All day, students have been going into room 114. Lucy, who is 15 years old, comes out equipped with breathing techniques to do at the start of her exams; 13-year-old Ed heads back to class feeling better about his skin, knowing what can cause flare-ups and which cream he needs to ease the pain; 16-year-old Mike leaves determined to quit smoking; 14-year-old Sam exits feeling validated: someone took her worries about her weight seriously.

All these students - and countless others that day - have been to see Emma, the school nurse. As well as delivering interventions to students, Emma also spends her days doing such things as administrating medication or providing mental health training to school staff. When she first started out, 10 years ago, she was one of three nurses at the school. Today, she’s the only one left - and she also works in two other schools in the local area.

This shortage of school nurse provision is a national problem and it comes at a time when this resource is arguably needed more than ever.

For example, there are the statistics for levels of obesity. In the mid 1980s, less than 2 per cent of children were obese. Today, research shows that one in 10 is obese by the time they begin primary school, while 22 per cent of boys and 18 per cent of girls are obese when they enter secondary school (Baker, 2019).

Evidence shows that obesity has an adverse effect on children’s physical health, social and emotional wellbeing, and self-esteem (Sahoo et al, 2015), while beyond the school gates, children with obesity are much more likely to be obese in adulthood, which brings an increased risk of type 2 diabetes, many types of cancer, coronary heart disease and stroke.

Children are suffering with mental health problems, too: the NHS estimated that one in eight of five- to 19-year-olds in England had at least one mental disorder when assessed in 2017, which has been exacerbated further by Covid. According to a YoungMinds survey in January 2021, 67 per cent of young people believed that the pandemic would have a long-term negative effect on their mental health.

Changing lives

Clearly, our young people need more support than ever before and yet health services are under enormous strain, so that support is incredibly difficult to find. Moreover, there is a real need for early intervention that is difficult to facilitate.

For these issues and more, school nurses should be a key part of the solution, says Sharon White, chief executive of the School and Public Health Nurses Association.

“As school nurses, we offer a confidential service to children and young people, providing they are not at any risk,” she says. “Children, young people and families tell us that our school nurses have changed their lives in terms of anxiety, depression and bedwetting, as well as behaviour, health protection and health promotion.”

There’s plenty of research to back White up. In 2015, the British School of Nursing published a paper that brought together 29 different studies into the impact of interventions by school nurses and analysed the findings. The results were immensely positive: interventions by school nurses resulted in a variety of positive outcomes for young people, and access to - and engagement with - school nurse services led to beneficial outcomes in relation to emotional health and a variety of lifestyle issues.

There was also increased engagement with other services, for example, requesting advice and support regarding sexual health, emotional health or other issues through text messaging or through clinic attendance. As well as individual engagement with school nurse services, some young people then went on to engage others, encouraging their peers to stop smoking or working as peer listeners. In addition, the studies found that young people took responsibility for their own health and were able to identify health risks.

The reach of the school nurses goes beyond students, too. While she has no specific research to rely on, White is clear that during the past 18 months, the role of the school nurse has been invaluable in offering support to staff.

“We are public health nurses: our role is around prevention and early help but, throughout the pandemic, schools have increasingly relied upon us: we’ve listened to the struggles from the school staff who have been on the front line all of the time, we’ve dealt with all of those personal issues and professional issues,” she says.

“Each and every one of us has suffered some kind of trauma because of Covid. [Nurses have been] helping school staff to understand the impact of trauma on themselves and then the wider school community.

“In the past, we were always seen as a nurse for schools but we were a nurse for the children. The role has massively advanced and the demand for that is exponential in terms of support for school staff.”

There’s no disputing the worth of a school nurse, then. But, as alluded to above, we have a problem: as childhood health declines, so does the number of school nurses. According to the Royal College of Nursing, there has been a drop of almost 30 per cent in school nurses since 2009, while the number of school-age pupils has risen by 4 per cent since 2015-16.

Nursing is a role in which people can make a tangible difference and one that can offer schools the support they really need. So, why are their numbers falling? Is it down to government funding cuts in public services? Or is it more to do with the role itself: the pay, conditions and workload?

There isn’t a straightforward answer. School nurses are public health nurses - and, since 2013, have been funded by local councils (see box, below). Cuts to local health services have undoubtedly contributed to a decline in numbers, says White.

“Our government has taken it upon itself to reduce the public health budget repeatedly, so it’s probably 35 per cent less than it was, and councils have had to make very tough decisions, and decide how they are going to use these reduced grants.

“I think children, young people and public health are very easy pickings because you can’t see the results straightaway,” she says.

“If a school nurse spends several sessions with a family, supporting behaviour management because a child isn’t coming to school, and then the child comes to school, that’s great; that’s a big tick. But, actually, when a child needs a lot of work around personal anxiety, bullying, depression - preventing them from needing access to Child and Adolescent Mental Health Services - those are things which are hard to measure in the immediate term.”

Making a tangible difference

However, funding cuts are just one part of the picture. School nursing is an ageing workforce and many chose to retire during the pandemic, says White, while others took the opportunity to move into immunisation or other healthcare teams that were crying out for staff and willing to pay more.

The very nature of the role has contributed to the issue: it has expanded beyond traditional nursing but doesn’t offer any more pay.

“Most of our time, now, is spent at the hard end of things- being reactive rather than proactive. It’s particularly unfulfilling to think: ‘this could have been prevented’. It’s driving people away because it’s so exhausting,” says White.

All this is hugely concerning, as has been recognised by the Institute for Public Policy Research (IPPR), which published a report in 2020 saying that the government needed to introduce legislation that guaranteed a ratio of one school nurse, or qualified professional, to every 600 students.

There’s evidence that this ratio works: in Finland it’s been the recommendation since 2004, and research has found that where health professionals are in a school environment, it has helped to improve wellbeing and academic performance (Fagan et al, 2017).

The IPPR says this could mean 11,500 more school nurses in the system, with training costs of £805 million and wage costs of £445 million. It’s not something that can happen overnight - and the IPPR recommends that, over the next decade, £80 million a year is invested into training schemes for school nurses.

It’s not cheap but, financially, it makes a lot of sense, says Chris Thomas, a senior research fellow at the IPPR.

“There is a very rationalist argument economically, too,” he explains. “We know that there are all kinds of consequences of having poor childhood health: they can go on to have chronic conditions in adulthood and that then impacts on employment opportunities.

“The obesity among this cohort of children threatens to cost hundreds of billions to the economy in the NHS over the course of their lifetime.”

As sensible an argument for school nurses as this seems, there’s no sign of it being heard and recognised by the government. And if that does not change, the impact on schools and young people risks being incredibly negative.

“It would be a real shame if the government and others don’t take action on school nurses,” says Thomas.

“Otherwise, when the consequences start to be felt, people start blaming the children, who have grown into adults by that point, and there’ll be an ignorance around how and why that’s happened. There will be very real consequences.”

Kate Parker is schools and colleges content producer at Tes

This article originally appeared in the 22 October 2021 issue under the headline “Tes focus on...School nurses”