Guidance

Supporting the public health nursing workforce: employer guidance

Updated 27 June 2023

Introduction: an effective workforce for the healthy child programme

This guidance has been developed with the Local Government Association (LGA) and wider partners.

Public health is at the forefront of transforming population health for all communities, and giving children and young people the best start in life sets the foundations for wellbeing during the early years and throughout the life course. The healthy child programme provides an evidence-based framework to support local public health delivery for children and young people aged 0 to 19. Local authorities are responsible for commissioning the programme, while health visitors and school nurses are recognised as providing leadership and supporting a multidisciplinary approach.

The current commissioning arrangements have given rise to a number of new ways of working and employment models. We have developed this guidance to support employers of health visitors and school nurses. This guidance complements the Standards for employers of public health teams in England and addresses specific employment issues relating to health visitors and school nurses. Health visitors and school nurses are nurses or midwives who fulfil both of the following criteria:

• are registered with the Nursing and Midwifery Council (NMC) on part 1 or 2 of the register
• hold an additional specialist public health qualification and are registered as such on part 3 of the NMC register

Employers may wish to consider this guidance to support health visiting and school nursing teams to work safely and effectively. This guidance is being incorporated within self-regulation and improvement frameworks for public services and used by service regulators including the Care Quality Commission (CQC). All health visitor and school nursing services must be registered with CQC.

All employers providing health visiting and school nursing services should already have established a monitoring system by which they can assess their organisational performance against this guidance, together with a process for review and, where necessary, outline their plans for improvement. Employers should ensure their systems, structures and processes promote equality and do not discriminate against any employee.

Purpose

The purpose of this guidance is to help employers support an effective workforce to sustain high quality outcomes for children, young people, families, carers and local communities. Good public health delivery can transform the lives of children, young people and families and protect them from harm.

In order to achieve consistently high quality outcomes for service users, health visiting and school nursing services must have, and maintain, the skills and knowledge to establish effective relationships with children, young people, families and professionals in a range of agencies and settings, and local communities that enable the healthy child programme to be delivered to improve outcomes and reduce inequalities.

Employers and employees can use this guidance along with an appropriate supervision framework and the resources identified in each section to help support recruitment and retention of health visitors and school nurses, which will underpin the quality and consistency of local service.

Who this guidance is for

This guidance is for all employers of health visiting and school nursing teams. It relates to all registered health visitors and school nurses, together with other registered nurses within their teams who are employed within the organisation, as well as managers and specialist community public health nurse (SCPHN) students. The landscape in which health visiting and school nursing services are delivered is changing - however, we anticipate that this guidance will be relevant to and adopted in all settings where health visiting, and school nursing teams are employed.

Other important guidance and resources

This guidance should be read in conjunction with:

• the NMC code, which sets out the professional standards that nurses and midwives must uphold in order to be registered to practise in the UK

• the Standards for employers of public health teams in England, which provides additional specific guidance on health visiting and school nursing services

See also the healthy child collection, which brings together guidance and resources on the healthy child programme and how to implement it.

Overview of the guidance

The guidance covers 4 key areas, as outlined below.

1. Accountability, governance and partnership working

Sets out how employers should:

• ensure there is a clear clinical governance framework in place,including risk assessment and action to minimise and prevent risk
• be informed by knowledge of effective health visitor and school nurse practice and the experience and expertise of service users, carers and practitioners
• provide access to appropriate tools and resources that health visitors and school nurses need to practice effectively
• support partnership working with others to deliver the healthy child programme

2. Effective workforce planning

Sets out how employers should:

• use workforce planning systems to ensure the right number of health visitors, school nurses and other professionals with the right skills and experience are in place so that they can meet current and future service demands
• ensure safe and manageable workloads to meet service demands

3. Professional registration and supervision

Sets out how employers should:

• support health visitors, school nurses and the wider team to maintain their professional registration and revalidation - revalidation is a public protection measure and legal requirement for nurses, midwives and health visitors to practice in the UK
• ensure access to regular and appropriate clinical supervision

4. Continuing professional development and training

Sets out how employers should:

• provide opportunities for effective continuing professional development (CPD), as well as access to research and relevant knowledge
• develop effective partnerships with higher education institutions and other organisations to support the delivery of education and CPD

1. Accountability, governance and partnership working

This section is about accountability, governance and reducing risk, which is underpinned by enabling the workforce to deliver evidence-based public health within an accountable framework. All health visiting and school nursing services must be registered with the Care Quality Commission (CQC). This is a legal requirement as defined by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

It is important to have a clear understanding of what constitutes good health visiting and school nursing practice. This includes the theories, skills, research and evidence that underpin health visiting and school nursing practice and the ways in which employing organisations can achieve and maintain it at strategic and operational levels through clear accountability and governance.

The guidance to support the commissioning of the healthy child programme 0 to 19: health visiting and school nursing services provides more in-depth information on the healthy child programme delivery by health visiting and school nursing teams.

Things to consider

Strategic accountability

This could include:

• developing a strategy to monitor the effectiveness and responsiveness of health visiting and school nursing service delivery
• ensuring clinical audit and risk assessment processes are in place
• ensuring clear lines of accountability within the organisation for health visiting and school nursing service delivery
• establishing and maintaining effective strategic partnerships with partner agencies, higher education institutions and other organisations

Operational accountability

Examples of operational accountability include:

• ensuring health visitors, school nurses and their teams can do their jobs safely and have access to appropriate tools and evidence-based resources to support their practice
• identifying a lead professional health visitor or school nurse who will be responsible for implementing and leading on the Standards for employers of public health teams in England
• liaising with external professional leads to support the implementation of these standards
• completing, reviewing and publishing an annual ‘health check’ or audit to assess whether the practice conditions and working environment of the organisation’s health visiting and school nursing workforce are safe, effective, caring, responsive and well led
• ensuring service delivery is underpinned by research and evidence (including NICE guidelines)
• ensuring health visiting and school nursing teams’ feedback and views are taken into account in how services are planned and organised
• working with professional bodies and professional organisations and supporting all health visiting and school nursing teams to be engaged in the work of such bodies
• ensuring that processes are in place to seek and collate the views of service users, carers and practitioners
• implementing a system to analyse and act upon the views of service users, carers and practitioners, so that continuous feedback informs and supports the delivery of quality services - for example, see Friends and Family Test and Establishing youth-friendly health and care services (‘You’re Welcome’)

Working with partners and promoting multidisciplinary working

This might include:

• promoting health visiting and school nursing practice awareness among service directors and strategic managers, local politicians, community leaders, voluntary sector stakeholders and professionals in universal services such as early years settings, schools, wider health, social care and the police
• explaining and promoting the role of health visiting and school nursing roles to the public, improving accessibility and encouraging children, young people and families to seek early help
• ensuring there are links between health visiting and school nursing teams and the relevant local authority member, OHID regional lead, the local health trust, integrated care boards (ICBs), higher education institutions and other organisations to support partnership working

Useful resources

Clinical audit - NHS England

High impact areas for health visiting and school nursing

Keep records of all evidence and decisions - NMC

Health visiting and school nursing service delivery model

The fundamental standards - CQC

What to expect from your nurses and midwives - NMC

2. Effective workforce planning

This is about having appropriate workforce planning systems in place in order to meet the needs of local service users now and in the future. Effective workforce planning systems should determine immediate staffing requirements and help to ensure that sufficient numbers of health visitors and school nurses are trained to meet future demand, working with both NHS England and higher education institutions.

Workforce planning should be based on an understanding of the factors that influence need and demand, including the size and specific circumstances of the local population. Workforce planning procedures should be regularly monitored and reviewed.

Things to consider

Workforce planning

Examples include:

• undertaking an assessment of current and future need and engaging with local, regional and national supply and demand systems
• ensuring that workforce planning systems involve effective and strategic partnerships with higher education institutions, local health partners and other agencies
• contributing to efforts to recruit and retain health visitor and school nurse students

Safe staffing

Examples include:

• ensuring health visiting and school nursing teams operate within their field of practice and expertise, for example, health visitors 0 to 5, school nurses 5 to 19
• using an evidence-based or validated workload management system which sets transparent benchmarks for safe workload levels in each service area
• ensuring each health visiting and school nursing workload is regularly assessed to take account of work complexity, individual worker capacity, and time needed for supervision and CPD
• ensuring that cases are allocated transparently and by prior discussion with the individual health visitor or school nurse, with due consideration of newly registered health visitor and school nurses having access to appropriate preceptorship
• providing health visiting and school nursing teams with appropriate evidence-based tools to do their job, including effective case recording and other IT systems, databases, access to the internet and mobile communications
• ensuring all health visitors and school nurses and their teams have access to high quality supervision to protect them from harm, arising from managing the complexity of their allocated cases as part of maintaining a safe workload
• taking contingency action when workload demands exceed staffing capacity, reporting regularly to strategic leaders about workload and capacity issues within services
• publishing information about average caseloads for health visiting and school nursing within the organisation
• providing administrative support to health visitors and school nurses, and help to maximise the time they are able to spend working directly with children, young people and families
• taking account of the recommendations of the Workplace health: management practices (NICE guideline NG13), making employee welfare services available for all health visitors and school nurses and their teams

Learning and development

Examples include:

• engaging with the health visitor and school nurse education sector in order to facilitate exchanges of personnel and expertise
• facilitating further learning and development across partner agencies and regional networks or local Communities of Practice and with higher education partners
• providing good quality practice placements, other types of practice learning, and effective workplace assessment to help ensure that the right numbers of new health visitors and school nurses of the right calibre are trained, developed and supported

Whistleblowing

Good employer practice in relation to whistleblowing includes:

• fostering a culture of openness and inclusion in the organisation that empowers health visitors and school nurses to make appropriate professional judgements within a supportive environment
• enabling health visiting and school nursing teams and managers to raise concerns through incident reporting or whistleblowing, including concerns about inadequate resources, operational difficulties, workload issues or their own skills and capacity for work without fear of recrimination
• having in place effective systems for reporting and responding to concerns raised by health visiting and school nursing teams and managers so that risks are assessed and preventative and protective measures are taken
• ensuring that the risks of violence, harassment and bullying are assessed, minimised and prevented - where such instances do occur, there should be clear procedures in place to address, monitor, resolve and review the situation

Useful resources

All Our Health: personalised care and population health

Emotional resilience toolkit - Mental Health Foundation

NHS England e-learning for healthcare programmes

Preceptorship - Royal College of Nursing

Public health contribution of nurses and midwives: guidance

Health matters: public health issues

Safe sustainable and productive staffing - NHS England

Workforce and HR support - LGA

Stress and mental health at work - Health and Safety Executive (HSE)

Improving the personal safety of lone workers - NHS Employers

3. Professional registration and supervision

This is about supporting health visitors, school nurses and their teams to meet the NMC legal requirements and professional standards. Employers should have an organisational policy that supports professional regulation, for example, on recruitment and throughout employment. Additionally, they need to understand their role and take appropriate steps to inform the NMC, as the regulator, of any concerns over fitness to practice, co-operate with investigations and hearings carried out by the NMC, and respond appropriately to its findings.

Things to consider

Professional registration

Employers should ensure health visitors, school nurses and their teams meet the legal requirement for professional registration and revalidation. This must be in line with statutory requirements for practice issued by the NMC on revalidation requirements, which includes:

• ensuring health visitors, school nurses and their teams have relevant indemnity insurance to cover the services they provide, in order to maintain their registration with a professional regulatory body, and to meet individual and organisational responsibility for when staff are delivering services
• supporting employees to achieve mandatory requirements of revalidation, for example, offering constructive practice related feedback to employees and ensuring access to CPD
• ensuring all health visitors, school nurses and their teams are able to undertake a protected meeting for confirmation of their revalidation with their line manager
• ensuring that all line managers undertaking confirmation on behalf of health visitors or school nurse employees have read and understood their responsibilities in the NMC guidance for confirmers

Supervision

This is about making high quality, regular supervision an integral part of health visiting and school nursing practise. This should start with students on placement, continue through SCPHN training and throughout the individual’s health visitor and school nurse’s career. Supervision should be based on a rigorous understanding of the NMC code. Supervision should challenge students and qualified practitioners to reflect critically on their practice and should foster professional curiosity and an inquiry approach to public health nursing.

There is also a need for health visitors and school nurses to be open and honest when things go wrong. There is also a duty within organisations to report adverse incidents or near misses that may have led to harm (see Professional duty of candour, NMC).

Frequency of supervision

Employers should:

• ensure that supervision takes place regularly and consistently and lasts for at least an hour of uninterrupted time
• monitor actual frequency and quality of supervision against clear statements about what is expected
• make sure that supervision takes place:
  • for students on placement - as agreed with student and higher education institution
  • for newly qualified health visitor and school nurses - at least weekly for the first 6 weeks of employment for a newly qualified health visitor and school nurse, at least fortnightly for the duration of the first 6 months, and a minimum of monthly supervision thereafter

Quality of supervision

Employers should:

• make a quiet space available for formal supervision, informal confidential professional discussions between colleagues, and team meetings - there should also be a suitable space for confidential interviews with adequate safety measures to protect practitioners
• ensure that health visitors and school nurses have regular and appropriate professional supervision from another NMC registrant and provide additional professional supervision by a registered health visitor or school nurse for practitioners whose line manager is not a health visitor or school nurse. This should include safeguarding, non-medical prescribing, newly qualified health visitors or school nurses, line management, reflective practice and review of learning and development needs, ensuring there are opportunities for regular safeguarding supervision from an appropriate supervisor
• ensure that health visitor and school nurse supervision is not treated as an isolated activity by incorporating it into the organisation’s health visitor and school nurse clinical governance and quality framework
• ensure that supervision supports students and qualified health visitors and school nurses to meet the NMC requirements
• provide regular supervision training for health visitor and school nurse supervisors, assigning explicit responsibility for the oversight of appropriate supervision and for issues that arise through supervision

Useful resources

National preceptorship framework for nursing - NHS England

Concerns about nurses, midwives or nursing associates - NMC

Guidance on the professional duty of candour - NMC

Revalidation - NMC

Standards of proficiency for specialist community public health nurses (SCPHN) - NMC

4. Continuing professional development and training

This is about the importance of continuing professional development and training for health visitors and school nurses. It emphasises supporting staff development through continuous learning, knowledge sharing, research-based practices and leadership development. These efforts aim to ensure ongoing professional growth and the delivery of high quality healthcare services.

Things to consider

Supporting staff development

Examples include:

• promoting continuous learning and knowledge sharing through which health visitors and school nurses are encouraged to draw out learning points by reflecting on their own practice in the light of experiences of peers
• ensuring that the NMC code is used as the basis for evaluating capability and identifying development needs
• being able to exchange staff knowledge and expertise where appropriate with the wider health system, social care and education sector
• having effective induction systems and put in place tailored support programmes as part of their personal development plan (PDP), including protected development time, a managed workload and tailored supervision
• having an appraisal or performance review system which assesses how well professional practice is delivered and identifies a learning and development plan to support the achievement of objectives
• providing time, resources and support for CPD, including access to learning opportunities, such as e-learning for healthcare from NHS England, and other quality online training resources
• having fair and transparent systems to enable health visiting and school nursing teams to develop their professional skills and knowledge throughout their careers through an entitlement to formal and informal CPD, including practice educator and/or specialist training as appropriate
• encouraging health visiting and school nursing teams to plan, reflect on and record CPD activity, using recording tools, such as an e-portfolio to log their individual and participatory learning to support NMC revalidation requirements
• providing opportunities to engage in reflective practice and review your learning and development needs

Promoting research based practice

Examples include:

• supporting health visiting and school nursing teams to make decisions and pursue actions that are informed by robust and rigorous evidence, so that service users can have confidence in the service they receive
• enabling health visitors and school nurses to work with others engaged in research and practice development activities in universities, professional bodies and professional organisations to develop the evidence base for good practice
• ensuring that practice educators are able to contribute to the learning, support, supervision and assessment of students on qualifying and CPD programmes

Developing leadership and networking

Examples include:

• ensuring that strategic leads for health visitors and school nurses understand and manage the organisational responsibility for this standard
• implementing formal partnership arrangements that promote and enable effective joint planning, shared communication and activities to further the delivery of health visitor and school nurse education and CPD
• supporting opportunities to engage in professional and informal networks to promote and share best practice and develop opportunities for joint research and evaluation
• having a clear policy for recruiting, training and supporting practice educators and practice development educators and mentors
• supporting staff to access qualifying health visitor and school nurse education and support through mentoring and preceptorships
• providing high quality placements and support for health visitor and school nurse students from qualified, experienced and supported practice educators
• providing funding for travel while undertaking duties on behalf of the organisation, and frequent supervision as agreed with the higher education institution and workplace
• working collaboratively with partner organisations to develop the skills and knowledge required to deliver high quality health visitor and school nurse education

Useful resources

Continuing professional development frameworks - Institute of Health Visiting

The code for nurses and midwives - NMC