In Tower Hamlets, a training programme has improved the way school and nursery nurses address mental health issues in children and young people
Many schoolchildren experience mental health problems, which school nurses are in a good position to detect and address early. However, staff need support and training in managing the emotional wellbeing and mental health of children and young people. This article describes a training programme designed to help school nurses and nursery nurses in Tower Hamlets to integrate mental health into their physical health interventions. The training promoted a bio-psychosocial model of health and a relational approach to communication. It has had a positive impact on nurses’ practice, in particular helping them to understand and engage with mental health issues in children, young people and their families.
Citation: Gibbons J et al (2019) Training to help school nurses address children’s mental health. Nursing Times [online]; 115: 3, 19-21.
Authors: Jane Gibbons is clinical psychologist; Lucy Marks is chief executive officer; Ruth Cohen is nurse and clinical director; all at Compass Wellbeing. Stephen Abbott is honorary senior research fellow, School of Health Sciences, City, University of London.
- This article has been double-blind peer reviewed
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School and nursery nurses can play a key role in promoting resilience and emotional wellbeing in children and young people, but they often feel ill-equipped and undertrained for that role. This article describes a training programme designed to help school and nursery nurses promote pupils’ emotional wellbeing and good mental health.
School nurses and mental health
There are high rates of mental health problems in children aged 5-16 years. Potentially, three children in every classroom in the UK have some form of diagnosable mental health condition, including anxiety, depression, a conduct disorder or an eating disorder (Green et al, 2005). However, fewer than half of those in the UK who experience clinically significant mental health difficulties receive appropriate and timely help (Khan, 2016).
School nurses can play a key role in promoting resilience and emotional wellbeing in children and young people (Department of Health and Department for Education, 2017). Engaging with them in the non-stigmatising environment of the school – as opposed to a child and adolescent mental health service (CAMHS) – they are ideally placed to address mental health issues. Public Health England (2016) highlights the impact that school nurses can have on child and family health and wellbeing, while the National Institute for Health and Care Excellence (2013) advises that primary and secondary schools should be supported to adopt a comprehensive whole-school approach to pupils’ social and emotional wellbeing.
Many school nurses feel under-equipped when pupils present with mental health issues. Haddad et al (2010) showed that, although school nurses consider mental health to be a key part of their role, it is one that takes up a disproportionate amount of their time and for which they feel undertrained. Compass Wellbeing is a social enterprise in Tower Hamlets, East London. In 2016, 28 school nurses and nursery nurses from Compass Wellbeing took part in a training programme designed to help them integrate mental health into their physical health interventions. This training was part of a wider transformational initiative. It was jointly funded by the Burdett Trust for Nursing and the London borough of Tower Hamlets. Compass Wellbeing worked closely with a research team at City, University of London, which evaluated the training.
Like the pupils with whom they work, school nurses and nursery nurses need to be listened to and understood. For our training to be effective, we had to listen to these nurses’ concerns and understand their work context, the systems issues they faced and the emotional impact of their work.
We conducted a comprehensive training needs assessment through an introductory workshop on communication skills, observation of clinical practice and a staff survey. Box 1 outlines the training needs and concerns that emerged.
Box 1. Key concerns and needs of staff
- Developing role in mental health will increase workload
- Emotionally demanding work
- Anxiety on opening conversations about mental health, fear of saying the wrong thing
- Little time and space to carry out responsibilities, including limited private space for confidential conversations and a lack of mental space to process the work
- Role is misunderstood/not seen by others, which inhibits having a joined-up approach with families and teachers
- Training in emotional wellbeing/mental health of children and young people
- Support to manage angry parents
The one-day communication skills workshop took place in September 2015 with 34 staff (16 school nurses, nine nursery nurses, nine support workers/administrative staff). In November and December 2015, live observations with two nurses conducting health assessments of children with asthma and eczema, and of two nurses delivering a human papillomavirus vaccine clinic for girls. The observers made notes on the following themes, which were used to inform the training content:
- Location and environment of the assessment or clinic – Did it take place in a private space affording confidentiality? Was it was interrupted (and, if so, how many times)? Was the nurse set a clear time boundary?
- How many times emotional issues and mental health were attended to and how many times the nurse missed an opportunity to talk about them;
- How many times the nurse used active listening skills.
Structure and content
The training programme was delivered twice (January-March 2016 and June-July 2016) by two senior clinical psychologists at community venues in Tower Hamlets. The second cohort was condensed within the school term. The training lasted for six days in three two-day blocks. In total, 28 staff (19 school nurses, nine nursery nurses) took part. Box 2 shows the contents of the programme. Learning was through presentations, videos, large- and small-group discussions, and skills-based learning using role play. Colleagues from CAMHS explained their service offer and how to make referrals.
Box 2. Training content
- Vulnerability, identifying problems, resilience and protective factors
- Attachment theory, systemic theory and emotional wellbeing
- Specific mental health difficulties, misconceptions, attitudes, stigma
- Bio-psychosocial model as an alternative to a diagnostic approach to mental health
- Referral pathways and how to make effective referrals
- Professional networks and systems, application of attachment theory and concept of a secure base at work, effective partnership working
- Reflective practice and supervision
Skills-based learning through role play
- Creating the structure for a helping relationship – setting limits to an appointment; maintaining boundaries; managing endings
- Communication skills – listening as an intervention; listening to understand; managing difficult emotions in an appointment; talking to children, young people and parents about a sensitive issue; referring to other services such as child and adolescent mental health services
- Learning from one’s own feelings and reactions – use of self in work
Between the two-day blocks of training, participants were given homework tasks comprising reflective and observational exercises. Participants were given private journals to record these exercises, alongside any other reflections on the training. During training sessions, they were encouraged to share reflections and feedback on a ‘talking wall’; this allowed staff to provide in-the-moment feedback during sessions rather than waiting until the end of training when rich data can be forgotten and lost. Comments were written on sticky notes, which were stuck to the wall throughout the training. Feedback was guided by themed questions, with participants writing free text when issues particularly resonated for them.
To help consolidate and embed learning, the training was followed by mandatory reflective practice groups that met monthly for 90 minutes. Participants were required to bring cases for discussion, which gave them an opportunity to talk about and share practice. The reflective practice group sessions helped them to continue developing their skills and manage complex issues in their caseloads. This had an impact on the wider team, helping the wider transformational change programme to take hold. The reflective practice groups are not currently provided but we hope to reintroduce them in the future.
The training was underpinned by a whole-systems approach, in which staff training is a component of wider transformational change – this is more likely to lead to sustainable change (Fixen et al, 2005).
Learning and impact
The impact of the training was measured in a variety of ways, with positive feedback and findings. Shortly after completing the training, participants were asked to complete an online survey. About a year later, they were contacted again and asked to send free-text feedback; a sample of 10 nurses took part in face-to-face interviews. Participants reported that the training had had a positive impact in several areas, including the skills, confidence and workplace culture; these are outlined in Box 3.
Immediate learning points and reflections were collected during training via the talking wall. These came to be known as our ‘Aha’ moments, which occurred as participants gained a framework to help them understand – and put a name to – their experiences with children and young people or went through conceptual shifts in their understandings: “Aha! Now I get it!”, “Aha! Now it makes sense!”.
Box 3. Participant feedback: positive results of the training
- Increase in confidence, knowledge and skills in managing emotional health
- Increased integrated working with other services
- Shift in thinking: considering mental health beyond a diagnostic model
- Enhanced ability to open difficult conversations, leading to an increase in effective referrals for mental health problems
- Changes in practice – using active listening to engage and build relationships
- Changes in culture – applying ideas from the training to interactions with colleagues, particularly teachers
Understanding of mental health
An example of this relates to a shift in thinking about mental health. We encouraged participants to think beyond a diagnostic model of mental health and use a bio-psychosocial, formulation-driven model to help them make sense of the distress presenting in an individual child within their wider family system. We used the metaphor of an onion: each child and parent can be understood as being wrapped in many layers of influence, and these layers can be peeled off to gain a richer understanding of the person. Participants connected with this idea and, from then onwards, made direct reference to “using the onion” to help them think about complex cases and the multiple influences on a child’s emotional and physical wellbeing.
This shift in thinking initially felt counterintuitive to staff who, first and foremost, saw themselves as working within a medical model. However, as the trainers drew on case material that could resonate for all, staff quickly embraced a more holistic way of thinking. As one nurse succinctly put it: “So, it’s not what’s wrong with you, but what’s happened to you.”
Participants said this conceptual shift pushed to be more curious about the context of distress and the lives of their clients, which led to greater understanding and empathy for others in the family, particularly parents. They reported finding it useful to keep this framework in mind when conducting a health assessment with a child or having a meeting with a (potentially angry) parent. They also reported being more mindful that parents may also be struggling and have their own mental health needs.
Another important ‘Aha’ moment relates to a shift in practice towards a more relational approach to communication. Participants made a conceptual shift in terms of their role, realising that active listening can:
- Be productive;
- Help to engage pupils and families;
- Facilitate meaningful relationships with them.
As one participant said, active listening is “not just doing nothing”. It may enable a child or parent to feel really understood, possibly for the first time, which will increase the likelihood of further engagement with a nurse and other professionals.
Participants expressed concern that they would need extra time to use this approach but they understood that, if it was used effectively, earlier and resulted in more effective engagement with children and families, it could save time in the long run.
Positive changes in practice
Participants described increased confidence in using communication skills, which has enhanced their practice, helped them to talk to parents and to open potentially difficult conversations about emotional health. They reported being able to take a more curious stance during health assessments, moving beyond a ‘tick-box’ approach.
One nurse talked about remembering “that others have a story that you can’t see – there is more going on than you realise”. Others reported they were more able to see other people’s points of view. As one stated, it helped them “keep in mind everything that is happening for this person, understand where others are coming from and be aware of the emotional state of children, parents, teachers”.
Furthermore, participants reported positive changes in their conversations and interactions with other professionals, particularly teachers. This included, for example, being more mindful of the pressures a teacher might be under and how that might affect the interface between schools and the school health service.
The training has enhanced the knowledge, skills and confidence of participating school nurses and nursery nurses in managing children and young people’s emotional health and wellbeing. Participants reported:
- Important shifts in their understanding of why and how children and young people might experience mental health difficulties;
- Improved skills and greater confidence in talking about mental health with children, young people and parents;
- Greater confidence in making effective referrals for specialist mental health support.
It is widely recognised that health visitors need training to manage service users’ mental health and emotional wellbeing, which is a core part of their job (Bishop et al, 2015). This is also an essential training need of school and nursery nurses; in addition, it is a way for nurses to integrate mental health in the physical healthcare setting.
The research team at City, University of London conducted out a full evaluation of the training. The results are being analysed and will be used to improve the programme. We hope to provide ongoing training in future and roll it out more widely.
- School nurses are well placed to promote and manage emotional wellbeing and mental health in children and young people (CYP)
- This training programme had a significant impact on nurses’ confidence, knowledge and skills in identifying and managing mental health issues
- Reflective practice after training is key to consolidate and embed learning
- Using a bio-psychosocial model of health enhances awareness of mental health issues in children, young people and their families
- Active listening helps school nurses build meaningful relationships with this group
- Acknowledgements – The authors would like to thank Meghan Buckley for her unwavering support throughout the project and Fiona Starr for her invaluable contribution to the design and delivery of the training programme.
Department of Health and Department for Education (2017) Transforming Children and Young People’s Mental Health Provision: A Green Paper.
Fixsen D et al (2005) Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida.
Green H et al (2005) Mental Health of Children and Young People in Great Britain, 2004.
Haddad M et al (2010) School nurses’ involvement, attitudes and training needs for mental health work: a UK-wide cross-sectional study. Journal of Advanced Nursing; 66: 11, 2471-2480.
National Institute for Health and Care Excellence (2013) Social and Emotional Wellbeing for Children and Young People. Local government briefing 12. London: NICE.
Public Health England (2016) The Mental Health of Children and Young People in England.