School Nurses and Primary Health Care

Phillipa Bennetts, RN, MCNA(NZ)

The Primary Health Care Strategy has provided an opportunity for nurses to seek new ways to provide best practice to the communities in which they work. One such area is in the delivery of adolescent health care and this is particularly relevant to school nurses.

Statistics show that adolescent health care has not seen the same level of improvement in service and reduction in morbidity as other age groups within New Zealand. The Youth 2000 National Secondary Survey highlighted that access, affordability and confidentiality were critical factors to adolescents seeking health care. The survey also found that the majority of young people reported high levels of general health but it showed some youth engaging in multiple risk behaviours that impacted on their current and future well-being (Youth, 2000).

The employment of registered nurses in schools in New Zealand has occurred historically in numerous different ways and to a variety of different standards. What the Primary Health Care Strategy does is provide an opportunity to revise the way we have met the needs of our young people while at school and develop a framework to support and develop the nurses in these roles.

The Auckland School Nurses Group (ASNG) currently has around 90 members and most are employed directly by the school and paid for out of the government operational grant. Legally schools are only required to employ a first aider to deal with incidents and injury. The employment of a registered nurse usually depends on the philosophy of the board of trustees and the principal, and the degree to which they acknowledge that health impacts on academic outcomes. This has lead to wide disparities in levels of skill and also in the levels of payment to these nurses. A recent survey carried out by the ASNG showed that nurses were paid anything from $15.00 to $27.00 per hour and most are paid for only 40 weeks of the year at this hourly rate, but choose to have the amount annualised so they receive an income for 52 weeks of the year.

Because these nurses are employed through vote education rather than vote health there have been no professional links to health and to the wider discipline of nursing to ensure continued professional development, supervision and also to allow negotiation for pay parity with other nurses in the health sector. It has been the responsibility of each individual to seek professional development, a challenge for some as schools were often reluctant to release them during school hours. The ASNG has run bi annual study days to try to fill this gap and this is often the only contact that a nurse may have with another health professional.

In November 2004 the ASNG voted to align themselves with the College of Nurses Aotearoa to begin to address these issues as nurses working in schools are passionately committed to improving health care for young people, but in making this career choice find that they are not integrated into the primary health care nursing pathway and all that has been entailed in that development.

Counties Manukau District Health Board (CMDHB) had recognised the success of a joint health/education initiative called AIMHI (Achievement in Multicultural High Schools) that commenced in seven decile 1 (high deprivation) South Auckland high schools and one in Porirua in 2002. This project saw the building and development of school based health clinics and a team approach to managing risks and resiliency in youth. This was also an opportunity to address the location and environmental conditions in which school nurses worked. Many had functioned for years in small rooms with no privacy and no waiting area for students.

The increased spotlight has raised many issues including the need to develop minimum regulations when establishing school based health clinics including addressing the ratio of students to nurse. Some schools are fortunate to have two nurses on some days a week for 650 students while others are the sole practitioner for 2,300 students.

CMDHB is funding a 12 month project with three ASNG RNs working part time to review sexual health across the education services and working closely with current health providers to identify ways of improving school based health services. The project will have wider benefits as a framework will develop for standards, policy, professional development, career pathways, supervision and minimum requirements to establish school based health clinics. Subsequently such a framework could and should be used generically in schools across New Zealand.

One success of the AIMHI project was the strength and support that the nurses gained from regular meetings with colleagues. In 2004 the formation of regional clusters within ASNG were developed to provide a forum for nurses in similar decile rated or geographically located schools to share concerns, information and support to one another. These groups meet at least twice a term and can now show this as a means of documented group supervision. A similar cluster group is run in the Hutt Valley facilitated by Gill Alcorn, and the ASNG keeps in close contact with this group. Nurses in schools are keen to develop a national forum to ensure that a collective voice is heard with regard to school nurses and school health concerns. With support from the College and perhaps the Ministry of health such a forum will be facilitated in the near future.

There is a strong move away from a reactive form of nursing in schools to a proactive model. We are constantly being reminded by the media (even as recently as the front page of the New Zealand Herald, Saturday, March 19 2005) that obesity and diabetes will reduce the life expectancy of our taitamariki (young people). Registered nurses in schools are well positioned to take up the challenge to make a difference. School clinics are one way to address the issue of access that young people identified as a barrier but there is a challenge in identifying the source of funding to equip and staff them. Each school, in conjunction with their community, needs to reflect on what will work for them. Schools that are in an area managed by one PHO are positioned well to form partnerships to best manage the health of the taitamariki. With SIA funding and no concerns with “clawback” nurses employed by schools can work with the GPs to provide onsite medical consultations. PHOs have access to many other health services e.g. physiotherapist, dieticians, GPs with special interests such as sexual health or dermatology, that can meet specific health needs. PHOs also offer a link for these RNs for supervision and professional development - two things that urgently need addressing. Where nurses work in densely populated urban areas with pupils coming from many different PHOs there are challenges with regard to managing the funding of these consultations and the need to manage “clawback” that can cause resentment amongst GPs. There may be a need for DHBs to manage the funding of some school based health clinics in conjunction with schools to ensure that urban youth are treated equally.

Of those nurses currently involved with school based health clinics most firmly believe that for nursing services to succeed there is a need to belong to the school to gain the credibility and trust of both students and staff. This role is undoubtedly a partnership between health and education where it can be a win/win situation for all parties. The opportunity to build a relationship with a young person over their five years at school, and work to empower them with the knowledge and understanding they need to ensure a healthy future is a challenge many of us find exciting. With the increasing integration of students with chronic illness into main stream education there is a greater need to provide support and education at school.

Teenage years are difficult for most healthy students let alone if you are hospitalised or compromised by ill health. Teenagers will often use these years to rebel against parents who have spent tireless hours caring for them. School based health clinics can work to support students and whanau to increase the strengths/resiliencies to ensure that the students reach their potential both in health and academic ability.

“Some of New Zealand’s current preventable adult morbidity can be attributed to the behaviours that are initiated during adolescence such as substance abuse, sexual behaviours, eating and exercise” (Youth, 2000). Where better to start to address these issues that have the potential to cost the New Zealand health service millions than in the schools where most attend for five years? We have a captive audience to work collaboratively with teachers to build students with good self esteem, protective factors/resiliencies and connection with significant adults.

School based health clinics and primary health care are at an exciting time in the delivery of health services in New Zealand. Nursing educators are developing primary health care pathways for student nurses to follow. Nurses in primary health care now have a career pathway to Nurse Practitioner to support those who choose this specialty. The role of the RN in schools is an intrinsic part of this development and I hope a challenging and exciting career choice for Adolescent Nurse Specialists in the future.