The need to be more consistently visible was a recurring theme in all eleven narrators’ stories. In order to provide support on a practical level school nurses need to be physically visible to the young people in schools, so they know who to contact and how to access them. This fits into Soja’s typology that Firstspace is physical space. Offering a service where support could be accessed regularly and consistently is crucial. Although support maybe a one off contact, the increasing complexities of young people’s emotional health needs, suggest that support often needs to be provided consistently and regularly over a period of time (CAMHS, 2008; Pryjmachuk et al., 2011). The need for direct human contact (Gray, 2009) and therefore physical face to face accessibility to the school nurse was seen as essential. The importance of physical face to face accessibility which is consistent in order to provide care is also supported in the literature (Allen, 2004; Allison et
al., 2007; Gray, 2009; Owen et al., 2010; BYC, 2011).
Locating their practice in schools means school nurses are where young people would expect to find them on a routine basis. Running regular and routine drop in clinics in schools each week can afford an easy access point to consistent support. This also acts as a source of familiarity and provides a material grounding for practice to operate. Indeed Soja (1996) describes Firstspace as a place of continuity and cohesion, where repetitive routines of everyday life and activity take place. However, as there are conflicting demands on their time, school nurses need to consider how they can maximise their potential in schools. They usually have a number of different schools on their caseload and so are not able to be
113 based in just one school. Therefore the practicalities of providing support regularly in Firstspace can be challenging.
A national study conducted by Chase et al. (2010) indicated that allocating physical space in schools for school nurses to work in was often a problem. They were reliant on schools allowing them access to pupils as well as space in which to work. However, these physical spaces may be removed at short notice; for example booked for a meeting by the school. Restricting physical access to accommodation may result in inequity, feelings of marginalisation, and undermine a sense of identity and status (O’Toole, 2010). This gatekeeping function is described by Joanna.
“Some schools I have not been into this academic term. They don’t want and haven’t asked for any input so I haven’t been. This makes me feel I am not wanted or valued” (Joanna 1:7).
These feelings of powerlessness and marginalisation are also discussed in more detail within Secondspace, highlighting the blurred boundaries depicted in Figure 6 (page 110). Despite this narrators also described examples of positive collaborative working relationships with school staff, working harmoniously together within the school’s physical environment.
“The school staff are fantastic…cos they’re very good at spotting, on the whole, you know who’s got an issue and then point you in the right direction or they…advise young people to come and see you the drop in (clinic)” (Susan 3:15-18).
However, in terms of being physically available in schools, Susan identified another challenge relating to working part time and with a high caseload:-
“I have a Senior school and five feeder primary schools but I only work 22 hours a week and in fact my base is 23 miles away from my caseload so, do the maths!” (Susan 4: 1-4).
114 Like Susan the majority of school nurses are based in health centres and have a number of schools on their caseload (RCN, 2005). Therefore they can only be available at set times within a school, thereby reducing potential access to young people. Yet adolescents who do not have access to appropriate health care services are at greater risk of physical and mental illness (Kisker and Brown, 1996; Young-Bradford and O’Sullivan, 2007). Milly and Daniella illustrated the challenges of providing access for young people;
“I would ideally like to spend more time with her than I am able to do, cos I’m only there once every 2 weeks at lunchtime. I would like to see her weekly really but I know I haven’t got the resources to do that” (Milly
5:17-20).
“There are…families that all you can do is telephone support and you feel that actually I haven’t done what I would have liked to do because of the constraints of your workload” (Daniella 10:13-14).
In 2004 the Department of Health published guidance for school nursing services. It recommended that each qualified school nurse should have only one secondary school, plus a cluster of feeder primary schools and they should be supported by a skill mixed team of staff (DH, 2004b). However, as the money was not ring fenced this recommendation did not come to fruition; leaving school nurses feeling frustrated (UNITE, 2009). Current changes within education may offer a potential opportunity to increase accessibility to the service. The move to Academy status provides schools with more flexibility in the way they can spend their budgets, and a small number have recently chosen to purchase additional school nursing hours (DH/DCSF, 2009; Streeting, 2010).
115 Once support was initiated, it was important to the narrators to provide it consistently, and not let young people down because other workload commitments had a higher priority.
“It is important to be able to consistently work with young people.
Problem is we end up having to let them down sometimes as we are called to a child protection conference and so have to go. But young people don’t work like that. If you say I am going to see you next Thursday at 1pm that’s what they expect” (Joanna 1:36-39).
The configuration of caseloads, often by schools’ geographical location or in line with Local Authority cluster arrangements, may also be described as Firstspace. The need to work consistently in a caseload, where at all possible, was also important in providing continuity and a service that was dependable. In addition this is cited by the young people themselves as what they want (British Youth Council, 2011).
“I think it’s quite important to stay in the same caseload for a couple of years….there was a lot of changes before I came…because of staffing issues. The school has said to me …we’re sick of the changes we never know who’s coming and the pupils don’t know and it’s important for the pupils to recognise you when you walk round the school. If I go into another meeting on different dates to my appointments for drop-in, lots of people know that I’m the School Nurse because I’ve been there now for 3 years” (Jackie 6:15-23).
“It’s the fact that I was aware of their vulnerability…I was able to know a lot about their background, a huge amount about intimate details to do with them, I think that was really helpful” (Susan 2:20; 2:25- 27).
A sense of ownership is derived from a consistent availability and familiarity was as important for the narrators as it is for young people in accessing school nursing services (Kelly et al., 2005). Laura (10: 9) believed that working consistently in a caseload was very important. She was “very protective of my caseload, yes very
116 schools, young people and their families. Jackie concurred saying she felt it was important to have the same caseload for at least a couple of years (6:15).
Inconsistent support or changing personnel each week runs counter to this. The NHS pledged repeatedly, within children’s services in particular, to address this by improving the young person’s healthcare journey, listening to their views, respecting confidentiality and reducing the need for repetitive recounting to different professionals (DH, 2005; DH, 2013b; HM Government, 2013). Some school nursing services introduced corporate caseload working in order to try and cope with large unmanageable caseloads (Sutton, 2004). Thereby moving away from a named nurse per school model, with referrals being allocated on the basis of need and school nurse capacity. However, anecdotal evidence suggests this has not been successful. Nonetheless in order for the young person to initiate support at the outset they need to know where to access it and from whom. Being visible was an issue that many narrators highlighted as fundamental to whether young people accessed available support. The visibility of the service has long been a key issue, which is largely due to the relatively small workforce (While and Barriball, 1993; Lightfoot and Bines, 1997; Sherwin and Williams, 2007; BYC, 2011). Several narrators discussed how they try to raise their visibility with the young people, including putting up posters, speaking at assemblies, working more collaboratively with teachers and other staff, such as home liaison personnel, GPs, and social care who could refer young people to them. Laura spoke about how she felt it was important to create opportunities to meet parents and young people, by being in the playground when parents are collecting their children, walking around school, or being known in the community, so she becomes a familiar and visible presence
117 (4:6-10). Milly described how she walks around the school at lunch time to raise her profile. She used this approach to also make contact with a particular young person she is supporting whose mum regularly misuses alcohol.
“…before I do a drop-in at a Middle School, I always walk around school just so they know I’m there. I spotted her and I said “oh, could you come and have a chat with me,” and I just asked how she was and told her that I knew what had happened. She looked very tired and she was talking about her Mom again. She said her Mom’s come out of hospital, but she is really worried about her” (Milly 3:26-27; 4:1-5).
Joanna reflected on what it means to her personally to be recognised in schools. She felt it was important to be visible and that physically being in the schools more can aid this.
“It is so important to be in your schools and visible to them so they recognise you and say Hi Jo when they see me in school. That means a lot to me” (Joanna 3:1-2).
Cara recounted that when she was more visible, this led to more contact with the young people.
“We have contact with hundreds of children you know particularly at assemblies…... I mean I don’t remember the children and automatically know who they are but they will remember you…. I think that they then feel comfortable coming to drop-ins…they know you” (Cara 2:13-17).
The British Youth Council (BYC, 2011) identified that young people themselves also want school nurses to be more visible. In response to this some school nursing services are reverting back to wearing traditional nurses’ uniforms to heighten their visibility and raise their profile (Sherwin, 2015), although this was not directly referred to within the stories.
118 This theme is noteworthy in that being physically available to young people, providing direct face to face human contact, is a practical problem as the current low numbers within the workforce make this challenging.
Secondspace / Conceived Space
In contrast to Firstspace (perceived) which is concerned with practicalities, Secondspace (conceived) is described by Soja (1996, p.79) as being an imaginary intellectual expanse “conceived and comprehended essentially
through thought”. This space is deemed within Figure 6 to relate to the
‘practice’ of school nursing in providing support and what ‘ways of thinking’ (thoughts of the mind) influences these ‘ways of doing’ (Royal College of Nursing, 2014). Once again this framework, offers us the prospect of exploring further common elements emerging from the narrators’ stories. Soja (2006) proposes that it is the conceived imaginary space that may best explain the social world (such as school nursing practice) as opposed to the empirical definitions of physical and material space that are associated with Firstspace. The identified themes of agency, structure and emotional investment are situated within Soja’s (1996) description of Secondspace (conceived) deemed to be the practice of nursing. Locating school nursing practice within this space (Figure 6) is useful in order to advocate improvements in social and spatial justice for young people through the consideration of better ideas and good intentions. It is how the school nurses imagine themselves in providing support which is the key feature of Secondspace.
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