6. School Nursing and Primary Care: The New Frontline?
6.1 Policy Context: School Nursing, Primary Care and the Need for Children’s Mental Health to Be ‘Everybody’s Business’
Over the years, and often in the absence of a formalized policy within the UK, nurses have been involved in children and young people’s mental health provision within both the school nursing and other primary care settings. This has not been without problems, as we will see, as School Nursing, a specialist area in itself, has primarily been directed at physical health issues within a public health setting, and therefore has traditionally been staffed by registered sick children’s nurses with a limited training in mental health (and sometimes a limited interest in the subject too). The growing need to support both school nurses, and also teaching and pastoral staff in schools (both state and private) was identified by Kurtz et al. (1994) in their study of the provision of CAMHS. This led to the idea that a new and specific group of CAMHS staff should offer consultation and supervision, as well as some hands on therapeutic work in the school and primary care setting with children and young people. With the publication of the ‘Together We Stand’ report (HAS 1995), the role of primary mental health workers (PMHWs) was born (alongside the Four Tier model of service provision), and whilst the PMHW role took a while to develop, it did take off and eventually most areas within the UK had some form of PMHW staffing, acting as a bridge between the frontline of primary healthcare and the more specialist provision of Tier 2 and Tier 3 specialist CAMHS. As time progressed, more questions were asked, mostly by managers who had less understanding of the impact that consultation and supervision could bring, as to why PMHWs were not more actively involved in face-to-face work. The growing influence of metrics in the NHS served to illustrate the number of contacts (face-to-face meetings) that PMHWs were having each week, which generally was less than the contact numbers that their colleagues in specialist CAMHS were achieving. Measuring the impact that PMHWs were achieving in terms of reducing referrals through specialist services, improving public health outcomes, and meeting the elusive goal of providing services at the earliest point of contact to avoid escalation, was far harder to demonstrate. Coupled with the fact that much of the funding for PMHWs had been provided in the rounds of additional public spending following the National Service Framework for Children in 2004 (the first year mandated spending on PMHW or preventative services, and was initially ring-fenced, so had to be spent on this area), the initial glow wore off. Sadly so did the ring-fencing of funds, which had been provided from the Department of Health in England, and that additional funding was absorbed into mainstream social care funding. When austerity hit the country following the banking crisis of 2007/8, and social care departments had to start making drastic cuts in what they were able to provide, the funding for PMHW service was soon lost, though the services struggled on in some isolated areas.
The idea that prevention is better than cure, and an improved general understanding of the mental health needs of children was, however, still being promulgated. The CAMHS Taskforce, set up by the Liberal Democrat Health Minister Norman Lamb, as part of the coalition government, maintained this preventative agenda in the publication of its ‘Future In Mind’ (2015) policy document. The recommendation within that document was that schools should have a much larger role in identifying and providing care, and that each school should have a mental health champion, in much the same way as they had been required to each have safeguarding leads, and Special Educational Needs Coordinators (SENCOs). What Future In Mind was not able to do, sadly, was to resurrect the concept of PMHWs, so a wide variety of different schemes have developed in the recent past to try and address the needs of Tier 1 provision of mental healthcare for children and young people.1
Although additional funding was promised for the implementation of Future In Mind recommendations, there was no ring-fencing of the money given to the commissioning groups, and there is some evidence (Young Minds 2018) that not all of this money did reach the frontline services, some being diverted to other health-spending priorities. Ironically, during this time, the provision of specialist school nursing services has also been under threat, and the pressures on the service make the role extremely difficult to perform (Children’s Commissioner 2016).
At the same time, the profile of children and young people’s mental healthcare has become more prominent. Whilst Young Minds and the Mental Health Foundation (MHF) had done a tremendous amount of work in the past, it was the adoption of royal patronage of the Place2Be charity that managed to bring more media attention to the issues, which other third sector organisations, big and small, had been striving to achieve for many years. Whilst the MHF had published the Bright Futures report (1999) describing children’s mental health as ‘Everybody’s Business’, and started to promote the idea that children’s mental health issues were far more widespread than had been previously recognized; it took a while before other parts of the children’s workforce started to think more psychologically and stop thinking that these were just ‘CAMHS’ problems. The fact that other charities and reports started using the phrase ‘everybody’s business’ to describe their own causes (i.e. King’s Fund 2008) showed the success of the concept, but rather diluted the unique message of the report. The readiness of the royal princes (Prince William and Prince Harry) to talk about their own mental health struggles as a result of losing their mother in tragic circumstances whilst they were still children themselves is commendable, and has certainly helped bring the importance of mental health in the younger age group into public focus.
6.2 The Timeline of the School Nurse
School nursing has changed considerably over the years, with the role of the school nurse needing to adapt to the changing environment and needs of children and young people. School nursing originated back in the Victorian era. The specific purpose of the school nurse was to improve children and young people’s health, especially those living in poverty and deprived areas. A key element leading to the development of school nursing was a report produced by the British Army (see Wright and Fanning 2014). This exposed the poor health of young men who were joining the army; it was found that between 40 and 60% of army volunteers had been found unfit for service. On further investigation by the government (who set up the Interdepartmental Committee on Physical Deterioration to identify the causes of poor health), it was found that it was not a general health problem, but young men were found to have treatable conditions, which had been left untreated, leading to considerable debilitating illnesses. As a result of this investigation, it was highlighted that not only could the young men not be enlisted in the Army, but also a large number of children were missing a considerable amount of their education due to taking high numbers of sick days. Therefore, it was deemed a matter of urgency to work with children and young people within schools to ensure that their health improved leading to less time away from education (Wright 2011).
This identification of need led to the start of school nursing. As this role began it was agreed that every child and young person should receive at least three medical examinations during their time of education, and clinics were run within schools to treat any health complaints found. It was acknowledged that a main cause of illness was poor nutrition and lack of developmental monitoring to enable problems to be recognised and treated early. Therefore, the main role of the early school nurse was to increase healthy nutrition and monitor the height and weight of children and young people throughout their developmental stages.
This underlying ethos has remained throughout the years, with the key role of the school nurse being to improve health and well-being of children and young people, to reduce the rate of child poverty and to safeguard children and their families. Alongside this, the introduction of vaccinations was established as healthcare progressed. School nurses became the lead in delivering vaccinations to high numbers of children within education. Whilst a number of these roles still resonate today within school nursing, there have also been some significant changes. It can be argued that from the beginning of the school nurse role, there has been a need to acknowledge a child or young person’s mental well-being as well as their physical. However, it is evident that this need has increased over the years with what was once a primarily physical care role becoming more and more about the mental and social well-being of our children and young people.
6.3 The Role of a School Nurse Today
School nursing today is viewed as a specialised area of nursing. It is not a stand-alone role but incorporates a team of nurses at varying levels with different experiences. School nurses make up part of public health teams and all school nurses are expected to engage in further community health study. As a result of this, school nurses today are often referred to as specialist community public health nurses (SCPHN). They work closely with other healthcare professionals such as Health Visitors. Ideally, school nurses should take over the care of children once they reach the age of 5 and start school. The school nurse is then responsible for their health and well-being until they leave school/college at 19. The aim of their role is to ensure that children and young people are given the best possible start in life enabling them to enter adulthood with optimal health.
Health development review—identifying targeted support that may be required to enable a child to reach their full potential in relation to both health and well-being. This should incorporate social care assessment of needs, risks and the choice of the child.
Healthy weight—provide dietary advice and monitor weight for signs of obesity or malnutrition. This should also cover dental health.
Targeted support—identify vulnerable groups and provide specific support for them. Vulnerable groups would include young carers, looked after children, young offenders, asylum seekers, refugees, those living in families where drug use or domestic violence was present, children at risk of abuse or sexual exploitation, and those at risk from female genital mutilation (FGM). Targeted support would also encompass early identification, support and training for complex health needs.
Sexual health and contraception—supporting young people to aid in the reduction of teenage pregnancies and sexually transmitted infections (STIs). This would include providing sessions on puberty, contraception options, pregnancy testing and emergency hormonal contraception.
Drugs, alcohol and tobacco—provide support and prevention of alcohol and drug misuse.
Emotional well-being—Supporting children and young people with their emotional health and well-being. Identifying when intervention and specialised support is required and referring to appropriate services.
Safeguarding—working within the multidisciplinary team to identify and support children and young people who are vulnerable to any type of abuse.
Immunisation—provide immunisations as required and continually reviewing immunisation and vaccine status of children and young people.
It is clear from this role breakdown that school nurses are responsible for covering a wide variety of health and social needs of children and young people at varying developmental stages. When considering the workload, mental health is only a small part of the extensive role. It has taken decades for mental health to be officially recognised within the role and even then, it is discussed in relation to emotional well-being. Mental health and emotional well-being are often used interchangeably; it is important that as healthcare professionals we recognise and acknowledge this, so that we do not misinterpret this as being different from mental healthcare. With this in mind, it is clear that school nurses are facing a significant challenge when identifying mental health distress and providing optimal support and care for a child or young person.
6.4 Challenges Faced by School Nurses When Caring for a Young Person in Mental Distress
It is evident that mental healthcare is not listed or even acknowledged as a predominant role of the school nurse. However, in practice, it is clear that this is a major factor requiring attention. Within the United Kingdom (UK), child and adolescent mental health is a significant public health concern (Membride et al. 2015). School nurses are frontline healthcare professionals often being the first person to engage with a child or young person experiencing mental distress. Working with children and young people to provide support in helping them to cope with the challenges of everyday life is a primary role for the school nurse (Sherwin 2016). Whilst medical advances have reduced the number of infectious diseases and illnesses in children and young people through vaccination programmes, the mental health of our children and young people has deteriorated over the years. It is believed that one in ten school-aged children and young people within the UK will experience a mental health problem (The Children’s Society 2014). Therefore, school nurses are viewed as being vital in ensuring that emotional support is provided to children and young people aged between 5 and 19 years aiding in the reduction of potential mental health illnesses or issues developing (Department of Health 2012).
Whilst school nurses are ideally placed to tackle this problem and provide support and care to children and young people in mental distress, there are a number of challenges that they face. School nurses can only address concerns if they are available and present within the school to do this. They are healthcare professionals working within an educational setting with limited medical provision available. They are required to work alongside teachers and support staff, who may have little knowledge of mental health and well-being. The environment within which they can see and assess a child or young person may vary significantly between schools, whilst also being inappropriate for the type of assessment required. This leads to the question, to what extent are these challenges present and how can they be overcome?
Throughout the history of the school nurse role, school nurses have usually been based within education settings. This was greatly advantageous in allowing the nurses to build positive relationships with staff and students. It enabled the nurse to be present whenever students were at school and meant that should a problem arise with a child or young person the nurses were readily available. When considering caring for a child or young person with a mental health illness or presenting in mental distress, it is of utmost importance that they feel comfortable with the healthcare professional and are able to trust them. This type of therapeutic relationship is often not established immediately but can take time and patience. When a school nurse is regularly based within a school, it enables them to build this type of relationship with the students easier, improving the likelihood of a student being able to disclose that they are struggling.
In some UK schools today, you will still find a school nurse based there permanently. However, this tends to only be in specialist schools, where children attending have complex health needs and require regular medical intervention. It is no longer normal practice for a school nurse to be based in one school. Current practice involves having locality teams and nominated leads for areas (Public Health England 2018). The locality teams will include Health Visitors and nurses, who are responsible for caring children and young people within a certain area, covering a number of schools and educational settings. Whilst this does allow a team to be developed, which incorporates a varied skill mix and nurses with differing specialist roles, it can take away the personal element of having one school nurse to cover a specific school. It has been highlighted that children and young people are often reluctant to approach their school nurse due to their lack of interaction with them (Pryjmachuk et al. 2011). Children and young people have expressed a need for school nurses to be more available at times convenient for them and their needs (Bartlett 2015).
Although this may appear like an easily resolved problem by placing school nurses back in schools, the complications around this are great. School nurses would often prefer to be in the schools working alongside teachers and engaging on a daily basis with the students. However, as we can see from the role of the school nurse, they have a very varied and demanding workload. Despite mental health concerns being viewed as high on the agenda, school nurses have to manage this within their given workload (Sherwin 2016). There are key challenges that school nurses have raised in relation to being accessible to children and young people experiencing mental distress. The three predominant ones are child protection (safeguarding children), lack of administrative support and lack of time (Membride et al. 2015). These three factors impact significantly on the availability of school nurses who have to tackle mental health problems. Child protection cases, involving case conferences and numerous meetings, along with the amount of administration work leads to a reduction in time for other activities. A number of school nurses feel if mental health education and support is to be improved within schools, there is a need to consider the provision of mental health advisors (Membride et al. 2015).
6.4.2 Role Clarity and School Provision
Another aspect of the school nurse role that can present as a challenge, when working with distressed children and young people, is their role identification. School nurses are healthcare professionals working with an education environment. The working relationship that the school nurses have with teachers and education staff within schools can vary greatly. Schools differ dramatically in their view and approach to mental health. In one school, teachers could have received training: about mental health illnesses, how to identify a mental health problem and management of illnesses. By comparison, another school may not view this topic as highly and use funding for other activities rather than mental health training for staff. This difference can occur within schools, all based in the same locality and overseen by the same team of school nurses.
When considering these different approaches that schools may take to mental health, it outlines how school nurses will have differing roles within schools. In a school where mental health is viewed with upmost importance, the nurse may be able to provide group sessions, work closely with education staff and actively promote positive mental health and well-being. However, when faced with a school less willing to engage, the opportunities for mental health promotion and awareness will be significantly decreased. It must be acknowledged that one of the problems can often be that teachers and educational staff also have high workloads and are required to prioritise workload in order to meet targets and outcomes. This can often lead to teachers having the same problems as school nurses: there is just not enough time or resources to effectively provide mental health support to children and young people.
Role clarity must also be made clear for students within schools regarding the differing roles of teachers from school nurses. As previously discussed, students often feel that they do not know who the school nurse is or what their role is (Pryjmachuk et al. 2011). For students to feel that they can approach a school nurse, they must understand their role and how it differs from all other staff members at the school. Children and young people can often struggle to see how the school nurse role fits into the educational setting, whilst having concerns that the school nurse will report any appointments back to the teachers. One positive way that school nurses and teachers could work together to improve this is by allowing school nurses to attend assemblies and speak to the students (Pryjmachuk et al. 2011).
As discussed, there are a number of things that can be done to help student awareness around who their school nurse is and what the role of the school nurse entails. However, even if a school is embracing all of these and is promoting the role of the school nurse, there must be an appropriate environment for school nurses to see children and young people. Children and young people in mental distress will often feel vulnerable, isolated and quite scared. Unfortunately, it is evident that a growing number of students are feeling this way due to an acute episode of mental distress or because of a mental health illness (Shapiro 2008). When a child or young person is brave enough to seek help, it is important that the correct environment is available for the school nurse to speak with them and assess them. Ideally, there should be a room in which the school nurse can see a student where they will not get disturbed. When considering best practice, this would be a dedicated room so that students can go there and also access information of support groups, etc.
6.5 Strategies to Aid School Nurses
It is evident that school nurses face a number of challenges when caring for children and young people in mental distress. They have a demanding workload with limited resources and time to meet the needs of the growing number of children and young people requiring support. However, there are a number of strategies and innovative ideas that have positively improved practice within this area across the UK:
6.5.1 Drop in Sessions
Through working with young people and listening to their wishes, drop in sessions have now been established in a number of schools. These sessions will often happen during the students’ lunch break and allow students to go to the session and see the school nurse without an appointment. This increases school nurse awareness and allows the school nurse to get to know the students (Sherwin 2016). Although these sessions are not long, they provide vital support for students and positively promote the school nurse’s role, whilst providing a safe space for students to discuss any concerns they have.
6.5.2 The Digital Approach
When faced with the challenges of time, resources and the need to provide cost-effective care, school nurses have started to take a digital approach to work with young people (Schuller and Thaker 2015). An instant message service is now being implemented in numerous areas across the UK. An example of this can be found in Doncaster where a team of school nurses set up e-clinics (Schuller and Thaker 2015). These provided an online confidential service for students to access Monday–Friday between the hours of 17.00 and 19.00. This service overcomes some of the previous challenges that have been discussed. It provides students’ access to support at a time more convenient for them, and they can do this through their electronic device making it much more accessible than having to physically attend an appointment.
ChatHealth is another digital initiative that has been extremely positive in improving the relationship between school nurses and students. ChatHealth has been designed for young people aged between 11 and 19 years old. It enables them to gain confidential advice from school nurses through a web-based text messaging service. This service is now being rolled out across the UK and recent figures show that one million students have already accessed this service (East Midlands Academic Health Science Network 2018).
6.6 Primary Mental Health Workers: History, Function and Methods of Working
As we noted at the beginning of this chapter, a new role was formed from the Kurtz et al. (ibid) research, which identified the gap between specialist CAMHS and the place where children and young people actually spent a great deal of their time, in school, or in contact with other primary care health services of universal social care services. The outreach function performed by PMHWs relied largely on skills available from specialist nurses, or from specialist children’s social workers, so in fact the majority of the PMHW workforce came from these two professional groups, with the addition of some other Allied Health Professionals (AHPs) from disciplines like Occupational Therapy, which also has a mental health focus, and a young person’s focus. Most NHS Trusts during this period were keen to mitigate risk in terms of employment by ensuring that they only employed registered healthcare professionals, which meant that these new workers were on relatively high Agenda for Change bandings (usually Band 6, equivalent to a ward sister/charge nurse in an acute setting), and this actually reflected the level of knowledge and experience that they needed. This can be contrasted with current developments, which include the employment of peer support workers, itself a valuable role, but one which does not require a state registered member of staff, and is usually on a lower banding and remuneration. Current efforts to recruit a new range of workers with a year’s training but no state registration will also result in a group of staff with no state registration, less experience and a lower banding than the PMHW group that they are destined to replace. Whilst the principle of increasing mental health support in schools is laudable, there are initially only seven trailblazer areas for the Mental Health Support Teams that the government has promised (DfE/DHSC 2018).
Workers in schools whose primary responsibility is for the mental health of the children and young people in that school or primary care setting also need to draw on a range of skills. Traditionally, as we have seen, PMHWs performed less of their role in face-to-face work, and concentrated on enabling school staff to work with young people directly. The rationale for this is largely based on the use of therapeutic relationships, understanding that school staff already have a relationship with the child or young person, which could be used to help them. As we have seen elsewhere in this book, therapeutic relationships take a while to develop, so a face-to-face approach may have some value, allowing the young person to develop a different sort of relationship with a healthcare professional, who is seen as somehow outside of the school system, and this may well be important for some young people who have developed a mistrust of that system, or who have experienced difficult relationships with school staff, which have centred on discipline issues and authoritarian principles. In this case, usually with older young people who have become alienated from the system, then the use of face-to-face work is important, and allows a health or care-based approach as the basis of that relationship. Nurses and others may choose in this case to emphasise their difference from the school system, they may not, for example, be primarily interested in the maintenance of discipline within the school. Whilst retaining an understanding of the need for rules, it is possible to look from a very different angle at the needs of individual young people, based on their pre-existing conditions (such as ADHD or ASD) and become an advocate within that system for creating change for that individual. This ‘othering’ from the system can be a quite powerful position, though may also need a set of negotiating skills that enable the advocacy to work within the system to create a new understanding of the young person’s health needs from an individual perspective. It may create conflict with the system, however, and trying to negotiate for an individual’s particular needs within some school systems can be challenging even for experienced nurses who may feel that their own knowledge and experience is not being understood or appreciated by school staff. This reflects very much what the young people themselves may be feeling, and that feeling of frustration with sometimes inflexible school rules and systems can be used to understand the young person’s perspective. A degree of personal awareness and reflective skills (as well as access to good clinical supervision) is important when working in these isolated posts, where a lone worker may spend a great deal of time as the only healthcare worker within a system, which has a very different perspective on how that system need to run, and be reacting to very different pressures of targets for attainment.
Being able to explain in clear terms what the needs of individuals and where these come from, in mental health terms, and from a healthcare perspective can be the biggest challenge for school-based staff. The ability to verbalise and articulate conditions, be they neurodevelopmental or based in anxiety or depression, for example, can be a challenge. This becomes a public health task, again one which should be familiar to nurses, of explaining the current understanding of health effects on children and young people. Teachers and other school staff are well-educated professionals, but their education and training has not traditionally included much on the psychology of young people, or their developmental needs. This may be surprising, but generally school teachers in secondary schools have completed degrees in a specialist subject, followed by a year’s training in teaching methods, focusing on educational provision and pedagogical technique. Those specializing in primary school teaching may have done a three year degree in teaching of this younger age group which includes some child development training, but again focused on how young people learn, rather than on their psychological needs or how mental health issues affect younger people. Teachers may well be trained in safeguarding children (child protection) and this includes a perspective of sociological understanding, but apart from the school’s safeguarding lead this may be limited to a relatively small amount of mandatory training. So whilst some staff undoubtedly have a very good understanding of the psychological lives of their students, many will have a relatively limited grasp of the effects on children and young people of life outside of school, and the attitudes displayed by some staff may reflect the prejudices of the general population. Psychoeducation or public mental health education therefore needs to be ready to challenge the attitudes of some staff who ‘don’t believe in ADHD’ or think that an autism diagnosis is an excuse for poor behaviour. Whilst public awareness has come a long way in the last few years, there remain pockets of very different ways of thinking about mental health within the general population, which may be reflected in school staff and others who provide primary care services.
On a more positive front, there are many teachers and support staff who do develop very good relationships with their students, and these positive supportive relationships can help to get children and young people through difficult parts of their lives. Teaching assistants now have a more formalized training, for example, and often support children with special needs through their school life, usually based on an understanding of the individual needs of young people. In primary and junior schools, where children are largely in class with one teacher for a whole year, this relationship can be fostered to enable young people, and provide them with the support they need. Traditionally, PMHW services would have provided the consultation and supervision to different teaching staff to guide them to understand these relationships and use them in positive ways to support individual need. Again nurses need to be able to understand how these supportive relationships can be used, and concentrate on the skills of empathy and listening, as well as maintaining a positive attitude to encourage the best responses from children. Passing on this skills-based approach within a school or primary care setting can be modelled, but is more likely to be something that needs to be taught in psychoeducational manner, which reflects the core understanding of educational staff. Teaching skills-based approaches, or getting staff to understand that what they may already be doing, based on an intuitive understanding, is actually a skill set in itself, and one that should be valued, is important, again articulating and verbalising the value of apparently simple skills which are often undervalued.
6.7 Third Sector/Charity Involvement
Whilst we have discussed the traditional primary care settings in which nurses work, schooling, both public and private, and elsewhere, NHS and private hospital settings, the landscape is changing and nurses have the opportunity to work elsewhere. The ‘third sector’ which includes charity and voluntary organisations includes an increasing number of nurse trained staff because the skills and experience that nurses bring are valued as useful. Within these settings, it is important to remember what role you are being asked to do, and how this affects your nursing registration. Childline, for example, is a national phone and online service for distressed children with a clear model of work and includes supervision. Nurses working as volunteers on this, or any other mental health charity, need to be clear as to what advice they are able to offer and use the guidelines of the organization for whom they are acting, rather than falling into a nursing role. At the same time, you would need to be aware that the NMC still considers you to be a nurse, even if you are acting in a different capacity, so some discussion of this potential clash with supervisory staff would be essential to avoid role conflict.
Likewise, working outside of the constraints of the NHS or larger providers means that nurses need to be aware of their vulnerability within an increasingly litigious society. Liability insurance, for example, is something most of us take for granted (it is provided by NHS employers and private providers as part of their responsibilities), but needs to be in place, and should be checked if working for a smaller organization, or if a private practice is established. Rees (2016) has identified some of the advantages of working in an entrepreneurial manner, including the flexibility and agility of smaller consultancy companies to engage in project work or training for a range of providers and commissioners. This level of autonomy can be very appealing or very scary, depending on your outlook.
Nurses work in a variety of primary care settings, or in universal care, but this means that they are working with a very different culture, which will have a different dominant culture and outlook. Priorities for the organization in which they are primarily located will not necessarily be healthcare focused, and the need to constantly argue for a different focus can be very wearing. Clinical supervision, and feeling part of the healthcare team is particularly important then you are physically remote from that team and culture for much of the working week. The level of autonomy and responsibility whilst working alone like this can be very freeing, and allows nurses to rely more on their experience and knowledge, but it can also be very isolating.