EFICACIA DEL PROGRAMA

One of the major criticisms of UK school nursing practice, is the lack of empirical evidence available about the impact of the service in terms of improving health outcomes (Croghan, Johnson and Aveyard, 2004; DeBell and Tomkins, 2006; DCSF/DH, 2008; DH, 2012; Croghan, 2013). The introduction of commissioning means that health services need to provide tangible evidence of improvements in health outcomes (DH, 2010b; DH, 2013b). Some aspects are measurable, for example the number of immunisations carried out or health promotion sessions delivered (DH/PHE, 2014a). However, measuring improvements in health outcomes for young people into adulthood, which occurs over a number of years, can be much more challenging. The impact that school nurses can have on helping young people to cope with difficult situations, thereby developing resilience into adulthood is even more difficult to quantify (Voogd, 2010). Nevertheless, there are some studies that have been conducted internationally that help provide a useful perspective.

Maughan (2003) undertook a research synthesis of 15 studies across a number of countries although none were of UK origin. The studies linked the input of school nurses to some improvements in educational outcomes. Measuring educational achievement, as opposed to health outcomes, could be seen as being easier because this is measured over a shorter time period. The majority of the studies (11 out of

42 15) were of a quasi- experimental design which, although the absence of randomisation may cast doubt on a study’s internal validity (Bryman, 2008) as it is quantitative in nature, findings may be more generalisable (Streubert and Carpenter, 1999; Parahoo, 2006). Overall the synthesis demonstrated that input from the school nurse did appear to help to decrease the number of pupils who were absent from school although other factors not identified may have influenced attendance rates. By providing more intense support to vulnerable individual children their school attendance improved, anxiety attacks decreased in school, and some risk taking behaviours such as smoking and alcohol consumption were reduced (Maughan, 2003). Therefore where intense support was provided, it is likely that the school nurse did have more impact, and educational as well as health outcomes improved. In addition those who provided more advanced counselling skills benefitted children further, as they did not have to be taken out of school to attend clinic appointments with other professionals. However, this research synthesis could only identify 15 studies worldwide confirming the dearth of research in this area (Maughan, 2003).

DeSocio and Hootman (2004) also conducted a review of the literature in the USA in relation to school nursing and improved school performance. Like Maughan (2003) they too found that there was a consensus in the literature, regarding positive outcomes in the mental health of children having regular contact with the school nurse. The importance of having a trusting relationship and the provision of supportive interventions, were found to help to reduce distress and in some cases, it was suggested that it helped to prevent more advanced symptoms developing. Lohan (2006) purports that those pupils who present as being

43 emotionally distressed at school are not ready or able to learn and so they need support to reduce their anxiety levels.

Bonaiuto (2007) conducted primary research in the form of a longitudinal study over a four year period. It explored the impact of school nursing within one of the largest districts in the USA. Using specific criteria, 240 pupils were identified and followed throughout the study. Benchmarks were set at the outset such as attendance rates at school, level of academic performance and how many interactions they had with the school nurse pre and post study. Pupils were monitored regularly throughout the study period and at the end 220 were found to have made a positive improvement in at least one of the benchmarked categories. In approximately a third of the sample group, pupils’ attendance, behaviour and school performance had improved. Significantly 59% reported that as a result of having regular contact with a school nurse, the young people perceived that their quality of life had improved. It is acknowledged that different basic tools were used to predict quality of life, and therefore a more standardised tool may have produced more reliable data. The data was collected manually which was a time consuming process and may have led to errors. Collecting data electronically may increase the accuracy of the data.

By comparison Baisch, Lundeen and Murphy (2011) conducted a quasi- experimental matched control study, using only electronic methods to gather data about immunisation rates and interactions with the school nurse. This was a mixed methods study that also collected data about the school staff’s perceptions about the impact of the school nurse and satisfaction levels about the service

44 provided within a large school district within USA. There were 11 schools and an equal number of control schools were included in the study in order to provide a comparison. School nurse involvement was valued and did have some impact compared to schools with no nurse. Interestingly, unlike any of the other studies, Baisch, Lundeen and Murphy (2011) also produced a cost analysis from the findings to provide details of costs and savings that school nurses can provide, compared to education staff dealing with the same issues presented by the young people. The study reported school staff, including teachers, spent a significant amount of time dealing with health related issues when there was no school nurse present. When there was a school nurse available, the savings on average per school were estimated to be $133,000 (£79,520) per annum. As the average salary of a school nurse in the USA is around $72,450 (£43,303), it seems that there is a distinct economic advantage in having a school nurse based in each school. This was also a model proposed by the UK Department of Health (DH, 2004b) which recommended there should be a qualified school nurse leading a skill mix team for every secondary school and cluster of primary schools. However, the budget was devolved to Trusts and the money was not ring fenced to school nursing services, and so very few Trusts within England met this recommendation (UNITE, 2009). By comparison the Welsh Assembly has made a firm commitment to funding a qualified school nurse in each secondary school (Godson, 2011).

Cotton et al. (2000) did attempt to cost school nursing services in the UK, but this related more to costs relating to indices of deprivation, as opposed to a comparative view on whether they were more cost effective than another profession. Although it as established that services could reduce or delegate task

45 orientated activities, to decrease costs and reallocate services to those with greater need (Cotton et al., 2000). This may include young people living in areas of high deprivation, those with long term medical conditions, or special educational needs or where there are safeguarding issues. They suggested that school nursing services would be more beneficial, have more impact and would be valued more highly if they focused on these key areas.

Caan (2010) highly recommends that a cost benefit analysis for key school nurse interventions, such as supporting emotional health needs, should be carried out as a matter of course at a national level. It could be argued that under the new NHS arrangements, where school nursing services are being commissioned and put out to tender, that this is a crucial activity which needs to be undertaken routinely. The need to provide evidence of cost effectiveness is an issue for all school nursing services internationally (Stock et al., 2002).

There are also economic implications for school nursing services within the current changing education political landscape in the UK. Many schools are moving out of Local Authority control and obtaining Academy status (Streeting, 2010). This leads to a debate as to what level of school health service should be provided and whether Academy status schools should have to purchase all or some aspects of the school health service (Voogd, 2011a). A report by the Children and Young People’s Health Outcome Forum (Lewis and Lenehan, 2012) indicates that as Academies have freedom to devolve their resources, they could commission additional support services for their pupils. Therefore Crabtree and Davis (2009) advocate that school nurses must engage in marketing their services, whether this

46 is to commissioners or directly to schools themselves. Indeed, the national service specification for school nursing (DH/PHE, 2014) outlines four levels of service provision that can be offered in order to meet the demands of the Healthy Child Programme (DH/DCSF, 2009). Therefore, if school nurses are able to cost their services more accurately, it will enable them to market their service more effectively. Chase et al. (2010) concurs by stressing that school nurses offer a range of services to support young people; but at times they may require additional guidance and support themselves.