Many participants struggled to find a balance between being highly accessible to young people and having uninterrupted clinical time for responding to young
the kids coming in, knocking on the door crying” (P26). Both accessibility and
uninterrupted clinical time had implications for the problem of untenable burden. Accessibility meant: “I never have to turn a child away, whereas I feel other people
have to turn them away for things” (P27). Conversely, uninterrupted clinical time made it possible to investigate presenting concerns more thoroughly, and helped uncover the nature of young people’s wicked problems: “time is what you need with adolescents and mental health, to establish relationships for them to tell you more about what’s going on” (P14).
Although many participants reported that they had autonomy and control of their time working in the school, this was not the case for all. Some participants did not have a great deal of autonomy or control of their time because the school demanded a highly accessible nurse, often for the purposes of responding to minor first aid and injury: “I was seeing a minimum of 20 students per day, up to 30 students per day… easily 15 of those would have been first aid issues. Anybody that was sick was sent to me” (P21). A lack of control and autonomy over time had significant implications for the scheduling of uninterrupted clinical time, an influencing condition that is discussed further in ability to function in the school.
Where participants had autonomy over their time they were divided as to the most optimal level of accessibility versus uninterrupted clinical time. Time was a finite resource so as accessibility increased, uninterrupted clinical time decreased. Some participants did not like to limit their accessibility, because they perceived that presenting for help often required courage: “when they need something, when they get that courage up to go and tell somebody, they want that person to be there” (P6). The same participant described observing how a young person could struggle with the help-seeking process, highlighting the importance of accessibility:
He walked up to my office, he turned around and walked away. He walked up, he turned around and walked away. He walked up and he threw open the door and said “I need to talk to you, I have a really embarrassing problem.” I could see his decision-making. Am I, aren’t I [going to go and see the nurse]? (P6)
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Participants who articulated a preference for prioritising accessibility over
uninterrupted clinical time reflected that young people tended only to present in
crisis: “it’s all fighting fires really, the kids who come through crying” (P26). For this reason, many participants perceived that any reason was essentially a good reason for young people to seek out the school nurse: “if you're feeling sad or you’ve got worries or you’ve got problems at home, anything, you can always come and run it by me in the first place” (P28); “we’ll accept anyone wherever [they’re] at. Come in and talk” (P27); “we always just have that open door policy. ‘Come on in’ is what we try and do” (P22).
The disadvantage of prioritising accessibility over uninterrupted clinical time was that participants with a high degree of accessibility often found it difficult to manage their time: “you just can’t [manage your time easily], because these poor students are standing there distressed” (P26). Another participant explained:
We put forward [that] the health centre is a really safe place to come to and you will get kids [who have] nowhere else to go. They want to talk to you, and they want to tell you that Mrs So-and-So’s said this to me, and I told her to eff-off [offensive phrase], and now I'm a scared rabbit and I don’t know where to go. I'm [like a deer] in the headlights, I've come to you. (P7) By contrast, participants who sought to prioritise periods of uninterrupted clinical
time perceived that this was essential to addressing wicked problems, because this
was necessary to elicit a highly detailed understanding of the young person’s life: [In] that first session… we discussed home… that his biological mum left him when he was three. [We talked about] the difficulties and fights at home with his dad… then we got on the subject of education… the behavioural issues and the suspensions… [Outside of school he was] getting involved with adult-orientated activities with fake identification. Trashing places, [he was] very lucky he’d not been caught by the police doing any of these things. He was the eldest Muslim boy in the family, so cultural issues as well and exploring those. We looked at sexual activity, which he was very open with.
He was dealing with a lot of different issues, and very at-risk of going down a really dark path in regards to his outcomes for the future. (P30)
Regardless of the way participants balanced uninterrupted clinical time against
accessibility, it was evident that time was in short supply. Participants frequently
articulated that demand outstripped nurse availability: “you could have three students asking to see you in one morning. You know they’ve all got difficulties and you haven’t got time, because you’ve got other things to do” (P29); “the huge amount of kids that need to be seen. Whether they’re referrals or they’re knocking on the door crying, when our books are full” (P26); “everybody now is spread very thin” (P24); “[The school health service is] so stretched now, it’s more a consultancy role … [there’s no] time to actually … do anything” (P14).
A lack of time aggravated the problem of untenable burden, because participants felt unable to provide adequate clinical services to those who needed it: “time [is the barrier]. Sometimes, you’re very busy. You can’t [do what you want to do]” (P29); “now that [a nearby secondary school] is down a nurse, we’re pulled from our school to go there as well. Now we still have the same volume of work at [current school], but less hours, so it’s very stressful” (P26).
This section concludes the first condition that influenced the experience of untenable
burden, conceptualised as the capacity to engage with wicked problems. While this
influencing condition strongly influenced participants’ willingness and ability to elicit the difficulties young people experienced, case, clinical and professional
support determined the degree to which participants felt supported in their clinical
interventions with wicked problems. This influencing condition is considered next.