IMPLEMENTACIÓN DEL PROGRAMA

According to DeBell and Tomkins (2006) there is a plethora of literature that identifies what the role of the school nurse is or could be in supporting young people. However, much of this literature relates to reports, non-statutory guidance for best practice or government policy drivers as opposed to primary source research that would help to build a firmer evidence base for the profession.

The Polnay Report (British Paediatric Association, 1995) highlighted that school nurses needed to work more proactively; but also needed to provide more support to those young people who are more vulnerable, such as those with long term medical conditions or in the ‘looked after’ system. In 1999 two key government

34 documents were produced which provided some clarity around the public health policy agenda and the role of the school nurse. Both Saving Lives: Our Healthier Nation (DH, 1999a) and Making a Difference (DH, 1999b), made it clear what was expected of school nursing services in relation to meeting the needs of children and young people. They also identified that it was an area of nursing that would benefit from further investment and development. In response to these key documents DeBell and Jackson (2000) proposed a national strategy for action in order to clarify the scope of role and to formulate a work plan to help services meet target areas. The strategy identified that the school nurse is often the first health professional to support and advise when a child or young person is emotionally distressed. They specified that school nurses with additional training could easily provide Tier 1 and possibly Tier 2 support as many young people did not require specialist interventions4_{. Yet once again this was non statutory}

guidance and was not adopted nationally.

Up until this time guidance was aimed at the providers of the school health service. Arguably this could be seen as focusing on the wrong group, as school nurses could easily articulate what support they wanted to provide. However, as much of their work is based in education which is a different organisation (Sherwin and Smith, 2009) it seemed to make sense to provide information directed at the stakeholders. In 2006 non statutory guidance was issued directly to the schools about what school nurses could offer (DfES/DH, 2006). One of the core functions of the role outlined in the document is that school nurses are able to offer

4_{The NHS Health Advisory Service (1995) recommended a four Tier approach to provide Child and}

35 “personalised support” and work with vulnerable young people on issues relating to emotional health, resilience building and self-esteem. The document proposed three levels of services that could be offered: basic functions, intermediate functions, and advanced functions. Although there are an increasing number of schools who purchase additional services relating to intermediate and advanced levels, which include the provision of ongoing intensive emotional support (Streeting, 2010).

Lightfoot and Bines (1997) used a qualitative approach to explore the role school nurses play in children’s mental health. In total 41 school nurses, managers and health authority purchasers were interviewed along with 27 teachers across 16 schools across the UK. Two research sites were chosen to try and reflect various socio economic areas, including urban and rural neighbourhoods, as well as differing proportions of minority ethnic groups. Whilst this may be considered a strength, making comparisons between findings is more challenging. For example, interviewing only one or two teachers in each school could have influenced the findings, as their level of involvement with the school nursing service may have been variable (Bryman, 2008). In addition 15 focus groups were held with parents and young people, although it is not stated how many were in each focus group, or the age range of the children/young people. There was no mention of how they were recruited or if any prior ethical approval was granted. This is surprising in a study involving children and young people as they are a vulnerable group within research terms (Parahoo, 2006). The study reported that even though teachers and nurses can play similar roles in supporting young people, school nurses can

36 make a distinctive contribution, as the support offered can be confidential providing there are no safeguarding concerns (Lightfoot and Bines, 1997).

In the same year DeBell and Everett (1997) conducted a mixed methods study which was much more in-depth and detailed, but only focused on one health authority in the East of England. However, the introduction to the study did attempt to locate the research within the national picture in order to provide some context. All 36 of the school nurses (total sample population) returned a questionnaire. The response rate for questionnaires sent out to 513 schools within the area was also impressive with 87.7% of schools returning information. Parahoo (2006) suggests that one of the main disadvantages of using questionnaires is that the response rate is often very low. This was not the case with this study, but there was no discussion offered as to why the responses rates were so high. Although one reason may be that the research team had a high profile as they shadowed the school nurses in their everyday practice and found that being a ‘listening ear’ for young people was a key role. There was also overwhelming evidence that school nurses regularly supported those experiencing emotional distress at school. They often tended to work beyond their contracted hours on a regular basis. Interestingly this was less likely when they were focusing on task orientated work such as screening and surveillance, but more likely when running drop in clinics and working with individual young people presenting with more complex and diverse issues (Debell and Everett, 1997). However, they also expressed concern that they did not feel they always had the skills to deal with extreme levels of distress associated with mental health problems.

37 The findings of a small scale quantitative study by Kari et al. (1998) were consistent with the findings of DeBell and Everett (1997). Yet the reliability and the validity of data could be questioned as the questionnaires were administered to pupils and completed and collected under direct teacher supervision. Despite this only 347 questionnaires out of 600 (58%) were returned. They found the role of the school nurse was not always fully utilised by pupils, and for them to offer more comprehensive support, further training was required (Kari et al. 1998). Notably some ten years later, Allen (2007) also found that school nurses were anxious about the level of skills they had. She set out to capture the experiences of school nurses providing support in drop in clinics. Purposive sampling was used to gather rich and in depth data involving twenty eight participants (Holloway and Wheeler, 2002; Holloway, 2005) utilising focus groups and individual interviews. The school nurses highlighted the need for emotional health support as the main reason why pupils attended the drop in clinics. Like DeBell and Everett’s (1997) study, Allen (2007) also found that extra training, as well as counselling skills, was needed by school nurses.

Brooks et al. (2007) offered a position paper critically examining the role school nurses play in helping young people navigate the school health journey. Supporting previous research findings (Lightfoot and Bines, 1997; DeBell and Everett, 1997; Kari et al., 1998; Madge and Franklin, 2003), the paper called for an expansion of the school nurse role, but one which is structured and clearly defined to avoid it becoming a ‘jack of all trades’ profession. In addition there was a call to raise its profile, so young people are aware of the ability of the school nurse to support their wellbeing and self-esteem, especially for those considered

38 particularly vulnerable and most at risk. Indeed O’Connor (2012) advocates that self-esteem should be taught as part of the school curriculum and that school nurses should be involved in delivery of the curriculum, as well as helping young people to formulate self-esteem concepts in order to build resilience.

Downie et al. (2002) conducted a small qualitative study of school nurses in Australia (n=9). Participants each kept a diary, which was analysed interpretively to identify the different dimensions of their role. Diaries allow for events to be recorded longitudinally either at or close to the time they occurred, providing a potentially more accurate viewpoint of the experience, which would enhance trustworthiness (Holloway and Wheeler, 2002; Munhall, 2012). However, they are reliant on participants actually completing them regularly, and potentially, participants may only record what they think the researchers want to know (Hawthorne effect) (Hansen, 2006). They may have wanted some aspects of the school nurses’ role to be more visible then others, which potentially could have influenced the findings. Nonetheless Munhall (2012) comments that any data collected historically must be seen as a translation of translations, and the subjective significance of the events recorded is consonant with the epistemology of qualitative research (Avis, 2005). In order to address the trustworthiness of the data, member checks were carried out to maintain a robust audit trail (Streubert and Carpenter, 1999). Analysis identified that provision of support was an important aspect of school nursing. Interestingly although identified as a separate category, it was highlighted that the provision of support and taking time to listen intertwined with all aspects of their role.

39 Concurring with Downie et al. (2002) is a more recent study conducted in Sweden by Morberg, Lagerstrom and Dellve (2012). The sample size was larger (n=39) and attempted to ascertain how school nurses experience their work in an educational setting. However, this study adopted an interesting stance by framing it in relation to Bourdieu’s (2000) concept of ‘capital’ (resources and power), ‘habitus’ (beliefs and values) and ‘field’ to provide a more in-depth theoretical analysis and academic debate. According to Bourdieu the concept of ‘field’ is the study of dominance differences between professional groups and the relationships that exist within social spaces. Interestingly the Nursing and Midwifery Council (2008b p.17) identifies that the three areas of nursing that are able to register as Specialist Community Public Health Nurses (including school nursing) are referred to as “fields of practice”. School nurses can often exist as lone workers within educational settings because their capital and habitus differ from teachers. However, this is often seen as strength of the role as pupils view nurses differently to teachers who can be seen to be authoritarian and disciplinarians (BYC, 2011). Application of Bourdieu’s (2000) work helps to understand the position of the nurse in trying to adopt a holistic approach, by providing support within a different professional hierarchical setting such as education.

As well as the provision of support, the importance of trust within the nurse-young person relationship was also highlighted (Morberg, Lagerstrom and Dellve, 2012). Within some of the closer relationships this was described as ‘mothering’, of which taking time to listen, often within conversations that occurred spontaneously, was fundamental. Yet the school nurses reported that just to ‘contain’ information without being able to help solve the young people’s problems was frustrating.

40 They described worrying about some young people when they were not at work. Morberg, Lagerstrom and Dellve (2012) appear to take a somewhat feminist perspective, suggesting that as school nursing is a female dominated profession, their ways of thinking and acting (mothering instinct) can emanate through into their practice. The authors suggest that despite being a small sample size and therefore not generalizable (Abbott and Sapsford, 1998), that this is typical of school nursing practice. As similar findings were reported by all the participants, who represented various locations across Sweden, this makes the findings potentially transferable (Parahoo, 2006).

Similarly Pavletic (2011) suggests such relationships are built on the need for some young people to have a positive attachment to a trusted adult. Young people seek out the nurse when they need reassurance, support, and comfort or want to just talk about their problems. However, Roehrig (1995) warns that school nurses need to be skilled in knowing when and how to terminate therapeutic relationships to avoid young people becoming dependent as opposed to empowered. Wilson et al. (2008) also explored school nurses’ experiences of working with young people with psychological problems. Out of 100 respondents, 22 reported that a lack of professional support and heavy workloads, impacted on not being able to build trusting and sustainable relationships and this caused feelings of isolation, frustration and powerlessness. A small scale qualitative conducted in Scotland which explored the range of mental health needs encountered by school nurses also highlighted that they felt they were well placed to build trusting relationships but often felt overwhelmed and out of their depth

41 and wanted more structured support and training themselves (Membridge, McFadyen and Atkinson, 2015).

SCENE 4: Impact of school nurses in improving outcomes for children and