4. Developing the programme theory in realist evaluation
In line with realist evaluation, the findings of this part of the evaluation were used to inform the initial programme theories. This stage was to understand the contextual issues and mechanisms operating within the programme and how they were expected to unfold in practice. Nurse managers who were able to articulate policy viewpoints about how the school nurse programme was designed and implemented at the two sites were involved in this stage.
Six key participants in managerial/team leadership roles participated in this part of the evaluation. Three took part in a focus group, whilst two were involved in a joint interview and one in an individual interview. All interviews and focus groups lasted about an hour.
The findings are presented within four broad components. At the end of each component is a box summarising the key points.
Programme implementation and the nine priority areas (pathways)
The early adoption of the School Nursing role began in September 2015, although both areas found that they could not really begin implementation until the November of that year. For both sites there was a minimal amount of national planning undertaken and so they had to develop their plans and strategy at the outset. This was made more difficult by the fact that, owing to the innovative nature of this role, no one was very familiar with what might be involved or what issues might arise. However, both areas found that leadership was key and needed managers who could write SBARs  , plan carefully and support staff through a period of change.
Each early adopter area therefore developed their own plans with regards to implementation of the new pathways, new partnerships, organising staff training and integrating the refocused service with existing processes. For instance, in Perth and Kinross, all schools held Integrated Team Meetings, which School Nurses attended, but it was found that the number of children the school nurse actually had contact with could be small. It was decided therefore that the school nurses would only attend for specific children, thus decreasing the amount of time they needed to spend in these meetings.
Other measures were also put in place as part of implementing the pathways. Managers thought it was important that some previous duties of SN were discontinued in order to facilitate the delivery of the priority areas. For example, drop-in clinics were stopped in both early adopter sites.
"The stopping of the drop-in clinics added capacity for the school nurses to adopt the programme because we were stopping something that was really if you like wasting their time because they were making themselves available for the drop-in but the young people were not accessing the drop-in therefore we took the decision to stop the drop-in which gave them extra capacity to be able to do the pilot" (R5).
Also, the school nursing service discontinued immunisations (but not in Perth and Kinross), sexual health and other health promotion-related activities in schools. Essentially, managers suggested that some of the activities duplicated efforts. It was mentioned that teachers covered, for example, sexual health promotion within the curriculum for excellence.
"Our school nurses no longer provide STI talks or contraception talks. They don't get involved in puberty because there was duplication because that's actually within the curriculum for excellence" (R4).
In terms of implementing the programme, a key challenge that was mentioned by managers was that the programme was implemented with little or no extra financial investment. For example, within Perth and Kinross, it was highlighted that existing resources were being diverted to support immunisations.
"One biggest thing for me is that they've not had the investment to do the pilot…there's not new money, we know that, you know. So you're funding an immunisation team, probably with money from school nursing. Which is most likely to happen, which, you know, it doesn't give it the same credibility as, you know, the health visiting got a lot of money ploughed into it by the Scottish Government, due to the Children's Act" (R1).
One of the major differences between the two areas was that the Perth and Kinross team still undertook immunisation in schools and the expansion of this agenda had taken most (75%) of their time.
"Immunisation has been unprecedented. I think that the additional MenC programme, nationally, as well as the flu, which is huge, has obviously taken up the school nurse's time, and therefore, the inability to test the pilot" (R3).
Within Dumfries and Galloway a separate team for immunisation had already been formed out of the school nursing budget.
The pathways, based on the identified priority areas, were established prior to implementation. Managers agreed that these are areas of vulnerability and high-risk behaviours for children and young people. Therefore targeting these areas would eventually improve outcomes, especially for those who need the service the most.
"These nine priority areas are looking for the most vulnerable children and I think the priorities in themselves are helping us to safeguard children" (R5 ).
Whilst there has been broad support for the priority areas, mangers also felt that the pathways may need some adjustment.
"I think there could still be a couple of areas that are maybe missed within the priority areas. One of them I think is specifically around support to girls who are pregnant within education" (R6).
This manager further explained although it could fit in within mental health and wellbeing, she was concerned that this extends beyond that priority area, especially if the father of the baby is also within education.
It was also mentioned that the mental health and well-being pathway was not finished and, because CAMHS is perceived as becoming stricter in their referral criteria and only taking more severe cases, managers in both areas felt this pathway needs some further development. Other pathways were also the subject of considerable local variation. For instance, different areas have different homelessness policies and it is unlikely one size will fit all. Managers therefore suggested that whilst the priority areas should be established at a national level and suggestions made for possible pathways, these need to be adapted according to local conditions and should be done in conjunction with partners.
There was also discussion regarding whether sexual health should be a distinct priority area. Managers mentioned that sexual health was being looked at within health zones, but this was suspended temporarily in order to focus on the current priority areas.
There was some feeling that certain issues were not being adequately covered in the pathways, especially sexual health. It was suggested that the priority area devoted to substance abuse could be widened and encompass a variety of risk taking behaviour, not necessarily just to do with substance misuse. Currently, the nurses from the early adopter areas have continued to offer help to young people around sexual health but it has not been clear how to properly support and record this activity.
"It's about making a provision of what can our practitioners and school nurses do if they're sat across from a child and that would be they have got sexual health issue. We have got in Dumfries and Galloway what we've called clinic in a bag where the practitioners have some training around sexual health awareness and some provision for STI testing, pregnancy testing, but the main thrust of it is if they need more input than that then they will be signposted to our sexual health department who will also meet children within schools" (R4).
It may be that other health staff should offer sexual health but, if so, this should be properly implemented and supported.
In terms of referral of children onto the pathways, the managers added that as part of the programme a new referral system was introduced at both early adopter sites to facilitate referrals. Both areas found that referrals were slow to start and it took sometime before school staff and other professionals understood the mechanism for referral. For the first time there was a formal referral system and the early adopter areas developed referral forms that could be used by partners. By and large the schools have used these forms. For parents and self-referral, the school nurse completes the form on behalf of the referrer. Referrals were also received through various meetings, for example the child's plan meetings or child protection meetings. GPs have been slow to use the referral system. In P&K, discussion with GPs to use the SN Referral System (this is an electronic system which pre-populates much of the patient data) has taken place. However, overall there have been very few referrals from primary care.
Managers mentioned that the most common priority area through the referral system is the mental health and wellbeing.
"The majority of referrals we've received have been mental health and wellbeing" (R3).
There is confusion as to whether referrals are in fact referrals or are 'Requests for Assistance' under the 2014 Children's Act. This needs to be clarified at national level. There is also some confusion as to the role of the HPI status of the child. In one area all children with an Additional HPI were placed on the School Nurses' caseload. In another area the School Nurses' caseload comprised only those children referred in regardless of HPI status.
Box 1. Summary - Implementation strategies and the nine priority areas
- Several previous school nurses' duties were discontinued to create additional capacity for implementing the nine priority areas.
- Priority areas should adequately cover important areas of vulnerability and this would eventually improve outcomes for children.
- There was a notion that there were still gaps in the priority areas
- New referral system introduced to facilitate referrals to the priority areas
Role clarity and standardisation
Managers viewed role clarity and standardisation of service as important aspects of the programme. They believed that the school nurse role is now well defined, both for school nursing team and other relevant agencies.
"I think as well whereas there wasn't always that clear role for a school nurse, now we're very clear on what the role of the school nurse is. We can also say no and I think that's something that the nine priority areas have given us the ability to say right where is the distinct role for a school nurse within that child that's got the vulnerability because you've not got your scattergun approach where just everybody gets involved just in case" (R4).
One manager even suggested that role clarity can promote early identification and delivery of appropriate interventions. Because once other agencies are aware of their distinct role, they are likely to involve them in relevant cases, possibly in a timely fashion.
"I think that (distinct role) can lead to earlier intervention, which can lead to better outcomes for the young people" (R5).
There was recognition that early identification and intervention was not mainly due to the introduction of the refocused role, but other policies such as GIRFEC also contributed.
It was consistently clear across all managers that the implementation of the priority areas has made the school nursing service more standardised.
"It was almost a case of prior to it the one who shouts the loudest gets and they would have schools that are very very demanding for quite low level stuff and yet schools that were very very needy, with children with a lot of vulnerability, that didn't get that service so I think they're able to actually be more consistent" (R4).
The method of working proposed by the refocused role was very different from much of the work undertaken by school nurses prior to the early adoption and not all staff would necessarily wish to work in this manner. The result was that several staff resigned or were reassigned out of the School Nurse Team. It was particularly stressful for staff in P&K as they endeavoured to cover the immunisation schedule as well as working according to the refocused school nursing role.
The high level of anxiety such a change can engender meant that staff support was a major concern. Although sickness rates did not appear to change much, there were resignations and retirals which placed further pressure on the remaining staff. In P&K four of the original staff resigned or retired. In D&G, the three Band 5 staff who were hired with a view to them being trained and filling school nurse posts all left (2 to undertake Health Visitor training and one was on secondment and returned to her original post). Unfortunately the delay in starting the school nurse training meant that they took other opportunities. It was also difficult because many of the newly hired staff were only on fixed term contracts and so could not afford to wait for the specialist school nurse training to be available.
"We've had, in our service anyway, two retirals, and two resignations. Because the school nurse model just wasn't something that some of our staff wanted to take on. So that's caused quite a significant challenge in capacity" (R3).
As staff left the teams, new staff were recruited who had an interest in this way of working. Because it was not possible to recruit Band 6 staff with the relevant qualifications (because the qualification had not yet been developed) Band 5 staff with a generic nursing qualification were employed with a view to them being offered training to upgrade their skills. Existing Band 5 staff were also encouraged to pursue further training. For some this was more problematic as they did not necessarily have a degree level qualification, which was required before starting an additional course or Specialist Practitioner Qualification ( SPQ).
The challenge for the early adopter areas has therefore been how to upgrade existing staff so that they are academically prepared to undertake additional study or SPQ, how to backfill staff who are on training and how to provide in-service training for the transitional period. The delay in initiating the full-time training at the selected three Higher Education Institutes (University of West of Scotland, Robert Gordon University and Queen Margaret University) has meant that there have been issues with staff retention.
Managers suggested that although the current role of SN was clear, there were still misunderstandings of the role of the wider school health team, including Band fives.
"And there is a piece of work within the pilot that still needs to have further discussion around the wider school nurse, and workforce, what that looks like. So, again, that's a discussion that is part of the pilot, but it still needs to be had" (R3).
Within school nursing service, Band sixes have led sub teams with wider additional staff (the lower Bands) supporting this. However, as the school nurse role changed the role of the other staff (bands) has had to change also.
Box 2. Summary - Role clarity and standardisation
- School nurse role now consistent and well defined both for school nurses and other key agencies
- Uncertainties still surround the role of the wider school health team
- Role clarity would potentially promotes early identification and intervention
Engagement and accessibility
Due to the wide diversity of the priority areas, relationships had not necessarily been established with all the partners prior to implementing the programme. Both areas found that it was essential to engage with partners. For instance, they had to make new links with other parts of the health system and also police, youth justice, homeless services and young carers. In P&K a School Nurse Development Team was established that met monthly and had representatives from education, youth justice, social work and other partners. The aim of this group was to help implement the programme and develop local pathways. It now meets every two months. A similar group was established in D&G.
The engagement of other sectors means it was very important to show how the revised school nurse role differs from other roles and what they have to offer, and also when their intervention would not be appropriate.
Overall, the broad areas covered by the priority areas were therefore perceived to have facilitated engagement with other agencies.
"Networking has been really good, 'cause we've met people within the different priority areas, like youth justice, homelessness, who we never really had any contact with before" (R3).
In terms of accessibility, children are currently being encouraged to access the SN service through referral from their pupil support teachers, but there are also other ways that children can be referred into the service.
Managers acknowledged that access to school nurses by children has slightly reduced. For instance, the provision of health promotion talks and drop-in clinics that made school nurses more accessible to a wider school population had all been removed in the refocused role. However, managers believed that the introduction of the pathways has made school nurses accessible in other respects. For example, they suggested that home visits have increased.
" …we do more home visits, than we did before" (R3).
Within Perth and Kinross, it was suggested that absence of mobile IT devices has restricted school nurses from being based in schools as often as they would have preferred.
"Our IT system doesn't lend itself well to that. Because you're right, that's where they have to be (schools), they have to be visible" (R1).
In order to overcome the limited accessibility, Dumfries and Galloway plans to introduce novel approaches that children can use to directly access school nurses. For example, a text message service was a possibility.
"We have acknowledged that we might look at how we get them to contact us through the IT systems as well. Through texting or through emailing and it's something that again was part of the service provision that we needed to look at" (R4).
Box 3. Summary - Engagement and accessibility
- Wide and diverse priority areas have improved engagement with other partner agencies
- Refocused role has left school nurses less accessible in schools than previously, which seems not ideal but home visits on the increase
- Dumfries and Galloway eager to overcome this by text message service where children can directly access school nurses, but this may require careful evaluation
Training and support
There had been little in the way of school nursing training since the 1990s, although some have been trained in a Specialist Public Health Qualification ( SPQ). Whilst master's level modules are being developed nationally, it was recognized that there needed to be substantial training support for existing staff. NES offered a 2 day Masterclass with a session on each of the nine pathways. Whilst this course was appreciated it was not always possible to have the training on consecutive days. In addition, it was not possible to provide in-depth training on all the topics within the two day period.
Each area then tried to introduce its own training schedule using locally available resources. Both areas aimed for one day a month for training but this became increasingly difficult, particularly in P&K where the immunisation schedule made it virtually impossible to realize. It was also difficult on occasion to find suitable trainers, and even where training was provided, it was recognized that staff often needed to receive initial training, be given the chance to put what they had learned into practice, and then receive follow up training.
The provision of good and timely training was a huge issue for management in the course of the implementation and covered everything from trying to find venues, to trying to find trainers who could cover the various pathways, to recognition that refresher training would need to be provided on an on-going basis.
As such, it was clear from all managers that training was the most crucial aspect of delivering a successful programme.
"Well, I suppose one of the main things is the training for the school nurses. We had the masterclass days and we've also done some training locally so that we understood the nine priority areas and they had the tools to be able to deliver the nine priority areas" (R5).
It was identified that more Band 6 nurses with a SPQ were required to adequately deliver the priority areas. In order to address this, managers acknowledged that those without the required qualification or Band 5 nurses would need to upskill to Band 6 and provision has already been made for them to acquire this at some designated Universities.
"You know, if you think, health visitors have to do an SPQ before they can ever become a Band 6. School nurses were a Band 6 without an SPQ. So there's discrepancies, straightaway. And I think, when the school nurses actually go to do the course, I think they will be so empowered, in terms of the knowledge that they haven't had, they can use it within their work" (R2).
However, due to limited spaces currently available, Band 6 school nurses have been given the priority to enroll on the programme. At present, the four Band 6s without SPQ in D&G are due to either start their SPQ training at University of West Scotland, or are upgrading their academic skills in preparation of starting their SPQ in the future. In P&K, four nurses will be starting their SPQ at Robert Gordon University. As the SPQ is full time this will have implications for staffing. Within P&K managers felt that taking staff away for further training could significantly deplete the current workforce.
"You know, if we take the staff out of, who are going to become students, and then see what we're left with, it's, again, disproportionate. I mean, you won't have many staff on the ground working" (R2).
Finally, because the role was new, several initiatives were introduce to support staff. Perth and Kinross used Value Based Reflective Practice sessions and Dumfries and Galloway introduced Preceptorship but this was discontinued as the programme developed. Dumfries and Galloway also used the safety huddle model for weekly meetings of teams and both areas provided one to one supervision.
Box 4. Summary - Training and support
- Training essential for preparing and equipping school nurses to deliver the priority areas, but SPQ increasingly necessary for the refocused role
- Strategic approach required in terms of training current staff, in order not to place unsustainable demand on the workforce
Overview of the initial programme theories
The four initial programme theories outlined below broadly captures the central tenet of each component. This would be tested and disentangled further in subsequent sections.
- The nine pathways (C) lead to streamlining of referrals (M), which improve children's outcome, especially for those who need the service the most (O).
- Standardisation of service and clarity of role (C) add credibility to the school nursing role (M), which result in enhanced professional status (O) and also promote interagency working (O).
- Regarding engagement and accessibility of the school nursing role (C), opportunities to be more accessible to the wider school population have reduced (M) but engagement with partner agencies and 'high risk' children has improved, which is important in terms of building trusting relationships (O).
- Training and support (C) facilitate the adoption of the programme and would provide opportunity for role development (M), which would empower nurses to deliver, identify and provide appropriate support within the priority areas (O).
Table 9 shows the initial programme theories, which are organised into context, mechanism and outcome configuration of realist evaluation.
Table 9 CMO theories for the components of the school nurse programme
1. Programme implementation and the nine priority areas or pathways
The nine pathways
Streamlining referrals, so mainly children referred through the nine pathways were seen
Improving children's outcomes, especially for those who need the service the most
2. Role clarity and standardisation
Standardisation of service and clarity of the SN role both for nurses and other agencies
Credibility added to the SN role
Enhanced professional status and supported interagency working to improve outcomes for children
3. Engagement and accessibility
Engagement with other agencies and and accessibility to children
Engagement with other agencies and to 'high risk' children but opportunities to be more accessible to the wider school population limited, due to removal of health promotion activities
Improved engagement with other agencies and 'high risk' children which is important in terms of building trusting relationships
4. Training and support
Training and support opportunities made available to nurses
Facilitation of the adoption of the programme and provided opportunity for role development
School nurses empowered to deliver, identify and provide support within the priority areas
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