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A new term: what school nurses need to know

Paul Watson
Clinical Facilitator  Practice Educator CP Supervisor Northamptonshire PCT
Isebrook Hospital Wellingborough

For some children and young people, returning to school after the summer holidays or a break can bring feelings of vulnerability, anxiety and even depression. In this article, Paul Watson looks at some of the ways in which the changes they face can be made easier ...

“I don't want to go. I don't know what it's going to be like. The children will laugh at me. The teachers wont want me there! Do I have to go, can't I stay at home?”
“Stop being silly, the children will all be lovely and I am sure that the teachers will be delighted to have you there. You'll enjoy it once you get there and start getting used to it. I refuse to ring them and tell them that you're not going in; and besides, you have to go to school - you're the school nurse …”

At first glance, this may sound like a very poorly presented joke; but it is actually how I am currently feeling. I have just accepted a new role of Team Leader for Health Visiting and School Nursing in a trust local to me, with a proportion of clinical time in a small cluster of schools. I have the anxiety of moving to a new trust, managing a team of health visitors and school nurses, and forming new relationships with the schools I have just taken over.

As we get older and more mature (something my wife says she is still watching for in me!) we learn new things and develop new skills; although worries, concerns and anxieties will inevitably surface during times of stress. As adults, we can acknowledge that there are times in our lives that will induce heightened levels of stress, such as moving house, having children and changing jobs. We accept that these situations will occur and can be tolerant of each other's needs, often making allowances in the workplace or for family members.

If we were to treat everyone as we would like to be treated ourselves, we would hopefully be happy and contented at all times. This is usually the case when we are considering the needs of our co-workers and friends, but it is not often at the forefront of our minds when we consider the worries and concerns of children and young people.

We all expect children and young people to go through major changes each year, and yet we give their views and feelings very little thought, often just passing the comment, “We've all been there, just get on with it!” Every year, children start a new school or move into a new class, often with many other pupils that they may not know and teachers that they are unsure of; so it is no wonder that some children do not want to return to school following a six-week period at home.

Many children can suffer from complex and extreme forms of anxiety about going to school, with symptoms including stomach aches, nausea, fatigue, shaking, a racing heart and frequent trips to the toilet. Some children can experience separation anxiety and feel unable to contemplate being away from their main carer. Older children are often more likely to suffer from a form of social phobia where they are anxious about their performance in school, such as reading aloud or answering questions in class.

At first, many children are unused to having their entire day organised for them, and will often feel very tired by the end, resulting in further stress. After a long summer break or time off due to illness, returning to school can be traumatic, as the child may no longer feel at home there. Unfortunately, as is common for young people, friendships may have moved on or changed direction, leaving the young person feeling isolated and lonely.

It is not surprising that children can become used to being at home, enjoying themselves and being looked after. Feelings of insecurity can arise once they return to the scrutiny of their teachers and other school staff.

Influencing health habits
School nurses usually work very closely with their designated schools around many health and social issues and, as such, are one of the few groups of nurses who can influence the population's health before habits become ingrained.1

Primary school
When children enter reception class for the first time, they are bombarded by new and exciting experiences that will overwhelm, excite and confuse them. They are suddenly surrounded by more people of their own age than ever before, and new and strange adults telling them what to do. It is in this first year that a child will encounter the school nursing service, having a routine health screen along with the national childhood measurement programme (NCMP).

Within the primary school the school nurse will also be seeing children in year six to conduct the NCMP measurements. Therefore, it should be remembered by school nursing staff, along with other school staff, that this can evoke real feelings of anxiety and concern in pupils if not handled sensitively. Schools should consider the development of school-based wellness teams to advise and advocate improved school-based wellness policies, with school nurses taking an active part in these initiatives.2

For children who have anxiety over returning to school there is a chance that other issues may be causing upset in their lives. If these children are then confronted with a group of people suddenly discussing their weight this can cause them deep distress.

For children who are overweight there is a chance that this could largely be the result of many conditions within the child's social framework, including fast food advertising, increased portion sizes and reduced access to healthy produce.2 For these children, having their weight highlighted to all will not do anything for their self-esteem, especially when it is as a result of their social surroundings, possibly leading to feelings of low self-worth and a lack of social or school engagement.

Secondary school
When children move into secondary school there is a change in the style and type of learning. For many children this might be the first time that they have sex and relationship education (SRE) and will often suffer anxiety around this topic. These worries can stem from issues and discussions at home, or concerns over the delivery of the sessions.

Such anxieties are not necessarily unwarranted as many other authors have detailed that teachers themselves feel unprepared in their initial degree studies for their role as SRE educators, resulting in a lack of confidence delivering such information, compounded by a lack of specific training when in post.3-5

Unfortunately, where there are increased levels of unease over a subject, especially when it comes from both the teacher and the pupil, the learning opportunities will not be fully exploited. It is for this reason that Currie et al (2000) and Blake et al (2001) have suggested that the younger a child is when SRE begins, the fewer problems they will have in communicating about such issues, with this resulting in improved internalisation of values, beliefs and behaviours.6,7

Although this will not resolve the concerns that teachers have regarding the delivery of SRE, there is a school of thought that suggests this can be done by the use of other agencies. Day and Lane, for example, believe that school nursing teams have a significant role in enabling multidisciplinary collaborative working and co-ordinating programmes, as well as providing a consistent approach to involving the wider community, in an attempt to deliver the best possible provisions with the minimum of stress and anxiety to all concerned.8-10

With the child-centred public health role of the school nurse and their teams they will inevitably find themselves working with a wider range of health issues and population groups.11

Children with additional needs
Having considered all of the issues detailed above, I would like you to take some time to think about the children who very often drop out of service provision during holidays, or periods of illness. These are children in need or children with needs. Some will have additional physical or educational needs but others will have social and environmental needs, often being part of a child protection plan.

While many children will respond to the transition to a new school or a new year without much of a problem, some will not. With most issues being similar to those listed above, many children will manage without too many concerns. There are a small number of pupils, however, who will have the opposite reaction. These children will see the school environment and the staff they are used to as their “rock”, providing them with emotional, social and academic support that they will not get at home. When approaching a holiday or known period of absence from school, such children may become more withdrawn than normal or bad behaviour may worsen. Their fears can be many and complex, ranging from abandonment from school and staff, to the very real fear of what is to come at home for the next six weeks.

Being at school is a difficult time for any child and balancing the child's management and welfare is difficult for any parent or teacher; although this can be made even more difficult if a child feels vulnerable or alone.12 As members of staff working with children we must be very aware of the issues that make them excited, worried or concerned. Unfortunately, we are only human and tend to judge people on the type of job that they have, what colour their skin is, how old they are, where they live or their background.13

As we encounter children with issues about either coming to school, or finishing school, we should always try to treat them in the best possible way, whatever their background, and not be judgmental, giving everyone equal opportunities.14 It must be remembered that all children are a product of their upbringing and environment, and that we, as professionals, are in a position to help and guide, rather than judge and criticise.14

I am not suggesting that we single out any child for special treatment but that we remember that, while difference may be obvious, it is no justification for passing judgement on any individual.14 What I am suggesting is that staff learn to listen to pupils, as by listening to what is being said, how it is being said, and how the young person is sitting, looking or reacting, the staff can try to build up a full picture of that person. Hopefully, if there are any needs that are then identified by education or the school nurse this will be highlighted and that work can begin.15

I would just like to finish by saying that we are all different and although we will all go through similar experiences throughout life, the way that we will react to these events will be different. As professionals in health and education we must be open to the needs and desires of others, guiding and assisting where necessary, while supporting our colleagues to do the same. By being aware of the potential needs of children and young people before problems occur we can deliver proactive interventions that will result in far better outcomes for the individuals requiring them.

References
1. Watson P. Freedom to influence. Nurs Stand 2008;23(6):64.
2. DiNapoli P, Lewis J. Understanding school-aged obesity through participatory action research. American Journal of Maternal/Child Nursing 2008;33(2):104-10.
3. Ingham R, Carrera C, Hyde M, Jaramazovic E, Stone N. Exploration of the Factors that Affect the Delivery of Sex and Sexuality Education and Support in Schools. Final report. University of Southampton; 1998.
4. Estyn. Sex and Relationships Guidance. Estyn, Cardiff; 2007.
5. Walker J, Green J, Tilford S. An evaluation of school sex education team training. Health Education 103(6):320-9.
6. Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J. Health and Health Behaviour among Young People. World Health Organisation Policy Series. International Report. Copenhagen: WHO; 2002.
7. Blake SM, Simkin L, Ledsky R, Perkins C, Calabrese JM. Effects of a parent-child communications intervention on young adolescents' risk for early onset of sexual intercourse. Family Planning Perspectives 33(2):52-61.
8. Day P, Lane D. Sex education: lessons to be learnt from going Dutch. Community Practitioner 1999;72(8):259-60.
9. Cotton L, Brazier J, Hall DMB et al. School nursing: costs and potential benefits. Journal of Advanced Nursing 2000 31(5):1063-71.
10. Cooper P. A coordinated school health plan. Educational Leadership 2005;63(1):32-6. 
11. Watson P. Back to school. Nurs Stand 2008;22(20):64.
12. Watson P. How the school nurse can help schools and pupils with bullying. Term Times 2008;78:11.
13. Watson P. Who am I? Who are you? Nursing in Practice 2009;45:96.
14. Watson P. Political correctness has overlooked some groups. Nurs Stand 2008;22(43):33.
15. Watson P. A week in the life of a school nurse. Nursing in Practice 2010; 53:38-9.