School nursing profession demands support on children's mental health

While schools were closed for the summer holidays, the main unions representing school nurses were in full voice. Both the Royal College of Nursing (RCN) and Unite highlighted an urgent need to improve mental health training for school nurses across the country. "Mental health issues are so common that all school nurses should be formally trained to be able to recognise them and offer help and support in the early stages," said Rosalind Godson, professional officer of the health sector from Unite. "However, they also need training in order to recognise when the problem is serious and needs referral."

The RCN warned of a "child health crisis" given that school nurse numbers have fallen slightly in the last five years at a time when the pupil population has been growing, pointing out they "have a unique opportunity to improve mental and emotional health". It said the £2m cuts to public health budgets in England, announced earlier this year, meant school nurses were at risk of further depletion.

Their intervention on mental health is timely. The latest national data on prevalence of child and adolescent mental health problems is notoriously outdated, going back to 2004. Yet evidence that mental health issues are getting worse continues to mount.

Chris Leaman, media and public affairs officer at mental health charity YoungMinds, says young people are up against a "perfect storm" of pressures, including exams and body image. A survey this year by the Association of Teachers and Lecturers (ATL) found half of educational professionals believed the number of children with mental health issues had risen over the last two years. Almost 90 said their workplace has had to provide more support for these pupils over the same period.

The scale of the problem has put mental health at the forefront of public policy reform, with the government pledging to bring mental health services on a par with physical health. It has allocated £1.25 billion for child and adolescent mental health services (CAMHS) over the next five years.

Access to support

The previous coalition government's Future in Mind report, published in March this year, sets out national aspirations for children's mental health services over the next five years, and is being carried forward by the Conservative government. The report emphasises the need to improve access to support, and the importance of prevention and early identification. It states that all children and young people with mental health problems should receive timely and effective support.

Given they form a daily environment in young people's lives, schools naturally have a major role to play, and the Department for Education has issued guidance for school leaders on counselling in schools. The British Association for Counselling & Psychotherapy estimates that between 64 and 80 per cent of secondary schools in England offer some form of counselling.

But many children have no access to such a service. Yet school nurses surveyed in the RCN's last census in 2009 listed pupil counselling as one of their top five time-consuming areas of work.

Authorities appear to be queuing up to stress that school nurses have a major role in pupil wellbeing. Future in Mind states that school nurses "can play a crucial role in supporting the emotional and mental health needs of school-aged children". Separate guidance for school nurses from the Department of Health and Public Health England, says they have a crucial role in "positive mental health within a family context and in creating confident communities and brighter futures for all".

The Nursing and Midwifery Council, the regulatory body for school nurses, sets out in its standards for public health that school nurses must relate and respond to mental health needs.

Meanwhile, waiting lists for children to be referred to CAMHS are lengthening as a result of rising demand and reductions in funding, putting even more onus on effective prevention to avoid the need for intervention from CAHMS.

For all the recent pronouncements on school nurses and mental health, their training in this area is negligible. School nurses are confronted with a range of issues around safeguarding, substance misuse, smoking cessation and nutrition and exercise, which are underpinned by mental health and wellbeing.

Richard Cotton, a school nurse for the past 10 years, estimates around three-quarters of his cases are mental health-related. While mental health was "mentioned" on his qualification course, he says it was never a core area.

He says one-day courses are available from his local CAMHS, but these are far from required for continuous training and development as a school nurse.

Cotton outlines a lack of confidence as one of the main consequences of the lack of mental health training. "A child could come in and say they've been self-harming or thinking of suicide. When that happens the first time you think 'what do I do?'"

"You learn on the job, but you still walk away wondering if you've given the right information. You still have doubts, you think about what that young person will decide to do that evening after speaking to you."

Cotton says when a child first comes to him with mental health-related issues, he will run through a set of initial questions, treading carefully to find out the severity of the problem without "putting ideas in their head".

"One-day courses will give ideas around what to ask initially, but if you lined up a handful of nurses from different schools, I bet they would all ask different things", says Cotton.

Andy Bell, deputy chief executive at the Mental Health Foundation, says: "We need to equip school nurses with the right evidence-based research, and train them to identify children who need further support. But school nurses can't be all things all of the time. It is impossible to expect them to cover everything that could possibly be done. Mental health requires a whole-system response."

Mark Haddad, senior lecturer in mental health at City University London, conducted a study among a random sample of school nurses in 2010, looking into their views concerning the mental health aspects of their role.

Ninety-three per cent reported that they saw mental health as an integral part of their job. Haddad then carried out focus groups with four school nursing teams across London and Manchester. He found worries about a lack of confidence to be a common theme, as well as issues around training.

"Lack of expertise, knowledge and training was cited as a barrier to doing mental health work in all of the groups."

Continued training

Nadine Littler, a lecturer in school nursing at the University of Cumbria, says not only should mental health be more central to initial training, but school nurses should be given continued training throughout their career.

The one-year course she teaches is "quite compressed", she says.

"Mental health is covered," she says, but rather than having a dedicated module, it is a theme running throughout the course. Her research leads her to believe that mental health issues take up approximately 80 per cent of a school nurses' role.

Another solution, she says, would be to have a specialised mental heath lead for every area. "We need more staff to tackle early intervention, but there hasn't been enough school nurses for years."

Public Health England (PHE) says it is developing new e-learning to support school nurses, and uploading developments and training via its professional webinars. But there is no indication of more ambitious plans.

As the government sets out its five-year vision for improving children and young people's mental health, this is one professional group whose contribution appears to be currently neglected.

SCHOOL NURSE ROLE

What are school nurses?

School nurses are responsible for delivering the Healthy Child Programme 5-19, to pupils. They are the biggest workforce delivering public health to this age group.

What training do school nurses have?

They are qualified nurses who hold an additional specialist public health qualification, which is recordable with the Nursing and Midwifery Council and is a year-long course.

Who commissions and funds them?

Local authorities are responsible for commissioning public health services for children, which includes school nurses for both maintained schools and academies. Above this, directors of public health are the lead commissioners for school nursing services, which are funded from the public health grant.

What do they do?

School nurses work across schools to promote public health among children and families. Their work covers issues including sexual health, mental health, safeguarding, helping manage pupils' health conditions and immunisations.

IN NUMBERS

• 1,475 - qualified school nurses as of May 2015 (1,186 full-time equivalent)
• 7.5 - average number of schools covered by state sector school nurses, most typically one secondary and six primaries
• 1 to 26 - range in the number of schools covered by state sector school nurses
• 99% of school nurses are women

Source: NHS Hospital & Community Health Service monthly workforce statistics; and Royal College of Nursing school nurses census 2009