previously excluded pupils were able to attend school with subsequent reduction on strain on the family (2 mentions); community nurses have more time for community work (2 mentions) and support to families (2 mentions). Once again, the bulk of respondents choose nurses as their first priority for increased staffing (N ¼ 6: 66%) with two others mentioning it as a second priority. 7.4. Contrast schools The principal teachers in the two contrast schools were asked to comment as to how the needs of their pupils with complex needs could be better met in the future. Both spoke of the need for a school-based nurse. For example: We need a school nurse available who is an expert on children’s needs: someone who can advise/support teaching staff, and provide home liaison. These views were also echoed by teachers and assistants; nearly all of whom mentioned the need to have a school-based nurse. Their willingness to be involved in the procedures was not ascertained formally.
8. Discussion A number of conclusions can be drawn from this study. The work of the two nurses varied across the two special schools. In School A which had more children requiring PEG or NG feeding, most of her time was
Table 4 The number and percentage of school staff unwilling to do the procedures listed Activity
Project School A (N ¼ 39)
Project School B (N ¼ 31)
Total (N ¼ 70)
Administering medication Glucometer checks Dressings Suction/oxygen Insulin injections Epilepsy–rectal valium NG feeds PEG feeding Catherisation Tracheotomy
11 16 34 34 35 36 37 37 36 35
6 14 10 19 20 19 18 20 22 26
17 30 44 53 55 55 55 57 58 61
28% 41% 87% 87% 90% 92% 95% 95% 92% 90%
19% 45% 32% 61% 65% 61% 58% 65% 71% 84%
24% 43% 63% 76% 79% 79% 79% 81% 83% 87%
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taken up with this. This school also had a higher proportion of staff who were unwilling to do these and other procedures, and this staff also made a higher proportion of referrals to the nurse; predominantly for skin complaints and general malaise in the children. In School B the nurse became more involved in health promotion activities with pupils of varying ages. This only occurred to a very limited extent in School A due to lack of time. Thus an unsurprising conclusion is that the role of the school nurse will vary according to the individual needs of pupils and that these will vary even across special schools. Indeed it is possible that changes can occur within a special school during the course of school year. For example the workload in Project School B changed on the death of a pupil who had required enteral feeding and suction. A starting point therefore, as recent Department of Health (2001) guidance suggests, is that a School Health Plan is drawn up based on individual health assessments of each pupil in the school which could then be aggregated to inform and shape appropriate service planning. The present study suggests that particular attention must be paid to the hands-on procedures that are required to be undertaken in schools with pupils who have special needs. For those pupils with particular medical needs, it has been proposed that an individual healthcare plan is drawn up (Department for Education and Employment, 1996). Although this may be done in conjunction with the multi-disciplinary team, including doctors and therapists, the school nurse is seen as the main coordinator. However, a nurse does not necessarily need to be based full-time in the school to undertake this role although he or she will need to maintain regular contact so that changes in children’s needs can be identified quickly and presuming that services can respond flexibly. These plans should also cover the management of risks and procedures for accessing medical assistance in case of emergencies. Once individual healthcare plans are formulated, the issue is then identifying the personnel who are involved in implementing the plan especially with those children who are medically frail or who are technologically dependent. When the children are at home, it is the parents who undertake all the procedures, sometimes with little training and on-going support, unless an emergency arises. By contrast, school staff appear unwilling to do these tasks although this was more evident in one of the project school than in the other. The reasons for this were hard to determine with any certainty. However, in the two contrast schools it was often teachers and assistants who undertook the procedures carried out by the school nurses in the project schools but they did this with insufficient training and support
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from health services staff and the teachers felt that this was not necessarily their role. This would appear to imply that when nurses are made more available to special schools, they are expected to undertake the procedures instead of school staff. Indeed a case could be made for nurses undertaking these routine tasks rather than training other care staff to do them. Nurse training would enable them to detect the signs and symptoms of potential deterioration in a child’s condition that can occur rapidly in some children. Moreover, nurses can provide an immediate response to medical emergencies; they are available to give advice to parents and other school staff, and they possess skills in the early detection of health needs and to instigate health promotion interventions. Nurses also provide a professional resource to back-up primary care staff and specialist disability teams. Contrariwise, there may be dangers that a school-base nurse would become professionally isolated and easily segregated from other paediatric nursing developments with most of their time spent on routine tasks. However, this is a challenge for all nursing staff irrespective of their work setting and it is incumbent on the individual and their manager to maintain and update the nurses’ skills. An argument could be made for other staff to be trained in carrying out routine tasks albeit under the supervision of a trained nurse (Marshall and Foster, 2002). Most obviously this could be a classroom or personal assistant although to date few have had training for this role nor do they have this written into their job descriptions. Ideally some form of nationally accredited training would be required, for example within the British National Vocational Qualifications (NVQ) framework, along with some form of training updates. There are also legal issues that need to be addressed in terms of liability if injury or death results from interventions made by non-medically trained personnel (Servian et al., 1998) as well as the issue as to which authority—education or health—would fund their appointment. But even if all this were to happen, the parents, school staff and other professionals consulted in this study gave greater priority to having nurses within the special school than more teachers, assistants and therapists. In the absence of clear guidance from government, local arrangements will continue to be necessary between education and health authorities. This study suggests that this will need to be done for each individual school although a broader strategic view will also be required to address issues such as joint training of educational and health staff and exploring the options of developing new forms of accredited training on a preservice as well as inservice basis. A related issue is the type of qualification and training that will best prepare nurses for working within schools.
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Paediatric nurses appear to be best qualified to meet the needs of pupils with specialised medical needs although they may not be so well equipped to take on the wider health promotion role envisaged in recent Government guidance. This too has implications for future training courses (Tommet et al., 1993). In the present study, the nurses had limited opportunity to fulfill a broader health promoting role within the wider school population. In part this was due to a lack of time, especially in one school but no coherent policy appeared to have been developed between the nurses and teachers as to the particular health gains they aimed to produce for the pupils in the school. However, in one school teachers delivered topics within the education curriculum while the nurse provided health promotion in response to parental request and individual pupil needs. Contacts with parents appeared to centre around particular incidents that had arisen in school. An overall School Health Plan would be one way of furthering this goal and this may indeed develop once the needs of particular pupils are adequately addressed and a clear statement is made about the role and functions of the nurse within a special school. 8.1. Limitations of the study The study was limited to two special schools for pupils with learning difficulties and may have limited applicability elsewhere as pupils’ needs vary and with nurses who have different expertise or remit from their managers. The project predated the aspirations for school nursing as set out in recent Departmental guidance (2001) although this approach would provide an informative contrast with the nursing roles adopted in the two special schools in this study.
More detailed information could have been obtained from the contrast schools regarding the procedures carried out by school staff and the access they had to advice and support from nurses who were not school based. This would give a clearer indication of the feasibility of using non-nursing staff to carry out routine procedures appropriately and efficiently. 8.2. Policy implications The study has highlighted the additional roles that school nurses will have to undertake with pupils who have special needs; especially those attending special schools. It has identified Registered Sick Children Nurses as being the most suited for these additional roles. These nurses would work within a community children’s nursing services but in partnership with support staff in learning disability teams. It is questionable though whether nurses are required to undertake many of the routine tasks. However, in the absence of a proactive policy to train and support other staff to undertake such tasks then it is likely that the school nurse will be expected to do them. This may deflect nurses from taking on the wider health promoting role envisaged in recent Government Guidance. Nevertheless a common policy for the deployment of nurses across all special schools is not recommended given the variation found among the needs of pupils attending the four schools in this study. Rather local arrangements will be required between education and health authorities which may be best facilitated by having a flexible personnel resource—including nurses and specially trained nursing assistants—that can be deployed as pupil’s needs change across and within schools.
Table 5 Recommendations from the study Nursing services to pupils in schools for children with severe learning difficulties should be provided by a Registered Sick Children’s Nurse within existing Disability Service provision; School Nursing Service provision or by the Community Paediatric Nursing Team as appropriate. Depending on the profile of the pupils in the school and assessment of their needs, the service may be staffed by a full-time nurse based in the school or by an appropriately qualified and skilled healthcare worker supervised by a nurse. The service must be flexible and responsive to needs. Training should be provided for education staff to raise their awareness of the healthcare needs of pupils and to build their confidence in working alongside professional nursing staff and/or healthcare workers to provide holistically for pupils. The development and implementation of individual pupil healthcare plans and protocols should be pursued to ensure that the health needs of pupils in school are met by the most appropriate agency. Healthcare plans for individual pupils should form part of the pupil’s Education Plan and be reviewed regularly in conjunction with all professionals and the child’s parents/carers.
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Schools and health services will need to work more closely together if they are to fulfill the aspirations for reducing health inequalities and promoting a healthier school population. In Northern Ireland a joint working group from the Departments of Health and Education has been set up to provide future guidance on school nursing. They are presently considering the main recommendations to emerge from this study (see Table 5).
Acknowledgements Our thanks to the Sonee Burghri for assistance with data analysis and the school staff and parents for their willingness to provide information. We acknowledge the guidance received from the project Steering Group and the work done by Brenda Murphy and Leigh Tweedie as project nurses.
References Department for Education and Employment, 1996. Supporting Pupils with Medical Needs. HMSO, London. Department of Health, 1998. Signposts for Success in Commissioning and Providing Health Services for People with Learning Disabilities. HMSO, London.
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Department of Health, 2001. School nurse practice development resource pack. Department of Health, London. Esparet, M.C., Moss, P.J., Roberts, K.A., Kerr, L., Green, A.E., 1999. Special needs children in the public schools: perceptions of school nurses and school teachers. Issues in Comparative Pediatric Nursing 22, 167–182. Glendinning, C., Kirk, S., Guiffrida, A., Lawton, D., 1999. The community-based care of technology-dependent children in the UK: definitions, numbers and costs. Research Report, NPCRDC, University of Manchester. Kirk, S., 1999. Caring for the technology-dependent children at home. British Journal of Community Nursing 4, 390–394. Marshall, D., Foster, I., 2002. Providing healthcare inputs to children in special schools. British Journal of Nursing 11 (1), 28–35. McCarthy, A.M., Williams, J.K., Eidahl, L., 1996. Children with chronic conditions: educators’ views. Journal of Pediatric Health Care 10 (6), 272–279. McConkey, R., Kelly, M., 2001. Nursing inputs into special schools in N. Ireland. International Journal of Nursing Studies 32, 395–403. Morris, J., 1999. Hurtling Into a Void: Transition to Adulthood for Young People with Complex Health and Support Needs. Pavilion Publishing, Brighton. Servian, R., Joanes, V., Lenehan, C., An Spires, S., 1998. Towards a Healthy Future. Policy Press, Bristol. Tommet, P.A., York, J.L., Tomlinson, P.S., Leonard, B.J., 1993. Graduate nurse education: developmental disabilities and special health care needs. Issues in Comparative Pediatric Nursing 16 (4), 239–258.