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A Day in the Life of a School Nurse
“I may go into school nursing when I am nearing retirement and need a quieter job”, a statement people often say to me. “How will you keep up your clinical skills as a school nurse?” is another one; or “So what do you actually do, apart from give out paracetamol and put on a plaster?”. The last is probably the most frequent question that I am asked. The one that makes me internally smile the most. If only they really knew.
The truth is that the role of the school nurse encompasses many specialities. School nurses are expected to have an abundance of knowledge; they are expected to know everything about everything. They never know what each shift will bring and what they will be expected to deal with, but they need to be prepared. To make things yet more complicated, there are no set guidelines or standards in place and, as yet, it is a role that remains largely unregulated. School nurses are in a vulnerable position and exposed to complaints and proceedings, from not just pupils and parents but indeed the wider school or medical community as a whole, when they are simply just doing their best. Medical negligence hangs over them.
Having worked as a school nurse for ten years, in this article I will look at the role of the school nurse in the independent sector, and how the nurses in its field remain exposed through lack of standards and regulation. I will look at teamwork and how it may be the safety net that, in my opinion, provides the biggest protection of all. It is the avenue that, if used well, loosens the medical negligence threat from around our necks.
The role of the school nurse
I am in a fortunate position to have worked, and still work, in a number of schools, both in permanent positions and as an agency or bank nurse. My work has primarily been, and continues to be, in co-educational independent schools for 13-18 year olds. Although it is evident that each school medical centre that I have worked in, or continue to work in, runs slightly differently, the role of the school nurse largely remains the same and they are expected to fulfil a vast array of specialities rolled into one.
The bread and butter work of a school nurse is to assess and treat illnesses (medical nurse), to assess and treat sporting injuries and head injuries (accident and emergency triage nurse), to dress wounds (tissue viability/infection control nurse), to discuss and administer emergency contraception (sexual health nurse), give vaccinations (practice nurse), take pupils bloods (phlebotomist), and to promote good health and nutrition to the pupils (nurse educator). In addition to this there are pupils with specific medical needs which need caring for; since the covid pandemic in 2020, there has been a recognised rise in childhood diabetes, having a direct knock on effect on the school nursing team who now find themselves as adding diabetic nurse to their repertoire. The asthma nurse who is required to fulfil asthma reviews on all pupils with asthma in the school. Or the increase in mental health issues in school age children, with the school nurse now fulfilling the role of mental health nurse until specific services can be accessed. This list is by no means exhaustive.
A recurring theme across independent schools is that the school nurse is, contrary to belief, not only responsible for the health and welfare of the pupils but is also available to help staff, their families and indeed anyone who knocks on the Medical Centre door. Whether this be a teacher’s five year old daughter who has a tick and is needing it removed, the member of the maintenance team who accidentally swallows the silicon sachet in his pasty at lunch, or a friend of the Headmaster’s who has a ‘funny turn’ whilst visiting the Headmaster for dinner; the school nurse, most often caring in nature, will help. The potential patient workload is huge, and far larger than the ‘852 pupils’ who may attend the school.
The school nurse never knows what will walk through the door next (and is indeed relieved if the pupil is walking; it is not uncommon to be called out to a collapsed patient) and is expected to be able to provide appropriate treatment for any eventuality.
The school nurse is the pupil’s advocate, even more so in an independent boarding school where the pupil’s parents may be out of the country and uncontactable. The boarding pupil is distinct from the day pupil, whose parent is able to collect their child at the end of the school day and take over their care. For the boarding school pupil who needs medical assistance, the responsibility of the pupil’s health falls on the shoulders of the school nurse, more often than not, twenty-four hours a day, seven days a week.
Lack of guidelines and protocols
As with all nurses, school nurses must work to uphold The Code (2018) as set out by the Nursing and Midwifery Council (NMC). The Code sets out professional standards of practice and behaviour which all nurses, midwives and nursing associates must adhere to, to practice in the United Kingdom. The NMC has also developed Standards of Proficiency (2024), which sets out skills, knowledge and attributes needed for the registered nurse to practise effectively. The school nurse must follow both The Code and Standards of Proficiency at all times.
Along with this, the Royal College of Nursing (RCN) has produced a document ‘Toolkit for school nurses’, to provide school nurses with knowledge, examples of clinical practice and resources to develop practice. The toolkit recognises that the role of the school nurse in the independent sector, however, can vary greatly and that the school nurse must “ …use evidence-based guidance from government health policy and professional organisations to promote the health and emotional wellbeing of the children in their care.”
With neither the NMC or RCN setting such clinical guidelines, there is minimal guidance on the nitty gritty, day to day, bread and butter work as described previously in this article. Yes, in England and Wales the school nurse can refer to the National Institute for Health and Care Excellence (NICE) evidence based recommendations, where relevant; they can draw on the Rugby Football Union (RFU) guidance in the case of a head injury, or where necessary even follow the Resuscitation Council’s guidelines, but for the majority of the work the independent school nurse encounters, it is up to the nursing team to develop their own protocols and use the best practice they are educated to do. They do the best they can, often drawing on advice from other independent school nurses who find themselves in a similar situation, but there are no set protocols or clinical guidelines, simply a group of nurses putting their heads together and brainstorming the best practice.
It is an oxymoron that the more serious the condition of the pupil or patient, the less exposed the school nurse may be to litigation. In the case of the 84 year old grandfather who had a severe rectal bleed when watching his grandson play cricket and was close to arrest, the 13 year old girl who accidentally ate a peanut and suffered an anaphylactic reaction, or the 13 year old boy having an acute asthma attack, the Resuscitation Council’s guidelines could be followed step by step, with the correct and successful care administered. However it is the (seemingly) less serious conditions which provide the challenges for the school nurse. For example, the medical assessment of the pupil with abdominal pain or the assessment of the pupil with an injury sustained on the sports field. There are no guidelines for assessing these conditions and the care given is subject to the individual nurses’ assessment, experience and opinion on the day. If they miss something, they may be subject to litigation. Their best on the day may not be good enough.
Unregulated
The school nurse is at yet greater risk due to limited inspection and regulation. It could easily be assumed that school health care settings are regulated to ensure healthcare standards are being upheld. Most health care settings in England (care homes, hospitals, private clinics, dentists, home based care, GP services, mental health services, hospices, emergency services – the list goes on) are subject to the Care Quality Commission (CQC) who regulate, monitor and inspect their service to ensure an expected standard of care.
It would make sense for the healthcare provision in independent schools to be monitored and regulated in a similar vein. Frustratingly, however, unless there are special educational or disability needs, the CQC omits healthcare sites in schools and the regulation falls on the responsibility of the Independent Sector Inspectorate (ISI), the body responsible for standards in the educational sector. The ISI inspection assesses the medical provision under the larger pastoral and welfare assessment; it looks at the wider view, skimming over the healthcare provisions and bypassing an opportunity to monitor and regulate care pathways, governance, staff knowledge, training days or, to put it simply, how well led the health care delivery in schools actually is.
The school nursing team is incorporated into the educational inspection, having to fit in with the teaching community rather than the healthcare community that they are so used to. Their language becomes ‘teaching’ rather than ‘healthcare’ and often they find themselves out on a limb both in terms of the school (not a teacher) and healthcare as a whole, opening them up to greater risk. How well they are integrated into the wider school team differs within schools. The more integrated team having the advantage of being able to use staff outside their direct team, namely teachers and matrons, as a valuable resource.
Teamwork
School nurses can enter the sector from a variety of backgrounds: emergency department nurses, community nurses, practice nurses, nurses who have come from big NHS hospitals, to those who have come from smaller private hospitals, those with experience in school nursing and others not. All bring a variety of experience and expertise to the role, none of which should be underestimated. Every nurse brings knowledge to the team, which another member may lack. Knowledge which can be tapped in to. This is why teamwork is so important.
The independent school nurse usually also works alongside doctors and physiotherapists as part of the wider health care team. Although the structure differs between schools, it is common for a GP practice to be affiliated to the school, holding regular clinics on site. Both the GPs and physiotherapists can be an invaluable source of advice and information to utilise. For the lone worker, perhaps in the evening or weekend, there is NHS 111 or a Minor Injuries Unit (MIU) that can be accessed for help and advice. All provide a crucial string in the safety net to prevent school nurses from facing a claim of medical negligence.
Drawing on my own experience, when a girl presented to me with a painful forearm from being hit at medium speed with a football, I suspected nothing but a bruise. The chances of her having sustained a more serious injury were minimal. It was not a high-impact injury, neither had she fallen on her arm. There was no swelling evident and no malformation: on assessment, nothing abnormal was noted. It was not unreasonable to ask her to return the next day for review if her pain remained. She returned, and as this is not what I expected, I discussed her case with a colleague. Erring on the side of caution, we decided that she should attend the MIU for assessment. An X-ray was taken, and unfortunately, a fracture of her radius confirmed. It was a fracture that I would have missed, had I not drawn on the advice of a colleague and the expertise of the MIU. Lesson learnt.
“Would you mind having a look at this rash?”, “Could you listen to this pupil’s chest for me?” “Can I ask you for your opinion on a pupil’s abdominal pain?”. An endless list of questions that reverberate around our team. But I do recognise that I am fortunate, that is exactly what it is. A team. A team which, from the senior clinical nurse down, breeds inquisitiveness. A team where nothing is a stupid question, where teamwork is actively encouraged, where the risk of negligence is minimised. I am the lucky one, as I know this is not always the culture. In many places, there is still a blame culture, or one where you are ridiculed and made to feel ill-educated if you ask for advice. I have worked in such a place and left.
Anna brings a decade of hands-on expertise to her role, having worked as a school nurse for 10 years.
If you need a School Nurse Expert Witness, Anna is available for instruction.
References
Nursing and Midwifery Council (2024). Standards of proficiency for registered nurses.
Resuscitation Council (2021) Resuscitation Guidelines.
Royal College of Nursing (2017). An RCN toolkit for school nurses.
UK Government (2024). UK concussion guidelines for non-elite (grassroots) sport.
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