2. BackgroundSchool nurses in the UK are registered public health nurses who work with children aged 5 to 19. The term ‘children’ throughout this paper will refer to any child or young person who would fall under the remit of a school nurse. Public Health England [3] and the School and Public Health Nurses Association [4] set out the role of the school nurse in three areas: universal, personalised or targeted, and specialist, with safeguarding forming a key component across all three (summarised in Appendix A, Box A1). Within this paper, the term ‘safeguarding’ refers to statutory and non-statutory child protection activity.The UK government mandated a variety of lockdown measures during the COVID-19 pandemic, including a nationwide lockdown from March–May 2020, followed by a series of regional restrictions and subsequent lockdowns across England, Wales, Scotland and Northern Ireland. During lockdown periods, the majority of schools closed to all except the children of key workers and children who were considered vulnerable. Many school nurses faced the challenge of delivering health promotion and education services, alongside an increasing safeguarding remit, remotely or with significantly restricted access to school premises. In addition, the school nurse workforce was compromised due to sickness, redeployment and personal caring and/or home-schooling responsibilities. The impacts of lockdowns and COVID-19-related restrictions on school nurses’ work have been reported in other countries with similar school nursing models. Evidence from America [5], Hong Kong [6] and Sweden [7] alludes to an emerging duality of the school nurse role during the pandemic, with traditional focuses such as health promotion competing with new COVID-19 responsibilities.The wider public health impacts of lockdown restrictions and reduced in-person contact for children have become apparent. Several international reports have highlighted children’s increased vulnerability during lockdowns to issues such as domestic abuse and exposure to substance misuse [8,9]. Online activity intensified, increasing children’s vulnerability to online bullying, emotional abuse, grooming, sexting and virtual sex [10]. Consequently, there was a significant increase in new child protection concerns [11]. For many children with pre-existing vulnerabilities and complex needs, the pandemic heightened exposure to risk, as respite and support became problematic [12,13].Amidst these challenges, school nurses accelerated and implemented new innovative practices to maintain contact with children and their families; facilitate interprofessional working; and expand the reach of their services through extended partnership working. A recent scoping review of international literature highlighted a range of creative school nurse practices that were adopted to ensure continued and responsive services [14]. The review also highlighted that little research has been published exploring the experiences of school nurses during COVID-19, including in the UK. The aim of this survey study was to gather information on how school nurses’ work evolved as a result of the COVID-19 pandemic, with a focus on their work with vulnerable children and young people. 3. Materials and MethodsThis cross-sectional study used an online survey that was developed to gather information on innovative practices in frontline school nurse work, focusing in part on work with vulnerable children, during the pandemic in the UK. Survey questions were informed by, and developed from, a range of interrelated policies and the research team’s professional practice and theoretical knowledge: for example, public health/school nursing models [4], family-centred care/partnership working [15], contextual safeguarding [16], and communication within safeguarding [17]. In addition, questions were further informed by scoping review findings and input from an expert advisory group (consisting of school nurses and professional organisation leads). Some questions were also adapted from a previous survey that was developed and implemented by a member of the research team [18]. Draft versions were reviewed by the team and advisory group and piloted on five Specialist Community and Public Health Nursing students at Oxford Brookes University. Iterative amendments were made based on feedback, mainly to improve question clarity, and the final survey was reviewed and approved by the research team and advisory group, and Oxford Brookes University Research Ethics Committee (registration no. 211550). The final survey included 20 main questions (all non-mandatory, some including embedded logic follow-up questions) across three sections (Supplementary Material File S1). Survey questions generated both quantitative and qualitative data, and the survey concluded with an invitation to participate in a follow-up focus group or interview. This invitation requested contact details, but through a different platform to maintain survey anonymity.The survey was live from 9 April 2022–31 May 2022. A convenience sampling approach was employed to reach UK-based school nurses, with an online survey advert being disseminated by professional school nurse organisations (School and Public Health Nurses Association, and Community Practitioners’ and Health Visitors’ Association) via their social media and internal communications channels. The research team also disseminated the survey via social media and other relevant professional networks. The advert contained an embedded anonymous link to the Qualtrics-hosted survey. The survey landing page included a brief description of the study, followed by the participant information sheet and an invitation to provide consent by checking a box. In order to maintain respondents’ anonymity, the survey was set to not capture or record IP addresses or geodata; as a result, multiple participation could not be ruled out. Participants could exit the survey at any time. Only fully completed and submitted surveys were included in the analysis; participants needed to select a final ‘submit’ option at the end of the survey for this criterion to be fulfilled. Only current practising school nurses (and school nurse students) based in the UK were eligible. Two hundred surveys were begun but after exclusion for non-completion/submission of the survey and not meeting inclusion criteria (e.g., non-UK-based), data from 78 participants were included in the analysis. This represents approximately 4% of the school nurse workforce in England and Wales [19]. The study was conducted and reported in line with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS). Data AnalysisQuantitative data were analysed using SPSS 25.0 (IBM Corp., Armonk, NY, USA) [20] and are presented descriptively. Results were calculated excluding any missing data; where appropriate, a number of responses to an individual survey item are highlighted. Qualitative data from the open-ended survey questions were analysed using a six-step reflexive thematic analysis [21,22], involving: (1) familiarisation with the data; (2) generation of initial codes; (3) searching for themes; (4) reviewing themes; (5) defining and naming themes; and (6) writing the report. Across the seven open-ended questions, a total of 382 free-text responses were provided, totalling 9688 words. The exact breakdown for question responses was as follows: Q12.2 = 63 responses (1493 words); Q15.2 = 10 responses (187 words); Q16 = 71 responses (2116 words); Q18.2 = 58 responses (1541 words); Q19.2 = 62 responses (1113 words); Q19.3 = 64 responses (1274 words); and Q20 = 54 responses (1964 words) (see Supplementary Material File S1). The data relating to each question were collated into separate transcripts, which were read and reread for familiarisation purposes. A semantic inductive coding approach was adopted, reflecting the descriptive nature of the data and a desire to foreground participants’ experiences. For example, the excerpts “I found contacting some families difficult as they chose not to engage at all” and “Others in the team had much more limited contact with children than would normally have been the case” were both coded as ‘reduced contact with service users’. Coding was undertaken by one researcher (S.B.) and reviewed and discussed by two additional researchers (D.S. and G.C.). A collaborative approach was taken to generate and refine themes, for which reflexive discussions were held to identify meaning patterns across the data and to describe the central organising concepts across code groupings [22]. The analytic findings were then reviewed by the advisory group and wider research team.

All members of the research team had a nursing or psychology registration, and all were involved in a wider project exploring global school nursing practices utilising multiple methodologies. The experience and knowledge obtained through this familiarity with the literature and school nursing practice more generally may have influenced the way survey data were viewed and analysed (for example, recognition of patterns of meaning based upon findings from earlier stages of the wider project). However, this would not have been to the detriment of the analytic process, but rather enabled findings to be located in the context of the team’s rich understanding of the issues facing school nurses during the pandemic.

5. DiscussionQuantitative and qualitative data obtained through this UK survey study illustrate the various ways school nurses’ practice was impacted by the pandemic, and findings support emerging evidence from other international research exploring the issue [14]. Nearly three-quarters of participants in the present study reported that their workload increased during COVID-19, and nearly two-thirds reported having reduced contact with children and families. All modes of alternative communication and service delivery, such as telephone and online meetings and/or consultations, were reported to have increased significantly, while face-to-face contact with service users decreased. Challenges in identifying and supporting vulnerable children were also reported. Qualitative analysis of data from open-ended survey questions yielded five themes which reflect the changes in school nurses’ practice during COVID-19: (1) A move from preventive to reactive school nursing; (2) Professional challenges of safeguarding in the digital context; (3) The changing nature of interprofessional working; (4) An increasing workload; and (5) Reduced visibility and representation of the child.Safeguarding and the prevention of harm and ill health make up a central part of school nurses’ work. In a pre-pandemic qualitative study [23], school nurse participants from across England described what they considered to be dramatic changes to safeguarding practice in recent years, with one participant stating that safeguarding formed 90% of their role. The changing nature of safeguarding work was attributed in part to external circumstances, e.g., the increased prevalence of specific issues such as child criminal exploitation. However, participants also discussed the impacts of staffing shortages and commissioning arrangements, leading many to conclude that the focus of their work had shifted from primary to secondary prevention, i.e., preventing the recurrence rather than the emergence of safeguarding issues. These findings, published shortly before the emergence of COVID-19, mirror many of the conclusions reached in the present study—in particular, participants’ concern that reactive service provision is likely to continue due to the emergent consequences of COVID-19. Post-pandemic literature is evidencing an increase in certain issues for children such as emotional and behavioural problems [24], anxiety and depression [25], and impacted peer relationships [26].It has been suggested that the pandemic and associated restrictions posed a ‘perfect storm’, with many parents under increased stress, and many children’s risk factors heightened alongside a reduction in typical protective services [27]. There is clear evidence that school nursing services were struggling prior to the pandemic, with a lack of staff and resources cited as barriers to school nurses’ ability to offer their fundamental service [23]. Many of these issues were exacerbated by COVID-19. Findings from the present study also suggest that the move from face-to-face to virtual service provision reduced the visibility of particularly vulnerable children. It is well acknowledged that the enduring impact of COVID-19 will continue to affect vulnerable children and families post-pandemic, thus underpinning the need for adequate safeguarding strategies [28].Data from the present study illustrate that school nurses faced an increased workload within an already-diminished workforce, simultaneously dealing with redeployment and sickness. The volume of administrative work surrounding caseload management is a perennial concern for practitioners [29]; school nurses in this study similarly described increased casework arising from pandemic-related issues. As virtual modes of service delivery are likely to continue—particularly in the context of interprofessional working—it is important that standard operational procedures at a national and local level are reviewed to reflect this increasingly normalised mode of multidisciplinary communication. There should be clear directives on the length of meetings, the time between meetings, and reasonable time frames for preparatory and follow-up work. Looking at broader funding issues for school nurses prior to the pandemic, Dawe and Sealey [30] highlighted the challenge of trying to achieve the same outcomes with year-on-year decreases in the public health budget. This issue is not unique to the UK, and yet, without adequate investment in school health resources (including but not limited to staff), the consequences of the pandemic for vulnerable children and young people are likely to snowball.Surveys administered by the Department of Education [31,32,33] during the pandemic illustrate variations in school referrals to children’s social care throughout the pandemic, correlating with school closures in the UK. For example, from May 2020 to July 2021, when compared to the same time period between 2017 and 2020, there was a general trend of reduced school referrals. In figures reported in the most recent survey [33], though the total number of referrals was comparable to previous years for the same period, school referrals had increased by 27%. Rather than reflecting an actual reduction and/or increase in safeguarding issues, these statistics likely reflect schools’ fluctuating ability to detect safeguarding needs. Supporting this, the majority of participants in the present study indicated that COVID-19 restrictions impacted their ability to identify vulnerable children.There appears to be an enduring lack of value in the school nursing role, including a poor understanding of the role amongst many professionals [30]. Findings from the present study support this conclusion, with participants alluding to the fact that their role was perceived to be non-essential in the pandemic effort (e.g., redeployment) and, paradoxically, capable of absorbing the workload of other services (e.g., child mental health services). However, it also appears that, for some school nurses at least, undertaking their roles during COVID-19 enhanced their professional standing, improving their relationships and lines of communication with key professionals. The value of these enhanced relationships is likely ultimately to benefit the protection of vulnerable children. Perhaps countries with established school nursing models need to explore raising the knowledge of school nurses as valued public health professionals to best benefit the most vulnerable. In addition, evidence from America has demonstrated that school nursing services can provide extensive medical and productivity (parental and teacher) cost savings [34], which additionally supports the need for a fully functioning preventive service.The reach and economy of online meetings is being realised in many work contexts and is forming part of a hybrid working model. This is in keeping with the digitisation of patient care recommended in the National Health Service (NHS) long-term plan [35], which recommends using technology to facilitate interprofessional communication and public access to care, as well as offering likely cost-saving benefits. The present study highlights that the pragmatic and necessary move to virtual/remote communication and service delivery with children is not without its limitations. Most notably these relate to concerns about confidentiality and the quality of interactions, as well as reduced visibility of the children themselves. That said, the increased use of digital platforms appears to have had distinct advantages for school nurses’ partnership working, and there is evidence from other clinical staff groups to describe the benefits of online multidisciplinary team meetings [36]. However, not all evidence on this matter is consistent, with a recent scoping review identifying numerous challenges to professional virtual working [14]. The present study further highlights that children were not always able to adequately engage with online services (for example, due to inconsistent access), with many participants indicating that online service provision was suboptimal for both staff and service users. It could be argued that the use of virtual/remote modes of communication and service delivery should supplement, rather than replace, face-to-face delivery post-pandemic. Future research should explore the effectiveness of delivering different aspects of the school nurse role virtually.Perhaps the most important finding from this study was that despite the increased activity around trying to maintain ‘eyes on the child’, there was a perceived loss of the child’s voice in many processes throughout the pandemic. This adds a new dimension to findings from earlier work, which showcased a range of innovative practices that were accelerated or introduced by school nurses to maintain contact with children. The learning from this, and other models of school health provision such as remote school nursing [37], must be carefully considered to ensure that school health delivery best serves local children. The results of this national survey would suggest that digital platforms for communication and service delivery with children might be part of a possible toolkit for the dispensation of school nurses, and employed in relation to identified needs.

Practice, organisational and policy recommendations arising from analysis of data obtained through this survey study include:

For professional organisations to continue to represent school nurses in relation to their changing work profile as a consequence of the pandemic. This will empower school nurses to negotiate the external expectations of their role;

For governments and local authorities to recognise the value of the school nurse as a public health specialist by commissioning school health models that place experienced school nurses in leadership and coordination roles within school communities. These should be supported by a sufficient workforce to ensure effective preventive public health work;

To recognise the strengths and limitations of virtual interprofessional meetings and utilise them accordingly (recognising that face-to-face meetings can be helpful for informal networking and discussion). This should be accompanied by clear directives on workload planning that recognise pre- and post-meeting work;

To return to face-to-face contact with children and young people in health promotion, education and specialist work. This recognises the importance of building trust, ensuring confidentiality, and holistic assessment when working with children and young people;

For local authorities to subscribe to a range of online/digital platforms that can form part of a toolkit for school nurses’ work with children and young people, employed according to assessed needs.

Strengths and LimitationsThis survey had 78 responses. The sample was self-selected and represented a relatively small proportion of UK school nurses. According to Launder [19], there were 2100 school nurses in England and Wales in 2019, therefore this survey’s sample size represents approximately 4% of the school nurse workforce across these two countries. (NB. This study covered all four of the UK nations; however, to the authors’ knowledge, there are no publicly available data describing school nurse numbers across the UK as a whole.) The small sample size limited the possibility of making inferences about complex relationships across the datasets. Additionally, the survey did not capture participants’ age or gender; it is, therefore, possible that recruitment methods for this study, which utilised social media and other digital communication strategies, may have disproportionately attracted younger participants. That being said, given the digital transitions necessitated by the pandemic, it is likely that the UK school nursing workforce as a whole is digitally competent. Moreover, the geographic range, various lengths of time in post, and the fact that all types of schools were represented suggest a good representation of the school nurse workforce in the UK. This diversity of representation, together with the contextual description provided by the qualitative data, strengthens the potential for findings to be applied to other contexts. The survey development was informed by a rigorous literature review, consultation with an advisory group, and piloting prior to finalisation, all of which served to maximise face validity.

As qualitative responses were gathered from open-text box survey responses, they were relatively short in length, and the research team was unable to probe or explore the nuances of key responses. The descriptive nature of the data resulted in a similarly descriptive approach to analysis. Future studies should utilise study designs that allow more in-depth exploration of school nurses’ experiences. This recommendation is being realised by the next stage of the wider project (to which the present study contributes), involving focus groups and interviews with school nurses.

Whilst this study specifically sought to capture the experiences of UK school nurses, it is likely that the findings are relevant to other countries with similar school nursing models, as well as other frontline professionals such as those working in the fields of social work, youth work and education. In addition, the key challenges of supporting vulnerable children are likely to be applicable to professionals globally who used similar service delivery models during, and in the aftermath of, the pandemic.