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Supporting school nurses as change agents

School nurse

Working with and promoting change has been a lasting feature of the Covid-19 pandemic. Speaking from the perspective of school nursing, but with huge relevance to all, Sharon White, chief executive of the School and Public Health Nurses Association (SAPHNA), shares her advice.

Like most other parts of the healthcare service, Covid has brought about such rapid – and necessary – change in the way that school nursing services are delivered. School nurses are also integral to bringing about change themselves. There is now much to reflect on, analyse; research, and build upon if we are to deliver services fit for the future.

During the pandemic our children, young people, families, and wider stakeholders adapted to more virtual offers. Of course, we have seen some fabulous innovative and effective practice provided remotely – delivered under challenging circumstances. Yet, despite this, we know that face-to-face must never be solely replaced.

Sadly, we have seen in a recent consultation, a proposal to replace school nursing with a text-only service for young people aged 11 plus. Clearly this cannot and must not happen, and thankfully, having stimulated debate and alongside key partners we were able to successfully have this proposal changed.

There is much research now being undertaken to better understand what our service users, evidence, research and outcomes tell us; only then can we implement any changes to accommodate the digital offer.

This work will help us to better understand this, but in the meantime, we know that we are amid a huge sea-change, not only of our services but across the NHS, social care, local authorities and education providers. This process of change can pose both threats and opportunities, and is something we need all to be prepared for.

As specialist community public health nurses we are all too familiar with change – such as the changes in commissioning in 2013 where, as a workforce, we transferred over to Local authority commissioning and, for some, to private and/or charity provider organisations. We are particularly competent in using it to bring about positive behaviour change in our children, young people and families, such as in positive mental health, smoking, healthy lifestyles, sexual health, etc.1,2,3

On a system-wide level, many school nursing leaders are often also involved, and well-versed, in utilising the NHS Change Model as a framework for any project or programme that is seeking to achieve transformational, sustainable change.4

Having said that, we also witness resistance to change within school nursing, as well as with our clients. This may be for a host of often very valid reasons, such as loss of motivation, feeling uncomfortable or threatened by change, feeling excluded or voiceless, a lack of understanding, and/ or wider personal and professional stressors. For many clients resistance to change may be from the impact of wider determinants of health acting as negative influences, such as poverty, housing, or employment.

What tools do we have?

On a professional level, it is always good to have useful tools in the kit to use when yourself, colleagues, clients or stakeholders may be negative to change. I feel this is worth further discussion, and here are three suggestions.

One model I like, and find easy to use and apply to most situations, is Simon Dodds’ 4N Chart.5  It can help to consider and better understand negativity using this simple framework:

  • Niggle – the negative feelings that I have in the present.
  • Nuggets – good feelings I have in the present
  • NoNos – bad feelings I do not want in the future
  • NiceIfs – good feelings I do want in the future.

Change is not easy, but it is helped by a range of factors. In health services and school nursing, we are most familiar with the NHS Change model. The five-step improvement approach provides us a systematic framework from the beginning to the end, giving the project a greater chance of sustainable success.

The five steps of the model are:

  1. Preparation – everything you need to do before the official start of your project.
  2. Launch – official start of the project.
  3. Diagnosis – understanding the current process, dispelling assumptions, using data to define the problem and to build upon the baseline data.
  4. Implementation – tests and measures potential solutions using a Plan Do Study Act cycle, implements the best solution and introduces standard work and mistake proofing for a quality sustainable process.
  5. Evaluation – achievements are celebrated, learning and principles are captured, and the improvement becomes the norm.

Another option, the Model for Improvement – involving the use of Plan, Do, Study, Act (PDSA) cycles – is incorporated within the five step approach and was designed to provide a framework for developing, testing and implementing changes that lead to improvement.6

What’s next?

As leaders of the healthy child programme, the building of key relationships with our partners and stakeholders; schools, social care, parents, children etc, has never been more critical.

Building and releasing capacity is a must, as we continue to exist within restricted budgets and rising demands. Time well spent on cementing and growing relationships, as we have witnessed during Covid, particularly with our school communities, will only go on to yield huge benefits.

Sharon White OBE, BSc (hons) specialist community public health nurse/school nurse, registered general nurse, state certified midwife.


  1. Evaluation of behaviour change interventions: school nurse toolkit
  2. Changing behaviour in families (
  3. Behaviour change overview – NICE Pathways
  4. The Change Model Guide. NHS England.
  5. The 4N Chart. Simon Dodds – Hexitime
  6. Plan, Do, Study, Act (PDSA) cycles and the model for improvement