The recent Rugby World Cup was the most competitive and best attended in the tournament’s history. But it also showed a sharp increase in the number of injuries. Rugby players are getting stronger and faster and the hits are getting bigger.
The increasing numbers of casulties and more evidence on the long term side effects of concussions experienced on pitch led Martin Rafferty, World Rugby’s chief medical officer, to suggest that sport’s rules should change to stop players returning to the pitch during a match if they suffer a head injury.
Statistics have shown that concussion is now the most commonly recorded injury in professional rugby union in England and is increasing in incidence.1
But more worrying perhaps is the trickle down of injuries to junior forms of the sport without medical supervision.
Research by Pollock et al compiling 25 studies on child and adolescent rugby concussions found that the incidence of concussions during matches ranged from between 0.3% and 11.4% for rugby union and 7.7% and 22.7% for rugby league.1 However, the researchers concluded that there needs to be more reliable data through routine monitoring and reporting in schools.1
A survey by the NSPCC in 2011 stated that nearly a quarter of children who play sports in school experience some level of physical harm.2
Research has found that a significant number of mild traumatic brain injuries are caused by accidents, from sports such as football, hockey and rugby.3
As young people’s brains are still developing the impact of a head injury can have lasting consequences.3
Theoretically school nurses are in a key position to monitor children for long-term side effects, both physical and psychological, following sports injuries and in particular head injuries.
But Mary Braine, a senior lecturer at the University of Salford and a nurse, says that this issue is not always on the agenda for school nurses. ‘Perhaps the guideline changes around the Rugby World Cup will help to raise the profile of brain injuries,’ she says.
Duties on injury protocol varies depending on the school setting that a nurse works in.
A state school, an independent school and a special school might treat the same injury in three discrete ways.
Marie Quinlivan, the medical centre sister at King Edward’s independent school in Witley, Surrey, says that ideally any nurse coming to work in an independent school should have minor injury training as it is a fairly large part of their job.
‘As for sports injuries that come through the door it could be a broken finger or a broken leg. We do have a certain amount of experience and training to be able to recognise injuries and when it is best to refer onwards.
‘We don’t really have a checklist that we have to go through when presented with an injury, we usually have to rely on past experience and our knowledge of managing injury.
‘For head injuries our protocol is to send them to the local hospital for an accurate check and then they will stay in the medical centre at the school overnight to be observed. We have the responsibility to let other staff in the school know that the child has suffered an injury and then to arrange any extra provision such as laptops, if they can’t write or leaving early from classes if they have a leg injury and need time to walk between lessons,’ says Ms Quinlivan.
Rosalind Godson, the professional officer for school nursing at Unite, says that school nurses in state schools do not have specific training around minor injuries, they have more of a public health and wellbeing role.
‘Instead the role of the state school nurse is to develop health and safety policies with school staff, so that they are equipped to deal with injuries when they arise.’
In the first instance the responsibility would come down to the first aider on duty. ‘All injuries would be recorded in a book which the school nurse would monitor whenever they come on site if they have the time,’ says Ms Godson.
Ms Godson does say however that nurses in special schools may have to have specific training around injuries based on a child’s personal care plan. ‘If the child has a condition which means that that they are injuring themselves on a regular basis the nurse will have measures in place to treat them.’
Due to the fact that school nurses take on more of a public health role, there are few resources available for school nurses specifically. However, Ms Braine cites the Headways website as a useful resource for nurses to be able to check for information on head injuries.
Working with other professionals
As the duties for school nurses for recognising and supporting injuries are so varied, Ms Quinlivan states that it is important that nurses have support from other medical professionals.
‘Working in an independent school means that we have good access to local hospitals and GPs who provide support for us if we had any concerns about a child. We are lucky because we have a good minor injuries unit nearby and we have regular meetings with the local GPs a couple of times a week,’ she said.
Ms Quinlivan says that they have to work within the facilities and the competencies that they have. She cites the lack of x-rays as one thing that can hinder their ability to properly assess injuries. She also states that the NMC Code requires nurses to work within their competencies and be able to understand when they have to refer on to consultants.
School nurses are also best placed to deal with injuries as soon as they occur but also to be aware of the long lasting physical and psychological impacts on the child.
Ms Braine points, in particular, to a minor head injury, which may not have a physical manifestation. ‘Instead there may be cognitive or developmental issues which they may initially be able to cope with.
‘For example while they are in primary school and they are used to the environment and the teachers it may seem that there have been no side effects. When they transition to secondary school, and they are in an environment that they are unsure of, that’s when the problems may re-emerge.’
Ms Braine, says this could flag up further issues of the relationship between primary and secondary school staff. ‘If staff do not communicate between schools, the fact that a child has had a knock may not be apparent to each other.’
Ms Godson says that school nurses in state schools, also do not have responsibility to monitor injuries once a child
is back in school. The school nurse will instead instigate an individual healthcare plan which will be drawn up involving all concerned.
The variation in school nursing roles means that children will have different services available to them based on the schools they attend.
It poses the question whether certain duties are passed on to other members of staff to cover up the fact that there are not enough school nurses per child. This could be why much of the responsibility is left with first aiders who will pass the responsibility on to parents, should the injury be more severe.
According to figures from the CPHVA in 2014, there were 1208 state school nurses in England for 9,419,100 children aged 5-19.4
The Royal College of Nursing’s school nursing conference in August 2015 also highlighted that there were not enough school nurses to combat the child health crisis and stated that Health Education England predicted that there was a 24% vacancy rate in this area of nursing.5
School nurses in different settings are expected to deal with head injuries in totally different ways, raising questions whether there should be a more standardised way to deal with them. Ultimately this highlights a two-tier healthcare system in schools that would not be accepted in society as a whole. Maybe it’s time to level the playing field.
1. Pollock A, Ofori-Asenso R, Parekh N,Kirkwood G. 2015. Concussion in youth rugby union and rugby league: a systematic review. British Journal of Sports Medicine. http://bjsm.bmj.com/content/49/8/506.full.
2.NSPCC. 2011. The experiences of children participating in organised sport in the UK. http://www.sportni.net/sportni/wp-content/uploads/2014/09/6-experiences_children.sport_headline_findings_wdf85012.pdf.
3.Braine M. 2013. Traumatic brain injury in children part 2: Recovery process and outcomes.
British Journal of School Nursing. http://www.magonlinelibrary.com/doi/10.12968/bjsn....
4.Halstead ME, Walter KD. 2010. Sport-Related Concussion in Children and Adolescents.
5. 121 Campaign in pictures. 2014. Unite CPHVA. http://www.unitetheunion.org/uploaded/documents/CP...
6. Press Association. 2015. Escalating child health crisis feared due to lack of school nurses. The Guardian. http://www.theguardian.com/society/2015/aug/24/chi...