School nursing

School nurses deliver both universal and targeted services and work across education and health, providing a link between school, home and the community.

Qualified school nurses will have undertaken a post-registration SCPHN qualification. They are also responsible for delivering programmes to improve health outcomes for school aged children and young people (5-19 years). This includes reducing childhood obesity, under 18 conception rates, prevalence of chlamydia, and supporting mental health. The school nurse team includes a range of staff, including other registered nurses and health care support workers.

A recent survey of school nurses and health visitors by the RCN highlighted the following top priorities:

• safeguarding and child protection 
• child and adolescent mental health 
• emotional resilience; wellbeing 
• domestic abuse 
• breast feeding.

In 2013 local authorities in England became responsible for commissioning school nursing services. The Department of Health and Public Health England have produced guidance and service specifications to support local authority commissioners, see: 

• Department of Health (2012) Getting it right for children, young people and families: health services
• Department of Health (2014) Maximising the school nursing team contribution to the public health of school-aged children
• Department of Health and Social Care (2014) School nursing: public health services. Guidance for putting in place public health services for children and young people from 5 to 19 years
• Public Health England (2018) Healthy child programme 0 to 19: health visitor and school nurse commissioning.

There have however been increasing concerns regarding the decrease in school nurses since that time, along with the impact of cuts to public health funding, see: The best start: The future of children's health (RCN, 2017) and The best start: The future of children’s health - One year on. Valuing school nurses and health visitors in England (RCN, 2018).

In Northern Ireland the important contribution of school nurses was acknowledged as part of a major review in 2015. See:

Department of Health NI. Healthy Futures 2010-2015 - The contribution of health visitors and school nurses in Northern Ireland (2015) 

In Scotland a review has led to the development of clear priorities and pathways, see:

• Scottish Government. Specialist school nursing: priority areas and pathways (2018)
• Scottish Government. The school nursing role in integrated community nursing teams (2018)

While in Wales, the school nursing framework has also included a focus on those children with medical needs, see:

• Welsh Government. School nursing framework for Wales (2017)
• Welsh Government. Supporting learners with healthcare needs (2017)
• Welsh Government. A School Nursing Framework for Wales - part 2 Nursing in Special Schools (2018)
• Welsh Assembly Government. Access to education and support for children and young people with medical needs (2010)

School nurses in independent and private boarding schools 

A nurse employed directly by a school or college leads, respond to, and influences the health agenda for the school environment, working directly alongside head teachers, teachers, governors, and parents to promote the health and wellbeing of the pupils.

Residential school medical facilities are inspected against national standards by the Independent Schools Inspectorate and in England for example registered with Ofsted and the Department for Education. Health facilities within schools must comply with health and safety requirements, enable confidentiality to be maintained and have access to facilities to wash hands and clean wounds where required, as well as to undress and examine a pupil if necessary while ensuring privacy and dignity at all times.

If medicines are to be administered, schools must have and implement a policy and procedures for doing so. The policy should include for example details of who is responsible for ensuring that staff are suitably trained and risk assessments for school visits, holidays and other school activities outside of the normal timetable. It is good practice for a record to be kept of all training provided and participant attendance.

Medicines administration, storage and record-keeping

Medicine (both prescription and non-prescription) must only be administered to a child under 16 where written permission for that particular medicine has been obtained from the child’s parent or carer – except in exceptional circumstances where the medicine has been prescribed to the child/young person without the knowledge of the parents. For examples of consent templates, see: Supporting pupils with medical conditions at school.

Schools should only accept prescribed medicines if they are in-date, labelled with the child’s name, provided in the original container as dispensed by a pharmacist (or dispensing doctor) and include the date of dispensing and instructions for administration, dosage and storage. For pupils from overseas, medicines should be prescribed by a UK-registered medical practitioner and dispensed accordingly. Overseas physicians may liaise with the medical officer for the school or a specialist medical practitioner to facilitate as required.

Medicines should be stored securely within the school in lockable facilities, but children should know where their medicines are; medicines and devices such as asthma inhalers and adrenaline pens should be always readily available to children and not locked away. 

A child who has been prescribed a controlled drug may legally have it in their possession if they are competent to do so. It is permissible for the school to look after a controlled drug, where it is agreed that it will be administered to the child for whom it has been prescribed. Controlled drugs should be kept in a locked non-portable container and only named staff should have access. A record should be kept for audit and safety purposes of any doses used and the amount of the controlled drug held.

For medicines that require refrigeration, an appropriate refrigerator with restricted access, should be identified and the medication should be placed in a closed, clearly labelled plastic container. This container should then be kept on a separate shelf in the fridge. It is important that medication kept in a domestic fridge is not inadvertently frozen; care should be taken to ensure this does not happen. 

Where appropriate, pupils, particularly those of secondary school age, should be allowed to be in charge of their own medication, either keeping it securely on their person or in lockable facilities. It is advisable for a risk assessment to be completed in order to minimise the potential for harm to occur. This will depend on the child’s age, maturity, parent/carer and school consent.

Schools must keep a written record each time a medicine is administered to a child stating what, how and how much was administered, when and by whom. Any side effects of the medication to be administered at school should be documented in school and reported according to the school policy and protocols.

Medication required during a school trip may be carried by the child, if this is normal practice. If not, then a trained member of staff should carry and administer the medication as necessary. A copy of any health care plans and or information on medical conditions should be taken on visits.

Home remedy protocols

Registered nurses working in independent schools or those employed directly by an educational establishment can administer a limited range of medications under a homely remedy protocol. A homely remedy is an over-the-counter (OTC) medicine that can be administered without a prescription. Homely remedies fall into two legal categories, GSL (general sales list), which are available widely or pharmacy (P) medicines which are available only from a pharmacy. They are normally given for minor ailments only and include medications such as paracetamol, emollients, oral rehydration sachets and cough medicine i.e. simple linctus.

Over the counter medicines e.g. for pain relief, should not be administered without first checking maximum dosages and when the previous dose was taken.

It is good practice for nurses working in independent schools to seek advice and support from the medical officer for the school and a local community pharmacist in developing medicines policies.

Patient group directions

Patient group directions cannot be used by nurses working in independent schools or by those employed directly by an educational establishment unless they have a contract with the health service provider in the area. See: To PGD or not to PGD? – that is the question. NICE has also produced guidance on obtaining agreement to develop a patient group direction (MPG2).

The Medicines and Healthcare Products Regulatory Agency (MHRA) has stated that: ‘PGDs do not extend to independent and public sector care homes or to those independent sector schools that provide health care entirely outside the NHS’. See: Patient Group Directions in the private, prison and police sectors.

Prescription Only Medicines (POM)

Independent school nurses are able to administer Prescription Only Medicines:

• under the direction of an independent or medical prescriber using a patient specific direction (PSD)
• where an independent school nurse is contracted by the clinical commissioning group/health board or local authority to administer vaccines as part of the national schedule and part of NHS provision. The school nurse can then adopt and sign up to the respective commissioning bodies PGDs, providing they have the appropriate skills and competence.

Certain Prescription Only Medicines are exempt under the legislation for the purpose of saving life, see: Human medicines legislation schedule 19. Parenteral adrenaline for anaphylaxis (1 mg in 1 ml), Chlorphenamine and hydrocortisone are among those substances listed.