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A class of their own

Mounting calls for community health nurses to be employed in all schools, coupled with the development of national professional standards, may finally harness their potential in the community, writes Mardi Chapman.

They are independent practitioners who see a wide range of primary healthcare concerns but school nurses are among the most fragmented and under-recognised groups within the nursing profession.

Labour force statistics show school nurses are a very small proportion of the nursing workforce - less than 1 per cent of all nurses working in public and private settings, according to 2008 Australian Institute of Health and Welfare data.

Their political clout is on a par with their size and they suffered a significant professional snub when excluded from the new national Nurses Award 2010 - an occupational award based on the premise that nursing is nursing, regardless of the work setting. Under the industrial changes, 150 nursing awards across Australia were rolled into a single national nursing award.

The good news for school nurses is that their clients value them to the point that some parent associations have called for an expansion of school nurse programs.

The Western Australian Council of State School Organisations has recently amended their health and safety policy to state that; "students at all existing and new schools in Western Australia should have access to a Health Service that is staffed by a Community Health Nurse on a full-time basis."

They will be asking the WA Premier, Minister for Education and Minister for Health to support and fund their request.

School nurse programs differ significantly between primary and secondary schools, the public and private sector, and between states.

State primary schools including those in WA, Queensland and Victoria typically have visiting nurses from child and family health services responsible for screening and health assessments. State secondary schools are more likely to have school-based youth health nurses with a focus on health promotion.

Many private schools around the country employ school-based nurses whose main priority is the management of acute conditions, including headaches, injuries, coughs and colds.

Research published by the NSW Centre for the Advancement of Adolescent Health and the School Nurses Association of NSW in 2008 found school nurses spent 57 per cent of their time in clinical activities.

About 13 per cent of their time was attributed to health counselling and 7 per cent to health promotion. Smaller amounts of time were spent on clinic management, policy and community development, resources and referrals.

Sue Peterie, president of the School Nurse Association of NSW, agreed that her day at a K-12 independent school is about 60 per cent clinical.

However she suggested the counselling load has increased to about 30 per cent of her time.

"The degree of stress is quite surprising in young people. There is pressure around academic performance, peer pressure in the classroom, problems with self-image and acceptance, and then some of those issues go home with cyber bullying for example."

The school also has a counsellor but she says the school nurse is perceived as an additional resource for "privacy, a talk and a cry".

Peterie worked as a general practice nurse before moving to school nursing and said the environments are similar although she misses the collegial support in a practice setting.

"Here I am totally autonomous. I rely on my own skills and knowledge. Personally I would love another nurse colleague to discuss issues with but I don't have that luxury."

Jenny Giudice, president of the Independent School Nurses Association of Western Australia, agreed that the biggest change from other areas of nursing is that school nurses are more independent.

"While school nurses also work closely with health and safety committees, pastoral care teams and others to best support children, ultimately if you are working by yourself it can be pretty tough."

Her association provides school nurses with a professional network, study days and guest speakers at regular meetings.

Suzanne Hood manages the health centre at Anglican Church Grammar School, a large Brisbane boarding school where a team of eight nurses provide 24 hour cover for everything from skateboard injuries to the management of chronic diseases such as diabetes or asthma.

They see an average of 50-60 students each day and an eight-bed facility is available for those who require greater care.

"It's a busy environment where we are assessing, stabilising, treating and referring students as required. There is some interesting medicine that comes through."

"There is certainly a place for the school nurse and the community has that expectation now that their children will be looked after."

Her team have also introduced health promotion sessions for students which reflect the range of conditions seen in the centre.

"We might talk about preventing ingrown toenails during the rugby season or run general hygiene sessions during the flu season," she said.

Hood is alert to professional development opportunities for her team and they have recently joined the local division of general practice to upskill in mental health first aid.

Her own background was in primary healthcare with the Royal Flying Doctor Service but she said many school nurses come from hospital settings with experience in relevant disciplines such as paediatrics.

"Most have an interest in primary healthcare, they like to work independently and they love children. It's a pleasant work environment and some of the nurses say it's the best job in the world."

In an effort to improve awareness of the role of the school nurse and to reinforce the professionalism they bring to their varied positions, the Victorian School Nurses developed their School Nursing Professional Practice Standards (2009).

The standards are currently being revised and developed into a national document, according to Julianne Bryce, senior federal professional officer at the ANF.

"There is a huge potential role for nurses in early intervention and the prevention of illness and injury. The development of national professional practice standards will lead to a shared understanding of what that role can be."

"Certainly we believe it is an incredibly important role - one of a number of nursing roles within primary health care."

Gina Harrex, past president of Victorian School Nurses, said the standards were developed to be broad and flexible in recognition of the different needs within different schools.

"Many people don't know what we do because there is a lack of consistency across the board."

She said pay rates differ and school nurses are often employed as educational support officers rather than as health professionals.

Considering that the job includes medication management, helping a child requiring intermittent catheterisation, or picking up the early warning signs of anorexia, a professional wage seems reasonable, Harrex said.

A 2010 survey of Queensland primary school nurses found most have multiple, post-basic training qualifications including midwifery, child health, mental health, and endorsed for immunisations.

"Schools who are employing registered nurses benefit from our knowledge of disease and underlying psychosocial issues," Harrex said.

"We have the ability to encourage healthy behaviours and when necessary to administer the right treatment or refer to other services so that children are back at school at the earliest opportunity."

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