Executive summary All children and young people with health needs should enjoy the same rights and opportunities as other pupils and should be fully included in every aspect of school life. However, this 2012 survey, drawn up in partnership by the Royal College of Nursing (RCN) and UNISON, reveals that some children and young people may be at risk because school staff are being pressured into providing care without adequate support, training and supervision and without robust policies and governance arrangements in place. A growing number of children and young people require health care support at school. Pupils may need help to take prescribed medication, such as antibiotics or painkillers. Others need support with long-term conditions such as asthma, diabetes, epilepsy or anaphylaxis. Some children may have restricted mobility, requiring the use of wheelchairs, standing frames and hoists or they may have complex conditions which require support such as airway suctioning, tube feeding and catheterisation. Registered nurses help to coordinate and oversee the health care support that is offered in schools and may also provide training and supervision to school staff who assist pupils with health needs. Teachers conditions of employment do not include giving or supervising a pupil taking medicines. Therefore, tasks relating to pupils with health care needs usually fall to members of school support staff, such as teaching assistants, classroom assistants, lunchtime supervisors and school administrators. We asked registered nurses and school support staff from across the UK to tell us about their experiences of supporting pupils with health needs. Here are our key findings. Key findings School nurses and specialist nurses are overseeing the provision of a complex range of health care support in schools, including a growing demand to provide emotional and mental health support to children and young people. Two thirds of the nurses surveyed felt that specific health care plans were not always in place to ensure that pupils with health needs properly supported at school. School support staff, such as teaching assistants and lunchtime supervisors, are being expected to provide health care support to pupils, ranging from administering prescribed medication through to toileting and dealing with soiling incidents. Some are expected to undertake complex health care procedures including physiotherapy, tube feeding, tracheostomy care and catheterisation. The majority of these staff do not receive regular training from an appropriate registered health professional or an accredited training provider, and some do not receive any training at all. Nearly one in three say that they do not feel competent or comfortable with the responsibility of administering medicine or providing health care support to pupils. 1
A shocking 18% of school support staff say that they felt forced into taking on these duties by their employer. Their desire not to let pupils down means they are taking on tasks that leave them feeling worried and vulnerable and potentially with little or no training. The majority of school support staff do not receive any remuneration for this additional work nor any recognition of the skills needed to provide health care support to pupils. A quarter of the support staff who assist pupils have not seen a copy of their school s policy on the management of medicines and health care procedures. And 82.6% do not know if the tasks they are being asked to carry out are covered by their employer s insurance policy. Recommendations n All children and young people with health needs in schools should have an up-to-date Individual Care Plan in place, which is drawn up in conjunction with the school nurse, community children s nurse or children s nurse specialist. n Individuals who provide health care support to pupils in schools should receive specific and accredited training, on a named child basis, with access to ongoing updates and appropriate supervision. Training should be given by an appropriate registered health professional or accredited training provider. Refresher training should be provided at least once a year. First aid training is not sufficient when meeting the needs of children and young people with additional health needs. n Authorities and schools should assess and match their staffing requirements to deal adequately with the health care support required. Schools should employ and deploy the right numbers of staff with appropriate training and their remuneration and grading should reflect these responsibilities. n Every school should have a clear, ratified policy in place regarding the management of medicines and health care procedures, which is understood by staff, parents and pupils. This should include reference to health and safety issues, including the commitment to carry out risk assessment. Adequate insurance cover should be in place, with appropriate assurance given to staff. To support the implementation of these recommendations the RCN and UNISON have drafted a position statement. This statement is intended to assist employers, local authorities, school leaders, health professionals, school staff and parents to work in partnership to ensure pupils health needs are met. A copy of the statement can be found at: unison.org.uk/acrobat/20539.pdf 2
About the survey Who we surveyed The survey was circulated throughout the UK. It was sent to registered nurses responsible for pupil health and wellbeing. This included registered nurses working in schools; community children s nurses; and specialist children s nurses, such as epilepsy specialist nurses and diabetes specialist nurses. The survey was also circulated to school support staff (i.e. those staff working in schools other than teachers). In particular, teaching assistants, classroom assistants, lunchtime supervisors and other staff who may be asked to support pupils with health needs. Responses were received from staff in mainstream schools as well as those working specialised education providers, such as special schools. Who answered the survey? The survey received 2,322 responses. 39% (906) were registered nurses. 57% (1,330) were members of school support staff. 4% (86) were from other registered health care professions, such as physiotherapists, occupational therapists and speech and language therapists. Roles and responsibilities To find out about the health care support being provided in schools we asked registered nurses and school support staff to tell us more about their roles and responsibilities. The view of registered nurses The school nurse functions as both health promoter and health educator, providing a link between school, home and the community to benefit the health of children and young people. Only a small number of nurses are employed directly in a school. Typically, a school nurse will cover a group of schools, sometime 12 or more. Some nurses specialise in a particular field of care, such as diabetes, and provide this one element of the service to a large number of schools. Others work as team leaders that are responsible for coordinating school nursing services across a particular area. 57.2% of the registered nurses that completed the survey said that they provided health care support directly to pupils in schools, whist others gave training and supervision to support staff in schools rather than directly providing care themselves. The health care support that nurses provided to pupils included hands-on care such as administering medications, vaccinations and immunisations, tracheostomy care, gastrostomy a nd nasogastric tube feeding, first aid, emergency medication for seizures, taking blood samples, sexual health screenings and development checks. It also included developing and monitoring specific care plans for pupils, providing advice and training to school staff and referring pupils to external agencies as needed. A significant number of nurses commented on the increasing need to provide emotional, behavioural and mental health support to pupils, in areas such as body image, obesity, anger management and self-harm. 64.9% of nurses said that they delivered training or supervision to school staff. This included general training on first aid, health and wellbeing as well as managing specific conditions such as asthma, diabetes, epilepsy and anaphylaxis, administering rescue medication (such as buccal midazolam) and using epipens, anapens and other specialist equipment. Some nurses also provided training in areas such as continence, audiometry, gastrostomy and nasogastric tube feeding, suctioning and tracheostomy care. 3
The view of school support staff A growing number of school support staff are being asked to administer medication and provide health care support to pupils. Of the school support staff surveyed 78.2% were expected to administer medicines as part of their job, and 79.9% undertook medical procedures or other health care support. Alongside general health, welfare and first aid duties, respondents were expected to undertake the following procedures (see table on the right). Other tasks included monitoring bloods and administering insulin for diabetic children, suctioning, using defibrillators and administering CPR, lifting children, stoma care, rescue medication (buccal midazolam), nasogastric feeding, application of splints/braces, maintaining hearing aids and dentures, hydrotherapy and emotional support for pupils with mental health problems. Health care support / procedure Percent Toileting and/or dealing with soiling incidents 75.4% Administration of medicines other than oral or rectal medication 74.9% (e.g. eye drops, skin creams, inhalers and nebulisers, medipens) Administration of oral medication (e.g. paracetamol) 63.7% Dressing wounds 45.8% Supporting the use of equipment, e.g. wheelchairs, hoists 44.7% Physical therapy 26.9% Tube (PEG) feeding 18.8% Administration of rectal medication (e.g. rectal diazepam) 12.4% Assistance with catheters and/or colostomy bags 11.2% Administering syringe injections (not medipens) 6.3% Tracheostomy care 5.9% Blood pressure checks 1.6% Individual Care Plans We asked nurses and health professionals if all children and young people with health needs had an Individual Care Plan in place. It is good practice for all pupils with health needs to have an up-to-date Individual Care Plan which is drawn up in conjunction with a school nurse or other relevant health professional. These plans should record any triggers, signs and symptoms, the medication and other treatments required, details of who will provide this support and what training they need, as well as signed permission from parents and headteacher for treatment to be administered. Only 27.1% said that children and young people with health needs had an Individual Care Plan in place. Twothirds (66.2%) said that a care plan was sometimes in place. And worryingly, 6.6% of those surveyed said that, in their experience, no such plans were in place for pupils. Recommendation n All children and young people with health needs in schools should have an up-to-date Individual Care Plan in place, which is drawn up in conjunction with the school nurse, community children s nurse or children s nurse specialist. Training and supervision We asked registered nurses and health care professionals about the training that is available to members of school support staff who are expected to assist pupils with health needs. We also asked school support staff to tell us about the training they had received. The view of registered nurses Only 35.7% of nurses said that school support staff always received training from an appropriate registered health professional or an accredited training provider. 4
Most said that school staff sometimes received appropriate training and had access to appropriate supervision from a health care professional. And a small, but significant, minority (3.9%) said that, in their experience, school support staff never received appropriate training, with 6.6% saying that staff did not have access to supervision. I worked very hard to put in place systems, planning and training to ensure that school staff received high quality training to administer emergency medication for epilepsy. This took time, energy and a lot of commitment it is no easy task. Staff updates on health issues are not given sufficient priority on school staff training days or need to be done after hours in their own time. Some schools are very reluctant to allow school nurses to provide training such as epipen/allergy training until an incident occurs I think the key area for school staff is knowing that they have access to a professional who can give help and advice as needed in addition to the initial training School nurses need to have an annual update/refresher on the training they are delivering. Whilst training budgets are so limited, school nurses are being put into the position of delivering training and running clinics without the appropriate training themselves. The view of school support staff When asked about the training they had received, the majority of school support staff said that they had attended a first aid course, often provided by external agencies such as St John s Ambulance. Despite the fact that first aid training alone is not sufficient to ensure that an individual can safely administer medicines or deal with complex health needs, less than half of respondents said that they had received any additional, specific training. Of those that had received specific training, most had been taught by a school nurse or specialist nurse to administer inhalers, use epipens and anapens, or undertake diabetic monitoring and catheterisation. Some had also received training on manual handling and lifting. A small number had received one-to-one training on specialised procedures (e.g. physiotherapy or restraining children) or using specialist equipment (e.g. portable ventilators or hearing aids). Over half of the support staff surveyed did not receive annual refresher training. Some said they received refresher training every three years (in line with the timetable for renewing first aid certificates). Several only received refresher training if it was requested or when a new child with health needs joined the school. Several respondents said that they had received no training whatsoever or had simply been briefly shown how to care for a pupil by a colleague or parent. We got full training from the child care team at the hospital and from the child s mum. The nurses came back to watch us and to sign us off as trained. We always administer medications with two of us present and keep a record book that is checked and signed every day. There are two children in our school that have rectal medication. There are no staff that have been trained in administering this. A few teaching assistants have raised this point on several occasions but nothing has been done about it. Sometimes we have training weeks after we learn of a child s medical needs instead of immediately. We often feel like we are putting the child at risk or use our spare time to research information from the internet to help us until the training takes place. Recommendation n Individuals who provide health care support to pupils in schools should receive specific and accredited training, on a named child basis, with access to ongoing updates and appropriate supervision. Training should be given by an appropriate registered health professional or accredited training provider. Refresher training should be provided at least once a year. First aid training is not sufficient when meeting the needs of children and young people with additional health needs. 5
Confidence and competence Nearly one in three (28.3%) school support staff said they did not feel competent or comfortable with the responsibility of administering medicine or providing health care support to pupils. Many school support staff commented on how important it was to them that pupils were fully included in school life. The desire not to let pupils down meant that some staff were taking on responsibilities that left them feeling worried and vulnerable. Some felt pressured into undertaking complicated tasks that they didn t feel confident doing. Others felt forced into providing intimate care to children or teenagers, such as toileting, nappy changing or massage, which left both them and the pupil feeling uncomfortable. A lot of these children do not have learning difficulties. If we didn t volunteer to give these children medicine etc then there would be no inclusion. I work with special needs children ages 4-7 as a teaching assistant. We are noticing that with each intake of children their medical needs are taking over the teaching aspect, I do not feel comfortable with what I am expected to do medical-wise. I went into the job to teach, not to be a nurse. I worry about the distribution of medication at lunchtime especially. I have three pupils on the same medication (Ritalin) that are all on different strengths. I worry that due to pressure and time constraints I may mix them up accidentally. I feel I don t have a choice. I support the child and their health care. I m worried if there was a problem, I would personally be to blame. Going on school trips was a big responsibility for me as I had to make sure I had a sterile area and was able to take the child to a private place to administer her medicine and I could wash my hands and get apron and gloves on without a huge fuss. In the 3 years I worked with this little girl only one other person got trained up and that was at the end of the term. So all the responsibility was on me, with no extra pay for such a huge responsibility. I have been the principal first aider at my school for 18 years, I am now 61 years old and don t feel quite as confident in my role any more. Originally it was basic giving out plasters, dealing with general injuries, sprains, cuts etc. w I am expected to deal with parents, medical professionals, have responsibility for all the medicines and deal with children with medical issues which I now feel is more the responsibility of a nurse than a first aider. I work in a secondary school with over a thousand students and each year we are getting more and more children with serious medical issues. One member of staff has been asked to tube feed pupils, but they find it very difficult and they gag when the stomach content comes back up the tube but if they don t do it they are made to feel that they are letting the team down or we are not putting children first. 6
Employment and deployment We asked about how duties relating to health care support had been agreed between school support staff and their employer. In most cases, individuals took on these tasks voluntarily, over and above the regular day-to-day responsibilities of their role. The majority did not receive any extra money for this additional work nor any recognition of the advanced knowledge and skills needed to provide health care support to pupils. Despite the fact that such duties must not be imposed, a shocking 18% of school support staff said that they felt forced into taking on these additional duties by their employer. If you provide health care support to pupils, how was this agreed between you and your employer? The duties are specified in my contract of employment I volunteered/agreed to take on these additional duties, and I am paid extra to do so I volunteered/agreed to take on these additional duties, but I am not paid any extra to do so I feel that I was forced into taking on these additional duties by my employer 21.6% 7.1% 53.2% 18.1% The view of school support staff Duties such as these are often agreed by support staff in my school because they feel they must agree in order to keep their job. Staff are being told that their contract will not be renewed or they will lose their job if they are not happy or competent doing all that is requested. People are under pressure all the time. Stress levels are very high. I feel our arms are up our back all the time and sometimes people are bullied into it. We should be paid extra for the responsibility and the level of accountability that comes with delivering health care. Last year, I was told that I was expected to carry out a medical procedure in my lunch time (this is my personal time, I am not paid during my lunch hour). I voiced my concern and the time slot was eventually changed to within learning time. We were instructed by our headteacher to administer insulin injections to a 5 year old girl. Bearing in mind we were classroom assistants on roughly 7000 a year I thought this was a big ask and refused to do it. Many support staff are managing medicines and health care interventions for barely the minimum wage and with inadequate training. I have been told by senior management the word care in my contract means that I have to draw off complicated doses of medicines, some of which are potentially life threatening to the pupil. I have also been told that I have no choice and no extra reimbursement for applying these medical procedures. The view of registered nurses School staff are increasingly being expected to take on more and more pupils with very significant health needs with less and less support from the health services. They are expected in some cases to do as much as a trained nurse would with minimal training and support. Before becoming a nurse, I worked in a school and part of my remit was to administer prescribed Ritalin (a controlled drug) to pupils. care plan in place, no formal documentation to record this administration (until I drew one up). Quite scary that I had unsupervised access to these types of drugs. Recommendation n Authorities and schools should assess and match their staffing requirements to deal adequately with the health care support required. Schools should employ and deploy the right numbers of staff with appropriate training and their remuneration and grading should reflect these responsibilities. 7
School policy and insurance Around a quarter (24.8%) of support staff did not know if their school had a policy in place regarding the management of medicines and health care procedures. When asked if insurance cover was in place for the duties they were carrying out, 82.6% did not know if these tasks were covered by their employer s insurance policy. Without doubt, it would be hugely beneficial for all schools to put in place a clear, ratified policy which is clearly communicated and understood by staff, parents and pupils. Also, assurance should be given to staff that adequate insurance cover is in place for each of the duties they are being required to undertake. Whilst I feel comfortable and supported in my current role, I worked for another school where I felt unsupported and ill trained to care for a child with complex special needs. I think that whilst some schools ensure their staff are supported, others are still struggling to provide adequate training and advice. I feel like when support staff raise queries regarding medicine or specialist equipment our thoughts aren t considered important and we are seen as just causing a fuss. I worry about our insurance should anything go wrong and don t feel that we would be protected or whether we would be cut adrift should anything happen. Most tasks are covered by insurance policy, some are not, such as giving of oxygen and using suction machines, but staff are still pressured into undertaking these tasks. I would like for all support staff to be given correct and official confirmation regarding insurance and whether they should/shouldn t be providing this level of care Having suffered from a needle stick injury I found that there was no clear procedure to follow. The injury could have been prevented had I been shown how to use [this] specific device by the diabetes nurse. Instead of hoisting a child from a wheelchair we have just picked the child up to save time, this is because we are expected to do so much. I had to have steroid injections and physiotherapy on my shoulder. At least three of us have suffered with problems with our shoulders or backs. Recommendation n Every school should have a clear, ratified policy in place regarding the management of medicines and health care procedures, which is understood by staff, parents and pupils. This should include reference to health and safety issues, including the commitment to carry out risk assessment. Adequate insurance cover should be in place, with appropriate assurance given to staff. Other areas of concern The current financial climate has had an impact on pupil support across the UK. Cuts to local authority funding and pressure on school budgets has meant that training and support for school staff has been slashed. Likewise, insufficient staffing and heavy workloads mean that the school nurse workforce is overstretched. In England, NHS service reforms and organisational upheaval means that valuable knowledge and expertise risks being lost. And as more schools in England become academies, it is increasingly challenging for local authorities to retain oversight of how schools are supporting pupils with health needs. There is a lack of clarity regarding the role of local authorities, service commissioners and forums, such as Health and Wellbeing Boards, in ensuring that correct and safe support is in place for pupils. Uncertainty over who is scrutinising the care provided in schools and who is ultimately accountable for pupil wellbeing is increasing the risk to children and young people. Academies present a real danger to joint working as they are so independent they do not have to work with statutory local authorities. A repeated challenge is the number of schools school nurses cover, it makes building a relationship and undertaking preventative activities a nice [thing] to do rather than a vital component of the role. 8
Conclusion This survey adds to an increasing body of evidence which highlights the risk to children and young people when authorities and schools do not have robust arrangements in place to support pupils with health needs. Whilst there are many examples of good practice, it is clear that more needs to be done to ensure that all schools are able to provide safe and well-planned health care support. To help with this, the RCN and UNISON have drafted a position statement. This statement is intended to assist employers, local authorities, school leaders, health professionals, school staff and parents to work in partnership to ensure pupils health needs are met. We welcome the opportunity to work together with government and other key decision-makers to enable all schools to provide safe and effective health care to children and young people. n Download a copy of the statement Providing support for children and young people with health needs in schools a joint statement from the Royal College of Nursing and UNISON : unison.org.uk/acrobat/20539.pdf UNISON UNISON represents 1.3 million people working to deliver public services, including around 450,000 health care professionals and nearly 250,000 school support staff. They include teaching and learning support, administrative, technical and professional staff who play an indispensable role in giving children and young people the best start in life. Contact: education@unison.co.uk RCN The Royal College of Nursing (RCN) is the voice of nursing across the UK and is the largest professional union of nursing staff in the world, with more than 400,000 members. The RCN promotes the interest of nurses and patients on a wide range of issues and helps shape health care policy by working closely with the UK government and other national and international institutions, trade unions, professional bodies and voluntary organisations. 9
Appendix Supporting pupils with health needs in schools RCN and UNISON survey 1. I am a member of: RCN UNISON Other (please specify) 2. I work as a... Member of school support staff (directed to complete questions 9-18) Registered Nurse (directed to complete questions 3-8) Other registered health care professional (directed to complete questions 3-8) Healthcare staff (directed to complete questions 3-8) Health care professionals 3. Do you provide health care support directly to pupils in schools? If, what kind of health care support do you provide? 4. Do you train or supervise school staff who provide health care support to pupils? If, what kind of training and supervision do you provide? 5. In your experience, do children and young people with health needs have an up to date Individual Care Plan in place, which is drawn up in conjunction with the school nurse, community children s nurse or children s nurse specialist? Always Sometimes Never 6. In your experience, do school staff receive training that is given by an appropriate registered health professional or accredited training provider? Always Sometimes Never 7. In your experience, do school staff who are providing health care support to pupils have access to appropriate supervision from a registered health professional? Always Sometimes Never 8. Do you have any other comments for us with regard to managing medicines and providing health care support? School support staff 9. Are you or other support staff colleagues expected to administer medicines as part of your job? 10. Are you or other support staff colleagues expected to undertake medical procedures or provide health care support as part of your job? 11. What health care support do you provide? administration of oral medication (e.g. paracetamol) administration of rectal medication (e.g. rectal diazepam) administration of other medicines (e.g. eye drops, skin creams, inhalers and nebulisers, medipens) assistance with catheters and/or colostomy bags blood pressure checks dressing wounds administering syringe injections (not medipens) tube (PEG) feeding physical therapy toileting and/or dealing with soiling incidents tracheostomy care supporting the use of equipment, e.g. wheelchairs, hoists Other (please specify) 10 12. Does your school have a clear policy in place regarding the management of medicines and health care procedures, which is understood by staff, parents and pupils? Don t know 13. If you provide health care support to pupils, how was this agreed between you and your employer? The duties are specified in my contract of employment I volunteered/agreed to take on these additional duties, and I am paid extra to do so I volunteered/agreed to take on these additional duties, but I am not paid any extra to do so I feel that I was forced into taking on these additional duties by my employer 14. If you provide health care support to pupils, what relevant training have you received and from whom? 15. If you provide health care support to pupils, do you feel competent and comfortable with this responsibility? 16. Do you receive refresher training at least once a year? If, how often do you receive refresher training? 17. Are the tasks you are asked to undertake covered by your employer s insurance policy? Don t know 18. Do you have any other comments for us with regard to managing medicines and providing health care support?